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VOL. 65 JANUARY,JUNE,, 1927
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UNIVERSITY OF lOWd
LABTALY.
“San
The Journal
OF
Nervous and Mental Disease
AN AMERICAN JOURNAL OF NEUROPSYCHIATRY
FOUNDED IN 1874
MANAGING EDITOR
DR. SMITH ELY JELLIFFE
WITH COLLABORATION OF
C. L. ALLEN, Los Angeles, Calif. DR. C. ARIENS KAPPERS, Amsterdam, Holland
C. E. ATWOOD, New York, N. Y. DR. EDW. J. KEMPF, New York, N. Y.
LEWELLYS F. BARKER, Baltimore, Md. pR. GEO. H. KIRBY, New York, N. Y.
B, BROUWER, Amsterdam, Holland DR. ADOLF MEYER, Baltimore, Md.
CARL D. ‘camp, Ann Arbor, Mich. DR. L. J. J. MUSKENS, Amsterdam, Holland
C. MACFIE CAMPBELL, Boston, Mass. DR
. GEO. H. PARKER, Cambridge, Mass.
Oe een Wea Re neA SHARP, Buffalo, N.Y,
k, N.Y.
eugene? DR. GREGORY STRAGNELL, New York, N. Y.
HARVEY CUSHING, Boston, Mass. ae. Gah BEA Ee
FREDERIC J. FARNELL, Providence, RI. Vitek ese) ag
DR. E. W. TAYLOR, Boston, Mass.
BERNARD GLUECK, New York, N. Y.
MENAS S. GREGORY, New York, N, y, DR. WALTER TIMME, New York, N. Y.
C. JUDSON HERRICK, Chicago, Ill. DR. FRED W. TILNEY, New York, N. Y.
GORDON HOLMES, London, Eng. DR. WM. A. WHITE, Washington, D. C.
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NEW YORK
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1O27
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N65.
ORIGINAL CONTRIBUTIONS
PAGE
The Columnar Arrangement of the Primary Afferent Centers in
the Brain-Stem of Man. By Walter Freeman, M.D.....1,
149, 282, 378
Castration Threats Against Children. By E. Pickworth Farrow,
MN, VERSCGS 95 cay rd ea ean Oe Neue ie PL Rn oi 21
Facial Diplegia in Multiple Neuritis. By Albert B. Yudelson,
Pe re Ls eRe soe are toon. o amc Pape ne 30
Malignant Hypernephroma Coincident with Arterio-sclerosis in
G@iildrengeebyeRobert Richard Dieterle, M.D).... 2.02... 6. 42
The Relation of the Cerebellum Weight to the Total Brain-
weight in Human Races and in Some Animals. By C. U.
BLT Gale ie mre ae Me oy ccs ora ego. vAeiv sie Bede oe & 0 02 TPs
Occlusion of the Posterior Inferior Cerebellar Artery. By
George Wilson, M.D., and N. W. Winkelman, M.D...... 125
Vertigo and the Death Wish. By Ernest E. Hadley, M.D...... 13
The Malaria Treatment of General Paresis. By Armando
Herranow vy Wedd uneodore CG... Fong, M.D... 2.3... 225
The Experimental Study of Pachymeningitis Hemorrhagica.
By Tracy Jackson Putnam, M.D., and Irma Kellers
LEU EMGL, AWA oe 2A eles we i, SRG 260
The Neuropathological Findings in a Case of Acute Sydenham’s
Phoneme ovmielovialtacierier =A MaiM LD). oo... acc neces PES)
The Syndrome of Mental Automatism and Its Role in the For-
mation of the Chronic Systematized Psychoses: A Review.
Sher eared URE levy 10 (40 ad 2d a dB pee a 345
Intraventricular Hemorrhage. A Clinical and Pathological
Study of Three Cases. By Irving J. Sands, M.D., and Max
AURIS ING UD. 9 oP elk ale ie Fy i be 360
Intravenous Treatment of Some Epileptics with Calcium
Chloride and Gluco-Calcium. By Elmer Klein, M.D., and
EMO LCIOTC MENLO at. ev icste le bias cass, as sod ecole eo obog oe 372
enexecnne peseby G,. LD, Aronovitch, M:D:........:...... 457
Endocrin and Biochemical Studies in Schizophrenia. By Karl
ONS doe Pai ei, OUD ae ee rr 465, 585
Subarachnoid Hemorrhage from a Medico-Legal Point of View.
Hohe ANT MGIC RGF 9 een BG BTUs Se Renae 484
iii]
iV ORIGINAL CONTRIBUTIONS
PAGE
An Introductory Study of the Erotic Behavior of Idiots. By
| Howard W. Potter, M.D) 38s a ee 497
The Pupils as an Aid to the Diagnosis in States of Coma. By
William C. Menninget, M.D? .7. | 2 are neds.
Blood Groups in Mental Diseases. By Frederick Proescher, |
M.D. and A.SwArkish. A Bay) ee ee 569
Society Proceedings: !
New ‘York Neurological) Societyau see ae 50, 307 3003
The Washington Society for Nervous and Mental Diseases. 171
Boston Society of Psychiatry and Neurology......... 398, 508
Special Review:
The Biology of the Intersex. By Ben Karpman, M,D..... 327
Critical Review:
“Die Frage der Laienanalyse.”’ Prof. Sigmund Freud.
By AoA. Brill; MiDi ean: eet: oe 412
Current Literature:
Vegetative Neurology ................04, 176, 421903) eee
sensori-Motor Neurology................70, 190, 42a
Symbolic Neurology... .......%-.2 0h eee 7, 2000 eer
Social Neurology, Religious Psychology, Medico-Legal,
s] A Orns Wenn Ae ee a 210
Book? Reviews | 1255. Uss ae eee 100, 214, 337, 445, 546, 638
Obituaries:
Emil Kraepelin ys, 5. y oe ae cake hs ee 110
Charles Herman Clark 0.27. ee 043
Robert, Hentys Cole), <2... Ut.0..2). Ga eee 454
Leonardo Bianchi). £0). 320.025 fae eee 551
Notes and, News |). 74004; $c 49. oo eee 224, 645
ae
ss ee ee f
VoL. 65 JANUARY, 1927 NO. E
The Journal
OF
Nervous and Mental Disease
An American Journal of Neuropsychiatry, Founded in 1874
ORIGINAL ARTICLES
THE COLUMNAR ARRANGEMENT OF THE PRIMARY
AFFERENT CENTERS IN THE BRAIN-STEM OF MAN *
By WaLTER FREEMAN, M.D.
\
SENIOR MEDICAL OFFICER, ST. ELIZABETHS HOSPITAL, WASHINGTON, D. C.
INTRODUCTION
The comparison between the architecture of the spinal cord and
that of the medulla oblongata has disclosed many interesting points
of similarity and difference. The fundamental basis is evidently the
same, yet when we pass from the segmental system proper, as it is
expressed in the spinal cord, to the segmental system in the brain-
stem, we find it complicated by the exaggeration of some of the
components and the practical suppression of others, as well as by
the appearance of new and suprasegmental structures. The analysis
of the condition must therefore be thorough in order completely to
discern the homologies.
It is with a view to the analysis of the end-stations of the primary
afferent fibers in the brain-stem that this investigation was under-
taken. The writer realizes that there are many gaps in our knowledge
of the true conditions and that more work must be done before these
gaps are closed, yet he believes that physiological experiments upon
sensation have now challenged anatomists to make further efforts
to determine the location of the various reception nuclei for the
afferent fibers. Moreover, with a recently adapted technic (see
Appendix B), the author has been able to discern these primary
afferent fibers clearly outlined at a time when most of the other fibers,
those that appear later in embryologic development have not yet
reached their full development.
*From the Reale Clinica delle Malattie Nervosi e Mentali: Rome, Italy,
Director Prof. E. Mingazzini, and from St. Elizabeths Hospital, Washington,
D. C., Superintendent Prof: Wm. A. White.
1]
2 WALTER FREEMAN
The author’s inspiration is due in no small measure to the works
of Kappers (1) and of Johnston (8) who through their studies upon
the comparative anatomy of this portion of the central nervous
system have done so much to establish our conceptions upon the
basis of simple primary mechanisms from which the higher ones are
later developed, and who have shown so clearly by their methods
of analysis which structures are to be looked upon as subserving
which function. It has been from the point of view of function
that their books have been written. As Johnston well says (p. 95):
“Tt must be insisted that a knowledge of mere structure is of little
value and may be misleading without a knowledge of function.”
On the other hand a study of structure in different vertebrates
allows us to form important conclusions in regard to the functions of
these structures. For instance the tractus solitarius, which for so
long has been considered to carry gustatory fibers, is apparently
anything but a primary gustatory tract, for it scarcely appears in
fishes in which organs of taste are developed to an extraordinary
degree, and is in full development in the cassowary which possesses
probably less than one hundred taste buds. Much more probably,
as Kappers has shown, the tractus solitarius is composed of fibers
conveying common visceral sensation from the upper respiratory
passages, and thus serves as the afferent path for impulses that are
concerned with air breathing. .
For many years now it has been recognized that the brain-stem
is the cephalic continuation of the segmented nervous system, and
that, disregarding the nerves of special sense, the afferent and efferent
neurones differ only in their degree of importance and in their com-
binations, from the homologous neurones of the spinal cord. ‘The
mesencephalic segment for instance gives rise to the third and fourth
nerves, the cerebellar segment to the fifth, the anterior hind-brain
segment to the sixth, seventh and eighth, and so on. Further than
this, however. comparative anatomists have disclosed in the Drain-
stem of the lower animals very definite longitudinal columns in which
the cell groups are to be found which preside over the functions of
each segment. For instance the column lying closest to the midline
is the somatic motor, supplying motor impulses to muscles derived
from primitive myomeres, and the one adjacent laterally is the visceral
motor. Externally again comes the visceral sensory, or as Winkler
calls it, the interoceptive, and at the extreme lateral portion the
somatic sensory. The somatic sensory may be divided into extero-
ceptive and proprioceptive parts. This general arrangement as it is
found in the simple brain of the dogfish, is shown in Fig. 1, which
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 3
I have adapted from Kappers (1, p. 268). I have shaded the pro-
prioceptive portion of the somatic sensory column less heavily. This
simple brain shows clearly the arrangement of the various columns.
Before proceeding to the detailed description of the columnar
arrangement of the primary afferent centers in the brain-stem of
man I believe that it 1s well to review the functions exercised by the
various nerves, laying special emphasis upon their similarities rather
Mths Re post.
FicurE 1. Schematic section of the medulla oblongata of the dogfish
Scyllium canicula, showing the typical arrangement of the columns. Each side
of the brain-stem can be divided into two parts, the ventrolateral motor plate
and the dorsolateral sensory plate. These parts can again be divided into
somatic motor and visceral motor columns, and somatic sensory and visceral
sensory columns. The somatic sensory column is shaded with vertical lines
and is made up of two parts, one subserving exteroceptive sensation, repre-
sented iby the radix spinalis trigemini which is more heavily shaded; the
other subserving proprioceptive sensation, represented by the N. lineae lateralis
posterioris and its reception nucleus. The visceral sensory or interoceptive
column is shaded with horizontal lines. (After Kappers: WVergleichende
Anatomie des Nervensystems, p. 268.)
than their differences. To resemble a typical spinal nerve each cranial
nerve should consist of a somatic motor, a somatic sensory, a visceral
motor and a visceral sensory portion. Each should supply some
cutaneous area with all forms of sensation, a portion of the alimentary
canal with visceral sensation, certain muscles, bones, joints, etc., with
deep sensation. I shall begin with a consideration of the dermatomeres
of the head.
4 WALTER FREEMAN
I. THE INNERVATION OF THE HEAD
In spite of considerable work done in the past upon the cutaneous:
innervation of the head, this remains the most uncertain of all fields
of the body. The uncertainty is due in part to the fact that it has.
been found only relatively recently by clinicians that the facial nerve
carries cutaneous fibers. Cushing (17) in his important work upon
the trigeminal nerve (1903), was the first to discuss from the clinical
point of view the cutaneous field of the ninth and tenth nerves,
although anatomists a long time before had shown the existence of
cutaneous fibers in these nerves. Even Cushing did not speak of the
facial nerve which was still at that time believed to contain no
cutaneous fibers. Later, Ramsay Hunt called attention to this nerve,
basing his conclusions upon the fact that herpes zoster of the auricle
and external auditory canal is often accompanied by facial paralysis,.
and loss of the sense of taste on the anterior part of the tongue. It is
known that the posterior auricular nerve 1s composed in part of
fibers coming from the seventh, partly from the ninth and partly
from the tenth nerves, in this respect resembling a nerve plexus, but:
the areas innervated by each nerve root have not yet been completely
delineated.
The anatomical method of delimiting the cutaneous fields supplied
by the lower cranial nerves is unsatisfactory. The various cutaneous.
filaments not only join together in a plexus, but the fields of the
sensory roots overlap. Sherrington (12) showed that the cutaneous
fields of the spinal roots overlap to a considerable degree so that two:
or even three roots may supply one particular cutaneous area, and
that no area is rendered entirely anesthetic by the section of a single
root. If the same condition obtains in the case of the cranial nerves,
then two or more roots must be paralyzed (excluding of course the:
trigeminus), before a definite area of anesthesia can be determined.
The extent of the fields, as Sherrington noted, is best determined
by the method of residual sensation, that 1s by outlining the area of
normal sensibility after section of the roots of two nerves on each
side of the root to be studied. A modification of this method is the
study of the borders of the anesthetic area after section of two
adjacent roots. The upper limit of anesthesia denotes the farthest ex-
tension caudally of the upper uninjured root, whereas the lower limit
represents the farthest extension cephalad of the low uninjured root.
Both of these conditions are seldom fulfilled satisfactorily in man.
Practically speaking nothing is known about the backward limit of
the cutaneous area supplied by the N. glossopharyngeus, nor the
forward limit of that supplied. by the N. vagus. These nerves are
ARRANGEMENT OF PRIMARY AFFERENT CENTERS h)
practically always involved at the same time in the disease process.
The excellent experimental method of Dusser de Barenne (81) of
strychninization of the dorsal roots finds almost insuperable obstacles
when it is a question of applying strychnine solution to the intracranial
radicular fibers of the lower cranial nerves. I have attempted this
without success.
Hunt (29, p. 338) believes that the zoster area will do much to
establish the extent of these fields. ‘* The importance of this method,”
he writes, “has already been demonstrated in the spinal ganglia by
Head and Campbell, and how much greater would be its significance
in the case of the geniculate; a small ganglion of unknown representa-
tion in which the cutaneous distribution was small, difficult of access
and of demonstration by the usual anesthetic methods.” This method
also finds its limitations, for not infrequently more than one ganglion
is involved, and the area covered by the eruption varies considerably.
However, this is at present the most useful method that we have at
our disposal. The method of residual sensation, the most exact, must
not be lost sight of, for it will give certain valuable indications.
The following outline is only tentative, but is believed to represent
the present state of our knowledge in regard to the dermatomeres
of the head. It is drawn partly from the anatomical findings, partly
from the zoster area, and partly from what observations we have
upon residual sensibility. One original observation is included. As
will be shown, the overlapping of the fields is considerable and is
possibly more marked than is actually shown in the diagrams.
A. Cutaneous Sensibility
The N. trigeminus carries cutaneous sensory fibers for practically
the whole face and a considerable portion of the scalp (Fig. 2a).
There are considerable individual variations. In the parotid region
there is a considerable extension upward over the border of the jaw,
and a smaller one at the tip of the chin. It seems probable that the
N. trigeminus supplies nearly all if not all the helix, antihelix, lobe
and tragus of the external ear, the anterior wall of the external
auditory canal, and the anterior half of the tympanum. ‘These parts
are certainly supplied by the N. facialis, but as a rule there is no
definite anesthesia here resulting from paralysis of the N. facialis.
This area is not supplied by the N. glossopharyngeus, for in Case l,
where the fifth and seventh nerves were both paralyzed, these portions
were anesthetic.
We possess considerable information about the distribution of the
various branches of the trigeminus upon the face. The ophthalmic
0 WALTER FREEMAN
Figure 2. Dermatomeres of the human head. (a) The trigeminal field.
The line on the scalp and side of the face is determined in casessof paralysis
of the II and III cervical nerves as the posterior border of the sensitive area.
The extension over the anterior surface of the ear is indicated by the followinz
facts. This area is not supplied by the N. glossopharyngeus or N. vagus,
because it is anesthetic in cases of paralysis of both fifth and seventh nerves
(Case 1). However, this area retains its cutaneous sensation after paralysis
of either fifth or seventh nerve separately. (b) The field probably supplied
by the seventh and ninth nerves. The field of the VII (vertical shading) is
determined by the eruption in cases of herpes oticus. Its anterior extension
in front of the tragus is found in cases of trigeminal neurectomy. The
extension to the posterior surface of the helix is of unknown extent. In
cases of paralysis of both fifth and seventh nerves the concha and the posterior
surface of the helix are sensitive showing that they are probably innervated
by the N. glossopharyngeus (horizontal shading). The zoster zone for the
N. glossopharyngeus includes a small area in the fissure between the auricle
and the mastoid region. Its posterior extent is unknown. (c) The fields for
the N. vagus (shaded) and the II c. segment. The intra-auricular portion is
indicated by the reflex phenomena that are induced by irritation of the ear.
The area surrounding the ear is the area supplied by the R. auricularis posticus.
The II c. segment is fairly well known through studies on residual sensibility.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 7
division supplies the scalp, the forehead above the eye, the cornea,
upper eyelid and a portion of the nose. The maxillary division sup-
plies the lower eyelid, the nose, upper lip, and a tongue-like projection
of skin to the outer side of the eye. The mandibular division supplies
the lower lip and chin, the cheek, the external ear and a not incon-
siderable portion of the scalp.
The N. trigeminus by its position and distribution therefore, is
situated at the oral end of the body and represents the most cephalic
cutaneous segments. Probably, however, as is shown by studies on
amphioxus and on the embryos of all vertebrates, the N. trigeminus
represents more than a single segment. In the simpler forms of life
the ophthalmic nerve is separated from the other portions, exists as
Ficure 3. Segmental cutaneous innervation of the head as shown by the
advance of the analgesic area in cases of syringobulbia. The most proximal
portion of the body is shown to correspond to the mouth. (From Dejerine:
Sémeiologie des affections du Systéme nerveux. )
a separate nerve, having its own sensory ganglion which becomes
fused with the other portions only in the more highly developed
organism. In its separate existence is lies close to the midbrain,
but later becomes displaced caudally (Kappers, p. 318).
The cutaneous fields of the maxillary and mandibular rami are
separated by the mouth. These two rami possessing a common
ganglion are to be looked upon (Johnston) as derivatives of the pre-
trematic and postrematic rami of an early branchial nerve. From
this point of view the mouth itself is a gill slit highly modified.
Whereas there is thus some evidence of the segmental distribution
of cutaneous fibers in the peripheral distribution of the N. trigeminus,
this evidence becomes much more convincing when the intracerebral
distribution of the primary nociceptive fibers is examined.
8 WALTER FREEMAN
These run in the radix spinalis trigemini and subserve a primitive
kind of sensibility which might be termed paleoesthetic in contrast
to the discriminative or neoesthetic kind. When the radix spinalis
trigemini is destroyed progressively as in cases of syringobulbia, the
loss of pain sensibility advances progressively over the head and
converges upon the mouth (see Fig. 3 from Dejerine). This has
led Winkler (14, Vol. 2, p. 10) to regard the cutaneous innervation
about the buccal orifice to be as much segmental in character as that
found about the anus. ‘Thus we may consider, he shows, that the
mouth is really the most anterior portion of the body, for the dermat-
omeres converge upon it, whereas the head and eyes are in reality
developed from the portions caudal and dorsal to the mouth. In
support of this theory Brouwer (16) has called attention to the fact
that the N. ophthalmicus of fishes spreads out dorsally to the maxil-
lary and mandibular divisions. How this primitive segmental repre-
sentation remains in the radix spinalis trigemini while the cutaneous
fields supplied by the several branches of the nerve have become so
profoundly altered is a subject that will be taken up later in the
consideration of the principle of usurpation.
Passing from the N. trigeminus to the N. facialis we find that it
has been recognized clinically only recently that the seventh nerve in
man contains cutaneous fibers. According to Winkler (Vol. 1, p.
386) “ The glossopalatine nerve (the sensory division of the facial
nerve) does not carry any more cutaneous fibers.” Most authors,
however, who have recently investigated the question believe that
there is a small area of skin innervated by the sensory division of the
facial nerve. The anatomical evidence is strongly in favor of it.
‘The seventh nerve of certain fishes contains a considerable number
of cutaneous fibers. These are diminished in other fishes but reappear
prominently in the amphibia. In mammals Rinehart (32) has
described a cutaneous sensory branch of the N. facialis in the albino
mouse, and as noted above, Retzius, His, v. Lenhossek and more
recently Baudouin (23) have found it in man. According to van
‘Gehuchten (6, p. 596-602) the facial nerve is sensitive at the stylo-
mastoid foramen. He speaks of the Nervus intermedius Wrisbergii
“ which is nothing else than the sensory part of the N. facialis.”
Ramsay Hunt (28) believes that the cutaneous area of the
geniculate ganglion is shown by herpes zoster of the auricle and
external auditory canal. On page 77 (1907) he states: “ Histological
and embryological investigations of the past ten years have shown
conclusively that the facial is a mixed nerve possessing an afferent
or sensory portion, which is the nerve of Wrisberg, and a ganglionic
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 9
structure, the geniculate, analogous in structure to the spinal ganglia
of the posterior roots, the cell type of the geniculate corresponding
exactly to that of the spinal and gasserian ganglia.” In 1909
Hunt (29) went even farther, showing that afferent fibers are found
in all three divisions of the facial nerve, the chorda tympani, the
great superficial petrosal nerve and the main motor trunk itself.
It is nearly twenty years now since Hunt called attention to the
condition which he terms the syndrome of the geniculate ganglion,
which is found in cases of herpes oticus. In this condition, as the
result of a specific inflammation of the geniculate ganglion there arise
herpetic vesicles covering the auricle and the external auditory canal,
neuralgic pain in the same region, paralysis of the facial musculature,
and loss of the sense of taste on the anterior two-thirds of the tongue.
In one case Hunt found degeneration of the sensory division of the
facial nerve at its entrance into the medulla oblongata. The number
of recorded cases of this condition has been multiplied in recent
years. Dejerine (4) discusses the condition in his Sémeiologie;
Sterz(ii) sand Herrick (9) admit the probability of cutaneous
representation in the facial nerve, Kappers accepts Hunt’s conclusions.
Recently (Vol. 1, 1924) a series of commuinications on the subject
of herpes oticus appeared in the Revue Neurologique.
The whole distribution of the cutaneous fibers of the seventh
nerve is not known although some work has been done in this regard
by Hunt himself and by others. In Dejerine’s case of herpes oticus
there was not only anesthesia of the auricle and the external auditory
canal, but also a large area of marked hypesthesia in the whole area
supplied by the posterior auricular nerve, and slight hypesthesia of
the whole face on the same side. The large extent of disturbed
sensation was possibly due to coincident inflammation of the periph-
eral nerve trunks. It is very doubtful if the cutaneous fibers of
the facial nerve extend far beyond the auricle and the external
auditory canal. The distribution of the eruption of vesicles in the
cases of herpes would constitute a better criterion.
The anterior extension of the cutaneous sensory field is easily
determined in patients on whom the avulsion of the posterior root of
the Gasserian ganglion has been performed (Fig. 2-b). The posterior
border of the anesthetic area is bounded by a line that runs a few
millimeters in front of the tragus, and sometimes in front of the
helix, though there are considerable variations in this regard. In
cases where both the N. trigeminus and the N. facialis are paralyzed,
however, there is definite extension of this anesthetic area, so that the
anterior border or normal sensibility has retreated into the external
10 WALTER FREEMAN
auditory canal and for a considerable distance over the auricle on its
anterior or external surface. The concha remains sensitive, being
innervated by the lower nerves.
The following case is a good example:
Case l. J. G, male, aged fifty-six years. (From the Neurosurgical
Clinic of the University Hospital, Philadelphia, Professor Charles H.
Frazier, to whom I am indebted for permission to report the case.)
Diagnosis: ‘Trigeminal Neuralgia. Radical operation of avulsion of
the posterior root of the gasserian ganglion followed by facial paralysis.
Case History. For 18 months the patient had suffered from lightning
pains in the left side of the face, chiefly in the cheek and lower jaw. His
general health was good. There were no symptoms or signs referable to
the other cranial nerves. Several teeth had been extracted without
furnishing relief. Under ether anesthesia the posterior root of the
gasserian ganglion was avulsed by Dr. Frazier. After operation there
was complete anesthesia of the right side of the face including the cornea.
The masseter muscles did not contract. Two days later there was com-
plete flaccid facial paralysis involving all the muscles. Taste sensation
was lost on the anterior part of the tongue. ‘There was no sensation
produced by pinching or by pressure upon the forehead, malar region or
lower jaw. The tongue, gums, teeth, hard palate and anterior pillar of
the fauces were insensitive to light and touch and pinprick. Unfortunately
the pressure sense in the tongue was not tested at this time. The area of
cutaneous anesthesia is shown in the photograph (Fig. 4-a). It includes
the whole of the helix and lobe of the ear on its anterior or external
surface. It is sharply bounded by the edge of the helix and does not
invade the posterior aspect of the helix. Nor does it invade the concha,
although the anterior wall of the external auditory canal as far as it was
tested was anesthetic.. The posterior wall was sensitive. The sensation
of the tympanum was not tested.
At no time were there any disturbances of deglutition or of phonation.
Seventeen months later, I again examined this patient. The facial
paralysis had completely disappeared. There was no return of function
in the muscles of mastication, which had undergone considerable atrophy.
Taste was normal on both sides of the anterior portion of the tongue.
Pressure sense was acutely felt on both sides of the tongue and over the
face as well. Although no algometer measurements were made, pain was
produced equally readily on the two sides of the face by deep pressure.
The area of cutaneous anesthesia is shown in the diagram Fig. 4-b.
The extension of the anesthetic area over the helix and lobe of the ear
had disappeared, and the line of anesthesia had advanced considerably
in front of the ear. The sensation of the whole of the external auditory
canal was normal and equal on the two sides.
Sensation was lost in the tongue, gums, cheek and hard palate, but the
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 11
anterior pillar was sensitive in its lower portion, as were all portions
farther in. The corneal and the nasolacrymal reflexes were absent on
the side of operation. The general health of the patient was excellent,
and except for having to wear protecting goggles he could attend to his
business as well as ever.
This case tends to show by the method of residual sensibility that
the sensory field of the seventh nerve includes the whole of the
anterior surface of the auricle and the lobe of the ear. This area
Ficure 4-a. Photograph of John G. (Case 1), one week after avulsion
of the roots of the fifth nerve. Facial paralysis of peripheral type developed
soon after operation. The area of anesthesia is outlined. It includes the ant.
or ext. surface of the auricle up to its post. margin, but it does not include
the concha. The tragus and the ant. wall of the ext. auditory canal are
anesthetic.
became insensitive after paralysis of both fifth and seventh nerves.
It is not insensitive after paralysis of either the fifth or the seventh
nerve separately, therefore it seems that this area is supplied by both
the fifth and seventh nerves. This case also serves to show the
anterior extension of the cutaneous field of the N. glossopharyngeus.
When both the N. trigeminus and the N. facialis were paralyzed,
the N. glossopharyngeus was the nerve situated the farthest forward,
and therefore served to innervate the concha, the posterior wall of
the external auditory canal, and the posterior surface of the helix.
In the mouth the additional area of mucous membrane made anesthetic
12 WALTER FREEMAN
by the paralysis of the facial nerve was not absolutely determined,
but it seemed that the sensitive area over the lower portion of’ the
anterior pillar was larger at the second than at the first examination.
Tactile and pain sensibility had not returned to the tongue, although
pressure was felt acutely on both sides, and taste had returned. This
serves to show that the N. facialis carries only fibers for gustatory
sensation to the tongue. The under surface of the tongue was not
tested however.
The findings in regard to deep sensibility confirm Davis’ (24)
work.
Ficure 4-b. Anesthetic area after recovery from facial paralysis—17 months
after operation. The anesthetic area over the scalp and cheek is somewhat ~
reduced. The whole of the auricle except the root of the helix is normally
sensitive. Pressure readings and other data are given in the text.
Our knowledge concerning the cutaneous area supplied by the
N. glossopharyngeus is still less definite than that concerning the
area supplied by the N. facialis. It is known that a small branch
runs from the sensory root to join the auricular branch of the vagus.
Before Hunt’s reports, Cushing (17) had assigned to the glosso-
pharyngeus and the vagus, a cutaneous distribution to the auricle
and external auditory canal, but he did not take the N. facialis into
account. In Hunt’s papers some consideration is given to the
possible role played by the N. glossopharyngeus in herpetic inflam-
mations of the auricle. He states that in two of his cases the eruption
of vesicles extended posteriorly to the cleft between the auricle and
the mastoid region, and suggests that in these cases the Ganglion
superius IX was also involved in the disease process. According to
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 13
Winkler the N. glossopharyngeus supplies sensation to a small
cutaneous area behind the auricle. Kappers (p. 306) states that the
ninth nerve has some cutaneous fibers which find their cells in the
superior glossopharyngeal ganglion. It seems probable that the an-
terior limit of the cutaneous field supplied by the N. glossopharyngeus
is outlined in the case reported (Case 1) in which both fifth and
seventh nerves were paralyzed. Less convincing evidence is that
supplied by the nature of the reflex phenomena that come about as
the result of douching the ear. Swallowing is often provoked.
The N. glossopharyngeus thus probably innervates the posterior
surface of the auricle and the cleft between it and the mastoid region,
the concha and the posterior wall of the external auditory canal.
This is indicated in Fig. 2-b. Further careful work is needed along
this line especially upon patients who present what Vernet (42) has
called the syndrome of the posterior lacerated foramen, exhibiting
paralysis of the last three or four cranial nerves, before this question
can be settled. From an anatomical point of view the statement of
Vernet that the N. glossopharyngeus carries only motor fibers, and
the N. vagus only sensory fibers cannot be taken as _ proven.
Herrick (9) accords the glossopharyngeus a general sensory dis-
tribution to the auricle.
The N. vagus has a larger cutaneous field that is fairly well known
through gross dissection of the branches of the posterior auricular
nerve. This area is sometimes the seat of neuralgia, provoked by
disease at other points in the distribution of the N. vagus. For
instance in cases of carcinoma of the larynx there may be severe
pain in the ear. In Vernet’s Case 5 there was paralysis of the palate,
pharynx and larynx on the right side with marked hyperesthesia in
the same area. This patient noted that upon cleaning his ears,
especially if he pressed upon the posterior wall of the external
auditory canal, coughing was immediately excited. Less marked
reflex phenomena are frequently noted. According to Kap-
pers (p. 305) the vagus carries cutaneous fibers. They supply the
skin of the auricle and external auditory meatus through the posterior
auricular nerve and find their ganglion cells in the G. jugulare.
According to van Gehuchten the ramus auricularis vagi comes from
the G. jugulare, receives an anastomotic connection with the N. glos-
sopharyngeus, penetrates the mastoid canal, anastomoses with a.
branch of the N. facialis and is distributed to the external surface of
the tympanum and the skin of the dorsal and superior half of the
external auditory canal (p. 553). Herrick believes that the vagus
supplies the external ear with sensory fibers. The delimitation of
14 WALTER FREEMAN
the field has not been worked out, so that at present we cannot say
positively how much is supplied by each nerve. The schema in
Fig. 2-b (from Dejerine) shows the distribution of the posterior
auricular nerve behind the ear rather than a known sensory field.
I have added the concha and the posterior wall of the external
auditory canal on the basis of reflex phenomena.
The first cervical segment has no dorsal root. The second root
has its ganglion and its cutaneous distribution that are well known
through the work of Bolk (15) and of Cushing (17). Overlapping
the cutaneous area of the trigeminus anteriorly to a slight extent,
the field of the second cervical root extends backward over most of
the scalp almost to the hair line at the root of the neck. Anteriorly
it overlaps the portion supplied by the N. vagus through the posterior
auricular nerve behind and above the external ear, and running
beneath the lobe of the ear it invades the field supplied by the N.
trigeminus in the parotid region. ‘This has often been shown after
section of the posterior root of the Gasserian ganglion. Often it
takes in a small triangular area of skin at the tip of the chin. It is
bordered and overlapped caudally by the cutaneous distribution of
the third cervical root. This is shown in Fig. 2-c (from Dejerine).
The foregoing studies relate to tactile, thermic and painful sensi-
bilities, that is to exteroceptive sensation. The distribution of pain
fibers is always the largest, and in cases of anesthesia due to paralysis
of one or more nerves, the analgesic area is always smaller than the
area anesthetic to light touch.
B. Deep Sensibility
The clinical studies of Henry Head (7) and his collaborators
upon sensation have clarified our knowledge of the peripheral
mechanism concerned in the transmission of sensory impulses. Head
divided sensation first into protopathic and epicritic sensibility, the
fibers for which run in the sensory cutaneous nerves, and deep
sensibility, the fibers for which run in the motor nerves. In the first
examinations of his arm after section of all the nerves carrying
cutaneous sensibility to a certain area, it was found that ordinary
touches were not only readily felt, but quite accurately localized.
Further investigation, however, showed that when the forearm was
shaved, and when tactile stimuli were applied with care so as to
cause a minimum deformation of the skin, such touches could no
longer be felt. In this way he ascertained that the sense of pressure,
of deep sensibility, was conveyed by the nerves supplying the muscles,
joints, tendons and bones. This deep sensibility is therefore closely
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 15
related to the sense of position and passive movement, which are
probably subserved by the same organs, and which compose the
cognitive part of proprioceptive sensibility.
Before we consider this question, however, it is well to determine
what we can in regard to the distribution of the sense of deep
pressure in the various cranial nerves. All muscles have sensory end-
organs, and motor nerves contain afferent fibers. In most cases the
ganglion cells for these afferent fibers are to be found in the dorsal
spinal ganglia and in their homologues the ganglia of the cranial
nerves. There are certain exceptions to this. For instance although
the oculomotor, trochlear and abducens nerves contain afferent fibers,
no sensory ganglia have been described for them. The sensory
ganglion of the N. hypoglossus is a curiosity that Froriep (46) has
described. ‘This investigator also found ganglion cells of sensory
type in among the fibers of the N. hypoglossus, and these may be
the ganglion cells supplying muscle sensibility to the intrinsic muscles
of the tongue. Another exception is the N. trigeminus. The motor
portion joins the mandibular division in the semilunar ganglion.
As we shall see later the muscle sensibility of the muscles of mastica-
tion is carried by fibers which pass unchanged through the gasserian
ganglion and, after entering the pons with the R. Sens. V, find their
ganglion cells in the radix mesencephalica trigemini.. This root has
been shown by Johnston to be homologous with the series of sensory
ganglion cells subserving muscle sensibility and occupying a dorso-
mesial location in the spinal cord of the lower fishes which possess
no dorsal root ganglia. Some evidence will be given tending to show
that the afferent fibers in the third, fourth and sixth nerves also find
their ganglion cells in this same mesencephalic root.
Fibers of deep sensibility for the face are carried in the facial
nerve. One of the most remarkable contributions to this subject
was made by Davis (24), upon anatomical, experimental and clinical
findings. In the first place he repeated and confirmed the work of
Amabilino. After section of the chorda tympani he found that
four-fifths of the cells of the G. geniculatum degenerated, but that
one-fifth remained intact. After section of the N. facialis at the
stylomastoid foramen he found one-fifth of the nerve cells in the
G. geniculatum in a state of chromatolysis, four-fifths remaining
intact.
In further experiments Davis sectioned the posterior root of the
G. semilunare in cats and found abolition of the corneal reflex and
of other ordinary pain reflexes. However, when he thrust needle
electrodes into the facial musculature and stimulated with the faradic
16 WALTER FREEMAN
current, the animal cried out and struggled violently. Section of
the N. facialis now abolished this reaction. In clinical cases of
trigeminal neurectomy the same investigator found that the response
to deep pressure was practically the same on both sides. In cases
in which facial paralysis was associated with paralysis of the fifth
nerve, however, there was no pain produced by pressure even amount-
ing to 15 kilograms. This finding has recently been confirmed by
Souques and Hartmann, and I have had the opportunity of examining
a patient in whom, after trigeminal neurectomy, facial paralysis
supervened (Case 1). These was loss of pain on deep pressure, but
some months afterwards, when the facial paralysis had disappeared,
deep pressure was felt equally on the two sides whereas there was
in the same areas no return of cutaneous sensibility.
Quoting from Davis: “ Applying Head’s theory of the sensory
mechanism in the peripheral nerves to the sensory supply of the face
it would mean that the trigeminal nerve carries the afferent proto-
pathic and epicritic impulses, while the facial nerve transmits the
impulses of deep sensibility from the face.” The fibers of deep
sensibility that run in the N. facialis probably also subserve the
kinesthetic sensation of the muscles supplied by the nerve. It is
noticed (see the discussion of Davis’ article) that patients with
ordinary facial paralysis are not aware of the contraction of these
muscles under stimulation by the galvanic current, although they
can perceive the cutaneous sensation perfectly.
It is highly probable however that the N. trigeminus conveys some
fibers for deep sensibility. Deep pressure upon the forehead is still
painful in cases of common facial paralysis although there is a
difference between the acuteness of the sensation on the two sides.
After trigeminal neurectomy, pain is not produced by pressure upon
the eyeball, and the oculocardiac reflex is absent upon the side of
operation. The fibers of the fifth nerve transmitting deep sensibility
probably come from the periosteum and the tunic of the eyeball.
In addition there are others that give sensibility to the hairs, especially
the moustachios which in the lower animals are highly developed and
of considerable importance as exploratory organs. Sensibility of the
dura mater may be grouped as deep sensibility and is carried to a
large extent by the N. trigeminus.
The deep sensory components of the vagus and glossopharyngeus
nerves probably serve for the conduction of deep pressure and
kinesthetic sensations from the muscles innervated by these nerves.
They probably belong more to the visceral than to the somatic type
of afferent fibers. Indeed in this regard it might be said that the
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 17
deep sensibility of the muscles of the face and jaws belongs rather
to the type of sensation known as visceral. The muscles under con-
sideration are developed from the branchial musculature and are
innervated by visceral motor nerves. However, the extension of
voluntary control over these muscles has led to a change in their
aspect. They have become striated, and the cells supplying them
have assumed the morphologic characters of the somatic motor ‘cells.
It is probable therefore that the afferent fibers have come more
to resemble the somatic afferent fibers, particularly those of a
proprioceptive character.
The fibers for deep sensibility to the tongue probably pass by
way of the N. hypoglossus. This opinion was given by Davis
although Marburg (55) in his referate believed that they might reach
the N. facialis through the chorda tympani. The former opinion is
probably correct although I know of no direct evidence to support it.
Case 3 reported below is suggestive in this regard but not conclusive.
It is stated (Dejerine) that the posterior portions of the dura
mater are supplied by the vagus and hypoglossus nerves.
C. Visceral Sensibility
The N. trigeminus supplies general sensation to the mucous
membranes of the lips, cheeks, gums and anterior part of the tongue
and fauces. This would make it appear that the N. trigeminus is a
‘mixed somatic and visceral sensory nerve whereas in the lower
vertebrates it is preeminently a somatic sensory nerve, carrying few
or no visceral afferent fibers. The explanation of the change may
be that the alimentary canal, with its true buccal orifice, begins at
the region of the fauces, and that the formation of the mouth is a
later addition, a sort of portico built up in front of the main entrance.
It thus develops that the fifth nerve, while primarily somato-sensory,
comes to carry some fibers that have taken on a visceral function.
In other words the visceral component is dependent upon the forma-
tion of the vertebrate mouth and is a secondary rather than a primary
relationship. This question is discussed at some length by Johns-
ton (8). Nevertheless as at present constituted, the N. trigeminus
carries common visceral sensory fibers. It carries no taste fibers.
As we shall see later the visceral sensory column is very well
developed at the level of the sensory nucleus of the N. trigeminus.
The N. trigeminus also supplies sensation to the mucous membrane
of the nares, septum, turbinates and accessory nasal sinuses at least
as far as the ethmoid region. According to Dejerine (4) it supplies
18 WALTER FREEMAN
also the sphenoid sinus. After section of the posterior root of the
gasserian ganglion the nasolacrymal reflex is absent.
According to Ramsay Hunt (30) 1915, the N. facialis carries
sensory fibers from the mucous membrane of the middle ear,
eustachian tube and mastoid cells, Kappers follows Cushing and
Oppenheim in ascribing to the seventh nerve the sensory fibers from
the mucous membrane of the inferior part of the tongue and possibly
the palate and the anterior pillar of the fauces. Winkler states that
fibers of deep sensibility reach N. facialis from the palatal muscula-
ture by way of the sphenopalatine ganglion, but it 1s probable that
these are mucosal fibers, because as Vernet has shown, there is no
disability of the palate in cases of facial paralysis. He believes that
the palate receives its motor supply from the spinal accessory nerve.
The mastoid cells are believed by Dejerine to be innervated by the
sensory branch of the vagus nerve. Hunt ascribes to the N. facialis
the innervation of the internal ear.
The area of mucous membrane supplied by the N. glosso-
pharyngeus is thus far poorly defined. Vernet even denies its exist-
ence after his investigation of a large number of cases in which the
ninth and tenth nerves were paralyzed by injury or disease of the
structures in the posterior lacerated foramen. It is highly probable
according to van Gehuchten (41) that his nerve supplies common
sensation to a small area of the tongue, the tonsil, posterior pillar
and the pharynx, the fossa of Rosenmuller, the internal wall of the
middle ear and the posterior wall of the Eustachian tube. There is a
very marked difference in the reflex produced by touching the back
of the tongue, the soft palate or the posterior wall of the pharynx
on one hand, and the epiglottis or rima glottidis on the other. In
the former case gagging 1s the normal result, while the least touch at
lower levels provokes reflex coughing. This suggests an entirely
different mechanism aroused, and it could best be explained by the
suggestion that the peripheral terminations of different nerves have
been stimulated. Deep muscular sensibility is supplied by the glosso-
pharyngeus to the muscle it innervates, the superior constrictor of
the esophagus (Vernet).
The visceral distribution of the N. vagus is by far greater than
all the others, comprising as it does, the respiratory passages, the
alimentary canal from the esophagus downward and the organs of
the thoracic, abdominal and pelvic cavities. The mastoid cells and a
part of the dura mater are included by Dejerine.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 19
Deaste
Taste is a specialized visceral sensation. The taste buds are
derived from the entoderm, and the fibers supplying them run in-
separably mingled with the fibers of general visceral sensibility.
In man the chorda tympani branch of the facial nerve supplies the
foliate papillae on the anterior part of the tongue, and the glosso-
pharyngeus supplies the circumvallate and fungiform papillae on the
posterior portion, together with some of the taste buds scattered
in the wall of the pharynx. Some of these in the pharynx according
to Winkler (V. 1, p. 400) may be innervated by the vagus through
the superior laryngeal nerve, and Herrick (p. 160) states that those
-about the epiglottis and larynx are supplied by the vagus through the
inferior laryngeal nerve. Practically speaking, however, though there
is gustatory representation in the N. vagus, it is minimal. It has been
proved conclusively that the N. trigeminus carries no gustatory fibers.
The foregoing consideration of the distribution and partition of
the cranial nerves nerves is deemed desirable, for by this means we
are enabled to see what sorts of fibers are carried by which nerves,
and then in the consideration of the morphology of the central nervous
system we shall attempt to account for the various physiological units
in terms of anatomy. We know for instance that the gustatory fibers
run in the VII and*IX nerves, a few in the X, and none in the V.
Therefore in the comparison of the reception nuclei of these various
cranial nerves we shall be guided by these physiological considerations
and shall attempt to identify the gustatory nuclei from what we know
of the part played by the peripheral nerve in the transmission of
gustatory impulses from the taste buds.
This is also one of the reasons why it is important to recognize
the cutaneous distribution of the N. facialis, and to account for the
deep sensory innervation of the face. It is only by a complete study
of the physiology as well as the anatomy of the nerves and their
centers that the role played by each can be ascertained.
Lett BEVONTERING ROOTS
After this rather extended consideration of the parts supplied with
different kinds of sensation by the various cranial nerves it is neces-
sary to take up the study of the course of the various types of fibers
after they have passed through their respective ganglia and entered
the substance of the central nervous system. There is a redistribu-
tion of the various elements of sensation in a different manner, a
regrouping of the various sorts of fibers, and new and intricate
relationships are encountered.
20 WALL ERS igen oye
Re ee oe Phew
In the spinal cord the distribution of the individual posterior
root is relatively the same at all levels, and is fairly well known
as a result of the multitude of investigations that have had this
knowledge as their goal. It is only through recognition of this dis-
tribution that we know where to look for fibers of the entering roots
of the cranial nerves. In other words, the inductive rather than the
deductive method of reasoning is followed in the subsequent chapters.
We must bear in mind that although there are evidences of segmenta-
tion quite well marked in the brain-stem, this segmentation is obscured
by (1) the alteration in size and shape of the neural tube; (2) the
fusion of some segments and the obliteration of others; (3) the
usurpation of the function of portions of several different nerves
by another nerve; (4) the modification of certain nerve components
to subserve special functions, e.g. taste; (5) the increasingly larger
number of new and suprasegmental structures.
As a foundation for the study of the entering sensory roots in
the medulla oblongata we can do no better than to review the course
of the dorsal root fibers of the spinal cord. In the description given
I follow Winkler, but consider the fibers rather from the point of
view of the impulses they transmit than from their grouping in
different fasciculi. The reason for this will become apparent when
we consider the afferent roots of the cranial nerves.
The dorsal root fibers enter the spinal cord in a series of small
fasciculi placed one above the other. Fach fasciculus is composed
of a smaller lateral, or as I prefer to call it a ventral division, and a
larger mesial or dorsal division. ‘The reason for the use of the terms
dorsal and ventral is that in the brain-stem the great expansion of
the dorsal portions of the neural axis has caused the dislocation of
the entering roots from the dorsolateral surface to the ventrolateral.
The homologue of the lateral branch entering the spinal cord therefore
becomes the mesial branch in the medulla oblongata, and the mesial
branch becomes the lateral one. At the risk of confusing the ventral
and dorsal sensory divisions with the motor and sensory ventral and
dorsal roots I think it advisable to use the terms ventral and dorsal
divisions of the sensory roots.
The entering fibers of the dorsal roots divide upon entering the
spinal cord in the zona marginalis into ascending and descending
branches which sooner or later penetrate the dorsal horn although
some of the ascending branches run by the dorsal funiculi all the way
to the dorsal column nuclei.
(To be continued)
CroltRATION LHREATS AGAINST CHILDREN
By E. PickwortH Farrow, M.A., D.Sc.
OF LIMEHURST, SPALDING; ENGLAND
INTRODUCTION
Anybody who, as an adult, has had the startling experience of
suddenly remembering quite clearly, after long-continued psycho-
analysis, castration threats being made against him as a very small
child, by overpowering adults, will want to do anything he can to
avoid the incidence of similar threats against other children, perhaps
his own, in the future. That is the sole object of the present article
although the writer fears that his written style may not be clear
enough for this task. . Until, the above very deep stage in
analysis was reached, the individual may have taken only a very
abstract theoretical interest, all along in analysis, in anything he may
have heard about the castration-complex, and may have thought
that nothing about it could possibly apply to himself, owing perhaps
to what he believes to have been his very careful. and guarded
upbringing. Afterwards, however, it becomes a very different
matter. The fright and worry following the conscious recollection
are apt to be very great—possibly far worse than in the worst night-
mare, largely owing to the fact that both the threats and the recollec-
tions happen in waking life, and there is thus no chance of escaping
from them by waking up.
When the fright has been worked off by the individual realizing
consciously—what he had never realized consciously before—that the
threat was solely a threat and one not intended to be carried out, a
great improvement in his health results, and he seems to have a dif-
ferent view of life from what he had had before.
Apparently the mind goes on thinking unconsciously about a
castration threat, if given, until this is reached in consciousness
again and removed by analysis. There is probably little doubt that
the lives of a very large number of people have been ruined (in
comparison with what they might have been) by these early castra-
tion threats in infancy, and that the resulting completely repressed
fear is one of the chief underlying causes of nervousness and
neuroticism. The matter is thus one of considerable psychopatho-
[21]
The Strate
UNIVERSITY OF IOWA
[LArary
22 E.zP FARROW
logical importance and in no sense one of impropriety, for we are
here dealing with the deeper etiology of the neuroses.
It is possible that some unanalyzed persons might consider that
the subject was unpleasant, but an analyzed person looks upon it
simply from the point of view of a small child.
In the deeper stages of the analyses of adult male neurotics
Professor Freud discovered to his surprise that a very high propor-
tion of them eventually remembered threats made in their early
childhood to cut off the genitalia as a punishment for, and deterrent
against, infantile exhibitionism and onanism,
The recollection of these threats was invariably accompanied by
very great horror, and emotional disturbance, which had previously
been entirely repressed, and this repressed horror had frequently
acted as a basis upon which the neurosis had subsequently been built
up. In many cases it was clear that the neurosis would never have
originated at all, and in other cases would not have been nearly so
severe, if this repressed horror had not been present, or if the threats
in question had never been made.
The severe complex associated with these childhood threats has
been named, of course, the “castration-complex,” and it is one of
the features of Freud’s discoveries which excites the greatest, or
most widespread, doubt. The present writer at one time shared the
general view. He considered the whole idea of the castration-
complex to be extremely far-fetched and improbable. First he dis-
believed in the commonness of the occurrence of the threats, and,
secondly, when they did occur, he did not believe that they could
possibly have such a bad and permanent mental effect as was stated.
Some considerable time later he followed a method of self-analysis
and was very surprised when he eventually clearly remembered,
with very great horror, a severe castration threat which was made
against him when about three and a half years old. An account of
this particular threat, and of the stages by which it was recollected,
has recently been published elsewhere. A detailed account of the
method of self-analysis employed has also recently been published.?
The results obtained by this method of self-analysis are not open to
the criticism that the analyst reads the alleged results into the mind
of his patient.
The writer’s skepticism was naturally more than shaken by this
revived memory. There seems little doubt to him that the common
Pea The International Journal of Psycho-Analysis, Vol. VI, Pt. 1, Jan.,
2 See The British Journal of Medical Psychology, Vol. V, Part II, 1925.
CASTRATION THREATS AGAINST CHILDREN 23
attitude of unreasoning skepticism concerning the castration-complex
is frequently closely related to the fact that the majority of unana-
lyzed people themselves possess similar repressed fears, and thus
wish to disbelieve in the existence of the complex. If any extremely
skeptical person were analyzed, the unfortunate probability is that
he would eventually remember, to his surprise and horror, a severe
threat of this nature made in his infancy.
Wittels has a chapter on the subject in his recent book on Freud
(Allen and Unwin) giving two useful references: viz., the chapter
in Sadger’s Die Lehre von den Geschlechtsverirrungen and Starke’s
essay in the Internationale Zeitschrift fiir dretliche Psychoanalyse,
1922. Wittel’s chapter is, however, psychological rather than
medical, and several points in it are probably unsound. For example,
after referring to Freud’s strong objection to the attempted intro-
duction of phylogenesis, Wittels says “ Nevertheless, the castration-
complex cannot be saved without an extensive use of phylogenetic
considerations.” It may be remarked, in passing, that certainly
nobody who knew anything about its effects would wish to “save”’
this particular complex from the point of view of ‘saving it, but
nevertheless Wittel’s view can probably not be supported.
Careful observation and inquiries extending over some time, in a
typical English provincial town render it probable that, on the
average, not more than two, or at the most three, boys out of every
ten escape some threat of this nature when between the ages of two
and six years.
At one time, the writer would have thought this improbable but
the threats are made owing to the following circumstances. The
infant boy when he first consciously discovers or realizes the presence
of the genitalia (sometimes as early as two years old) is almost
invariably extremely proud of them. On account of this fact he will
be inclined to exhibit them to adults and to other children. He will
probably not perform this exhibition in the presence of either of the
parents owing to the same fear which may have produced an earlier
Cdipus complex; but he is more likely to do so in the presence of
other people, particularly persons of the opposite sex, such as
servants.
If the exhibition were made in the presence of a man, the latter
would probably say, “ You must not do that. It is considered very
improper,’ and would probably smack the child if the act were
repeated. Some men might make a cutting-off threat but they would
probably only do so in a half-hearted way, feeling rather ashamed
of themselves. Admittedly, some men apparently see humor in
making cutting-off threats in a joking way to a child, but the lewd
24 E. P. FARROW
attitude of mind which can see anything funny in a remark of this
kind is difficult of comprehension by any sane person and such
remarks naturally deserve strong condemnation. Nevertheless they
would probably not have the very bad mental effects of apparently
seriously intended castration threats.
Experience, however, shows that in relation to this particular
matter women are in an altogether different class from men.. Many
women, especially unmarried women and servants, apparently have
not the slightest conception of the extreme mental importance of the
genitalia to the small boy, and experience shows that, if a small boy
exposes himself in the presence of a servant, the latter is extremely
likely to say, “If you do that it will be cut off’ unless she has been
specially warned not to do so. Probably this idea occurs to her
merely as being the simplest and most likely method that she can
think of for preventing the recurrence of the infantile exhibition and
is without the slightest inherent viciousness on her part. All she
wishes to do is to prevent the exhibition and she has not the slightest
conception of the great mental harm which analysis would in all
probability show as having been caused by this method. Otherwise
she would certainly have adopted some other plan. As it is, the
castration threats will probably be increased in severity until the
desired end is attained by this particular process. For example, in
the writer’s case, a pie-dish and scissors were eventually produced
by an unmarried cousin and a servant. It is unnecessary to dilate
on the terrible nature of the fright which this caused, for even verbal
threats have a very bad effect.
The horror which comes to the surface in psychoanalysis when
castration threats in infancy are eventually remembered is so great
that any cautious investigator would immediately be caused to wonder
whether the individual may not be “reading back” into the early
castration threats unpleasant emotion attached to many incidents in
his later life. If this is not the case, it would probably be very diff-
cult to prove this conclusively. Much evidence indicates, however,
that the horror arises from the great mental importance of the geni-
talia and is properly attached to the castration threats as such, that it
originates immediately after the threats, and is not “read back”
from later unpleasant incidents. Tor instance, the improvement in
health which follows immediately after the working off of the fright
is one of the phenomena which indicate this.
If cases of severe psychosis, which are unanalyzable, owing to
such characteristics as suspicion, excitement, stubbornness or silence,
could be analyzed it seems very probable that repressed castration
horror might frequently be found to have played an important part
CASTRATION THREATS AGAINST CHILDREN 25
in the etiology of some of the disorders, in the same way as has been
found to be the case in the simpler conditions of the neuroses.
The chief difficulty in the way of avoiding these threats is that a
child while he is between the ages of two and six years may be left
alone with any one of many different persons. Most of these would
doubtless not make a castration threat; but out of the number there
is almost certain to be one who will, unless the child’s infantile ten-
dency to exhibitionism has been previously checked by some other
method. It is in this way that the high proportion of adult males
with various types of severities of castration complexes arises, viz.,
not less than seven to three.
Indeed, when one considers the strength of the early infantile
tendency towards exhibition and handling of the genitalia; and the
fact that, when this occurs, a cutting-off threat appears to be such a
spontaneous reaction on the part of such a large number of adults,
the proportion is probably far higher than this.
With regard to this matter, a scientific friend said to the writer
recently “ When one first hears of the castration-complex the idea
seems to be quite impossible, but when one looks carefully into the
matter, and considers the habits of small boys, one then sees, at once,
that it is probably almost impossible for a small boy to escape a
threat of this kind. However, I think that it is very sad if the
human mind does not possess some ways and means of repairing
the likely damage caused by these threats.”
With regard to the latter point, it would appear that the human
mind only seems able to endeavor to repair the damage by means
of covering it over; and, in the absence of analysis, the original
damage apparently remains in full force. This is possibly what
might have been expected when the fright is so great that it is com-
pletely repressed in the mind and, in the ordinary way, is not available
for alteration or modification. Some adults seem to think that
children are almost lifeless objects with no intelligence and do not
realize that they are usually extremely intelligent and complete small
men and women.
In view of these facts it seems desirable that practitioners should
warn the parents of small boys of the very great danger they incur
in leaving them alone with unmarried women. They should not be
left alone with anybody who has not been given definite instructions
not to make mutilation threats against the genitalia. Servants should
be told that, in the case of exhibition, the child is to be repeatedly
told that this is very improper and that he must not do it; and that,
if this fails, the fact is to be reported to the parents. It is, however,
unfortunately, almost impossible to be certain that these instructions
26 E, P. FARROW
will reach every person who may be left alone with the child—for
example a relative or friend of a servant may be in the house. In
view of this difficulty it might be advisable for the parents of a small
boy to tell him, not later than the age of two, that he must not expose
the genitalia in the presence of anybody. Also that if anybody ever
makes a cutting-off threat against these parts, he is not to be fright-
ened, for there is no possibility whatever of its being carried out, also
that he is at once to report any such threat to the parents.
Psychological preventive medicine will probably ultimately
acknowledge a great debt to the research method of analysis for
having discovered the common occurrence of castration threats in
infancy, and the very great permanent repressed mental damage
which they cause. If only the incidence of these early miuti-
lation threats could be reduced, a considerable reduction in the
incidence and severity of those later disorders (both neuroses and
psychoses) which have a purely mental basis might reasonably be
expected to follow. A reduction in the number of cases which would
be benefited by the painful, long and laborious, process of psycho-
analysis would be eminently satisfactory, for there always will be
far more such cases than analysts to undertake the work. It is also
of course infinitely more sensible, and satisfactory, to prevent dis-
orders rather than to attempt to cure them later when they have
become complicated. It must be annoying to an analyst to have
spent hundreds of hours of valuable time only to find that it would
have been unnecessary, and the patient would have been in good
health, if it had not been for the underlying completely repressed
mental chaos and confusion caused in the patient’s childhood by a
castration threat made by some ignorant servant.
There is something psychologically unique about the genitalia
which makes it extremely detrimental to threaten castration while a
threat to cut off the nose, thumbs, or legs for example would do no, or
very little, harm at all. In fact the writer knows of a case in which
a threat to cut out the tongue (for impertinence) was mentally
actually welcomed by the child as providing a means whereby he
could displace fright arising from an earlier castration threat on to
the tongue threat. The latter then acted as one of a long series of
cover-memories each member of which helped to render the original
highly unpleasant castration threat more completely unconscious than
it would otherwise have been.
Deep analytic research rather indicates that castration phantasies
and complexes may sometimes arise ab initio from the process of
weaning from the mother’s breast, and from various other causes—a
sort of substituting or transferring process. These forms of the
CMON MALION erika SVAGAINST. CHILDREN 27
complex, however, would not be likely to be nearly so severe as those
forms which arise from specific threats and it is not the mere exist-
ence of a complex in itself which is important, but its severity and
its relation to other tendencies in the individual mind.
Indeed, if those transferred fears which may possibly be derived
from the weaning process are to be termed a castration-“ complex,”
that which is produced as a result of actual definite and specific
threats against the genitalia should certainly be known by a different
name for the writer feels sure that there is no comparison whatever
in the definiteness and respective intensities of the fears resulting
from these two different types of causes. Before such a castration
threat the individual may have a fundamentally fairly happy outlook
upon the world; but after such a castration threat—if the threat is a
severe one—the outlook upon the world may be fundamentally very
depressed and miserable.
Only those who, as the present writer, can remember the details
of a severe castration threat, and their respective attitudes towards
the world before and after this threat, can realize what a funda-
mental change in his outlook on life a severe castration threat may
produce in the individual.
The writer has been very impressed and interested to find that,
since he “got up” and removed all the repressed horror formerly
associated with his own castration-complex, occasionally when he is
talking with some other individual about ordinary every-day mat-
ters, this individual may occasionally and for no apparent reason,
suddenly begin to “shout” “castration-complex”’ to the writer—
seemingly by perhaps only a slight but nevertheless peculiar and
highly distinctive frightened and depressed look about the eyes, by
his general manner and actions, etc.
This occasional phenomenon was so striking that, after it had
occurred a few times, the writer began to wonder whatever the
explanation or cause of it could be. He can only think that it must
mean that some of the particular effects of the castration-complex
in the directions indicated must be so highly specific, and that the
writer, who had the effects of a bad castration-complex in his mind
for about thirty years, is apparently inwardly so well acquainted
with some of these very specific effects that now, after these effects
have been removed from his own mind, when he occasionally sees
these particular effects displayed in another individual, the matter
forces itself upon his attention, no matter what he may have been
thinking about just previously. Of course it would not do to argue
from this that the other occasional individual necessarily has a cas-
tration-complex—such an attitude would not be nearly sufficiently
9
28 E. P. FARROW
cautious and it would be unscientific—except possibly as a prelim-
inary hypothesis. It is nevertheless of considerable scientific interest
that the above phenomenon occasionally occurs in a striking manner.
It is, in any event, very apparent to the writer that all physicians in
charge of cases of mental disorder should preferably have been
deeply analyzed.
It is clear that one moral which may be drawn from the facts
stated in the writer’s paper in the /nternational Journal of Psycho-
Analysis already referred to is the likely effects which such a very bad
fright in infancy might have upon the development of subsequent
mental disorder. The present writer considers it probable that such
thoughtless, but terrifying “ acted ” castration threats in early infancy
are probably far more common than might be supposed—for his
cousin—while untruthful and possessing some other most undesirable
characteristics, could not be generally described as particularly
vicious. Indeed in some ways she was kindly enough.
The writer remembered the characteristics of the coarse plush-like
table cloth of a yellowish green color, referred to in the paper just
cited, at which the dressmaker was sitting, so clearly in the analytical
recollection of the castration threat that he was sufficiently interested
to inquire the technical name of this particular material at a local
furnishing shop. He was informed that it is termed “ Mohair.”
About a year after getting up his own castration-complex, the
writer gradually noticed, at odd intervals during a month or so, the
existence of a tablecloth in one of the rooms in the house where he
now lives which was e-ractly the same as the one which figured in the
above analytical recollection. When, at the end of a month or so, he
realized this fact fully consciously he was extremely interested.
Nevertheless, wishing to be very cautious, and thinking that this par-
ticular tablecloth might possibly be a recent purchase, he inquired of
his mother whether this was the case. However, his mother replied,
“No, that tablecloth was bought at the time of my marriage.”
Apparently the writer was only able to realize the existence of
this tablecloth consciously after all the fright associated with the
castration threat had become worked off his mind, and apparently
it took nearly a year for this particular result to be achieved.
Thus this was apparently another instance ot a mental blind-spot
similar in nature to another one dealt with in the writer’s article in
the Journal of Mental Science (London), October, 1925.
All those who are doubtful of the effects of castration threats
upon children should read Ernst Simmel’s short but very valuable
and interesting article upon this subject entitled “A Screen Memory
im statu nascendi” in the International Journal of Psycho-Analysis,
Cast RATION TTAREATS AGAINST CHILDREN 29
‘October, 1925. Simmel’s article is especially valuable because it is
directly observational and does not depend upon psychoanalysis at all.
In it he describes the severe nature of the fright which a joking
threat of this kind, on the part of a surgeon, produced in his small
son at the age of two and a half years.
It will be realized of course that one is not in favor of infantile
exhibitionism. The whole point is the great importance that it should
be prevented by more rational methods than these unhuman cutting-
off threats. |
It is so obvious, for example, that severe smackings would be a
far more sensible and appropriate form of deterrent. Admittedly
they would give more physical pain and would not act so rapidly as
the other method; but the great trouble, of course, about castration
threats is that they penetrate so deeply into the mind, and are apt to
do so far more than is intended.
Many large books on such subjects as “ The Nervous Child”
make no mention whatever of the effects of such threats. This
omission seems merely funny to an analyzed person. ,
Doubtless the harmful effects of these threats to the individual
child may be divided into two entirely distinct and sharply contrasted
elements; (1) the fright in itself, and (2) the disappointment and
injury consequent upon the non-fulfillment of the wishes associated
with the infantile sexuality, and their repression, following upon,
or as a result of, the fright. Doubtless (2) is unavoidable in a civil-
ized community but physical pain might very sensibly be substituted
Rot. CLs :
The great difficulty is that many unanalyzed adults themselves
possess fairly severe castration-complexes. Owing to this they are
themselves disinclined, or unable, to recognize the facts, and would
be disinclined to take steps against such threats in the future. Such
action would unconsciously remind them of their own repressed
horror. Thus all the labor and pain of analysis will perhaps have to
go on until people do eventually become convinced.
The counterpart of the castration-complex in the female—or
rather those influences which tend to reduce its effects—cannot unfor-
tunately be so readily dealt with in a civilized society as the incidence
of the complex in the male might be avoided. There is thus not so
much point in dealing with it here.
The writer is indebted to his friends, Dr. J. H. Power and
Dr. J. Stanley White, for suggesting some improvements of literary
exposition in this paper.
FACIAL DIPLEGIA IN MOP Pian euale
By ALBERT B. YupELson, M.D.*
ASSOCIATE IN NEUROLOGY, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL;
ATTENDING NEUROLOGIST, COOK COUNTY HOSPITAL AND
WESLEY MEMORIAL HOSPITAL, CHICAGO
I
The incidence of facial diplegia in multiple neuritis is considered
generally as unusual. In 1916 Hugh T. Patrick (1) reviewed the
literature on this subject and recorded three cases in addition to
twenty-nine previously collected. In only one of the three is given
a history of a febrile illness prior to the onset of the palsy. No
history of alcohol, metallic, or organic poisoning was present. The
paralysis in the facial muscles was more severe than in the extremities
and persisted longer. Difficulty in swallowing was present in one
case. After an exhaustive discussion over the causative agents of
generalized polyneuritis in which facial diplegia is present, this
author suggests that there “seemed to be some special poison pecu-
liarly noxious to the seventh nerve,’ and continues: “ What this
special agent or these special agents may be, if there be such, is
matter for conjecture.” The following study shows that he antici-
pated what was later proven to be a fact. A virus affecting the
peripheral nerves, spinal ganglia, and the spinal cord has been found
to be the etiological factor in the disease.
II
Gordon Holmes (63) had observed or obtained notes on about
twelve cases of polyneuritis during the winter of 1917, among men
from all parts of the British front in France. The symptoms and
course of these cases were in all particulars identical with cases he
had seen in London in civilian practice some years prior to the war.
It is reasonable to assume that the illness in the soldiers was not due
either to local conditions or exposure, for the number in the series
was small and the distribution of the cases very extensive. None of
the patients gave a history of alcoholism, organic, or metallic poison-
ing. Nor did the disease follow any known infection.
The onset in almost every case began with malaise and tempera-
* Read before The Chicago Neurological Society, February 18, 1926.
[30]
PAs AL DIP LEG ANN MULLIPLE NEORITIS 31
ture which ranged from 102° to 103° F. The subjective sensory
symptoms such as pain in the legs and the lumbo-sacral spine appeared
on the second or third day. Motor weakness in the lower extremities
followed a day later. Then the arms became paretic, though less
severely. About the same time the face generally became paralyzed
bilaterally. Speech was unnatural and the patients “had some diffi-
culty in swallowing.’ When the disease became fully developed,
the flaccid paralysis, though incomplete, was bilateral and extensive.
There was foot-drop and no movement of ankles or toes, but no
atrophy or contractures. In other joints in the lower limbs there
was feeble movement of small range. The intercostal and abdominal
muscles were weak. “All groups of muscle supplied by the facial
nerve are severely paralyzed.” The face was expressionless and had
all the features of bilateral facial palsy from the early days of the
illness. The tongue, the vocal cords, or the larynx were not affected.
“Almost all experienced more or less difficulty in swallowing solid
foods.” Diplopia was present in three cases: two were due to lateral
rectus paralysis. In only one case was a feeble response of the
patellar reflexes obtained. All other deep reflexes were absent from
the early stages in the disease. The superficial abdominal and the
cremasteric reflexes were present, but not the plantars in the patients
whose lower limbs were severely affected.
Objective sensory tests showed prompt appreciation of touch,
pain, heat and cold, and their location. Muscle and joint sense was
impaired and vibration sense was delayed. Mentality was clear. No
complications. There were no abnormal vasomotor, trophic, or
secretory manifestations. Vesical sphincter disturbance was almost
-a constant finding in this series. In three cases the blood and spinal
fluid were examined. Cultures could not be obtained in either. The
spinal fluid showed no increased cell count nor any other abnormality.
Thus, aside from the relative uniformity of the paresis, the fact that
the proximal groups were affected almost equally with the distal
segments of the feet and the involvement of some of the cranial
nerves, especially the facial, and also the vesical sphincter, Gordon
Holmes states: “The motor disturbances correspond closely to that
of any other type of generalized peripheral neuritis.”
Two of the patients died, one from bronchitis and one from
bronchopneumonia. Recovery was rapid in the surviving men.
Deglutitional and sphincter palsy disappeared first. The pain dimin-
ished and the restoration of muscle power followed. But weakness
in the facial muscle generally persisted. Microscopic examination of
the tissues obtained from the two fatal cases showed early state of
Sf Ads ee a) Pe ry
degeneration in the sciatic. ‘ The myolin sheaths being broken up
in spherical or oval globules.” Some alteration in the anterior horn
cells of the cord was visible. Some of the cells were slightly
swollen, but there was no round cell infiltration. Similar but less
marked changes were noticeable in the large cells of the motor cortex.
It is obvious from this series that the symptomatology of the
disease, its course, and ultimate recovery point definitely to the
diagnosis of febrile peripheral polyneuritis. In all these cases severe
Ficure 1. Patient at rest. Note the expressionless face and the drooping
of lower lip.
facial _diplegia was a constant feature. The post-mortem patho-
logical findings prove equally conclusively that the infection affects
not only the peripheral nerves but also the central nervous system in
certain stages of the illness. The changes are not inflammatory but
degenerative in character.
ITI
Sir John Rose Bradford (64) observed a series of thirty care-
fully selected typical cases of acute infective polyneuritis which, he
says, present “all the leading phenomena of the disease.” The study
PaGial DIP lLeEGiaeiye MULEIPLE NEGRITIS 33
was made on British troops in France and in Flanders during 1917.
The clinical symptoms, which were constant and uniform in all cases
in the series, were manifested by generalized palsy which is different
in character and in distribution from other well known forms of
neuritis. The palsy was progressive. ‘Twenty of the thirty cases
were examined by this author. Characteristic of the onset is a slight
illness five or six weeks prior to the palsy. The onset is mild and
transient, consisting of a diffuse headache and vomiting of short
duration. Ina small portion of the cases the symptoms were more
severe. Pain in the back aggravated by movement and pain in the
limbs appear later in the course of the disease. The pyrexia was
slight in these cases, 100°-101" F. In a few patients. 103°. The
fever lasts two to four days, then there is a quiescent period, or a
period of “latent infection,” which lasts about six weeks, during
which time the patient is well and free from any symptoms. Then
he suddenly develops tingling and numbness, which is followed by
palsy in two or three days. It seems that the severer the early symp-
toms the shorter the interval between them and the weakness in the
legs, which is not really a complete paralysis, and which shows a
tendency to improve after twenty-four hours. Headache and a slight
rise in temperature may occur at the time of or simultaneously with
the palsy. The motor weakness’is ascending in character.
In Bradford’s cases the involvement was greater in the proximal
than in the distal segments. Patients who were unable to move the
hip or shoulder joints were able to move their toes and fingers freely.
The paralysis was symmetrical in its distribution, though not equal
bilaterally, nor of the same degree in all the cases. Not individual
muscles or muscle groups are affected but the whole limb. In the
severe cases the muscles of the trunk, chest, and abdomen, and even
the neck, may show a flaccid paralysis. Facial diplegia was practi-
cally a constant finding in this series. ‘In fourteen out of seventeen
cases the palsy was known to be bilateral in its distribution at the
same period of the illness.” It appeared some days after the legs
had become paralyzed. One side was affected first and the other two
or three days later. There was no atrophy or contractures.
There was incomplete sensory loss corresponding to the cutaneous
distribution of some spinal roots.
The tendon reflexes were lost when the disease had reached its
full development. The superficial reflexes, excepting the plantars,
were obtained. Sphincters were not involved. There was tachy-
cardia, 100-120, without fever while the patient was in bed. Men-
tality was clear. A slight albuminuria was present. Leucocytosis,
34 Aavey UDELL ON
12,500-19,000, was found. No abnormal cells present. Spinal fluid,
obtained under normal pressure, was “limpid” and otherwise nor-
mal. Klebs-Loeffler bacillus was not found in the throat of any of
these cases, nor was a history of alcohol or metallic poisoning given.
Complete recovery was slow, about six months. In a series of
thirty cases death occurred in eight in from five to twelve days after
the onset of the palsy. The cause of death was attributed to weak-
ness of the pulmonary muscles and the diaphragm, though no case of
massive collapse of the lung was found.
Ficure 2. Patient trying to close her eyes tightly. The left eye remains
open wider than the right.
Seven out of the eight fatal cases came to autopsy. Edema of
the brain and general visceral congestion were the only naked-eye
post-mortem findings. No adenopathy was observed, except some
mediastinal enlarged and soft glands.
The morbid anatomy of six of the eight fatal cases was examined
by E. F. Bashford,(65) who makes the statement that “the sectio
cadaveris of itself did not explain the fatal issues.” The brain
showed great congestion of the dural vessels, edema of the pia-
PAGAL DIPCEGIAWIN MULTIPLE NEURITIS 35
arachnoid and small congested vessels in the white matter. The cord
showed marked venous engourgement.
Microscopic examination of the cord showed minute and widely
diffuse hemorrhages in the dorsal enlargement and extensive inter-
stitial cellularity in the cervical and lumbar enlargements. The
central neural canal showed proliferation of the ependymal cells.
The nerve cells in the cervical and lumbar enlargements appeared
greatly reduced in number in the anterior horns and the posterior
columns, and the tract cells at various levels on one side or the other.
Characteristic of the pathology was its irregular distribution. In
the long series of serial sections examined it was not possible to
observe that the lesions were limited to any area of the gray matter
of the cord. Occasional tract cells were degenerated and shrunken.
The cervical posterior root ganglia revealed practically no abnor-
mality, while the dorsal and lumbar posterior root ganglia showed
shrunken nuclei and vacuolation of the cytoplasm in the cells.
In the brain nothing was found beyond a slight degree of round
cell infiltration around some cells of the motor cortex. Similar find-
ings appeared in the cerebellum and in the pons. The voluntary
muscle fibers showed degenerative changes similar to the nerve.
The pathology appears to be due to a septicemia which enters the
nervous system by way of the nerve trunk and is marked by a degen-
eration of the peripheral nerve fibers first and involvement of the
spinal root ganglia and the spinal cord later, without predilection for
or selection of any special tracts or levels in the cord, and with an
irregular distribution of the pathologic process within its sphere of
invasion.
Bashford transmitted the disease experimentally from man to
monkey and from monkey to monkey by subdural inoculation of an
emulsion of the human cord of a fatal case and from the fresh cord
of the first monkey to another. Also by inoculation of a pure cul-
ture. The onset of the transmitted disease, the symptomatology and
pathological findings in the experimental animals which were killed
or died were identical with those in man. The illness was milder in
some animals than in others. This work proves conclusively the
infective nature of polyneuritis and that the symptomatology is a
manifestation of the degree and progress of the ascending infection.
IV
J. A. Wilson (66) isolated the virus of infective polyneuritis
from the two human cords of Bradford’s patients and from monkeys
inoculated with an emulsion of these cords, prepared by Bashford.
36 A.B YODELSON
Manifestly, the organism is widely distributed in the nervous system,
for it is easily recovered from the cerebral cortex. This is especially
significant because in none of the cases were mental changes noted.
The organism is a strict anaerobe 0.2-0.5 w in diameter, rounded, oval,
or kidney-shaped; arranged in pairs, groups of 5-8, or rarely in
chains of 3-5. It is stained with Loeffler’s polychrome blue for
twenty minutes.
Figure 3. Patient is unable to drink without folding her lower lip between”
her fingers while pouring fluid into the mouth and throwing the head
backwards in swallowing.
The constancy of facial diplegia in all of Gordon Holmes’ cases:
and in the large majority of Bradford’s cases speaks not so much for
the vulnerability of the seventh cranial nerve as for the aptitude of
the infection to invade motor nerves, cranial nerves among them..
The disease being of an ascending character, the involvement is a
question of extent rather than that of degree. In cases where the
facial is not involved, it is probably because the disease has subsided.
before it reached the cranial nerves.
It is true that in many cases the quadriplegia is mild and the
facial diplegia is intense. Indeed, in all cases of diplegia facialis in
a
PACIAML DIFPLEGIAVING MULTIPLE NEURITIS 37
febrile polyneuritis the facial paralysis persists a long time after the
palsy elsewhere has cleared up. But the researches of Marie, Meige,
and Gosset (67) have clearly shown that certain peripheral motor
nerve fibers have their individuality. The seventh having the largest
purely motor distribution of any other cranial nerve, it is possible
that it is more generally affected in infective polyneuritis because of
its individual vulnerability to that infection, but not to metallic or
organic poisoning. If exposure is a factor, as is shown by some
authors,(62) the face is certainly most liable to palsy. Bradford
thinks that it is quite exceptional for facial palsy to be really absent
in infective polyneuritis. There is always a general weakness of the
facial muscles. The palsy being bilateral, it is overlooked because
there is no marked facial asymmetry.
The case to be presented, which is one of infective polyneuritis,
is illustrative of the variation in the modes of onset of this disease
as well as the degree and extent of the infective process as manifested
by the symptomatology and the course of the illness.
Case X. A white woman, forty-five years old, married eleven years,
was admitted in a wheel chair to Wesley Memorial Hospital, July 22,
1925. She was unable to walk because of weakness in the legs and
severe pain in the feet. The pain alternated with numbness and hot and
cold sensation in both feet. Family and personal histories unimportant.
No history of alcohol, metallic, or organic poisoning could be elicited.
Patient had a mild attack of influenza in January, 1925. She recovered
completely after a few days. About the last of February she attended
a curling game in a small town in Saskatchewan, and was chilled through.
Diarrhea followed the same night and continued for a few days. It
recurred and lasted for about a month, causing a loss of about fifteen
pounds in weight. She improved, felt well, and regained weight until
about the middle of May. While: housecleaning she felt pain in the
lower limbs from the heels up to the hips, worse at night, but was able
to walk. Late in May the patient had a chilling sensation in her feet
which lasted two hours. The feet felt numb for a few days after that.
The gait was slow and uncertain. She turned her left ankle one day in
walking. Weakness in the legs continued till the middle of June, when
extreme pain set in in the hips, legs, and feet. The pain was so severe
that she could not walk nor move her limbs freely.
About the last of June, or the first of July, she noticed that the right
side of the face was drawn upward and the left corner of the mouth
drooped. Two days later the right side of the mouth also drooped.
The face became symmetrical, but the patient could not close her eyes or
mouth completely, speak plainly, move her lips or any’ facial muscles.
The lower lip dropped, so that when trying to drink the patient had to
hold the lip between her thumb and index finger and pour the fluid into
38 Ay BOYUDELSON
the mouth. Deglutition was not involved. The patient stated that she
ran a temperature in February when she had the diarrhea, but she did
not know how high the fever was.
When first seen in the hospital there was a complete bilateral facial
paralysis. The patient could not wrinkle her forehead, frown, or com-
pletely close her eyes. The left eye remained open wider than the right.
The lips were motionless when she spoke. Labials could not be enunci-
ated. The mouth was partly open all the time. She was unable to drink
without folding the lower lp between her fingers while pouring fluid
into the mouth and throwing the head backwards in swallowing. Laugh-
ing, whistling, or puffing out the cheeks produced no contraction of the
facial muscles. The naso-labial folds were flat and the face completely
expressionless.
None of the other cranial nerves was involved. The sense of smell
was acute to mild aromatics. Vision was normal with glasses which the
patient had been wearing for the past several years. The fundi were
normal. The pupils were circular, equal, active to light, and in accom-
modation. No diplopia or nystagmus. The corneae were sensitive to
the slightest touch. The conjunctivae were slightly inflamed and
lacrimation free. Mastication was strong; lateral motion of the lower
maxilla was free and ample. The jaw jerk was present. There was
appreciation of sensation to all stimuli to the distribution of the fifth
cranial pair. Taste was not impaired. Hearing was normal bilaterally.
The tongue protruded fully without deviation. The palate rose well and
gutturals were clearly and strongly uttered. Phonation was clear and
deglutition was not involved. The pulse was regular but rapid, on the
least exertion 100-110, returning to 80-85 at complete rest. No vaso-
motor disturbances. The temperature was normal during the patient’s
entire stay in the hospital. Respiration ranged between 20 and 24. No
adenopathy or localization focus of infection was found.
There was no evidence of palsy in the muscles of the neck, the
shoulder girdle, or the upper extremities in any muscle group. Myo-
dynamometric pressure with the right hand was 42; left 37. Digital
movements were quick and accurate. Coordination was faulty in both
arms. No tremors or past pointing. Stereognosis intact. Provoked
myotatic irritability over the shoulders and deltoids was present but
not marked.
All movements in the lower extremities were slow and weak in active
and passive motion from the hip girdle to the toes, especially the flexors.
Rotation and adduction was good. Abduction weak. The ankle joints
were weakest in dorso-flexion. There was marked footdrop bilaterally,
more prominent in the left. Muscle and joint sense was disturbed.
Heel-to-knee test showed marked ataxia. Distance between two points of
the compass was not recognized within 15 cm. over the lower half of the
thighs, and not at all over the legs, where tactile sensibility was also
disturbed. No ataxia in the Romberg position. No atrophies. All
superficial reflexes were present and equal. The plantars were abolished.
EE
PACIAL DIPLEGIASIN MULTIPLE NEURITIS 39
Deep reflexes in the upper extremities were equally present, though sub-
dued. In the lower limbs, neither the knee nor the Achilles jerks could
be elicited under reinforcement.
One week after the patient entered the hospital she complained fre-
quently of numbness and pins-and-needles sensation in the finger tips
bilaterally. No pain. The pain was very severe in the legs and the feet.
The weight of bed clothes or light pressure on the muscles of the lower
extremities from the lower thirds of the thighs downwards was very —
painful, especially the flexors, where direct myotatic irritability was
increased. The lower down, the worse the pain. Tactile sensibility was
impaired over the pereneal area in the left leg. There was delayed sensa-
tion to pain and tactile anesthesia over the dorsum of both feet. Pin
prick was dull distally and over the toes.
The facial muscles did not react to a quite strong faradic current, nor
to galvanism at first. But on the thirteenth day the reaction to the
galvanic current was noticed. Similar electric phenomena were seen in
the tibialis anticus muscles, except that response to galvanism was
noticed on the ninth day. The muscles of the upper extremities reacted
normally to both currents from the start.
The urine was entirely normal. The blood showed 4,890,000 reds
_and 11,700 whites with a normal differential. Blood Wassermann nega-
tive. Lumbar puncture was refused. Blood cultures were not made.
ING proreimumnrogens c1, a. sistent P30)
POA CCl aa th. sacs eee e ee es ae
DASE, TRnALe Ro ator kes Og. ear ta ota Nee 1.87
RCAC IC Pram gee ita site aa cri Oh nee < 4.07
OCCMSE OGL nees es eek, cya fc 5% eed ace 130
The pain in the feet ceased on August 20th, about one month after
the patient entered the hospital. She can stand alone. August 24th the
patient walked unassisted, slowly. August 28th patient walked up and
down eight steps. No pain in the feet. September 5th patient walked
freely without pain. She can slightly wrinkle her forehead. She can
drink without holding up her lower lip. Labials cannot be enunciated.
She left the hospital on this date.
September 21st, patient can close both eyes tightly. Gait is steady
and more rapid. October 10th, dorsoflexion in both feet is strong. Facial
expression is much improved. Lips are still motionless when speaking
and labials cannot be enunciated. October 30th, naso-labial folds are
marked. Patient can whistle slightly. November 27th, knee and Achilles
reflexes are readily elicited under reinforcement. Lips are still weak
and labials are indistinctly enunciated. January 13, 1926, deep reflexes
in the lower extremities are practically normal. Plantars are present.
The face is more expressive, especially when the patient laughs. She
still is unable to puff out her cheeks because the lips are weak. Enuncia-
tion of labials is indistinct, but patient can close her mouth and lip
movement is distinctly noticeable when she speaks.
40
Av Bae UDELS ON.
CONCLUSION
1. This is a case of infective polyneuritis.
2. Facial diplegia is a usual finding at some stage of this type of
polyneuritis.
3. Infective polyneuritis is not to be classed with peripheral
neuritis without neuritic involvement.
me pad
HSS ON inks
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FACIAL DIPLEGIA IN MULTIPLE NEURITIS 41
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MALIGNANT HYPERNEPHROMA COINCIDENT WITH
ARTERIOSCLE ROS Isa (Ne GH TD ee
By RosBert RICHARD DIETERLE, M.D.
ANN ARBOR, MICHIGAN
This paper constitutes a more detailed histopathological descrip-
tion of Hoag’s case (1), the brain of which was received for
examination in this laboratory shortly prior to his clinical report
from the Pediatrics Department of the University Hospital. Since
that somewhat hastily prepared examination which was made for
Hoag’s article, a more thorough and extensive study of this brain has
been completed. It was, therefore, deemed worth while to report
these findings under the above title because of the few cases of like
nature found in the literature. On account of the present trends of
interest concerning the glands of internal secretion, and since specific
glandular therapy has contributed to our knowledge of certain
morbid endocrinal diseases, it was thought that it was not unscientific
to infer that a hypernephroma, theoretically producing an over-
abundance of specific secretion, might be the direct factor in pro-
ducing the arteriosclerotic softening of the brain in this case; for in
the field of the strikingly abnormal there may be an accentuation of
functions called pathological, which, perhaps, can throw some light
upon normal functioning.
The case is that of K. T., aged four years and three months, who
was brought to the University Hospital because of convulsions alter-
nating with a semistuporous condition. A month prior to admission
she was suddenly attacked with a unilateral convulsion with uncon-
sciousness lasting three hours. A second attack followed a month
later. Following a third one she remained semistuporous.
In this short abstract of the clinical examination from Hoag’s article
and for the report it is necessary to mention only a few of the salient
points. The blood-pressure was 145-160 systolic and 90-100 diastolic.
The blood count was normal and the spinal fluid negative.
A clinical diagnosis of malignant hypernephroma with sexual pre-
*From the State Psychopathic Hospital, Department of Neuro-Pathology,
Ann Arbor, Michigan, through the courtesy of Dr. D. M. Cowie of the
Department of Pediatrics, University Hospital, from which a clinical report
of this case was made by Hoag in American Journal of Diseases of Children,
Vol. 25, pp. 441-454, June, 1923.
[42]
ARTERIOSCLEROSIS IN CHILDREN 43
cocity was made. The X-ray examination verified the presence of an
abdominal tumor and accordingly, surgical operation revealed a large
tumor mass lying retroperitoneally and covering the upper pole of the
right kidney. Pathological diagnosis by Dr. Warthin confirmed the
clinical diagnosis of malignant hypernephroma. The mass was incapable
of removal and in spite of blood transfusion the patient died.
Necropsy data (Drs. Warthin and Weller)—The panniculus was
3 cm. thick over the pubes. Section of the breasts showed no glandular
tissue. The thymus was very small, showing fibroid atrophy; the cor-
puscles of Hassal were quite numerous. The heart showed no pathologic
changes except a slight right-sided dilatation. The pleura was not
adherent. The lungs were studded with numerous nodules, those beneath
the pleura varying from 0.5 to 1.5 cm. in diameter. These were sharply
circumscribed, soft, yellowish, neoplastic masses, which on section resem-
bled medullary carcinoma, although the general architecture was slightly
suggestive of suprarenal cortex (malignant hypernephroma). The lungs
were edematous and congested. The thyroid was small, the colloid
abundant. The gastrointestinal viscera and adnexia were normal except
for slight hyperplasia of the lymph nodes and Peyer’s patches. The
left suprarenal was thinner than normal, and on section appeared
hypoplastic. The situation of the right suprarenal was occupied by a
large neoplastic mass, measuring 10 cm. in greatest length, 6 cm. in
width and 5 cm. in thickness, notwithstanding the fact that part of
it had been removed surgically. This mass was retroperitoneal, but
had elevated the peritoneum sufficiently to cause its attachment to the
under-surface of the liver. The kidney had been pushed downward
and was uninvolved in the new growth. On macroscopic section, normal
suprarenal tissue was not found. The mass was friable and necrotic
in most places, but the firmer portions were light yellow, with a fatty
appearance. Microscopically, some.areas resembled a suprarenal cortex.
The atypical portions more closely resembled a medullary carcinoma,
but many of the cells contained lipoids. Some areas showed a marked
perivascular arrangement of the cells, more like an angiosarcoma. The
kidneys showed cloudy swelling and acute congestion. The vaginal
orifice admitted the finger with slight difficulty; the vaginal canal meas-
ured 6 cm. in length. The uterus was undeveloped, measuring 3 cm.
from fundus to external cervical os. The ovaries were free, 2.0 by 0.5
cm., and showed on section an unusual number of large cystic follicles,
but no evidence of menstruation.
Examination of Brain—The brain had been hardened in 10 per
cent formaldehyd for nine days. It had a length of 16.2 cm. and a
breadth of 12.8 cm. In volume, it gave the impression of being larger
than usual for a child of this age. The pia mater was clear, with
slight congestion of the larger veins. The convolutions’ of the convexity
were normally formed but had not reached full development. In a few
places, there were small areas in which the surface of the convolutions
appeared softened.
The base of the brain showed erosions of the tip of the temporal
44 ROR DEE Lee
lobe from mechanical injuries during its removal. The basilar artery
was partly filled with blood clot. At a point about 1 cm. from its
bifurcation, there was a small patch of thickening of the artery wall.
Vertical sections of the brain showed no gross abnormalities aside
from the small areas of superficial softening. In these, the cortex
appeared macerated and separated easily from the underlying white
substance.
The pineal gland was somewhat flattened and measured 7 mm. in
width and 5 mm. anteroposteriorly.
Histopathology of Brain——A. section of the basilar artery at the
point of thickening showed a uniform layer of adventitia made up of
normal connective-tissue fibers without hyaline change or increased
cellularity. The media was somewhat irregular in thickness and its
nuclei were rather pale. The elastica presented the usual wavy character
but it was slightly thinned and stretched in appearance and showed
some fibrous alterations and splitting of its layers. The intima was
irregularly thickened with a material that stained a brownish yellow
in the Van Gieson preparations. This substance appeared somewhat
glistening and refractive. Upon closer inspection it resembled a coagulum
‘with small rounded and spindle shaped holes, the latter resembling clefts
of cholesterin crystals. In its greater accumulations it was less
cellular ; in others, where its growth was younger it was very proliferative
in character. This patchy intimal thickening partly occluded the vessel-
lumen and its patchiness subtended the irregular arcs making up the
circle of the lumen. (See Fig. 1.) The Herxheimer fat stains showed
heavy deposits of lipoids in this substance. The fatty material did not
extend into the media.
Sections of the principal regions of the cortex and especially those
which showed superficial softening in the gross were stained by the
Van Gieson method for purposes of orentation and in toluidin blue
for cell studies. In all of these the pia was thickened and cellular and
its fibers were closely approximated. Especially over the sulci was
the increase very marked, but here the fibers were spread widely apart
in collections of broad fasciculi. Shorter branching fibers in a tangled
mass were found in one place with an accumulation of fluid coagulum
giving it an edematous appearance. The veins were congested and
their walls thickened. The arteries showed an increase in the thickness
of all their layers. One or two were particularly striking. Figure 2
shows one of these which had formed a sulcus for itself causing the
overlying cortex to fold over its upper surface. In a very accentuated
way the vessels entering the cortex from the pia stood out as bold,
erect and thickened strokes perpendicular to the cortical surface. In ~
short all the vessels showed in longitudinal- and cross-section a very
marked sclerosis. The Weigert’s elastic preparations brought out clearly
the thickened elastic layer.
In foci the softening process had altered the architectonic in a very
uniform way. Its depth extended approximately from one to two milli-
a
ARTERIOSCLEROSIS IN CHILDREN 45
meters inwardly from the surface. This obtained where it often sur-
rounded a cortical fissure, so that the process in making a_ perfect
lamination was so loosened in appearance as to be possible of delamination
NIFIED FIELD. ZEISS OB}. D.D.
. COoMPENS OCULAR 6
leaving the more normal remaining cortex exposed at about the beginning
of the third layer of nerve cells. The location of the strip of softening
was so definite and limited that the molecular layer was easily torn.
off with the pia mater in the process of sectioning.
46 yaaa gee BY # aS OY wi EY &:
This stratum had rather a definite architecture. Its nervous paren-
chyma was broken up into small islands of varying shapes and sizes
and these were sometimes spread apart in an artefactive way by mechan-
ical agents. Between them were strands of proliferating vessels with
vascular buds and dense collections of angioblasts and fibroblasts very
rich in chromatin. Many new vessels, perfectly formed, ramified the
parenchyma in a delicate vine or root-like manner. (Fig. 2.) The
center areas of the islets were relatively acellular but their borders
near the new vessels showed enormous numbers of glia cells in large
swollen progressive forms, with many fat-containing granule cells and
glial phagocytes. The Mann preparations brought out very strikingly
the ameboid glia with their abundant cytoplasm and the fibrous glia with
their long sweeping processes. There were many collections of glial
moss with beautiful mitoses. All stages of early and late proliferative
changes could be followed. Where the reparative process was older
there was less proliferation of all elements and a marked presence of
fibrous connective tissue surrounded by glial scars containing numerous
closely aggregated fibrous neuroglia.
Histological Diagnosis—Pia mater: Marked fibroid hyperplasia with
edema, chronic passive congestion and vascular sclerosis. Cortex: Arterio-
sclerosis with focal encephalomalacia in varying stages of anisomorphic
sclerosis. Status spongiosus with marked reparative glial, vascular and
fibrous tissue proliferation.
The-cerebellum and spinal cord showed no striking alterations. Their
pia mater showed the same fibrosis. Basilar artery—sclerosis with
marked hyperplasia of the intima. The pituitary contained a predomin-
ance of eosinophilic cells. The accumulation of round cells in its stalk
mentioned in Hoag’s article proved to be bone-marrow cells. The pineal
gland was negative.
The Literature-——In Hoag’s presentation of the literature attention
has largely been given to the clinical aspects of sexual virilism and its
relation to hypernephromata. In it there is a review of Krabbe’s (2)
hypothesis of the origin of the suprarenal tumor and its relation to the
somatic factor of virilism.
ARTE RIOSG PE ROSS INGCHILDREN 47
In all of the case reports the autopsy. examinations are notable for
their incompleteness. Particularly is this true of the brain reports.
This is perhaps largely due to the fact that examination of the head is
oftener difficult to obtain.
It remains for the practical theorist to arrange his material. Falta (3)
cites Wiesel’s report of a tumor of the sympathetic in a two-year-old
child with arteriosclerosis ‘‘resembling histologically experimental
atherosclerosis’; and also Herde’s cases, one a paraganglionic chromaffin
tumor with arteriosclerosis and the other a similar tumor with a genuine
Schrumpfniere. Thus it was thought important to add our case to
this group and to discuss the clinical and experimental evidence regarding
the possible etiologic factors involved in the production of arteriosclerosis.
DISCUSSION
Since from the pathological standpoint the striking feature of
these cases is the coincidence of the tumor of chromaffin tissue with
arteriosclerosis nothing further remains than. to correlate these
factors in a theoretical way. In a discussion involving so delicate a
problem one is certainly cast into speculation. The pathology of the
case at hand belongs to the field of those developmental disturbances
whose origin is to be sought in that broad expanse of heredo-congeni-
tal causes, that is, in an intrinsic failure of the germplasm or, in the
action of some blastophthoric agent at an early time in embryonic or
fetal life. The tumor itself, if it is not also true of all neoplasms, is
of a teratoid nature. Yet one wonders even in the face of evidence
if such terms as blastophthoria do not blind the pathologist to any
insight into actual play of forces by the use of such catch-words
neologized from “ inheritance,’ “ disposition,’ and “ degeneration.”
Since in our case we are concerned with the adrenal gland and
particularly with its cortex, for even the atypical tumor-cells showed
lipoids, it is evident that we are dealing with a double factor of
etiology. Falta’s cases seem to indicate a relation between chromaffin-
increase and vascular sclerosis. Our case would seem, therefore, to
demand a like disturbance of the chromaffin factor. ‘This is not
difficult to assume, though it postulates a metamorphosis of chromaffin
cells beyond microscopic identification. The double nature of the
adrenal gland with its separate anlagen is important from both the
standpoints of anatomic relations and pathologic relations as to
normal and abnormal functioning. Thus there is some experimental
evidence of a hormone activity of the cortex upon the secretion of
epinephrin. The vascular hypertension in this case.indicates a like
relationship perhaps through increased cortical stimulation or through
increase in the chromaffin cells of the medulla in the tumor (4).
Atheroma may be experimentally produced by long continued injec-
48 Reke DID ERLE
tion of epinephrin. That this secretion in the amounts in which it is
liberated in the blood even in the greatest concentration, recorded
experimentally, can have an effect upon the production of atheroma
seems doubtful. The relations of an assumed hyperfunction of the
adrenals to interstitial nephritis and high blood-pressure has not been
satisfactorily demonstrated. There is evidence that the adrenal
cortex has a detoxicating function. As stated above, nature’s own
experiments in producing abnormalities are perhaps under even better
control than the laboratory experiment. Therefore, the function of
the abnormal may be analogous to the function of the normal.
(Herde’s Schrumpfniere case.)
If we assume that the cortical softening in our case is a direct
sequel of vascular failure there- is a relatively simple sequence of
events following the development of a hypernephroma. On the other
hand bodily processes are so closely coordinated that what often
seems chronological may be more synchronous than we know. Ina
case of this kind it is perhaps not out of order to look for more
separate developmental disturbances. If we assume a disturbance of
brain-cortical development as a result of a more primary Dblasto-
phthoria which at the same time gives rise to the tumor-formation,
we have then a tendency on the part of the organism to restitute to
normal. . Certain intimate relationships seem to exist between brain
and adrenal. Thus it has been noted that in the normal embryo the
adrenal cortex is greatly enlarged, but in anencephalous monsters
this tissue or the characteristic boundary line between its cortex and
medulla is absent, that is, there is a cortical hypoplasia or aplasia.
Schafer has suggested that a special lipoid formed in the adrenal
cortex may be used in the development of the myelin for medullated
nerve fibers. Caskey and Spencer (5) have recently shown that
epinephrin exerts a specific effect in the brain by a dynamic action
upon its cells causing an increased metabolism. In fact it is an impor-
tant theory that this portion of the gland is a factor in the develop-
ment of the highly organized nervous system of man, particularly
the brain.
Whichever view is taken as to which is the more primary etiology
the situation is not made clearer, but it does nevertheless emphasize
the close correlations. If the general functional alterations persist,
a consequent change in structure must result. In both ways this
was nonaltruistic to the organism. If separately related between
adrenal cortex and brain, and between adrenal medulla and cerebral
vessels, the processes must have produced with increasing demand
of nutrition through higher differentiation, more interdependence
between interstitium and parenchyma; and then the failure of the
ARTERIOSCLEROSIS IN CHILDREN 49
nutritive element perhaps finally caused an ascendency of degenera-
tive nervous tissue changes and a stimulation of reparative processes.
The presence of progressive neuroglia in the entire brain indicates
isomorphic sclerosis besides the local reparative or anismorphic
sclerosis. In this connection is Hyman’s (6) report of a case of
hypernephroma associated with tuberose sclerosis and Bourneville’s
observations cited by Falta (7), that in idiots with tuberose sclerosis
there exist adenomata of the adrenals. Lastly in our search for cor-
relations mention must be made of Alzheimer’s disease. Its relation
to hypothyroid states was pointed out by Lafora (8). The arterio-
sclerotic features of this disease demand further and more complete
autopsy findings in correlation with the soma. If the severe mor-
bidity of the processes in this case had not culminated so quickly
might she not have lived long enough to be a case of Alzheimer’s
disease ?
These are largely theories and only questions to be asked, but
there is in tumors of the adrenal cortex a premature development of
the entire organism, a sort of transient prematurity associated with
childish dimensions and an early development of the sexual organs
showing a relation between genetic constitution and metabolic rate.
This, the theoretically dual nature of the case reveals through the
abnormal functioning of the two portions of the adrenal resulting in
a sexual precocity over a precocious senility. It does not seem con-
trary to scientific methods to infer a relationship between such strik-
ing abnormalities when by their grossly perverse nature they seem to
present to our perceptions, in such a magnified and specific way, most
important mechanisms of growth. Still one must not be led by this
seeming patency of affairs into the “uncharted seas of endocrin-
ology.” To assume that the adrenal gland plays the definite major
role in the production of such changes and thus lightens our igno-
rance concerning complex biological mechanisms is to really believe
that these cases are the missing links in the evolution of a disease
that manifests itself in many ways.
BIBLIOGRAPHY
. Hoag, Lynne. Malignant Hypernephroma in Children. -American Journa:
of Diseases of Children, June, 1923, Vol. 25, pp. 441-454.
. Krabbe, K. H. New York Med. Jr., 114:4 (July 6), 1921.
. Falta, W. Endocrine Diseases, 3rd Ed., 1923, pp. 364, translated by Mevers
Oppenheim and Fishberg. Archives Int. Med., Nov. 15, 1924, 34:631.
. Caskey and Spencer. Jour. Physiol., LX XI, No. 3, Feb., 1925.
Hyman, A. Jour. Urol., 8:37, Oct., 1922.
malta. '1-oc.,Cit., Dp. 00/7.
maarora,, ) brabajos Cajal, Vol; XI, 1913: 5. 55.
—
CONAWAY
SOCIETY PROCEEDINGS
NEW YORK NEUROLOGICAL SOCIETY
THE Four HuNDRED AND THIRTIETH REGULAR MEETING, NOVEM-
BER 9, 1926, COMBINED WITH THE ACADEMY OF MEDICINE,
SECTION OF NEUROLOGY AND PsycHIATRY. Dr. I. ABRAHAM-
SON AND Dr. Tuomas K. Davis, PRESIDED.
A CASE;-OF MULTIPLE DURAL NEOPLASMS
Dr. E. D. FRIEDMAN
Helen W., a German housewife of 44, was admitted to Mt. Sinai
Hospital on September 4, 1926. She had been a sufferer from epi-
lepsy since the age of 14. The attacks were at first left sided and
later became generalized. They ceased five months ago. ‘There
have been no menses since February, 1926. |
Her present illness began about one year ago with headache.
This was chiefly occipital, and was accompanied by a drawing sensa-
tion in the neck. The headaches became progressively worse and at
times were associated with vomiting. She noted recently that her
vision became poor.
On the morning of her admission to the hospital, she complained
of diplopia, dizzy spells and occasional twitchings of the right upper
extremity. The family had observed that her memory was failing
and that she had become flighty. In walking, she would turn her
head to the right. Occasionally she suffered from nocturnal enuresis.
The physical examination revealed slight inequality of the pupils
with a little irregularity of the left; a low grade papilloedema; a
slight left facial weakness and some paresis of the right 6th. Hearing
was normal and the vestibular tests gave normal responses. There
was slight weakness of the left arm and leg, and mild hyperreflexia
on the left. Abdominals were not elicited but there was no Babinski
sign. There were no frank cerebellar signs in the limbs. In walking,
the patient tilted her head backward with the chin directed to the
right and the occiput to the left. There. was some asynergia of gait
and station and a tendency to veer to the right. Her visual fields
were grossly normal, and there were no disturbances in sensation.
She was facetious and jovial. The examination was punctuated by
humorous comments on the part of the patient, and she apparently
had no insight into the gravity of her illness.
The general medical status revealed no abnormalities. Blood
pressure was a bit low—100/65. The urine was negative. The
spinal fluid showed only a moderate increase in pressure. The signs
pointed both to the right frontal lobe and to the posterior fossa.
[50]
NEW YORK NEUROLOGICAL SOCIETY ay
Ventriculography was attempted, but the patient soon afterwards
succumbed as a result of paralysis of respiration.
The post-mortem examination revealed numerous smooth, white,
hard tumors on the inner surface of the dura. Most of them lay near
the midline. They were more numerous on the right side. More
than 25 such growths were counted. There were in addition neo-
plasms similar in character on the inferior surface of the right
tentorium, in the region of the right pontofacial angle, and on the
posterior margin of the foramen magnum. All of these apparently
took origin from the inner surface of the dura, but did not infiltrate
the brain. The surface of the brain presented the evidences of
increased intracranial pressure. In the right frontal region, near
the midline and extending on to the mesial surface of the hemisphere,
there was a large area which was soft, friable, and discolored,—
apparently degenerative in character, and contained in its depth free
blood. The right cerebral hemisphere was swollen about this region
and produced a concavity on the mesial surface of the left frontal
lobe due to pressure.. This mass was not adherent to the overlying
meninges. The floor of the 3rd ventricle was thinned out and bulg-
ing. There was evidence of a pressure cone of the base of the cere-
bellum. There was an area of erosion on the inner table of the skull
in the right frontal region.
The post-mortem diagnosis was multiple endotheliomata of the
dura, with a large area of softening and degeneration in the right
frontal lobe.
Discussion. Dr. J. H. Globus said: The specimen shown by Dr.
Friedman is indeed an exceedingly uncommon one, and, as any
uncommon specimen, it is of interest mainly to the pathologist.
Clinically, however, a specimen of this sort is not an especially
instructive one, because the signs and symptoms arising from such a
multiplicity of tumors do not give the neurologist any opportunity
to identify or localize the lesion, for multiple tumors of this sort
are so easily confused with inflammatory lesions of the brain. Patho-
logically, however, such exceedingly unique specimens are highly
useful. Very likely specimens of this type may throw light on the
origin of endotheliomata, and put to test the explanation, suggested
by Cushing, for the origin of these tumors. He believes, as you
know, that endotheliomata are misplaced embryonal rests of the
arachnoid. They have been displaced and carried away into the
dura, there giving rise to tumor formation. For this reason he
names such neoplasms meningeomata.
In this case, among the many dural nodules, a similar tumor was
found extending into the frontal lobe. The specimen leads one to
believe that the explanation of Cushing is a correct one, and this is
the only service which was rendered by this case.
Dr. J. Ramsay Hunt said: Some years ago in my study of
tumors of the acoustic nerve and neurofibromatosis. I encountered
the association of multiple fibroid tumors of the dura mater with
general neurofibromatosis. In the literature a similar association
has been recorded although the occurrence is rare.
52 NEW YORK NEUROLOGICAL SOCIETY
The pathological appearance of the dura was exactly as in Dr.
Friedman’s case, and was limited to the dural covering of the brain,
and did not extend into the spinal canal. At the time some con-
sideration was given to the possible origin of these tumors in the
nerve supply of the dura mater; in other words, that the condition
was a dural neurofibromatosis, and in a few of the tumors medullated
nerve fibers were demonstrated, and it might be well to consider this
possibility in future pathological investigations.
THE CHANGING MANIFESTATIONS OF THE NEUROSES
Dr. I. S. WECHSLER
The observations which I have to make are not altogether novel,
and the explanations are perhaps not quite correct, but I venture
both in the hope of criticism and discussion.
When one looks over papers and textbooks, even as recent as the
1924 revised edition of Oppenheim, one finds considerable attention
devoted to the manifestations of the neuroses which we never see—
hysterical hemiplegias, other paralyses, aphonias, astasia-abasia, and
all sorts. of conversion signs. But all those cases were abundantly
seen by the older observers. It would be comforting to think that
we are the better diagnosticians, but it is not quite true. Men of
the type of Charcot, Moebius, Weir Mitchel, Binswanger, etc., were
very accurate observers, and they undoubtedly saw all the mani-
festations of the neuroses which we do not see to-day. And I have
proof that they were right. If you take the first quarter of this
century in which few of the hysterical paralyses have been ob-
served, you find one island wherein tens of thousands of. patients
showed just those symptoms. I refer to the war. During that
period, whether it was the phlegmatic Englishman, the stolid German,
the volatile Frenchman, the somber Russian, or the composite Ameri-
can, they all showed the hysterical palsies, stammering, blindness,
and so forth. It is evident therefore that those hysterical manifesta-
tions can and do occur. It is we who do not see them in civil practice.
My observations are based on rather extensive experience at the
Vanderbilt Clinic, which has a yearly admission of about 2,000
patients, on work at the Mount Sinai Hospital and Dispensary, at
the Montefiore Home and the Central Neurological, the last two of
which have chronic cases. Among the thousands of cases seen per-
sonally I recall but one case of hysterical convulsions such as de-
scribed by Charcot, one or two hemiplegias and monoplegias, and a
few aphonias. The question is, why don’t we see them? Why do
not other American neurologists see them? What has happened in so
short a time, or has anything happened at all? It seems to me there
must be some explanation.
If you look on a neurosis as an attempt at adjustment, and if you
accept the opinion that a neurosis is the result of a conflict, then you
must concede that both the older and more recent manifestations of
the neuroses are all attempts at adjustment. What we do see are
NEUEN ORR NEUROLOGICAL SOCIETY 533
anxiety neuroses, phobias, so-called neurasthenias, compulsion
neuroses, maladjustment cases, borderline types. The former may
be designated as low somatic types of adjustment, and the latter
higher psychological types. Both are the results of conflicts and
attempts at adjustments which the patients must make in order to
hurdle life’s difficulties.
I think it is conceded by many that religion (by that I do not
mean the philosophical or speculative aspects, but the ceremonial and
ritualistic), represents in a measure a neurosis which is accepted and
condoned by society. When a person makes the sign of the cross,
puts on phylacteries or salaams to the east he does exactly what the
compulsive neurotic does when he goes through his ritual, fixing his
pillow, counting numbers, or doing certain things; with this differ-
ence, that the social compulsive act is not in conflict with the social
eroup. In religious ritual the neurotic has his outlet for the neurosis :
he need not get into the conflict with society by begetting a neurosis.
The Jew putting on phylacteries in the synagogue is considered per-
fectly sane; let him do it in the street and he would probably be
apprehended as queer. Religious ritual, then, offers an outlet for
individual neuroses.
If you take a Catholic girl who is disappointed in love, takes the
veil and enters a convent, thus marrying her ideal, she escapes an
individual neurosis because she loses herself in a social neurosis. The
same procedure suddenly followed by a Mohammedan, Jewish, or
Protestant girl would arouse grave suspicions as to her sanity.
Throughout the ages waves of religious movements (tarantula dances,
flagellations, crusades) expressed themselves in hysterical manifesta-
tions. To this day we have in this country epidemic or endemic re-
vivalist meetings, in which whole communities find hysterical outlet.
It may be observed that the very loud hysterical shrieks which funda-
mentalist ritualistic fervor employs against modernism are only the
signs of helplessness in a losing fight, of infantile neurotic reactions
in the face of advancing reality. They may insist on erasing evolu-
tion from text-books; their fight is but the last gasp before the
avalanche of knowledge that is coming on to overwhelm reaction.
You may ask, if my observation is correct, can it be that one
generation has brought about such a change in the manifestations of
the neuroses? Even if we only reckon the period of recorded history,
almost a hundred generations, what does one generation amount to?
But it is quite possible that the intense and very rapid diffusion of
_ knowledge in recent years, the familiarization with scientific facts, the
spread of the knowledge of evolution, the weakening of religious
ritual, have tended to mature the sense of reality and gradually pre-
vented the widespread infantile, low level types of reaction to conflicts
arising from the struggle for adaptation. A child will express his
displeasure in the face of conflict by kicking or screaming, but the
adult can no longer adopt the same method. This may be one ex-
planation: but I should like to offer another, perhaps even more
theoretical and philosophical: A neurosis is the penalty one may
‘pay for growing up, or for the unsuccessful attempt to grow up.
54 NEW YORK NEUROLOGICAL SOCIATY
Growing to adult state is bound up with a great many difficulties,
with the need of hurdling obstacles in the path of life. Those who
cannot hurdle those difficulties will react with neuroses at one or
another time. We see that at puberty, in adolescence, in social and
love life. The neurosis represents the attempt at adjustment, the
failure in the conflict and the flight from reality.
The question in my mind is, is it possible that groups, like indi-
viduals, go through the same stages of development? May we say -
that phylogenesis repeats ontogenesis, the reverse of what happens
in general organic life? Before I develop this point a little further,
I should like to cite a few statistics. I have taken the records of the
patients admitted to the Vanderbilt Clinic for the past few years.
Fifty-five and a half per cent of the total number of admissions to
the neurological department represent neuroses. The colored popu-
lation of the clinic showed only 29 per cent of neuroses. Then I
compared the incidence among the American negroes and the British
West Indians. You will all agree with me that the British West
Indian negro is a better type than the American negro. He is more
intelligent, better educated, and socially superior to his American
brother. The American negro had 27.5 per cent neuroses, and the
British West Indian negro 35.5 per cent, about 8 per cent higher
than the American. The negro with better opportunities and perhaps
a little more freedom has developed neuroses to a greater extent.
Again merely stating the question, Does the group of necessity
develop neuroses in its march upwards? I do not know either the
incidence or types of neuroses among the Japanese and Chinese; nor
do I know whether neuroses exist among primitive peoples. <A
priori I should say that there can be no neuroses among primitive
people, because their whole social existence is a neurosis, an infantile
reaction to life. The group spirit and force of taboo is so great that
there is no possibility of revolt. One cannot transgress social usage
or taboo in primitive society without incurring the punishment of
death. Only civilized man can afford the luxury of a neurosis. I
do not know whether my speculations apply to all groups. I am
merely wondering if we can speak of a neurosis as a manifestation
of the group in its march up the scale of civilization as of the indi-
vidual in his growth up the tree of life.
Occasionally a neurosis is the revolt against the social hypocrisy
which forces people into ways of living to which they cannot possibly
get used. Sometime I shall write an essay entitled, In Praise of
Hypocrisy, with apologies to Erasmus’ In Praise of Folly. It seems
to me that the very violence with which the social group reacts to
the hypocrite betokens a defense mechanism on the part of all of us.
It 1s quite possible that diffusion of psychoanalytic knowledge,
the realization of the mental mechanisms constantly at play and the
influence of the psychology of motivity on human thought and action
will affect our methods of adjustment. Thus far it is premature to
say that it has affected behavior. Besides the subject of psycho-
analysis is too vast for a discussion in this connection; here I would
merely hint at it.
NEW YORK NEUROLOGICAL SOCIETY 55
In summing up, I wish to repeat the observation that we do not
see the types of neuroses that have been classically described in
years gone by; that the older types are low-level or somatic reactions ;
and that what we see to-day are higher, psychological manifestations.
Only the methods of adjustment have changed, not the reactions of
the individuals or the need for neuroses. If anything, the conflicts
have become more intense, the needs for neuroses greater and the
social casualties more numerous.
Discussion: Dr. Louis Casamajor said: Dr. Wechsler has many
interesting points in regard to the neuroses as we see them to-day.
Those who have been working with neurological material for a
number of years have noticed a change in the neuroses, and we all
have felt for a number of years that the old hysteria of Charcot, with
the conversion paralyses and the anesthesias are things which are
disappearing from our medical life. We have not altogether under-
stood what this meant, and we do not quite understand it to-day, be-
cause it is not altogether true. Certainly in the days before the war
we did not see much of the anesthesias, the paralyses, and the con-
versions, those things which Dr. Wechsler calls the lower levels of
the neuroses. During the years of the war, in those very primitive
conditions in which man found himself, many of these things came
back, and the old type of good old-fashioned neurosis seems to have
been reéstablished in our symptomatology. After the war, again,
Wwe saw a tendency for the neuroses to return to the higher levels
of expression, but new elements began to come in, and that element
which tended to bring the neuroses back to the lower levels seemed
to be principally the element of compensation, and the good old-
fashioned neuroses which we see to-day seem to be almost completely
restricted to those neuroses which arise as the result of the Work-
men’s Compensation and Veteran’s Bureau laws. I will invite anyone
who wants to see the old-fashioned neuroses of twenty years ago
to go to the Veterans Hospital, where you will see all of them, and
it would appear that the element of compensation has done something
to bring out that type of neurotic expression. What Dr. Wechsler
has said about the education, culture and civilization of the indi-
vidual has a great deal to do with the type of neurotic expression.
Probably the lowest type of neurotic expression is a conversion. That
is probably the easiest one to manifest, and it is certainly the most
common. If one would attempt to make a series of neurotic symp-
toms, I think paralysis would come first as the lowest. Then come
the anesthesias and so on up through the anxieties to what may be
the higher levels for the neuroses, where we can place the phobias
and compulsions. However, I do not know that things are changing
very much. In reality it takes a very little to bring the neurotic
down to a lower level and while we may have much of what we con-
sider the higher type of neurosis, we have a lot of the lower ones.
Practically all of my life I have been connected with the Vander-
bilt Clinic, where twenty years ago we saw very few neuroses among
the negroes. Most of the negroes lived then in small groups and a
great number of them lived in the “San Juan Hill” district, in very
56 NEW YORK NEUROLOGICAL SOCIETY
primitive conditions. Following the war the percentage of neurotic
negroes increased, and this increase was mostly among the British
West Indian negroes. I feel that this change is due principally to
the changes that have taken place in the negroes’ living conditions
when he moved from small, simple communities, such as that of the
“San Juan Hill,” to that larger negro city in Harlem, with its cus-
toms, its civilization, and their reaching out for personal and racial
expression of some sort, while being surrounded by a white civiliza-
tion in which they are in competition. This has brought upon these
still primitive people cultural standards three or four jumps ahead of
the previous generations. ‘They may try to adjust these conditions
my means of neurotic difficulty in just about the same way as the
whites do.
Dr. Foster Kennedy said: Dr. Wechsler’s thoughtful and pro-
vocative discussion is hard to criticize and very hard to discuss. It
is nearly seventeen years since I came from a large European clinical
material to an equally large American clinical material. I was then
immediately surprised to note the absence here of many examples of
constructive conversion hysteria with which I had been entirely
familiar in London. We were never, in Queen Square, without two
to six cases of hysterical hemiplegia, one or two cases of hysterical
blindness, and at least hysterical aphonia was to be seen in the house.
I think in the Neurological Institute in New York and on our service
at Bellevue such cases are rare; they were just as rare seventeen
years ago. I do not think in America any particular change is taking
place in 1 the neuroses, at least in the time I have been seeing American
clinical material. There is a difference in the reactions here to the
reactions which occur in Europe, and which occur I think equally
in Germany, France, England, and Italy. Dr. Wechsler tried to
give a reason for this. His reasons are fairly plausible. I do not
know that they are sufficiently sound. He assumed that the con-
version hysteria is a more primitive and more somatic reaction than
a generalized phobia. That jumps the eye, but it may not be true.
i remember in France differentiating in my mind the soldier with a
generalized neurosis, a generalized defense reflex condition in an
organism given over to only one emotion, of fear; the officer, who
with too much conscience and striving hard to do his best was
neurotic about his responsibility toward his men, and broke down
thereby. Usually it was the Tommy, I think, rather than the officer,
who, having been hit with a bit of flying earth, sustained an hysteri-
cal paralysis of the arm, which he thought for a moment has been
blown off. Perhaps a medical officer suggested then that he had a
brachial palsy, and the idea put into the man’s mind gave him a
paralyzed arm. I used to call this “localized suggestion.” One
was a breakdown of the man’s whole emotional nature. The other
was a conservation measure of his emotional nature. The man who
got hysterical paraplegia was never unhappy emotionally. He was
in the same position as the wounded man, and the wounded man was
not neurotic. The man who had a sufficiently severe wound to solve
the problem of the war for him was not neurotic. The man who
NEW YORK NEUROLOGICAL SOCIETY Jf
succeeded by suggestion given to him from without, either by a
slight wound or a bit of flying earth hitting him, or the badly directed
verbal suggestion of a medical officer, in getting a paralysis of the
arm was in precisely the same state as the wounded man, and was
not unhappy ; so that conversion hysteria is a method, inadequate if
you will, of getting over one of those hurdles which Dr. Wechsler
spoke of as confronting every person who reaches adult life. We
may find that the hurdle‘is too big; we balk at it; we cannot get over
the five-bar gate. One way of explaining to the world our inability
to get over that hurdle is to say that we are paralyzed, and that by
reason of that paralysis it is not necessary to tackle the difficulty,
and we are free of our obligation to get over that hurdle. If we do
not get that suggestion, if we cannot convince ourselves that we are
paralyzed, or cannot accept the suggestion of another that we are
paralyzed, or aphonic, or in some way get out of the difficulty, then
we may develop a phobia. I remember a lady who had a phobia that
she could not get into a ferry, or into a motor car; she was in an
automobile accident and had an injury to her leg. On that slender
substructure she erected a complete hysterical paraplegia. While
she had the hysterical paraplegia, she was perfectly happy emotionally.
Her fears were relieved. When she was cured of her paraplegia,
her phobias returned. I think that conversion hysteria is a fairly
adequate attempt on the part of a weak nervous system to cope with
the difficulties of life, and the American population does not accept
a suggestion as readily as does the European. Anyway, he did not
when I saw him seventeen years ago, any more than he does to-day.
One statement of Dr. Wechsler’s interested me, when he said the
more intelligent the person is, the more neurotic. I should like to
ask him what he meant by the more neurotic. Does he mean more
fearful, more tremulous, more given over to ritualistic observances,
or does he mean that conversion hysteria is more common?
Dr. Casamajor’s statement that compensation can produce con-
version hysteria of the type that we are all familiar with in Europe
is another example here that by properly directed suggestion con-
version hysteria will be produced, and suggestion will produce the
necessary paralysis, the necessary blindness. After all, we were all
at times scared stiff in the war, and if we could have gotten rid of
the war in some way or other compatible with our dignity as a human
being, we would have been very glad to have done it!
The person who getting hurt in a railroad accident sees an oppor-
tunity to sue a rich corporation against which he feels a grievance,
has a basis for a conversion hysteria which the ordinary person does
not have.
Dr. J. Ramsay Hunt said: A few years ago Dr. Dana and
others in this country wrote on the subject of “The Passing of
Neurasthenia,”’ a disease which was described by Beard, and has
sometimes been called the American neurosis. What these writers
meant was, not that neurasthenia had died, but simply that we had
come to look at neurasthenia in another way. We had acquired a
much deeper insight into this condition, its causes and relation to
other disorders. And while neurasthenia lost some of its importance
58 NEW YORK NEUROLOGICAL SOCIETY
as a disease, it gained immensely in our better understanding of it
asasyndrome. This, it seems to me, has taken place with the psycho-
neuroses in general, and we must bear in mind our own change in
viewpoint and our increased knowledge of these disorders, especially
of mental mechanisms and the important psychic aspects of this
great field. |
In this country the conversion hysteria of the gross somatic type
has always been comparatively rare, as compared with France, and
there is little doubt that this group was overemphasized by the French
school in Charcot’s day. We do not now attach so much importance
to these somatic forms as we are interested more particularly in the
deeper psychic mechanisms of these cases. This removes a potent
suggestive factor which was undoubtedly active in the Charcot
school...
Dr. Wechsler’s paper is interesting in suggesting that the psycho-
neuroses which are, as it were, a by-product of our civilization, change
with the evolution of society. And while this may be true, I think
the lapse of time which is implied as having caused a change is far
too short to have had any material effect upon this group of dis-
orders. I would ascribe the apparent change rather to the progress
which medicine has made in the last decades and the rapidly shifting
point of view in our conception of the psychoneuroses. It is here
that I would look for the apparent change in the natural history of
the neuroses rather than in the psychic and somatic manifestations
themselves.
Dr. Wechsler (closing the discussion) said: The war neuroses
differ in one fundamental respect from the peace neuroses. A war
neurosis represents essentially an ego neurosis. The mechanism is
the same as in the peace neuroses, but the neurosis is not the same
type. In war you found an individual who had a sense of patriotism,
loyalty, honor, esprit de corps, etc. He could not possibly escape or
revolt against them. The ego or self-preservation instincts were
involved; therefore, it was a definite ego neurosis, and not a psycho-
sexual basis as in the peace neuroses. The latter are rooted in the
individual all the way back to his childhood. We may accept this
even if we would not accept the Freudian explanation in toto. Ifa.
man past forty who has never been neurotic before presents a
syndrome of neurasthenia or other neurosis we generally look for
brain-tumor, general paresis or cerebral arteriosclerosis. Very few
men get up neuroses suddenly, though all of us are capable of react-
ing with a neurosis if the conflict is sufficiently intense. In the peace
neuroses, then, you can find traces all the way back to childhood. Of
course it is possible that the men who developed neuroses in the war
would have developed them in peace, but I think it is a different type of
neurosis. Most observers during the war recorded the fact that
officers were subject to different types of neurosis than the ordinary
soldiers. It was the officers who developed the phobias and the
anxieties or the higher psychological reactions. The plain soldier
reacted with a conversion symptom or a low somatic neurosis.
The question of compensation, too, I think could be divided into
two parts. What Dr. Casamajor says is perfectly true, but I think’
NEW YORK NEUROLOGICAL SOCIETY 59
the following may serve as an explanation. One may find in an
industrial accident an unconscious excuse for getting out of a dif-
ficulty with which one was confronted in life. A man may have a
horrible home life, the accident merely serving as an excellent excuse
for getting out of the situation. Of course, if he does this consciously
he comes dangerously near the malingering class. The other type,
the true traumatic neurosis, may Bet be considered as an actual
or ego neurosis.
The question whether the more intelligent the more neurotic, is
hard to answer. I believe that horses do not get up neuroses. One
has to have a certain amount of brains to have a neurosis, a definite
layer of consciousness, a certain depth to the unconscious and a fair
degree of intelligence. It is true we see hysterias in mental defec-
tives, but I do not think that an anencephalic individual can get up
a neurosis. He does not get up anything else either, for that matter.
To infer that the American is more intelligent than other people
would be flattering to us, but we should probably have the League
of Nations in arms against us for saying it. But I do think that
a certain degree of intelligence is necessary for a neurosis. It is
curious that compulsion neuroses, or the highest psychological types,
are most common among highly intelligent people.
Answering Dr. Hunt that we as diagnosticians have changed and
not the neuroses, it probably is so with regard to neurasthenia. The
reason for that is that the concept of neurasthenia has changed.
Formerly everything that we did not know how to label was included
under it. Psychasthenia was taken out of it and made a separate
entity, and so was anxiety neurosis, anxiety hysteria, etc. Neuras-
thenia has disappeared, not because our observations are faulty, but
because our methods have changed. As I said, the method of adjust-
ment has changed, not the need for neuroses. Dr. Kennedy’s re-
mark that the American has a different method of reacting may be
true, but why does he have that? To say that we are different psycho-
logically is obviously not quite true. What is different is our en-
vironmental situation. Unfortunately I have no experience with
other peoples, and so I can hardly make comparisons. It would be
interesting, however, if some one could take up anthropologic studies
with regard to the neuroses and also investigate the influence of
religion on the neurotic behavior of various groups and in various
countries.
PNCEBHALIVIC AMYOTROPHIES
AuGuUsST WIMMER
PROFESSOR OF PSYCHIATRY AND NEUROLOGY, UNIVERSITY OF COPENHAGEN
(By Invitation )
Discussion: Dr. Sachs said: It may interest Professor Wimmer
himself to know that in this country during the epidemics of en-
cephalitis, we have observed a few of the cases which he would
group as encephalitic amyotrophies; but we are particularly im-
60 NEW YORK NEUROLOGICAL» SOCIELY
pressed by another group of cases which from a pathological point
of view can be similarly interpreted, and those are the cases in which
were all the symptoms of encephalitis, and in addition, the clinical
picture of complete acute transverse myelitis; instead of the region
of the anterior horns having been particularly affected, as in these
cases of Dr. Wimmer’s, there was no doubt a central myelitis. The
interesting question is why the process should be selective, even to
this degree, and the idea that the encephalitic virus itself was present
in the tissue would make it a little easier to interpret so that in some
of these cases the virus was located in the anterior horns, and in the
case observed here, the virus must have assembled around the central
canal and the parts contiguous to it. The especially interesting and
striking feature about the cases which Professor Wimmer presented
was the very complete resemblance of his cases to the pathological
pictures we have been accustomed to associate with amyotrophic
lateral sclerosis. I would lke Dr. Wimmer to state one thing,
whether in the second case which he reported with the very complete
and excellent microscopic pictures, it was a case of long standing,
or whether it was one that had developed rather rapidly, because if
the case was of short duration the complete degeneration in the
pyramidal tracts is very striking; but if a case of that sort had lasted
for more than a couple of years, I could more easily understand it.
If the case had been one of much shorter duration, I think the de-
generation in the lateral columns is surprisingly complete. The other
point of especial interest to me is to ask if he thinks that amyo-
trophic lateral sclerosis as a rule is of infectious origin, or not. In
those cases which I have seen, I have not in a single instance been
able clinically to establish, or convince myself, that there has been
an infectious origin. We tried for a time to see whether there had
been any history of trauma. That also has failed, so that in the
whole field of amyotrophic lateral sclerosis, the etiological factor has
been very much in doubt. I would not be at all surprised if we were
compelled to infer that this was a disease of infectious origin, and
the surprise would be no greater for us than for instance the cases
of chorea, which we no longer have any doubt in pronouncing of
infectious origin; and whereas twenty-five or thirty years ago we
spoke of them as functional, now we know them to be organic.
The interesting point about this whole discussion is that it not
only shows us the widespread changes that this one virus causes, but
it is going to help us to interpret amyotrophic lateral sclerosis, and
perhaps other degenerative groups. I want personally to thank Dr.
Wimmer for his excellent presentation, and I am certain that all of
those present have enjoyed his address.
Dr. J. Ramsay Hunt said: It is a great pleasure to be here this
evening, and to greet Professor Wimmer.
My own experience with the amyotrophies, as a complication of
encephalitis, is very small. I only recall two cases that I have seen
in which there were amyotrophies. One was in the upper extremity,
and the other was in the lower extremity, and both were unilateral.
In neither of them was there sensory disturbances or a history of
NEW YORK NEUROLOGICAL SOCIETY 61
sensory disturbance which would indicate a neuritis. A pressure
neuritis could also be excluded and this should always be borne in
mind, for in severe types with delirium and unconsciousness, often
requiring restraint, the nerves or muscles may suffer injury during
the acute period of the disease. In my two cases the atrophic changes
were confined to a small area and were not definitely neural in dis-
tribution so I concluded they were probably dependent upon small
areas Of localization within the spinal cord. I have seen nothing like
the interesting case that Professor Wimmer has recorded of amyo-
trophic lateral sclerosis of encephalitic origin. Excepting that he has
presented in such detail his microscopic findings, my first feeling
would be that the patient was a case of potential or incipient amyo-
trophic lateral sclerosis, and that the infection had merely precipitated
the progress of the disease. In other words, that the encephalitis
was a secondary and not a primary factor in the causation of the
disease. We all know that amyotrophic lateral sclerosis is a disease
which does at times progress with great rapidity. I think we have all
seen cases where the disease has been greatly aggravated by an acute
illness. I cannot say, however, that I recall any case in which the
disease directly resulted from an acute infection, but I do not doubt
that such associations are to be found recorded in the literature. For
my part, I think in many ways a safe interpretation would be to
regard the condition as having been precipitated or aggravated by the
virus of encephalitis, rather than to say that this disorder, which we
regard as a system disease, is directly caused by the infectious agent
of this disease. Professor Wimmer’s experience with the amyotro-
phies of encephalitis is now so large and he has given this subject
such intensive study that his opinion must be regarded as authorita-
tive and deserving of very serious consideration. It certainly will
stimulate us all to review our ideas of this most interesting subject.
Dr. M. Neustaedter said: Dr. Hunt’s suggestion, as I[ take it,
is that there probably was a locus minoris resistentiae which gave
way to the infection. In the beginning of the epidemics we thought
that the virus had a selective affinity for the brain, particularly the
midbrain. Since then we met with all sorts of syndromes referable
to lesions of the entire cerebrospinal axis and peripheral nerves. I
have seen a case of a central myelitis that was without doubt due to
the encephalitic virus, but I have not met with the syndrome of
amyotrophic lateral sclerosis due to encephalitis. It is characteristic
that lately in New York City the chronic form of the post-encephalitic
form has been mostly of the Parkinsonian syndrome. It seems to me
that we might postulate that the virus has no particular selective
affinity for any part of the cerebrospinal axis, but that it will affect
any part with a locus minoris resistentiae, and thus diverse syndromes
will become manifested.
Dr. Henry Alsop Riley said: I have listened to Dr. Wimmer
with great pleasure this evening, chiefly on account of his interesting
presentation, but also because in 1921, I brought together a group of
cases of “spinal forms of epidemic encephalitis ” for the meeting of
the Association for Research in Nervous and Mental Disease which
62 NEW YORK NEURKOLOGICAR SOCIAL
considered the subject of epidemic encephalitis in December, 1920.
A few features of this study remain quite freshly in my memory
and they may be of interest to you. In my cases, the occurrence of
actual fascicular twitchings was relatively rare, the abnormal involun-
tary movements being of a considerably more gross character than
those we are accustomed to see in the classical instances of amyo-
trophic lateral sclerosis and involved a group of fasciculi or even a
part of a muscle.
It occurred to me that this difference might be due to the involve-
ment of a connector neurone whereas the finer fascicular twitchings
were caused by direct involvement of individual ventral horn cells.
As is well known, there are about ten times the number of ventral
horn cells as there are pyramidal tract fibers and therefore, to bring
the individual ventral horn cells under the influence of the pyramidal
tract fibers, it is necessary to interpolate between this fiber and the
eventual ending of its influence over the ventral horn cells an in-
tercalated connector neurone which in turn establishes synaptic
junction with about ten ventral horn cells. The involvement of this
connector neurone may be the explanation of the larger involuntary
movements which were seen in the spinal form of epidemic encepha-
litis, the brunt of the attack falling on these cells rather than on the
ventral horn cells themselves.
Another point of interest was the appearance of pain of a radic-
ular type in the dermatomes corresponding to the segmental deriva-
tion of the muscles which later showed loss of strength and atrophy
as a result of involvement of the ventral horn cells with which they
were connected in the ventral gray column. This suggested the
possibility of the progress of the disease over the dorsal roots, to the
connector neurones and eventually to the ventral horn cells them-
selves.
I was also interested in what Dr. Sachs said about the appear-
ance of transverse myelitic phenomena. I found a number of cases
which represented this type of involvement but at the time I sug-
gested that this type of pathological involvement might be the result
of hemorrhage in the grey and white matter rather than from a
direct action of the disease process itself. These phenomena seemed
to be secondary in character, an incident as it were in the course of
the development of the clinical picture.
One of the illustrations used by Dr. Wimmer was very similar
to a case which was in the Presbyterian Hospital and came to autopsy.
In this patient, the muscular washing was generalized and extremely
marked. Pathological examination of this spinal cord showed an
appearance as if the entire ventral horn cell population had been
wiped out in a more or less devastating process, only an occasional
ventral horn cell remaining to be seen in the sections.
Dr. Wimmer (closing the discussion): I thank the gentlemen
for their observations on epidemic encephalitis. I do not fully con-
trol the English language, but I should like to add a few remarks.
Dr. Sachs found the duration of .my principal case rather short.
I do not think the duration of these encephalitic amyotrophies is
NEW YORK NEUROLOGICAL SOCIETY 63
shorter than the usual average duration of amyotrophic lateral
sclerosis. In France it has been given as from three to three and a
half years, and cases of a longer extent are supposed to be exceedingly
rare, and have very rarely been published. So I think that this fairly
short duration of the amyotrophic encephalitis syndrome will go very
well with the clinical course of the amyotrophic lateral sclerosis, the
so-called Charcot’s disease. In my opinion, the short duration of this
so-called degenerative disease has always made it rather strange that
it should be a degenerative disease of the spinal cord, seeing that in
almost every other true primary degenerative lesion of the spinal
cord or the nervous system the duration is usually very long. Three
and a half years for a chronic amyotrophic condition is rather short,
I think. Dr. Sachs is not disinclined to believe in the possible in-
fectious origin for the cases of so-called Charcot’s disease. He re-
marked only that in his personal cases he had never been able to say
that a definite infection had preceded the nervous disease. On this
point our ideas have changed a little with the experience of the
epidemic of encephalitis, for really cases where it is quite impossible
to ascertain the initial infectious stage are rather numerous, at least
in my observation, and even in those cases we get a most marked
clinical picture of the epidemic encephalitis ; and then again, you get
most marked anatomic findings, so in my opinion the diagnosis of
epidemic encephalitis need not be based on the presence or not of an
initial, more or less typical classical stage, but on the total clinical
picture, so that this circumstance, that in so-called classical amyo-
trophic lateral sclerosis we cannot ascertain a definite infection would
not, to me, exclude the possibility of an infectious origin.
Dr. Hunt suggested that this seeming connection between exoge-
nous infection and amyotrophic lateral sclerosis syndrome may
sometimes be only an aggravation of a preceding or preéxisting spinal
disease by the infection. That is a possibility, but as regards my
cases here, there were no clinical symptoms of a preéxisting lesion of
the spinal cord. At least the patient could give me no signs whatever
of such a condition. We have to think of this possibility, for we can
never exclude possibilities, and yet I think it is more economical to
go the other way. I really have touched a little lightly perhaps on
the most important question, the possible anatomical and histological
predisposition of all these systemic lesions of the spinal cord. Surely
there are always some local predispositions for the localization of
exogenic pathogenic causes. You will scarcely find any of the ex-
isting diseases that has not got, according to Bauer, some local histo-
logical predisposition. Maybe some time we will find what that
predisposition is; but as yet it is more or less a mere word. There-
fore I have not gone very far into it. I shall not deny that such a
predisposition may exist, and that it might also in the case of en-
cephalitis make out for the special localization the seemingly systemic
localization of the morbid changes.
CURRENT LITERATURE
I. VEGETATIVE NEUROLOGY.
2. ENDOCRINOPATHIES.
Else, J. E., and Irvine, H. S. THE CAuSES OF SURGICAL FAILURE IN
HyperTuyroipisM. [J. A. M. A., Vol. 83, Oct. 14.]
A review of the literature shows that from 65 to 75 per cent of the
patients operated on for exophthalmic goiter make a complete(?)
recovery. The majority of the remaining 25 to 35 per cent are bene-
fited; but some show no improvement, and death occurs in from 1 to 4
per cent. In the cardiovascular group of goiters, including the toxic
adenomas, adenomatous and compensatory hyperplasia, better results are
obtained. During the last two and a half years, approximately 300 cases
of goiter of various types have been studied. In this group were several
cases in which the patients had been previously operated on without com-
plete relief. These cases were studied in conjunction with unoperated
cases of similar types in order to determine, if possible, the causes of
the incomplete results or failure. The authors found that deaths or severe
reactions following operation are for the most part due to avoidable errors.
Inéomplete results following operation on patients with hyperthyroidism
are due to delayed operation, insufficient operation, or insufficient after-
care. It is urged that patients with hyperthyroidism must be operated on
early if permanent lesions are to be prevented. Medical treatment will
usually carry a patient over the crisis into the stage of remission, but
beyond its use in preparing patients in a precarious condition for opera-
tion, it has no place in the treatment of toxic goiter. Hyperthyroidism
is a surgical disease. ‘The authors stress the fact that after-treatment
is as important as the operation. A surgeon’s responsibility does not
end until the patient is in the best possible physical condition. A surgeon
is not. justified in operating in, or treating, a case of hyperthyroidism
without frequent determinations of the basal metabolic rate.
Huddleson and Bailey. Tuyroip DysFUNCTION AND NEUROPSYCHIATRIC
Disorpers.'~[Am. Arch. of ‘Neur.and Psych), Vol. Vil, Nooo) vias
M. A. |]
The material reported on by Huddleston and Bailey consisted of ninety-
four consecutive outpatient cases, clinically examined, of war veterans
suffering from thyroid dysfunction accompanied by some neuropsychiatric
disorder. They conclude: (1) that the incidence of dysthyroidism,
increased by the war, is now in the decline but has not yet reached its
[64]
VEGETATIVE NEUROLOGY 65:
prewar level; (2) that the bulk of this increase is made up of toxic non-
exophthalmic, vagotonic cases, and cases transitional between this and the
sympathicotonic type; (3) that many causes for the increase have been
variously operative, none predominating; and (4) that there is a distinct
tendency toward improvement in all types of toxic cases caused by the war.
Kessel, Leo, Lieb, C. C., and Hyman, H. T. Stupy or ExopHTHALMIC
GOITER AND THE INVOLUNTARY NERVOUS SYSTEM. [Journal A. M. A...
Mom SAIL, Oct.:7.] ©
These authors define exophthalmic goiter as (1) a clinical collection
of sympathomimetic symptoms (tachycardia, tremor, exophthalmos,.
sweating, asthenia, polyrrhea [diarrhea], etc.), associated with (2)
metabolic upset (elevated basal metabolism), and usually accompanied
by (3) hyperplasia of the thyroid gland. No one of these three com-
ponents is pathognomonic. Elevations of basal metabolism may occur
in other conditions dissociated from goiter or alterations in the involuntary
nervous system. Hyperplasia may also occur dissociated from alterations.
in the involuntary nervous system or elevation of the basal metabolism.
Sympathomimetic manifestations may be present with or without hyper-
plasia of the thyroid gland and with a normal basal metabolism. It is to
the last group of symptoms that the authors apply the term “ autonomic
imbalance.” This syndrome differs from exophthalmic goiter only in
that the basal metabolism remains normal. Patients with active exoph-
thalmic goiter usually give a history of autonomic imbalance, and those
with arrested exophthalmic goiter differ only in presenting a history of
crisis. The transition from autonomic imbalance to exophthalmic goiter
occurred in a patient under observation. This led the authors to believe
that disturbance of the vegetative nervous system plays an important role
in the causation of exophthalmic goiter. The fact that. stimulation of
the vegetative nervous system by epinephrin produces an elevation of
the basal metabolism and that this increase is independent of the thyroid
gland suggested a more complete study of the vegetative nervous system,
especially the thoracolumbar parasympathetic division. Since it is claimed
that epinephrin acts only on the myoneural junctions of the parasym-
pathetic, the sensitiveness of these patients to the subcutaneous injection
of epinephrin localizes the abnormality in the myoneural junctions.
Holst, J. PATHOGENESIS OF ExopHTHALMIC GoITER. [Norsk Mag. f.
acto Ol XS XIII. Non/,.p. 927; J. Ay M.A.
Holst comments on the way in which a primary exophthalmic goiter
may keep up an active growth with progressive emaciation of the rest
a certain independent autonomy. It begins with multiple epithelial tumors
which merge into each other until the pathologic condition is diffuse.
Cancer of the thyroid sometimes induces fulminating exophthalmic goiter
symptoms. He adds that acromegaly, which in many respects resembles
exophthalmic goiter most closely, is the result of an epithelial tumor in
the organ which resembles the thyroid most, namely, the pituitary body.
66 CURRENT LITERATURE
Major, Ralph H. Aciposis in HypPEertHyroipism. [Journal A. M. A.,
Vol PIX XT selangi 34
Two cases of marked acidosis associated with hyperthyroidism of
moderate severity are here reported, the condition appearing in one
instance after roentgen-ray treatment of the gland, and, in the other,
following a lobectomy performed under nitrous oxid and oxygen anes-
thesia. Both patients responded promptly to the administration of alkali.
Labbé, M., et al. DirrerENTIAL DIAGNosIS oF EXOPHTHALMIC GOITER.
[Bulletins de la Société Médicale des Hopitaux, Vol. XLVI, No. 20,
Dp. GU2Z 9 Ae bar|
Labbé and his co-workers relate that their experience with eight cases
of typical exophthalmic goiter, eleven with the incomplete clinical picture
and seven of simple goiter, has confirmed the statements of the Americans
in this line. Exophthalmic goiter seems to consist of two superposed sets
of symptoms: those from hyperthyroidism, revealed by the exaggeration
of the basal metabolism and the test hyperglycemia, and those from
sympathicotonia, revealed by the tachycardia, the exophthalmos, hot
flashes, vasomotor disturbances, sweats, attacks of diarrhea and pigmenta-
tion, all of which can be realized in animals by irritation of the cervical
sympathetic nerve. The association of the thyroid syndrome and the
sympathicotonic syndrome is easily understood on considering the
physiologic relations between the thyroid and the sympathetic system.
Each may act on the other, and set up a vicious circle, but each of the
two syndromes can develop alone, as they show by some cases reported.
In three of their cases tuberculosis seemed to be the primary factor.
Labbé examines the basal metabolism by means of a war gas mask, with
Tissot valve, spirometer and Laulanié’s eudiometer. This combination,
he says, allows greater precision than the Haldane apparatus. The hyper-
glycemia is tested with the Bang method.
Appelmans, R. THE PLACE oF THE THRYOID GLAND IN ANAPHYLAXIS.
[C. Ra soc, de Biols Dec. 941972 pe lZ42 a aN aa
R. Appelmans has endeavored to confirm the statement of Képinow,
who found that in animals from which the thyroid gland had been removed
the injection of the dechaining dose after previous sensitization failed
to bring about anaphylactic shock. On a series of eleven animals—pre-
sumably guinea-pigs—a sensitizing injection of 0.04 c.c. of human serum
was made. In three of them thyroidectomy was performed 2, 7, and 11
days previous to the injection; in two of them thyroidectomy was carried
out at the same time as the injection; in four of them thyroidectomy was
performed 2, 2, 7, and 8 days after the injection; while the remaining
two animals were used as nonthyroidectomized controls. At a period
varying from 17 to 24 days after the sensitizing dose, the dechaining
dose—0.05 to 3 c.c. in quantity—was injected into either the heart or
the peritoneum. In every case typical shock occurred, and, with the
exception of two of the animals in which the thyroid had been removed
VEGETATIVE NEUROLOGY 67
subsequent to the sensitizing injection and one of the controls, all of
them died. All the animals were examined post mortem, and in only one
was any vestige of the gland to be found—and this in one of the fatal
cases. From these experiments it is concluded that the thyroid gland
plays no part in the phenomenon of anaphylaxis. This conclusion, it
may be noted, can only be held valid for the particular species of animal
investigated.
Stoll, H. F. Basar MerapotismM IN HypertHyroipisM. [Boston Medical
Pages urcical Journal” VolsClLax x xy Lie No. 4: 9.227, |
More evidence showing that variations in basal metabolic rates are
not due solely to diseases of the thyroid. Careful anamnesis and thorough
clinical examination should always precede the biochemical tests.- There
are borderline cases, however, in which the metabolic rate will prove
very helpful. In conjunction with the usual clinical signs of toxicity the
basal metabolic rate assists materially in deciding what form of therapy
is more advisable. As changes in the metabolic rate frequently precede
changes in the clinical picture, metabolism estimations at stated periods
afford a valuable means of checking any therapeutic measure, either
‘medical or surgical.
Parisot, J.. and Richard, G. THe Sign oF THE THuyroip. [Bulletins de
la Société Médicale des Hopitaux, Paris, Vol. XLVI, No. 17, p. 806.]
The effect on the heart of thyroid injections was studied in 17 cases
of hyperthyroidism, in 11 with other thyroid disturbance, 32 with normal
glands, and 12 with hypothyroid stigmata. The reaction depends on the
relative activity of the vagus or the sympathetic system. One reaction
was constant and capital in hyperthyroidism, namely, a pronounced slow-
‘ing of the pulse, after thyroid in large doses. This constant reaction is
called the sign of the thyroid. The systolic blood pressure usually
‘declined also, and the oculocardiac reflex was exaggerated. It is of
‘special value in estimating the possibility of thyroid participation in a
complex polyglandular syndrome.
Sestini. Ture Tuyroip GLANpD AND ImMMuNItTY. [Lo Sperimentale,
MoOleUEX XIV, .p: 1-3.]
An experimental research to determine what part if any the thyroid
‘gland takes in the processes of immunity. He took 15 animals, used 4
‘as controls and vaccinated 11 against typhoid. The vaccinations were
‘made in the peritoneum at intervals of about a week. When examined
‘later the thyroid was found to be in a condition of hyperfunction, with
an increase in lipoids, in fuchsinophil granules, and changes in the colloid
—a true state of teleangectoid hyperplastic struma. It is difficult to say
whether the thyroid formed antibodies, but the hyperplastic struma points
to an increase in the internal secretion of the gland from hyperproduction
of hormones, which through the nervous system might act on the cells
of different organs at a distance.
68 CURRENT. LITERATURE
Kimball, O. P. PREVENTION OF SIMPLE GOITER IN MAN. [Americar
Journal of Medical Sciences, Vol. CLXIII, No. 5, p. 634.]
A plea for prophylaxis as a public health measure. Education of the
pupils could be combined with the actual administration of iodin, so that
after leaving school they could continue the treatment if necessary. As
thyroid enlargement is approximately six times as frequent in girls as
in boys, each community must decide whether it will include both sexes.
in prophylactic measures, as it must also decide regarding the ages when
the use of iodin should begin and end. Between the ages of eleven and
seventeen years, beginning with the fifth grade, is the principal period.
Hammett, T. S. Strupies on Tuyrorip Apparatus IV. [Am. Jl. of
Anat., XXXI, No. 2.]
The removal of the parathyroid glands from the albino rat resulted
in a marked and valid increase in the size of the submaxillary glands.
This result does not follow thyroparathyroidectomy. Hence, in Hammett’s
opinion, the cause of the enlargement is not attributable to any local
irritation produced by the operative procedure. It is possible that the
hypertrophy or hyperplasia is a response to an increased functional
activity induced bythe increased neural irritability resulting from the
removal of the parathyroids.
Tsuji, K. THyrorip FuNcTION ON DIFFERENT Diets. [Acta Sch.
Med. Univ. Imp. Kioto, Vol. IV, No. 4.]
This clinical experimental study aims to determine whether diet, as
such, can specifically influence thyroid function. Rats which have been
fed on large quantities of egg-yolk or milk show a definite hypertrophy
of the thyroid. Hypertrophy of various organs also resulted. These
organs atrophy in thyroidectomized rats, in spite of large quantities of
egg-yolk or milk in the food. These substances therefore act on the
thyroid in a similar way as iodin (or possibly by reason of their iodin
content ).
Maranon, G. Rep THyrorip Spor. [Bull. d. 1. Soc. Méd. d. Hop., XLVI,
No. 34.]
The well known reddening of the skin by rubbing or from pressure
in the hyperthyroid patient is here made the object of a special study.
He discusses the relation of this sign to Lian’s local hyperesthesia in:
hyperthyroidism and to other problems of dermographism.
Rowe, HE. RoENTGEN TREATMENT OF Toxic GoITER. [Nebraska State
Meds ls lanepie2zse|
There has been great advancement in the knowledge of thyroid
disease. The number of patients seeking relief by nonsurgical means is.
large. It is important to determine by scientific investigation the possi-
bility of successful treatment by roentgen ray. The surgeons are some-
VEGETATIVE NEUROLOGY 69
what hostile to treatment by the X-ray, chiefly because roentgenologists
have entered into direct competition with them in a field that has been
largely surgical. Internists have seized upon the method of treatment
and are offering assistance by studies in metabolism and the- problems
which have to deal with thyroid disease. The whole problem of thyroid
intoxication is bound up with the problem of the manufacture, storage
and use of thyroxin, which is a chemical production of the thyroid gland.
The many types of pathological changes in the thyroid gland may be
summed up as colloidal, adenomatous, and exophthalmic. All other
changes are but the usual tissue changes which might occur in any organ
‘under the same circumstances. There are no pathognomonic changes
determining the state of thyrotoxicosis. Many case records illustrated
by charts show by pulse, weight and metabolism the changes which
patients undergo while taking the Roentgen treatment. It is definitely
observed and the opinion based on this study, that the X-ray will accom-
plish as much as the surgery. It may require a longer time, but the results
are just as good and the mortality is nil. The charts show the published
records of Drs. Means and Aub, and others who have been working
along these lines. Most types of toxic goiters are amenable to Roentgen
therapy. The contraindications are (1) Colloid, cystic, fibrous and nodular
goiter, without toxicity. (2) Goiter causing marked pressure without
symptoms. (3) Intrathoracic goiter. The treatment of thyroid intoxica-
tion is major roentgenological work. Improvement.-is first noticed by a
reduction of pulse rate, increase in weight, improvement in nervousness
and insomnia. In about 50 per cent the exophthalmos will eventually
disappear. In most cases it improves. In some it does not appear.
Thyroid enlargement is one of the last objective signs to disappear. The
end results depend entirely on the damage done, when the hyperthyroidism
disappears. If degeneration of heart muscle and nephritis occur, im-
provement is often great, but a complete cure cannot be expected where
these changes have occurred. All patients should have metabolism rate
taken both for diagnostic purposes and from time to time in order to
follow the treatment. [Author’s abstract. ]
‘Richardson, Edward P. ReELative V ALUE OF SURGERY AND ROENTGEN
Ray IN THE TREATMENT OF HypertTHyrRoIpISM. [J. A. M. A.,
Vol. LXXXIV, March 24.]
This author states that a comparison of the cases treated by roentgen
ray and those treated by thyroidectomy shows that the average results
in all cases treated by subtotal thyroidectomy are better than the results
in a selected two-thirds of the cases treated by roentgen ray. The
metabolism shows a drop to about + 10, as compared with + 20 for the
roentgen-ray cases; the pulse, a drop to 80, as compared with 90; the
weight, a tendency to more persistent and greater increase. The rate of
fall in metabolism and pulse is about equal. The reason for this is that
70 CURRENT Livia en
in certain of the patients who underwent ligation of both superior thyroid
arteries, followed by thyroidectomy in two stages, the whole of the surgical
treatment required four months, and in one case eight months for comple-
tion. In nine cases treated by immediate subtotal thyroidectomy in one
stage the sharp fall in metabolism and pulse and gain in weight are
striking. Richardson says there can be no doubt that the average results
in surgery are better than those following roentgen-ray treatment. The
roentgen ray has a beneficial effect in certain cases of hyperthyroidism,
but this effect is not sufficiently constant to be relied on as the sole form
of treatment. In selected cases of exophthalmic goiter, the use of
roentgen-ray treatment under careful control is justifiable for a period
of four months, during which the patient receives about five treatments.
If, after four months of treatment, the degree of improvement obtained
in general condition and basal metabolic rate does not promise “ cure,”
operation should be undertaken.
Enderlen and Hitzler. RerCURRENCE OF GoITER. [Beit. z. klin. Chir.,
GXXVILENO 34: | Aon S|
Statistics are given showing recurrence in 29 per cent of 795 cases
followed to date, with operative treatment of the recurrence in 9 per cent.
To avoid recurrence, a change to a region free from endemic goiter might
be considered. It is possible that the absence of recurrences in the records
of certain surgeons may be due in part to the locality being free from
endemic goiter.
Grant, R. L. T. Basar Merazportic Rates 1N EXOPHTHALMIC GOITER.
[Med. Jl. of Australia, II, No. 25.]
Increased basal metabolism was constant in the findings of this author.
He is an advocate of the surgical versus the medical treatment of exoph-
thalmic goiter. The basal metabolism of ten cases of exophthalmic goiter
and one case of toxic goiter was studied by Grant.
Schwensen, C. AURICULAR FIBRILLATION IN HYPERTHYROIDISM. [Uges.
f. Laeo., LX XXIV Now 505 ]a AeA
Subsidence of auricular fibrillation after operative treatment of exoph-
thalmic goiter has been reported by Fridericia and others. Schwensen
reports a case associated with irregular heart action and auricular fibrilla-
tion. The heart beat was 160, the radial pulse 100. After roentgen-ray
treatment, the symptoms became much aggravated for five weeks but then
improved, and the electrocardiogram soon became entirely normal. The
right ventricle returned to normal size at the same time.
Lang, F. J. DeatH From Gorter. [Klin. Woch., Dec. 9, 1922, I, No. 50.]
The author discusses the causes of death in goiter. Toxic action on -
the phrenic nerves; persistent thymus; compression of trachea; are the
chief factors involved. The function of the nonstriated musculature of
VEGRLATIV EAVNECUROLOGY 71
the lung is one of the important factors to be considered, but this he does
not adequately analyze.
Bircher, E. History or lop1In TREATMENT OF GOITER. [Schweiz. med.
huoche ry ol cL No,.29, pa 7l3s elasAceN oA: |
Bircher remarks that according to the Swiss newspapers and the
medical press, iodin prophylaxis and treatment of goiter is the most
important discovery of recent decades. Physicians and school teachers
and others are vying with each other in giving iodin to those in their
charge, but, he says, the harm wrought by this in cases of goiter is
already so great—much of it irreparable—that this abuse of iodin must
be halted before it is too late. He recalls that burnt sponge was used
in treatment of goiter from the earliest days of history, and its value is in
the iodin it contains. Hippocrates, Galen, Pliny mention it, and the
Chinese used it fifteen centuries before Christ. Jodin was isolated in
1811, and Coindet extolled it in treatment of goiter in 1820. He warned,
then, that the patient taking it must be kept under close medical super-
vision. During 1920 Bircher encountered thirty-six cases of severe
thyroid derangement for which iodin treatment was responsible. It had
been taken under advice of a physician in some, of a druggist in others,
with self-drugging in the rest. In one woman of forty-two with goiter
20 gm. of potassium iodid in the course of twelve weeks was followed by
intense nervousness and excitement, tremor, salivation and palpitations,
pulse reaching 116, and slight hemiplegia. On account of the heart
disturbances—the exaggeration of which had been the indication for the
treatment—Bircher did not dare to operate, and necropsy soon after
revealed 380 mg. of iodin in the thyroid, which weighed 400 gm. The
goiter had developed many years before in connection with a childbirth.
The operation in these cases was always exceptionally difficult and
tedious. The physiologic iodin content of the thyroid is from 2 to 9 mg.,
he adds; in these cases it reached 20, 30, and in the above case, 380 mg.
Over 50 per cent of internally treated goiters return in one, two or three
years, and the surgeons report a similar proportion of recurrences after
thyroidectomy. We must bear in mind further that exophthalmic goiter
proves fatal in an average of 25 per cent of the cases. Notwithstanding
the extensive research on iodin and the thyroid in the last hundred years,
the physiology and pharmacology of iodin is so uncertainly known and
the experiences with it have been so contradictory that it seems like a
dangerous experiment to give this metallic poison, in food or drinks, on
an extensive scale and for long periods. To give it indiscriminately to
the iodin-refractory and the iodin-susceptible, the thyroid sound or patho-
logic, is an irresponsible procedure. He says of the Ohio experiment
with iodin prophylaxis in the schools that it is far from convincing, as
also similar experiences in Switzerland. He calls attention further to the
differences between goiter in America and in Switzerland, and cites
2 CURRENT LITERATURE
figures from different regions in Switzerland showing goiter in 72 to 100
per cent of the school children, while all but 3.3 to 9 per cent of the
recruits from those regions were free from goiter.
Zandren, Sven. THe Heart 1n MyxepemMa. [Zent. f. Herz u. Gefass.,
July, 1922.]
Sven Zandren finds that the characteristic symptoms referable to the
heart in myxedema are the following: (1) Dilatation of the heart in both
directions, no signs of a valvular defect or of myocarditis and a normal
or subnormal blood pressure. (2) Subjective symptoms of dyspnea and
palpitation may exist for a long time unchanged. Gradually there develop
demas, localized mainly in the lower parts of the body which reach
enormous dimensions; the skin becomes thickened, it cannot be lifted in
folds and it is cold and scaly. (3) There is a disproportion between the
objective findings in the heart and the pronounced edema with the severe
subjective symptoms of insufficiency. (4) There is no or only a slight
therapeutic effect noticeable from the usual treatment of the heart, but an
excellent result is seen from the administration of thyroid gland prepara-
tions. (5) In many cases it is possible to demonstrate slight somatic or
psychic symptoms of hypothyroidism.
Fleming, G. B. THe ResprraAtoRY EXCHANGE IN CRETINISM AND
Monco.tran: Ipiocy. ~ [| Quart. J.2M. CXL 1 aled.coaa
In the untreated cretin the basal metabolism is unduly low, but is
raised to a normal level by thyroid treatment. In six Mongolian idiots
the basal metabolism was found to be normal, and thyroid treatment had
no effect.
Talbot, F. B., and Moriarty, M. E. Basar MerapoLismM IN CRETINISM.
[Am Jk of Dis of Child; XX V ,-NG 3a A A
Talbot and Moriarty show, first, that determinations of the basal
metabolism make possible an early diagnosis of cretinism, before the
usual clinical symptoms appear; second, the correct standard to use in
childhood in determining whether a subject is suffering from hypo-
thyroidism or not, and third, that determinations of the basal metabolism
are of distinct value in indicating the amount of thyroid which may be
given with maximum efficiency. The basal metabolism findings in a
series of ten cretins are given, and it is shown that the basal metabolism
and physical development of a cretin before treatment are considerably
lower than they should be, illustrating the importance of the thyroid
gland as a growth promoting factor. The metabolism of the untreated
and treated cretins is plotted for comparison with the normal, showing
the heat production for each square meter of body surface, total calories
referred to weight, and total calories with reference to age. In the
majority of cases studied, the most marked clinical improvement was not
obtained until enough thyroid had been given to raise the metabolism to
VEGETATIVE NEUROLOGY 73
the expected metabolism for the age. Since the purpose of treatment in
cretins is to bring them up to the average normal for the age, it seems
wise to give sufficient thyroid to bring the metabolism to the expected
total metabolism for the age. The evidence to date is that this level must
be reached before the best therapeutic results can be obtained.
poi, i. eMONGOLOID Inrocy, _[1ijd: v, Gen, Jan: 20,,1923, I, No.. 3.
Po Ace vir A |
The peculiar eye symptom in this disorder is due to arrested develop-
ment of the epicanthus, which arrest of development may find an ex-
pression in brain structure as well. He states there is a hypothetical
“hormone index,” specific for each individual, and that the hormone
index in mongoloid idiots differs in some definite manner. How to
measure the irritating or destructive element is a biochemical problem.
Millet, J. A. P., and Bowen, B. D. RercoGNITION AND TREATMENT OF
HypotHyroipism. [N. Y. St. Jl. of Med., XXIII, No. 3.]
In this clinical paper eighteen cases of hypothyroidism are
analyzed. They showed either: (a) myxedema, (b) clinical hypothyroid-
ism, or (c) stigmata suggestive of hypothyroidism, with decreased basal
metabolism and improvement under thyroid therapy. Cases falling in this
third group are classified with difficulty since low basal metabolism is not
specific for thyroid dysfunction. The most satisfactory type of thyroid
therapy is the intravenous administration of thyroxin. Thyroxin and
desiccated thyroid are uncertainly absorbed when taken by mouth, but of
the two, desiccated thyroid is to be preferred. to thyroid administration.
Hotz, G. ENprEmMic GOITER AND CRETINISM AND THEIR PROPHYLAXIS.
[Klin. Woch., Oct. 14, 1922. B. M. J.]
G. Hotz describes the recent attempts made in Switzerland to prevent
goiter. They are based on the old experience that iodine, administered
in small doses for a long period, diminishes the most common forms of
goiter. It is now known that only very small doses of iodine are
required. It should be given for many years (during the whole period
of childhood and in the years of sexual activity). Various conditions of
the thyroid gland are found in cretins. The author’s observations show
that in early childhood the cretinous condition often develops under the
influence of a large vascular active goiter, and that by the early resection
of most of the goiter the cretinous condition may be arrested; the child
then develops in a normal manner and increases in height. In cretinous
families usually the mother or father or both parents suffer from goiter.
Chemical researches respecting endemic goiter are at present in their
early stages. One fact is known with certainty—that the normal thyroid
gland substance, iodothyrin, iodothyreoglobulin, and thyroxin are able
to prevent or diminish goiter. The prophylactic iodine treatment shows
that potassium iodide has the same action. The iodine prophylaxis is
74 CURKENT LITERATURE
carried out in Switzerland in two ways: (1) Potassium iodide is added
to the ordinary cooking salt in the proportion of 0.5 gram of potassium
iodide to 100 kg. of ordinary cooking salt. This iodized salt is sold at
the same price as ordinary common salt, and can be employed for house-
hold use. This prophylaxis is carried out in the cantons Appenzell and
Wallis. (2) In other districts tablets, each containing 5 mg. of iodine,
are given to the children in schools; one is given weekly. The reports
of Bayard show a marked diminution of goiter in the districts where the
iodized cooking salt is used. The reports of Steinlin and Imbach respect-
ing 7,500 school children treated with tablets show a diminution of the
number of cases of goiter. The cost of the tablets for each child for a
year was one franc. Caution in the treatment is, of course, necessary, as
in certain cases of goiter in adults small doses of iodine lead to symptoms
of Graves’ disease.
Ugon, A. Armand. CoNncENITAL MyxepeMa. [Arch. Lat.-Amer. de
Ped., XVI, No. 9.]
A clinical report of a young cretin whose mother had had a goiter for
twenty-two years with slowly developing hyperthyroid symptoms. Therapy
begun at the age of eleven had produced good results.
Lisser, H. A Caste or Aputt MyxEepEMA AND ONE oF CHILDHOOD
MyxeEpeMA. [The Medical Clinics of North America, VI, No. 2,
Dec 7e
The first patient was a man of thirty-eight years, whose illness dated
back fifteen years. At that time he began to notice puffiness involving
pretty much the entire body and he became very drowsy. He slept from
twelve to fourteen hours during the night and often several hours during
the day as well. About eight years prior to admission, his speech became
thick, havy and slow, and the intonation of his voice became very deep and
low. Also about this time his hair began to fall out, leaving him quite
bald. The hair on his body for the most part disappeared. He shaved
only twice a week. He never perspired and always felt cold, requiring
blankets in immediate contact with his body at night.
On examination, the skin was cold, very dry, quite thick and rough,
with a little scaling. His complexion showed the characteristic
““ Christmas-red-apple cheeks.” The axillary, pubic and body hair was
quite scanty. His face was round and the features thick and puffy. The
pulse varied between 52 and 64. The extremities were thick and looked
edematous, but there was very little pitting on pressure. The temperature
was 95° F. (35° C.). The basal metabolism measured 45.2 per cent
below normal.
This patient was treated with thyroxin, and spectacular improvement
took place from the very beginning. After nine months of treatment, he
was a new individual. He had a growth of hair on his scalp; his weight
VEGETATIVE NEGROLOGY 75
had decreased 25 pounds; his temperature had come up to normal; his
puffiness had entirely disappeared; his facial expression was bright, alert
and cheerful; his voice was higher pitched. He was back at work and
felt perfectly well.
The second patient, a female of fourteen years, likewise showed all
of the physical attributes characteristic of myxedema. In addition, she
was retarded mentally, measuring only seven years on the Binet-Simon —
scale. This child was treated with Burroughs and Wellcome’s tablets of
thyroid extract, the dose varying from 2 to 7% grains (0.130 to 0.4924
gram) per diem. The results of treatment in this patient were gratifying
in some particulars; but her skeletal growth was slight, and her intellectual
advancement, as measured by the Binet-Simon scale, was practically nil.
Urechia, C.-I., and Grigoriu, C. ExTirPATION oF THE PINEAL GLAND.
[C. R. Soc. Biologie, July-September, 1922, p. 815.]
These authors have successfully removed the pineal gland from a
couple of cocks, and have been enabled to study the changes subsequently
ensuing. After the operation the birds presented an involution of the
secondary sexual organs lasting approximately for two months; when this
period had elapsed growth set in rapidly, and the development of these
organs became well marked. Eight months after the extirpation of the
gland the animals were killed. They presented on inspection no difference
from the controls of the same generation. The weight of the testicles was
the same, but the interstitial tissue was in greater abundance in the
operated animals. As regards the pituitary, this gland was found to be
considerably enlarged, being about three times the size of that common
to normal cocks. On microscopic examination it was possible to sub:
stantiate an increase in the acidophilic cells, the presence of numerous
acini filled with acidophilic colloidal material, and a simple hypertrophy
of the nervous lobe. The conclusion is drawn from these two experiments
that the result of the removal of the pineal gland was to increase the size
of the pituitary, and probably to stimulate its function.
Lereboullet, P. PatrHoLocy oF THE PINEAL. [Paris letter, J. A. M. A.,
Vol. LXXXIITI, Aug. 4.]
The pathology of the pineal body is not only more limited but also
less clearly marked. It is characterized by three types of manifestations:
(1) a dystrophic syndrome evidenced by accelerated growth, the height
rapidly reaching the maximum but not exceeding it; there is no sign of
giantism, but occasionally nanism will be observed; the precocious develop-
ment of the genital organs and increased pilosity accompany rapid growth
and are often very marked; (2) a nervous syndrome, characterized by
cerebral hypertension, together with headache, vomiting, convulsions,
disturbances of vision, etc., to which are added certain signs revealed by
lumbar puncture and notably hypertension of the cerebrospinal fluid, and
76 CURRENT ‘LITERATURE
(3) a peculiar ocular syndrome, distinguished by partial paralysis of the
rotary muscles of the eye, due, according to Spiller, to a lesion of the
anterior corpora quadrigemina. With this triple syndrome may be com-
bined certain contingent factors: obesity and polyuria, which may be due
to a secondary involvement of the floor of the third ventricle. A third
sign is closely related to those characteristic of precocious puberty;
namely, precocious mental development quite superior to that of children
of the same age, as has been noted in several instances.
Lepehne, G. PuysioLoGy AND PATHOLOGY OF THE SPLEEN: [Deut.
med. Woch., XLVIII, No. 48.]
Lepehne reviews the function of the spleen as an organ which serves
partly as a “regionary lymphatic gland of the blood” (Helly), partly as
an endocrine organ influencing the production of blood cells, and partly
in relation to the metabolism of iron and cholesterol. The destructive
action on red corpuscles and platelets and the question of production of
antibodies are especially discussed.
Widal, F., Abrami, P., and de Gennes, L. CoLLoIpOCLASIS AND THE
ENDOCRINE GLANDS. [Presse Médicale, XXX, p. 385. J. A. M. A.]
Widal and his coworkers report a further instructive example of
instability of the colloids, and treatment of this colloidoclastic diathesis.
The asthma was traced to ovarian disturbance, followed by thyroid
malfunctioning, and on the basis of this endocrine derangement an
anaphylaxis to various substances, especially rose pollen, developed,
entailing asthma. It began at puberty. Treatment was begun after
twenty-six years and the effect of thyroid treatment and of desensitization
has been most remarkable. The symptoms can be banished and brought
on again at will by treatment, and by suspension of treatment.
Weil, P. Emile, et al. Broop Test or Liver FuNcTIONING. [Presse
Médicale, Vol. XXX, No. 52, p. 553. J. A. M. A.]
Whenever the liver is seriously pathologic the blood is profoundly
altered, and coagulation does not occur as in normal conditions. Weil
and his coworkers list seven various abnormal features of coagulation as
determined in a large number of cases of liver disease. They call this
the syndrome hémocrasique des hépatiques, and state that it can be
estimated by the bleeding time. This is exaggerated and irregular with
liver disease, and this is one of the earliest signs of any infection or
intoxication modifying liver functioning. The blood coagulates less
readily, there is less retraction of the clot, and the clot crumbles or is
redissolved—all of which is manifest in the changes in the bleeding time.
The curve of repeated bleeding-time tests shows the great spontaneous
irregularity, fasting, especially in females, and above all when.-there is
a tendency to hemorrhage. The curve of the bleeding time can be in-
structively supplemented by determining the fibrinogen content, refraction,
VEGETATIVE NEUROLOGY Ta,
and the viscosity of the plasma, but even without these, the bleeding
time curve alone will throw light on important functions of the liver
hitherto left unexplored in the clinic.
Mann, F. C., and Magath, T. B. Puysiotocy or Liver. [Archives of
Internal Medicine, Vol. XX XI, No. 1, p. 73]
After total removal of the liver in animals there is a marked and
progressive decrease in the blood sugar. The glycogen content of the
muscles also decreases. A characteristic syndrome then develops until
death.
Wechsler, I. S., and Brock, Samuel. Six Cases or Dystonira. [Am.
Atch, Neur. and Psych., Vol. VIII, No. 5.]
A study of six hitherto unreported cases of dystonia with numerous
unusual and atypical features. An attempt is made to enlarge the concept
of the disease entity and to include in it a myostatic form, as contrasted
with, and as a counterpart of, the recognized myokinetic type. Additional
_ clinical and physiological evidence is adduced to support the concept of a
myostatic variant. Partial and almost total decerebrate postural disturb-
ances are demonstrated in the cases herein reported, and form a char-
acteristic part of the syndrome. This adds further weight to the existence
of the myostatic component and is of aid in delimiting the anatomical
level. An abstract of the cases follow:
Case I—of dystonia musculorum deformans of the kinetic type
beginning in the right hand and, up to the present, involving the muscula-
ture of both upper extremities, neck and head, with a fragment of
decerebrate rigidity phenomena.
Case II — of dystonia musculorum deformans of the kinetic type with
the occurrence both of fragmentary and almost complete decerebrate
rigidity phenomena.
Case III — of dystonia musculorum deformans with (1) a remarkable
familial incidence, (2) speech disturbance, (3) a remission of the hyper-
kinetic phenomena with a resultant, (4) myostatic residuum, (5) a hemi-
dystonic distribution and (6) a fragment of decerebrate rigidity.
Case IV — of dystonia musculorum deformans, illustrating the myo-
static or postural form, with very few hyperkinetic phenomena.
Case V—A postural or static instance of dystonia musculorum
deformans (dysbasia lordotica progressiva) with very slight kinetic
involvement. |
Case VI — of dystonia musculorum deformans of the kinetic type
revealing (1) fragments of decerebrate rigidity, (2) a paralysis agitans-.
like tremor of right thumb and hand, (3) a dorsal extension (Babinski)
of the left big toe.
Their conclusions are: (1) There exists a myostatic variety of
dystonia musculorum deformans as contrasted with the usual myokinetic
form. (2) Phenomena of decerebrate rigidity may frequently be observed
78 GURKENT LUT Bick ie
in dystonia musculorum deformans. (3) All cases of dystonia have an
underlying postural background, one of the manifestations of which are
the phenomena of decerebrate rigidity. (4) The myostatic and myokinetic
phases of dystonia, which may be observed in all cases, are capable of
dissociation. Either the static or kinetic phase may dominate the clinical
picture. (5) The involvement in dystonia may be segmental in character.
(6) In dystonia musculorum deformans there are some features found of
other striatal diseases, which serve to emphasize their basic relationship.
[Author’s abstract. ]
Marfan, A. B. Tuymus DeatH. [Paris Méd., XII, No. 44. J. A.
MA]
Marfan believes that there are many causes of sudden death in young
children. Some sort of autointoxication in-eczema may be the cause,
while it is probably a local lesion of the superior cervical ganglion in cases
of retropharyngeal abscess, etc. The only thing which these and other
sudden deaths have in common is a certain predisposition of the young
organism for it. Marfan describes a case of a rachitic girl of twenty-one
months, who had suffered from several attacks of epileptiform convul-
sions before. The child was in a hospital under observation for a few
days, and died suddenly, just while she was being dismissed as perfectly
healthy. She had an enlarged thymus (35 gm.). The heart was in
systole. The real thymus death is not due to compression of organs. It
happens chiefly under anesthetics. The victims are usually pale and fat
children, with rickets and enlargement of lymphatic glands. Marfan
considers the causes of it as identical with the causes of rachitis, and
recommends specific treatment if indicated by the Wassermann and
tuberculin tests.
II. SENSORI-MOTOR NEUROLOGY.
4. PONS; CEREBELLUM.
Bakker, 8S. P. Tue AssociATION-SYSTEM IN THE CEREBELLUM. [Neder-
landsch Tijdschrift voor Geneeskunde, LX VIII, Sept. 6, p. 1341.]
Bakker reports to the Amsterdam Neurologists’ Society the results -
of his experimental work on the association-system in the cerebellum of
rabbits. By the studies of Brouwer and Coenen the association-system
of the flocculus was made known, but facts concerning the vermis and
the hemispheres are wanting. Bakker made a superficial lesion of the
cerebellum without damaging the nuclei. After three weeks Marchi’s
method was used. In a lesion of the hemisphere degenerated fibers are
seen to run near to the vermis, along the commissures dorsally of the
nuclei, to the contralateral hemisphere and the adjacent flocculus. Massa’s
bundles are to be followed to the nucleus dentatus, while some in the region
SENSORI-MOTOR NEUROLOGY 79
of the fibre perforantes penetrate the region of Deiters’ nucleus. In a
small experimental lesion of the vermis it appeared that the degeneration
ran not only to all the lamellz of the vermis which were undamaged but
also to the hemispheres and to a less extent to the flocculus. The degenera-
tion was to be followed chiefly to the nucleus emboliformis, while there
was hardly any going to the nucleus dentatus; it could be followed to
Deiters’ nucleus on both sides. [Leonard J. Kidd, London. ]
Morquio, L. Necropsy FINpINGS IN FRIEDREICH’s Disease. [Arch.
Amer. Med., 1925. ]
In this boy of eleven years under observation for more than a year
who died from typhoid there had been pain and weakness of the legs
for about a year. These pains did not spread, and they occurred only
in the knees and when walking. There was a swaying gait of a cere-
bellar ataxia type and the speech was impaired. Necropsy showed intact
cerebellum. The lesions were chiefly confined to the spinal cord.
Earl, C. J. ©. CrREBELLAR HAEMORRHAGE IN A Boy. [Irish Journ. of
Med. Sci., Series 3, No. 33, p. 502.]
A boy of eleven, of good antecedents, was perfectly well till within
24 hours of his death from cerebellar hemorrhage. He was chopping
wood and was called in to go to bed; immediately he entered the house
he complained of violent headache, and vomited but had no vertigo; from
that time he did not speak intelligently. For eight hours he vomited
almost incessantly, and then became quiet and unconscious. Seven hours
later he became violent, throwing his limbs about wildly. No evidence
was found of any cranial nerve palsies, so far as his strong purposeless
movements in all his limbs permitted. Pupils of moderate size, equal
and active. No deviation of head or eyes. No paralysis. He responds
sharply to painful stimuli. All reflexes plus, but equal on the two sides.
Abdominal reflexes absent, and bilateral extensor plantar responses. No
hypotonia. No neck-rigidity; no Kernig sign. A provisional diagnosis
was made of encephalitis lethargica fulminans. Death two hours after
admission. Necropsy showed absence of injury or fracture, and no disease
oi middle or of internal ear or of the sinuses. Meninges congested; left
side of brain edematous and larger than right. A massive hemorrhage
in left cerebellar lobe, completely filling it and obliterating its structure.
Brain otherwise normal, except for the edema. No evidence of syphilis.
[Leonard J. Kidd, London. |
Zylberlast-Zand, Madame Natalie. A Case oF A SENSORY AND TROPHIC
SYNDROME OF PoNTINE ORIGIN. [Revue Neurologique, An. 31, T. 2,
No. 6, p. 596. ]
The symptoms consisted of a weakness of the left upper and lower
extremities; sensory disturbances most marked in the first three fingers
and the radial half of the left hand and forearm; pain in the left arm
80 CURRENT LITERATURE
and right side of the face; an increase of the vestibular reflex on the
right; trophic changes consisting of hyperkeratosis, edema and cyanosis
of the skin in the parts affected by the sensory change; and some myo-
tonia in the left side of the neck and the left hand. The sudden onset
of the symptoms, without fever, led to the diagnosis of a small hemorrhage
situated in the pons. [Camp, Ann Arbor.)
Freeman, W., and Morin, P. MrseNcEPHALIC AUTOMATIC REFLEXES.
[Revue Neurologique, An. 31, T. 1, No. 2, p. 158.]
Postural tonic reactions are due to mesencephalic reflexes. In athetosis
one may observe the signs of decerebrations and in fact athetosis is
the changing postures of decerebrate rigidity, manifesting the liberation
of the mesencephalon from the control of superior centers. [Camp, Ann
Arbor. |
Porges, O. PyLoRoSPASM IN CASE OF CEREBELLAR Tumor. [Wiener
klin. Woch., Feb. 5, 1925.]
A clinical observation in which pylorospasm seemed to be associated
with the cerebellum in a patient with a cerebellar cancer metatasis. There
were also lesions in the dorsal nucleus of the vagus.
Van Rijnberk, G. Recent RESEARCH ON CEREBELLUM. [Ned. Tijd. v.
Geneeskunde, July 26, 1924.]
A critical review, richly illustrated, of the present day conceptions
concerning cerebellar structure and functions.
Saito, M. ExprrRIMENTAL INVESTIGATION ON THE CONNECTIONS OF THE
CoRTEX CEREBELLI WITH THE Pons, MEDULLA OBLONGATA, AND
INTRINSIC CEREBELLAR Nuc er. [Arb. a. d. Neurol. Inst. Wien,
XXIII (H. 3), 74.]
Saito, M. FurTHER INVESTIGATIONS ON THE INTRINSIC CONNECTIONS OF
THE CorTEX CEREBELLI. THE ANTERIOR Lope. [Arb. a. d. Neurol.
Inst. Wien, XXIV (H. 1), 77. Med. Science.]
Experiments were made in rabbits with the following results: the
cortex of the lobus petrosus cerebelli is connected with the superior
cerebellar peduncle, while that of the lobus paramedianus is connected
with the middle cerebellar peduncle. The fibers which effect this
connection end in the lateral nucleus and form a homolateral path
between cortex cerebelli and pons. No degeneration of this path occurs
in rabbits after lesions of the vermis. Whether a similar connection
exists between cortex cerebelli and inferior cerebellar peduncle cannot be
stated with certainty. The medulla oblongata, however, is connected with
the cerebellum by means of the so-called perforating fibers which, lateral
to nucleus tecti and mesial to nucleus dentatus, take a dorsoventral course
and end by arborizing in the area of Deiters’s nucleus. The author con-
SENSORI-MOTOR NEUROLOGY 81
firms the existence of the path described by Lowy between formatio
vermicularis and nucleus angularis. According to Saito, the fibers of
Lowy’s bundle which arise from lobus lateralis (paramedianus) have a
lateral situation, while those arising from the vermis have a mesial posi-
tion, and they all end among the cells of the restiform body. The author
confirms Clarke and Horsley’s observations regarding the connections of
the vermis and lateral lobe with the vestibular nucleus, and of the cortex
cerebelli in general with the intrinsic cerebellar nuclei. The same can
be said as regards the arcuate system of Clarke and Horsley, though
according to Saito the connection between the lateral lobe and formatio
vermicularis is more intimate than described by these authors. In the
rabbit all the intrinsic cerebellar connections are more intimate than in
the dog and cat.
The cortex of the anterior lobe of the cerebellum has in the rabbit
a special connection with the paraflocculus. After extirpation of this
lobe degeneration of nerve-fibers occurs in the nucleus tecti and, in a
smaller degree, in the nucleus emboliformis and area of the Deiters
nucleus. [C. da Fano. ]
Roussy, G., Levy, G., and Bertillon, F. CrreBerLarR HremMisyNDROME
witH INTENTION TREMOR AND ATHETOID MovEMENTS, PROBABLY DUE
TO A LESION IN THE SUPERIOR PoRTION OF THE RED Nuc Leus, Rusro-
THALAMIC. [Revue Neurologique, An. 32, T. 1, No. 1, p. 29.]
The lesion was probably vascular. The cerebellar symptoms, localized
on the right side, were: asynergy, dysmetria, adiadokokinesia, intention
tremor and hypotonia. The athetoid movements were present in the right
foot. The right hand has an abnormal position. There was slight weak-
ness on the right. Temperature sense was increased and vibratory sense
diminished on the right. [Camp, Ann Arbor. ]
Pekelsky, A. THE NucLEI OF THE RAPHE AND NEIGHBORING PoRTIONS
OF THE RETICULAR FORMATION. Part I. MAmMats. [Arb. a. d.
Neurol. Inst. Wien, XXIII (H. 3), 21. Med. Sc.]
The nuclei termed by the author “ derivatives of the reticular forma-
tion” comprise the nucleus funicult anterioris and the nucleus interfascicu-
laris hypoglosst. The nucleus funiculi anterioris is situated dorsally to
the mesial accessory olivary nucleus and was first described by Obersteiner
in man; it was found by the author in various mammals, in which it under-
goes various modifications in size and aspect. The nucleus interfascicularis
hypoglossi is situated along and among the issuing fibers of the hypo-
glossus, and consists of relatively small and pale cells readily distinguished
from the large and well-stained motor cells of the reticular formation. It
corresponds to Jacobsohn’s nucleus sympathicus sublingualis and is found
in most mammals, being particularly plain in the cat. A similar group
of cells can occasionally be seen (e.g., in the pig) among the issuing
82 CURRENT LITERATURE
fibers of the abducens. The chief part of the mesial portion of the
reticular formation is occupied by the nucleus centralis infertor, which
is situated dorsally to the inferior olivary nucleus and reaches in man
and higher mammals the dorsal longitudinal bundle; in rodents and other
lower mammals it hardly reaches the predorsal bundle. In these animals
the nucleus has, therefore, a ventral situation and a triangular shape the
base of which conforms with the inferior olive; when in upper sections
of the medulla oblongata the olive disappears, the ventral position of.
the nucleus becomes even plainer. It then corresponds to Winkler’s
nucleus ventralis formationis reticularis. In carnivora and rodents the
nucleus continues orally till the motor nucleus of the trigeminus, but in
other mammals it ends at about the level of the knee of the facial. The
nucleus centralis inferior consists of small and large cells, the latter being
less numerous than the former in man and higher mammals. Some of the
small cells of the raphe probably belong to this nucleus, while others seem
caudal prolongations of the nuclei pontis. In fact they form simple nests
of cells and not a true nucleus as described by Jacobsohn in man (nucleus
pallidus raphes) and by Kohnstamm in the rabbit. The nucleus centralis
superior has an homologous situation and likewise consists of small and
large cells, the latter gradually diminishing in higher mammals-and almost
completely disappearing in man.
Among the nuclei of the reticular formation, caudal and oral prolonga-
tions of the nuclei pontis are found. The principal caudal prolongation
gives rise to the arcuate nucleus, which occurs not only in man (Kolliker,
Zingerle) but also in certain other mammals, as the elephant. According
to the author the nucleus retro-pyramidalis of Cajal and Deéjérine
(Ziehen’s nucleus conterminalis) should be considered as homologous to,
if not identical with, the arcuate nucleus because of its connections with
the external arcuate fibers. This nucleus is found in rodents, carnivora,
and ungulata. The principal oral prolongation of the nuclei pontis is the
nucleus reticularis tegmenti, which is particularly well developed in man.
Within it Ziehen observed another nucleus which he termed nucleus
pterygoideus; the author finds that the Ziehen nucleus is more readily
identified in monkeys and other mammals because of its large nerve-cells;
he therefore proposes calling it pars magnocellularis of the nucleus reticu-
laris tegmenti. This nucleus probably corresponds to the paramesial group
of Borowieki and was described by Kappers in the cat; but the author
cannot agree with Kappers as to its identification with Hoevell’s nucleus
reticularis superior ventromedialis. The nuclei of the raphe and neigh-
boring portion of the reticular formation are in small part also due to
prolongations of the central grey matter. Such are the outlying portion
of the nucleus funiculi teretis, which is particularly well developed in
certain mammals, and the cells which continue ventrally the nucleus dor-
salis of the raphe and form in a more oral situation a defined group on
each side of the Sylvian aqueduct; this group is probably a stage in the
SENSORI-MOTOR NEUROLOGY 83
development of the nucleus lateralis aqueducti, which the author has
identified in a considerable number of mammals. From the physiological
point of view the nuclei described may be considered as the central sta-
tions of some of the labyrinth reflexes described by Magnus and de Kleijn.
Leda Fano. |
Simonelli, G. Microscopic EXAMINATION OF CEREBELLA IN WHICH
LESIONS OF THE Lobus PosTERIOR HAp BEEN EXPERIMENTALLY PRO-
DUCED, WITH A CONSIDERATION OF INGVAR’S DOCTRINE OF CEREBELLAR
FuncTIon. [Rev. Neurol., 1924.]
In a notice of Ingvar’s paper in Brain on cerebellar localization
(Medical Science, 1924, 1X, 385), reference was made to his view that
certain immediate results of acute experimental cerebellar lesions could
not be regarded, following Luciani and Simonelli, as “ dynamic ”’ or “ irri-
tative”? symptoms. It was pointed out that Magnus had been able to
show that symptoms of this nature do actually occur and that Ingvar’s
opinion was therefore ill-founded. In the present short paper, Simonelli
discusses this question, giving reasons for not accepting Ingvar’s con-
clusions on the point. Further, in respect of the lesions produced by
Ingvar and regarded by him as restricted to the lobus posterior, he quotes
his own experience to the effect that macroscopically localized lesions of
this region, produced by a more delicate method than that employed by
Ingvar, are associated with gross nerve-cell destruction in the roof and
dentate nuclei even when these are not directly involved in the lesion. The
production of strictly localized cerebellar lesions, therefore, of a kind from
which conclusions as to topographical representation of the musculature
in the cortex cerebelli can be drawn, appears to be impossible. This
observation is of interest in considering the various theories of cerebellar
localization which have been based on pathological material which has
not been subjected to subsequent microscopic investigation. [F. M. R.
Walshe. |
Waldorp, C. P. CEREBELLAR Tumor. [Rev. Asac. Méd. Argentina,
1924. ]
A clinical case of tumor in the middle lobe of the cerebellum con-
firmed by postmortem. It occurred in a woman of twenty-eight years who
did not respond to any form of treatment; removal was attempted. She
died in bulbar syncope. There were alternating occurrence of the cere-
bellar symptoms, the prone position, with the legs extended, to relieve
the intense headache, and the disturbances in the vegetative synapses for
the vagus were outstanding symptoms.
Berlucchi, C. Tue PorymorrH CELLS oF THE DENTATE Fascia OF OLD
ANIMALS. [Riv. di patol. Nerv. e Mentale, 1923. Med. Sc.]
The structural details discussed in this paper were first noted by
Doinikoff (Journ. f. Psychol. u. Neurol., 1908, XIII, 166). He observed
84 CURRENT LITERATURE
that in the rabbit the cell bodies of some of the polymorph cells of the
dentate fascia were provided with short and relatively thin processes which
after a brief course became lost in an apparently granular material
arranged like a halo around the cells. Later on, Lafora (Trab. d. lab.
invest. biol., 1914, XII, 39) noticed in an old dog that some of the large
pyramids of the inferior or central portion of the cornu ammonis were
provided with peculiarly ramified dendrons. At a short distance from
the cell body these gave rise to a considerable number of collaterals, most
of which subdivided into two or more finer processes. The dendrons with
their collaterals were like feathery tufts and were surrounded by an
amorphous material similar to that described by Doinikoff. Lafora, hav-
ing failed to observe phenomena of this kind in young dogs, thought that
they were perhaps due to the old age of the first animals investigated,
and tried to identify them with the so-called senile plaques of Redlich-
Fischer. A few years afterwards, Del Rio Hortega (Trab. d. lab. invest.
biol., 1918, XVI, 291), pointed out that the dendritic proliferation of the
polymorph cells of the dentate fascia is a process common to many mam-
mals of a certain age. In some of them, like the dog, cat, and horse, the
processes arise from one or more dendrons (cells with feathery appen-
dices), while in others, like the bull, cow, rabbit, sheep, and goat, they
arise from the cell body (pluriramified cells). Del Rio Hortega showed,
in addition, that the short processes in question are much more numerous
and subdivide much more frequently than had previously been suspected,
while the surrounding halo of apparently amorphous material is not seen
whenever the impregnation of the fine processes and their minor branches
is more or less complete. The phenomenon is not limited to senility,
because it can be observed also in adult animals and in minor proportions
even in young ones (calves, young goats). Del Rio Hortega’s observa-
tions were confirmed by M. Prados y Such (Arch. de neurobiol., 1920,
I, 73), who found similar cells in the polymorph layer of the dentate
fascia of some monkeys and pointed out that the dendritic proliferation
is not a regressive but a progressive process evolving pari passu with the
somatic development of certain animals. When considered from this
point of view, it has a considerable analogy with the multiple production
of protoplasmic processes and other appendices observed by Cajal, Dogiel,
Levi, Pizzorno, and others in certain types of spinal ganglion cells.
The conclusions now reached by Berlucchi are entirely in agreement
with the results obtained by the former authors. He succeeded in
impregnating cells of the kind described, by Golgi’s chromate of silver
method, by means of which also the neighboring neuroglia cells were
stained. The numerous and presumably multiplied processes of these last
showed the well-known intimate connections with small blood-vessels and
capillaries on the one hand, and became, on the other, so intermixed with
the fine ramifications of the proliferating dendrons as to render a dis-
crimination between the two kinds of processes extremely difficult.
[C. da Fano. ]
SENSORI-MOTOR NEUROLOGY 85
Papilian, V., and Cruceanu, H. CEREBELLUM AND ORGANIC FUNCTIONS.
Pein eoc. Biola Marchals i925)
In this series of experiments the cerebellum in twelve dogs was injured.
Acceleration of the heart beat and respiratory movements followed, the
oculocardiac and oculorespiratory reflexes became exaggerated, blood
sugar and blood nitrogen were augmented. Histological examination
later showed that the medulla and the brain were not included in the
lesions.
Weed, Lewis R., and Langworthy, Orthello R. DercerEBRATE RIGIDITY
inmiaecOrossum:, j | Amer.cfk Physiol: 1 XX 1i 28. |
Decerebration in adult opossums was followed by the development of
a true rigidity, involving the extensor musculature of neck, trunk, tail,
forelegs and to a lesser extent of hindlegs. The reactions were quite
similar to those of the higher mammals subjected to similar transections
of the brain stem. ‘The decerebrate adult opossum differed from the
higher mammals under similar experimental conditions by exhibiting very
frequently rhythmic, well-coordinated movements of progression. In the
pouch-young opossums, decerebration was followed, except in the two
oldest of the series (eighty-two days and eighty-nine days old), by the
occurrence of progressive movements of a prolonged nature, without an
extensor rigidity. In the two oldest of the pouch-young, there was evi-
dence of a true rigidity in the intervals of quiescence between the periods
of progressive movements. [Author’s abstract. ]
Tsubura, S. INCREASED INTRACRANIAL PRESSURES AND MEDULLARY
ev theo ot btite exper. bath, V, 28)l.. Med. Sc. |
Raised intracranial pressure acts first on the respiratory center, causing
transitory hyperpnea, followed by sudden stoppage of respiration. The
findings agree with those of Dixon and Halliburton. The centers next
to be affected are the cardio-inhibitory and vasoconstrictor centers, in
the form of an increase in the tonus and in reflex excitability. There are
indications also of alterations in the cardio-accelerator and vasodilator
centers. The vasoconstriction affects the whole body. There is some
liberation of adrenalin, but this does not represent an important factor
in causing the rise of blood-pressure. High pressures lead to paralysis
of the cardio-inhibitory, and finally of the vasoconstrictor centers. The
effects produced are partly the result of anemia, and partly due to the
diminution of blood-flow, with attendant accumulation of waste products.
[Author’s abstract. ]
Estable, C. SrruCTURE OF THE CORTEX CEREBELLI, WITH SOME PuHysI0-
LoGicaL Conciusions. [Trav. lab. rech. biol, XXI, 169. Med. Sc.]
This long paper does not add much to our knowledge of the structure
of the cortex cerebelli as expounded by Cajal’s school; it is, however,
worth mentioning because investigations were carried out in a number
86 CURRENT ‘LITERATURE
of mammals and birds, and because it contains at the end some physio-
logical considerations which are summarized by the author about as
follows: the cortex cerebelli is endowed with at least two functions which
are carried out by two distinct systems of histological elements: one
formed by the Purkinje cells and climbing fibers, and one consisting of
the remaining neurons and the moss fibers. Without considering the
two systems as truly isolated entities, one may safely assume that the
latter or “ omnicellular moss fibers system” presides over the cerebellar
functions of coordination and equilibrium, and that very likely the moss
fibers have a vestibular and medullary origin. This does not exclude
the possible derivation of the climbing fibers from the same regions. The
thickness of the cortex cerebelli appears to be related to the size of the
body, development of the muscular system, and conditions of equilibrium
of the animals considered. In birds and Cheiroptera the layer of basket
cells increases at the expense of the small stellate cells (granules of the
molecule layer). The so-called baskets or nests of the Purkinje cells are
entirely formed by the descending collaterals of the basket cells (deep
stellate cells) of the molecular layer. The basket fibers converge towards
the cone of origin of the axon of the Purkinje cells, but never anastomose
or show phenomena of incrustation. The axon of the granules of the
molecule layer is frequently provided with a terminal pear-shaped
enlargement by means of which it ends on a protoplasmic process of a
Purkinje cell; this form of synapse is analogous to that occurring between.
the collaterals of the basket cells and the body of the Purkinje cells.
[C. da Fano. ]
5. PEDUNCLES; MIDBRAIN.
Dresel, K. A Doc WitHout HEMISPHERES AND STRIATUM. [Klin.
Woch., Dec. 2, 1924.]
This well known investigator here reports upon an experimenta:
research during which he has kept a dog alive for three months after
the extirpation of both hemispheres and of the striate body. It was still
able to learn things and look for food but lacked spontaneity and only
showed defense flight to all stimuli. Its food had to be put into its.
pharynx. Unilateral extirpation was followed by menagery movements.
toward the operated side. Turning toward the opposite side was impos-
sible. The substantia nigra degenerated early; no rigidity was observed,.
only propulsion and retropulsion in the dog operated on both sides. The
differences between experimental animals and man is that without the
hemispheres man behaves approximately like a dog without both hemi-.
spheres and the striate bodies. [Fortunately he does not conclude as do:
many pseudo physiologists who have made extirpation experiments that
because his dog lived the removed structures were of no importance: the:
spleen for instance, or the tonsils, etc. ]
SENSORI-MOTOR NEUROLOGY 87
Ratner, J. Tumor or INTERBRAIN. [Klin. Woch., March 26, 1925.]
A clinical study with pathological examination of a case of endo-
thelioma which was found compressing the paraventricular region and
hypothalamus. Macroscopic changes were absent in the tuber cinereum,
the pituitary or other endocrine glands save for an atrophy of the thyroid.
Pluriglandular insufficiency symptoms had been marked.
Mella, H. DiENCEPHALIC CENTERS CONTROLLING ASSOCIATED LOCOMOTOR
Movements. [Arch. Neurol. & Psychiat., X, 141. Med. Sc.]
The syndrome of paralysis agitans is often described as consisting of
three elementary components, muscular rigidity, tremor, and the loss of
what are called “ automatic associated movements.” These movements are
supposed to be represented in and activated by the corpus striatum, and
it is with the object of throwing further light upon this localization that
Mella’s observations have been undertaken. His experiments were all
of the acute nonsurvival type, only one of his cats surviving for more
than two hours. Transections of the brain were performed at various.
levels cephalad to the plane of the tentorium, and it was found that in
the more anterior transections, approximately 10 mm. cephalad to the
tentorium and severing the hemispheres and part of the basal ganglia,
the animal showed moderate extensor rigidity and responded to cutaneous.
stimuli by the performance of reflex movements of all four limbs of a
form suggesting locomotion. On subsequent transection, not more than
5 mm. cephalad to the tentorium, more marked decerebrate rigidity devel-
oped and the reflex movements mentioned above could not be elicited.
Mella concludes that a mechanism controlling these “associated move-
ments” must lie between the two planes of transection in a region com-
prising part of the corpus striatum and the corpus Luysii.
{It is a familiar observation that decerebrate preparations in which
transection has been made at the cephalad limits of the region within
which it must fall to produce the rigidity often show powerful walking
and leaping movements, though they do not possess the full range of
reflex coordination of movement and of posture shown by the thalamus
or midbrain preparations (Medical Science, 1922, VII, 109). In part
these activities may be the immediate and stimulating result of transection,
but for the rest they are reflex, and their analysis and their anatomical
representation in the brain-stem have already been determined with a
degree of accuracy and precision which renders us independent of Mella’s.
experiments. It is clear, also, that the diencephalic structures invoked
by him are not concerned in their production, since they occur in the
midbrain preparation. Moreover, irradiation of reflex movements is not
peculiar to these preparations, for it is seen in the bulbospinal animal
(Sherrington).
On the other hand, it is difficult to see in what way these observations
can throw any light upon the genesis of the Parkinsonian syndrome. The
88 CURRENT LITERATURE
reflex movements seen in the animals operated upon by Mella are in no
way comparable with the so-called automatic associated movements said
to be lost in paralysis agitans, nor is the rigidity of this disease compar-
able “with that seen in decerebrate preparations in which the movements
described by Mella have been abolished.
In fact, the constantly repeated statement that the peculiar facies,
stance, gait, and type of voluntary movement of paralysis agitans result
from the loss of a specific type of automatic associated movement having
its central representation in the corpus striatum rests upon a wholly
speculative basis. In addition to his tremor and diffuse muscular rigidity
the subject of paralysis agitans shows a slight but appreciable lack of
force, a slowness of execution, a limitation of range, and an unduly ready
fatigue in all voluntary movements. There is no true paralysis, but the
play of emotional expression and of gesture and the movements of arms
and trunk which lend spring and life to the motor activities of the normal
individual, are greatly diminished or lost, hence the characteristic facies,
stance, and gait of patients with this disease. We are not, however, called
upon to speak of this loss as that of a specific type of movement controlled
by the corpus striatum. All that the facts allow us to state is that the
movements lost are of a kind which are normally carried out with a
minimum of muscular force. The energy involved in a transient facial
expression must be very inconsiderable. In short, the movements lost
are those which must be the first to be “ damped down” and extinguished
by the slow development of that diffuse muscular rigidity which later
becomes the prime factor in the causation of that slowness of execution,
limitation of range, and ready fatigability of movement which are charac-
teristic of the fully-developed malady. As rigidity increases the patient’s
facies becomes more fixed and masklike, his movements more monotonous
and restricted to the absolutely essential components, until finally, in a
few instances, we see a helpless and bedridden individual fixed in a per-
sistent and characteristic attitude of flexion. It seems possible, therefore,
that the so-called loss of automatic associated movements is simply the
clinical expression of a developing rigidity in the musculature, which
naturally exerts its first and most striking effect upon those movements
which are carried out normally with minimal force. It will be objected
that the Parkinsonian facies and movement exist in the absence of any
demonstrable rigidity, and cannot be attributed to this cause. It must
be remembered, however, that our clinical tests for increased muscular
tone are of the crudest description, consisting simply of passive movements
of the limbs and the estimating of increased musctilar resistance by this
means. Clearly, muscular rigidity must be gross before it can be detected
by this rough device, and we are not, therefore, in a position to exclude.
rigidity as underlying the symptoms in question. If this interpretation
be correct, then the two elementary components of the syndrome are
rigidity and tremor, for, although the latter has been loosely spoken of
SENSORI-MOTOR NEUROLOGY 89
as ‘rigidity spread out thin,” the true relation of these two phenomena
has not been elucidated by the reiteration of this aphorism, and remains
obscure. It seems, then, that Mella’s experiments have been directed to
the cerebral localization of a type of movement in the existence of which
there is no reason to believe, and are based upon hypothetical notions of
the physiology of the corpus striatum for which there is no convincing
evidence. [F. M. R. Walshe. ]
Zingerle, H. Posture REFLEXES IN Man. [Klin. Woch., Oct. 7, 1924. ]
Clinico-physiological résumé of the automatic changes of posture
which may be induced by passive movements of the head or extremities
in subjects reclining with closed eyes. Subcortical reflexes may be investi-
gated by his technic.
Ingvar, S. ON THE PHYLOGENESIS OF THE MIDBRAIN, WITH SPECIAL
REFERENCE TO THE Optic THALAMUS. [Deutsche Ztschr. f. Nerven-
Meikle OI 302. Ned: Sc.)
The optic thalamus is built according to the same general plan in
reptiles, birds, and mammals, while the architecture of the cerebral hemis-
pheres differ very considerably in these classes of animals. As is well
known, the cerebral cortex of birds, for instance, is very little developed,
while their corpora striata reach dimensions which, in proportion to the
cortex, are almost gigantic. This means that the general plan of structure
of the optic thalamus is not influenced by that of the hemispheres. The
optic thalamus must, therefore, have an autonomous specific function, that
is to say, independent from that of the hemispheres. [C. da Fano. ]
Adler, E. LocaLization oF CENTER FoR SLEEP. [Med. Klinik, Sept. 21,
1924. |
Pathological study of a patient who had died from infectious endo-
carditis. She had lain in a lethargic condition for two weeks due to an
embolism in the gray substance to the left of the third ventricle with
abscess formation. There was also an affection of the right side and
of the left hypothalamus and thalamus. The lesion he assumes may have
blocked the incoming stimuli, thus affording some support to the Mauthner
and related hypotheses concerning the physiopathology of sleep.
Rogers, F. T. Stupigs oN THE BRAIN-STEM. VIII. DiureEsis AND
ANHYDRAEMIA FOLLOWING DESTRUCTION OF THE ‘THALAMUS.
IX. On THE RELATION OF CEREBRAL PUNCTURE HYPERTHERMIA TO AN
ASSOCIATED ANHYDRAEMIA. [Am. J. Physiol., LXVIII, 499.
Med. Sc. ]
In previous papers the author has recorded the fact that destruction
of the thalamus in birds is followed by rapid loss of weight’ and inability
to maintain the temperature. Further analysis of this phenomenon shows
that this loss of weight is due to an excessive loss of water through greatly
90 CURRENT LITERATURE
increased diuresis. Under standard conditions of feeding and external
temperature water is lost at the rate of 10 to 60 per cent of the body
weight per twenty-four hours as compared with 4 to 7 per cent in normal
fasting birds. The more rapid the loss of water the quicker the animal
dies. Simple decerebration is not followed by diuresis provided the thala-
mus is left intact. Traumatism of the hypophysis is not necessary to
produce the effect. This is in agreement with previous observations of
Bayley and Brewer, who elicited a similar diuresis by a minute hypothal-
amic lesion, without decerebration, and with minimal disturbances to the
third ventricle. As a result of recent work the question has been raised
whether some. of the effects observed after experimental lesions of the
pituitary might not actually be due to the accidental injuries to the base
of the brain, and these observations seem to answer that question in the
affirmative. In order to maintain the birds at their normal temperature
of about 40° C. after destruction of the thalamus, it is necessary to keep
them at a temperature of about 30° C. In such animals a hyperthermia
may develop if the loss of water is sufficiently rapid and severe. It is
pointed out that the hyperthermia in these experiments was induced by a
cerebral lesion without involvement of hypothetical temperature-regulating
centers in the corpus striatum. It has also been shown previously that
complete removal of both corpora striata does not in itself lead to dis-
turbances of temperature regulation.
Hirsch, EH. SLeep AREAS IN THE Mipprain. [Med. Klinik, Sept. 21,
1924. |
This clinical and pathological study permits the author to support an
idea that lesions of the oculomotor nuclei and of the thalamus bring
about lethargic conditions. He draws the wider inference of a fictional
“sleep-center.”
Ill. SYMBOLIC NEUROLOGY.
3. PSYCHOSES.
Menninger, Karl A. Ture THyromp AND Psycuiatry. [Southwestern
Medicine, Nov. 1923.]
This is a brief article contributed to a symposium on the thyroid
gland, illustrating with a number of psychiatric cases that while we are
as yet too ignorant of the exact role of endocrine elements to be dogmatic,
certain deductions about the thyroid, which is apparently concerned with
the physiology of the emotions, may be safely made; (1) nervous symp-
toms may be the first indication of hyperthyroidism (exophthalmic goiter)
as well as of other endocrine diseases; (2) mental defect often arises
upon a basis of hypothyroidism, and we should look for these because
they can be cured; (3) insufficient and perverted thyroid secretion
SYMBOLIC NEUROLOGY 91
may produce nervous and mental symptoms which are amenable to
treatment. (Author’s abstract. )
Hoffmann, H. ScuizorHymia-CycitotHyMia. [Zschr. f. d. ges. Neur.
tee sve) Ol. LOAN Le]
Hoffmann has followed up with rich result Kretschmer’s report of
investigations in the Lundborg family. Preponderating schizoid anom-
alies were found in the family relationship of schizophrenics while in the
families of the few circular cases predominantly cycloid individuals were
found. Hoffmann uses the word “change of symptom” rather than
“change of dominance,’ which he had used before, to denote the fact
that not infrequently a predominantly schizoid individual later shows a
cycloid character and vice versa.
Buscaino, V. M. DEMENTIA PRAECOX AND SOME HISTOLOGICAL FINp-
Incs. [Schw. Arch. f. Neur. u. Psych., 1924.]
Peculiar grape-shaped conglomerates are found by this investigator
in the white and extracortical gray substance of the brain. In dementia
precox various types of amentia including delirium tremens, and in the
brain of rabbits poisoned with histamin. He also found some amins in
the urine of such patients, and believes that they originate in the
duodenum.
Pogorschelsky, H. MoncoLian Ipiocy In Cousins. [ Monat. f. Kinderh.,
April, 1924. ]
These cousins aged eighteen and five months, respectively, showed
definite mongoloid symptoms.
Steck, H. NerurotocicaAL RESEARCHES UPON SCHIZOPHRENICS. [Zschr.
f.-d, ges. Neur. u. Psych., Vol. LX XXII. ]
Steck reports from extended investigations upon 400 schizophrenics
that a large number of neurological disturbances are present quite gen-
erally in the catatonic group but a pathognomonic reflex formula cannot
be assumed. Catalepsy, akinesia, hyperkinesia, the Rtissel reflex and
waxy complexion and other symptoms show connection with striate
disturbances and point back to the basal ganglia. Disturbance of the
apparatus of the basal ganglia is effected physically as well as psychically.
Pellini, E. J.. and Greenfield, A. D. PRESENCE oF Toxic SUBSTANCES
IN BLoop SrruM IN MorpuHin HasitruaTion. [Arch. Internal Med.,
May, 1924.]
In this study the authors failed to find any toxic substance in the
blood of dogs habituated to morphin. The blood serum of these dogs.
did not produce circulatory disturbances in normal animals into which
the serum was injected. They dispose of a lot of rubbishy biochemical
eoreseaTcnh.”
92 CURRENT LITERATURE
Jamin, Fr. PsyCHIC INFANTILISM. [Zschr. f. d. ges. Neur. u. Psych.;
Vol -LAXXITIF
Jamin discusses the frequent disturbances evident in the years before
puberty, from ten to twelve in boys and seven to nine in girls. They
are lassitude, divertibility of attention, disturbances of sleep, ill temper,
excitability, shut-in disposition, tendency to affective outbreaks, untruth-
fulness decked out phantastically, terrifying dream pictures, running
away, impulsive actions. He believes the cause may lie in disturbance
of the endocrinous balance which often will be restored. The treatment
therefore may be predominantly that of waiting.
Pierce, B. Menta States IN ALcoHOLISM. [Lancet, April 26, 1924. ]
Pierce reviews the alcoholic psychoses, the effect of a single dose
of alcohol on inhibition and on instinct. He suggests that the primary
influence of alcohol is on the vegetative nervous system. That it pro-
duces a dilatation of the peripheral vessels is well known, and possibly
it also acts on the nervous mechanisms involved in the expression ot
the emotions, including the endocrine organs. But where so much is
vague and uncertain it is difficult to draw conclusions. Until more is
known’ of the physiology of the nervous system and its relation to
instinct, it will be impossible to speak with confidence on the mental
action of alcohol.
Claude, H., et al. DementiA Precox. [Encéphale, Vol. 19, March.
Ae oie |
Claude, Borel and Robin emphasize the fact that all forms of schizo-
phrenia are not identical with true dementia precox. Three stages
can usually be observed in the development of the disease: first, Kret-
schmer’s schizoid predisposition—not a pathologic condition; then, after
certain exciting causes, comes a period of schizomania—that is, losing
touch with reality by living an introverted, autistic life. This is fol-
lowed by a “dislocation” of psychic functions, in which an entire
maladaptation of the individual occurs. This stage may be considered
real dementia with total disintegration of the intellectual, emotional and
volitional spheres. It should, however, be differentiated from the pre-
ceding stage of schizomania in which only the higher synthetic functions
are lost. The course may be rapidly progressive from the first, or the
third stage may not develop until late in life, or never.
Jacobi, W. Psycuratric INTERFEROMETRIC StupiEs. [Zschr. f. d. ges.
Neur. uu. Psych, Volk UX2-X 111]
Jacobi reports some of the results obtained by the use of the Lowe-
Zeiss interferometer to test the defensive ferments in psychiatric cases.
The large amount of material affords support to the majority of findings
by other methods. Suggestive indication was obtained of the pathological
physiology of the psychoses though no light was thrown upon differential
SYMBOLIC NEUROLOGY 93
diagnosis and prognosis. Even in normal individuals there is found
deterioration of internal secretory organs but less in them, in hysterics
and in the manic-depressive than in epileptic dementia, general paresis,
demeaitia precox and amentia. The serological formule permitted one
to assume no relation with the clinical course not even in general paresis
with brain destruction. In dementia precox the chief value was found
in the deterioration of the sex glands, the least in that of the brain,
though even here a large number was obtained. No special types of
deterioration could be found in the subgroups of dementia precox. The
method shows no marked sex specificness. Closer relations with the
reactions of Sachs and v. Oettingen or with those of Neumann and
Hermann were not evident.
Oksala, H. PRESENILE PsycHoses. [Ztschr. f. d. ges. Neur. u. Psych.,
Wola AA, Noss 1,92:]
Oksala reports clinically and histologically three cases which were
diagnosed in the Munich clinic; two as presenile pernicious psychoses
and one as anxiety psychosis. Histologically the first two cases hac
much in common while the third differed. Oksala does not consider the
distinction from acute schizophrenic disease sufficiently clear either
clinically or histopathologically but believes that a study of the heredity
may furnish light. |
Claude, H., and Brousseau, A. NATURE OF DEMENTIA Precox. [Bulletin
Méd., March 29, 1924. ]
These authors distinguish two main types under the dementia precox
group. One type of simple puerile self-absorption, degenerative and
mental weakness of emotional nature, and a second type consisting in
illusions and hallucinations complicated ideational delusions with retained
but split mental activities.
Woltman, Henry W. THe MenTAL CHANGES ASSOCIATED WITH PERNI-
cious ANEMIA. [Am. Jl. Psych., Vol. 4, Jan.]
Recently evidence has been produced that may shed new light on the
etiology of pernicious anemia. Briefly, it has been shown on biopsy
and necropsy evidence that the achlorhydria is not the result of atrophy
of the gastric mucous membrane, as heretofore taught, but represents a
prmiary, constitutional, familial deficiency, present from infancy.
Achylia has been found to be present in a large percentage of other
members of the families of pernicious anemia patients. Some of these
were only four years of age. It is only on such an abiotrophic basis,
supposedly, that pernicious anemia may develop. Furthermore, Naegeli
has demonstrated that hemolysis is often lacking, and regards a primary
bone marrow deficiency as the important conception.» The frequent
appearance of pernicious anemia in families may find its explanation
here.
94 CURRENT LITERATURE
The onset of the symptoms pointing to a neurotoxic process, and the
appearance of anemia, do not coincide, as a rule. It is well known that
cord changes may precede the appearance of the anemia. This also
holds true for the psychoses, as Langdon first pointed out in 1905, when
he referred to the condition as pernicious anemia. For this unorthodoxy
he was severely berated; however, the possibility is now widely
acknowledged as fact.
It is possible that nervous changes may progress to a fatal issue
without the appearance of anemia. Presumably we may be confronted
with the paradox of pernicious anemia without anemia. It might not
be an idle speculation to venture that certain cases of psychosis may
progress likewise.
There must be something fairly characteristic in the mental picture
of patients having pernicious anemia to prompt the observation so
frequently made by internists that “these patients are different in some
way from other patients; they listen to what you say, they do not argue,
they raise no objections; they are almost too good.” Numerous writers
have referred to apathy, indolence, decreased mental work, loss of mem-
ory, delirium, stupid indifference to surroundings, to external impressions,
and to the disease itself, instability, shallow confusion with impairment
of ideas of time and place, abeyance of the mind, loss of inhibition,
peevishness, gradual mental deterioration varied by control, patience,
good temper and an angelic disposition for longer or shorter intervals,
somnolence with a tendency on being aroused to exhibit a certain degree
of mental confusion, particularly to surroundings, which may manifest
itself in a delirium of a low, quiet type, a continuance of the dream
state which the patients cannot shake off on being aroused, and which
usually subsides spontaneously, or on further stimulation (Lazarus,
Pickett, Langdon, Church, Siemerling, Pontoppidan, and Petrén).
While such patients do give one the impression of apathy, this con-
dition seems to be physical rather than mental and emotional. On
better acquaintance with patients having pernicious anemia one learns
that they are usually depressed and apprehensive; affable like a tuber-
culosis patient, but without hope. Although they do not have pain,
they suffer with annoying and persistent paresthesias, rapid fatigue,
disturbance of taste, sore mouths, flatulence, diarrhea, and vague visceral
sensations, all of which lead them to the conviction they so frequently
express, that “there must be something serious the matter.” Hunter
is no doubt right in deprecating the appellation “ pernicious,” because
this in itself does not instill confidence in the patient regarding the
physician’s ability or his own to combat the disease. A psychosis may
appear at any time. Many very excellent contributions covering this
subject have appeared. Those of Marcus, Barrett, and Lurie are par-
ticularly important. Barrett emphasizes the frequency of this condition
in psychopathic wards. In 650 necropsies on the insane in Michigan,
SYMBOLIC NEUROLOGY 95
pernicious anemia was found in 15 (2.3 per cent). Weisenburg gives
the incidence of mental symptoms as 40 per cent, and emphasizes the
diversity of reactions. In 647 cases, Cabot found 102 (15 per cent)
in which there were mental symptoms: delirium in 44, delusions in 14,
hallucinations in 8, dementia in 9, melancholia in 3, and mania in 3.
Of 1,498 patients with pernicious anemia, who were seen in the Mayo
Clinic since July, 1914, about 4 per cent presented an outspoken psy-
chosis. It is to be remembered that most of these are still ambulatory
patients; how many more may develop a psychosis before death cannot
be determined. Thirty-five and two-tenths per cent show lesser mental
changes, manifest even on casual observation. It may be added that
these patients were all carefully studied from hematologic and serologic
standpoints, gastric and stool examinations were made, and the cases
passed on by experienced internists. Another criticism may be answered
here with regard to bothriocephalus infections in Minnesota. While
this intestinal parasite is relatively common in Minnesota as compared
to its incidence in other states, actually it is rarely found, even by
physicians practicing among the Finns in the northern part of the state.
Even infected patients do not often present the typical blood picture
of pernicious anemia, and free hydrochloric acid is often present on
gastric analysis.
Barrett sums up the psychotic picture by saying that these patients
have in common, irritability and suspiciousness, which forms the ground-
work for delusions of persecution, the content of which is usually influ-
enced by the somatoneurologic findings. He places this condition among
the paranoid states which are symptomatic of a toxic process affecting
the nervous system.
Bonhoffer considers cases of pernicious anemia with a_ psychosis
indistinguishable from the infection psychosis. Putnam and Taylor em-
phasize the exaggeration of native traits. All four of Lurie’s patients,
and the patient recently reported by Darden and Hall, had delusions of
persecution. The psychosis may for a time closely resemble dementia
precox, dementia paralytica (Marcus, Camp), or Korsakow’s psychosis
(Bonhoffer, Barrett).
Why it is that some patients develop a psychosis while others do not,
is a question hard to answer. It may be that constitutional factors play
the deciding part; this was very evident in some of our cases, but by
no means in all. Hereditary predisposition is stressed by Putnam and
Taylor, Marcus, and Barrett. Bonhoffer believes these symptoms may
occur in patients otherwise well and without hereditary taint. The
care with which this point is inquired into, as well as an estimate of
the same factors in patients who do not develop a psychosis, is, of
course, of greatest importance. Too often this point is entirely over-
looked in the nonpsychotic group, which results in a conclusion that
is entirely distorted and erroneous. Patients who pass through mild
96 CURRENT LITERATURE
and transitory psychoses are not likely to enter a psychopathic hospital ;
those who develop the more severe and lasting psychoses, and who are
in consequence hospitalized, may present an altogether different family
history. From the study of our cases it would appear that patients
having a poor endowment and who are inherently unstable develop
psychoses more readily.
To be sure pernicious anemia may be expected to exert a modifying
influence on the psychotic picture of patients suffering from an unrelated
type of psychosis, such as manic-depressive insanity, just as syphilis
may color the psychotic picture of a patient suffering from some other
type of major psychosis.
It is usually said that the mental disturbances proceed pari passu
with the intensity of the anemia. This may be true so far as mild
confusional states go, but it does not invariably hold for cases in which
the more marked mental disturbances are exhibited. Indeed, the same
discrepancy seems to obtain here that has been noted with regard to
the cord and peripheral nerve changes, which may fluctuate with entire
independence of the degree of anemia.
The same lack of parallelism may exist in diabetes mellitus, as
shown by Singer and Clark. Here, too, the psychotic picture closelv
resembled that seen in pernicious anemia.
Just what influence the pathologic changes have in the production
of a psychosis cannot be determined with certainty. They, no doubt,
contribute to its development, yet they may be found in patients who
have not had mental disturbances.
Pernicious anemia is important as a cause of mental disturbances;
pernicious anemia is more common than is generally believed; this
disease often escapes detection unless a low threshold of suspicion
regarding it has been developed. (Author’s abstract. )
Breukink, H. TREATMENT OF CERTAIN MeEntTAL AFFEcTIONS. | Ned.
Tijd. y. Gen., Vol. 68,. Marchi) J2ASMiA
Breukink explains his method, which differs from Breuer’s and
Freud’s in important respects, and is peculiarly useful in differential
diagnosis and prognosis. “ When it is possible to hypnotize the patient,
his affection is curable.’ He gives instances of degenerative psychoses
which had long been mistaken for dementia precox, but which yielded
to proper treatment. The injury.from herding such cases with dementia
precox is obvious.
Hermann, J. HistopATHOLOGY OF DEMENTIA PRAEcOX. [Zschr. f. d.
ges. Neur. u. Psych., LXXXVI.]
Hermann presents a very valuable study of about 50 cases in which
extensive brain alterations could be demonstrated. Extensive fatty
degeneration and sclerosis of ganglion cells were found, still more marked
foci of destruction and diffuse cellular loss which were evident to some
SYMBOLIC NEUROLOGY ff
extent in Brodmann’s 5th layer but for the greater part in the 3d layer.
There were found also neuroglia foci in the medullary ridge such as
Walter has described. The greater number of the changes lies in the
cortex though many times changes were evident also in the deeper gray
substance, found in one case in the globus pallidum, a case with marked
catatonic symptoms. In a case with epileptiform attacks, death occurring
in status, there was acute cell disease (Nissl) with typical neuroglia
reaction and foci of atypical neuroglia cells (Alzheimer).
Alford, L. B. DEMENTIA PREcox, A Tyre or HEREDITARY DEGENERA-
TION. [Journal Missouri State Medical Association, January,
Sead 1.4
Since pathological studies have been inconclusive and _ etiological
studies of various sorts have brought forth no positive evidence, the best
chance of knowing the pathological process at work in dementia precox
is probably from analogy. By virtue of its peculiar nature, the onset
without exciting influence, the chronic and progressive course and the
absence of demonstrable etiology other than heredity, it resembles most
the degenerative conditions that come from an innate weakness of certain
structures. These are more numerous than is generally supposed; they
are about 50 in number altogether, some which may be mentioned being
progressive muscular atrophy and dystrophy, Friedreich’s ataxia, Hunt-
ington’s chorea, familial essential tremors, familial optic atrophy and
otosclerosis. Each condition is entirely distinct from the other and has
its peculiar set of affected structures. Structures seem to be affected in
accordance with function rather than by virtue of anatomical relation.
What occurs in the higher level types, where pathology is obscure must
be assumed by comparison with tnose involving lower levels at which
pathological changes are definite. Dementia precox is thus assumed to
be one of the group of hereditary degenerations having its own set of
structures which are affected by the degeneration. It should be studied
in relation to other members of the group. Future investigation should
concern various aspects of heredity. [Author’s abstract. |
Dunlap, C. B. DreEMeENTIA PRAECOX. [Amis Psych. Vol A& Jan?)
This is a careful study of brain changes on the basis of eight cases.
Dementia precox is less a structural brain disease than pellagra or
alcoholism according to Dunlap. In both of the latter conditions
changes, if present in the brain, are not primary but are secondary, not
so much to varying somatic conditions as to fairly specific somatic
conditions. Dunlap’s study strongly indicates that dementia precox is
completely lacking in any fundamental or constant alteration of nerve
cells, though it shows, at times, within the brain the presence of nerve
cell changes secondary to those varying somatic states found in so-called
normal control cases. Dunlap suggests that any nerve cell alterations
that may be seen in dementia precox, might be termed a reaction of the
98 CURRENT LITERATURE
nerve cells to various, mostly unknown, somatic conditions (plus post-
mortem and technical factors) such as operate in controls. Since these
nerve cell reactions in dementia precox seem in no way specific and are
not constant or uniform; since they do not differ materially in degree or
in kind from changes in the cells of control cases, it is justifiable to
believe that they are dependent on the same general causes that operate
in the controls and not on any special conditions existent in dementia
precox. In other words, the cell changes found do not seem related to
dementia precox.
Targowla, R., and Badonnel, M. KipNEy FuNcTION IN MENTAL Dis-
EASE), [Pr. Media Sept<8,1923.4
The ureosecretory coefficient and the elimination of phenolsulphone-
phthalein is here studied in patients suffering from various psychoses.
Impaired function of the kidneys was frequent, especially in states of
confusion, mania and melancholia. Diuretics are without effect, but
function becomes normal with amelioration of the mental state. Among
twenty-two cases of paresis insufficiency of the kidneys was found in
nineteen.
Lisser, Hans and Nixon, Chas. E. Mentrat RETARDATION AND DUCTLESS
GLAND Disease. [J.A.M.A., Vol. LXXXIV, Oct. 6]
Cases of mental retardation in which outspoken ductless gland disorders
could also be detected are here recorded. The mental retardation was
definite in all, and the endocrine disturbances were likewise obvious. It
is indicated by the authors that a glandular origin for the mental retarda-
tion must remain for the present an unproved theory. It is noted, how-
ever, that thyroid feeding definitely advances the intelligence of mentally
defective subjects of congenital myxedema. When pituitary extracts of
similar potency are available, comparable results may be achieved in
mental defectives, the subjects of dyspituitarism. Since the proof of
such a contention hinges on mental improvement by appropriate organo-
therapy, it is stated that considerable experience with pituitary prepara-
tions now available has resulted in suggestive and encouraging results in a
few instances, but not sufficiently striking or consistent to prove the fore-
going hypothesis at present.
Vivian, M. Morreuine Hasit. [Med. Press and Circ., Nov. 29, 1922.]
M. Vivian states that she has found emetine to be a valuable aid in
the treatment of patients suffering from the morphine habit. Her plan
is to reduce very gradually the dose of morphine to 0.06 gram (one
grain) a day, several weeks being allowed for this reduction. The dose
0.06 gram a day is then reduced over a period of six to twelve months
by five milligrams at a time until no morphia is taken. Emetine
hydrochloride is given hypodermically from the first, 0.01 gram thrice
daily for one or two months and then 0.01 gram twice a day until the
fa
SYMBOLIC NEUROLOGY 99
treatment is completed. The author quotes Paton as her authority for
this treatment and refers to his statement that emetine is a specific for
alcoholism and for some forms of neurasthenia associated with dyspepsia,
irregular action of the bowel and feeling of fatigue.
Roasendi, G AuTOPHAGIA AND AUTOMUTILATIONS IN MENTAL Di1s-
ORDERS. [Policlinico, May 7, 1923.]
Three cases of automutilation in paresis are here recorded. One, a
‘man, cut off a finger to suck the blood; another ligated the scrotum. A
young woman during an epileptic equivalent sliced off a toe with a painful
corn. The hemorrhage very nearly proved fatal, but the epilepsy seemed
to be arrested thereafter.
Burt, C. Cavusat Factors oF JuvENILE Crime. [Br. Jl. of Med.
Perce ate 1023.0). Ase AL]
Nearly 200 cases of juvenile delinquency, and, as a control. series,
400 normal children have been investigated by Burt in parallel inquiries;
and the various adverse conditions, discoverable in their family history,
in their social environment, and in their physical, intellectual and tem-
peramental status, have been ascertained and tabulated for each group.
Delinquency in the young seems assignable, generally, to a wide variety,
and, usually, to a plurality of converging factors; so that the juvenile
criminal is far from constituting a homogeneous psychologic class. To
attribute crime, in general, to either a predominantly hereditary or a
predominantly environmental origin appears impossible; in one individual
the former type of factor may be paramount; in another, the latter;
while, with a large assortment of cases, both seem, on an average and in
the long rum, to be of almost equal weight. Heredity appears to operate,
not directly through the transmission of a criminal disposition as such,
but rather indirectly, through such congenital conditions as dulness,
-deficiency, temperamental instability, or the excessive development of some
single primitive instinct. Of environmental factors those centering in
the moral character of the delinquent’s home, and, most of all, in his
personal relations with his parents, are of the greatest influence.
Psychologic factors, whether due to heredity or to environment, are
‘supreme both in number and strength over the rest. Emotional condi-
tions are more significant than intellectual; while complexes provide
everywhere a ready mechanism for the direction of overpowering instincts
-and of repressed emotionality into open acts of crime.
BooK REVIEWS
Barbour, D. N. PsycHo-ANALYSIS AND EvERYMAN. [Geo. Alle
& Unwin, Ltd., London. |
That there is psychoanalysis and psychoanalysis. everyone with a
grain of sense should know. The name and the thing should not be
confused. The Atlantic City boardwalk fakir who uses the term
on his billboard deals as little with the real article as quacks do with
any real aspect of medicine, but such is the magic of words that even
the supposedly intelligent fail to distinguish between this type and
the kindred echoes found in such magazines as Occult Science,.
Psychology, etc.
When a popular exposé really seems to get an idea of the outlines.
of the psychoanalytic principles we welcome it, and this book does in
our opinion present a clear and explicit account of some of the
current ideas which have been developed by psychopathology in
this field.
The author puts in some of his own ideas in his exposition and.
here and there alters the technical terms, but apart from questions of
exact logic these interpolations do not interfere with the fact that
this is a fairly readable and comparatively accurate account of the
general conceptions of psychoanalysis. It is particularly interesting
as it applies the principles to everybody, not to that fictional non-
existent person only, “ the abnormal.”
Ward, Stephen. Etuics. AN Historicat INtTrRopucTION. [Oxford
University Press, London. |
In the author’s Preface we read that “ philosophers know noth-.
ing,’ for after all “ philosophy is largely a wrangle.” We are dis-
posed to agree with him and thus all the more pleasantly turn to his
historical resumé of what different times, as precipitated by different
philosophers, have thought about what in general is meant by ethics,
Here is certainly a charming primer from which no one can turn
after reading it without the sense that they have gained something”
very real and valuable.
Dewey, John. EXPERIENCE AND NATURE. [Open Court Publishing
Co., Chicago
Dr. Paul Carus of Chicago was a striking figure in the intellectual’
circles of that city especially in its formative stages. After his death:
his family established a Paul Carus Lecture memorial. This present
volume, by Professor Dewey of Columbia, is the first fruit of this.
lectureship.
[100]
BOOK REVIEWS 101
In all respects it is a happy choice, for the present volume sets a
standard of the most superior character. Dr. Dewey’s lectures are
delightful; no amount of characterization in-a book review can
convey their many-sided, interesting, and humanistic qualities.
The title alone shows just what to expect. Human experience
in its contact with nature is most charmingly portrayed, and through
it all runs a vein of healthy, sturdy contact with reality rather than
a pedagogic effort to encompass the universe. We feel our readers
will profit greatly in their reading of this set of lectures.
Grosz, Karl. KLINISCHE UND LIQUOURDIAGNOSTIK DER RUCKEN-
MARKSTUMOREN. [Julius Springer, Wien. Mks. 7.]|
The author is an assistant in Wagner v. Jauregg’s clinic in Vienna
and the clinical material here analyzed was personally observed here
or in v. Eiselberg’s surgical clinic, and checked up either by operation
or by autopsy.
It is thus a clinical document of great value and as such will
prove of great service to neurologist and surgeon interested in spinal
cord tumors. The case histories are given in full and hence no
abstract is possible. The book should be possessed and read.
Carus, C. Gustav. SyYMBOLIK DER MENSCHLICHEN GESTALT. Neu
bearbeitet und erweitert von THEopoR LressING, Dritte Auflage.
[ Niels Kampmann Verlag, Celle. |
This is a curious book. Carus, the author, was born in 1789 and
died at the age of eighty. He was professor of comparative anatomy
and morphology in Dresden and wrote many interesting and unique
philosophical and natural history studies which belonged in general
to the Goethe period and which to the present day contain many
fascinating features which modern students of constitution could
study to advantage.
The book is so well known as to need no extended discussion,
but the present new edition has added materially to many of its
features and rendered it even more interesting. In case one should
care to get an idea of what it is about, it deals chiefly with form
relationships, mathematically considered between the human organism,
its parts, and all the rest of the universe. It is full of ingenious
notions.
Liertz, Rh. Lupwic II. Konic von BAYERN. [Frankes Buch-
handlung, Habelschwerdt 1 Schlef. |
Much has been written of the tragedies of the Bavarian house
of the Wittelsbachs, and the special tragedy of this monarch who
took to his death the gifted neuroanatomist and psychiater, v. Gudden,
has been the subject of much discussion and brought about the use
of printers’ ink galore.
Dr. Liertz does not here attempt a life history of Ludwig II, nor
even a complete discussion of his psychotic evolution. He limits
102 BOOK REVIEWS
himself to a discussion of his ego evolution and to the development
of his delusional system. |
This intriguing story is written from the psychoanalytic stand-
point and interestingly enough the author is a good churchman of
Rome and has written psychoanalytic works stamped by official sanc-
tion from this holy city, evidence possibly that the European church
in this respect is a little more enlightened than some not so centrally
located. One of his works upon psychoanalysis has reached a fifth
edition (13-16 thousand), a record not reached by any with which
we are acquainted.
What strikes us most in this work is its sympathy with human
nature. rather than its formal psychiatric character. It is a very
readable work and throws much light upon the man so much beloved
by many in spite of his illness.
Bruck, Carl. EXPERIMENTELLE TELEPATHIE. [Julius Puttmann,
Stuttgart. ]
In a brochure of 100 pages with 83 text pictures and 24 plates
there is here presented what is entitled “some new investigations con-
cerning telepathic reproduction of drawings.” There is an introduc-
tory chapter by Mrs. E. M. Sidgwick, vice-president of the English
Society for Psychical Research, and Dr. Arthur Kronfeld of Berlin.
The procedure is an old one. The medium or what not is hypno-
tized. A picture is observed very intensively by Dr .Bruck in an
adjoining room and then wrapped up. The medium is then taken
into the room and under suggestion is told to reproduce the picture.
The results are here partly placed in evidence.
Kronfeld assures the reader of the honesty of the entire pro-
cedure and gives a very instructive discussion of the possible signifi-
cance of the phenomena in which he quite nicely emphasizes the
“ubiquity of the occult.” What can anyone really explain about
anything; one may think we understand much but at bottom all life
is a mystery and rationalization is but a special case of seeking
security in the face of the unknowable. The book itself is a much
more interesting document than most of its kind.
Pfeifer, Richard Arwed. MyYELOGENETISCH-ANATOMISCHE UNTER-
SUCHUNGEN UEBER DEN ZENTRALEN ABSCHNITT DER SEHLEITUNG.
[Julius Springer, Berlin. |
We have had occasion to call attention to previous studies of
Pfeifer upon the cortical representation of the optic tracts. He has
here gathered them together, rewritten and rearranged the material,
and given us an up-to-date, thoroughly scholarly, and impressive
monograph. As a pupil of Flechsig’s, he has carried the myelo-
genetic method to its best advantages.
He believes he has something new to say. One can read with
great interest his discussion of the work of his predecessors upon the
optic tracts, von Monakow, Henschen, Niessl, v. Mayendorf, Brouwer,
Adolf Meyer, and others, and gain a clear picture of the development
BOOK REVIEWS 103
of our present day knowledge of certain parts of the central optic
pathways.
The author’s own investigations drawn from the rich collections
of Flechsig are then given in great detail and are beautifully illustrated.
As an anatomical study, and as a justification of the value of the
myelogenetic method, it is of great value, and constitutes a contribu-
tion to the analysis of the optic pathways of distinct service to neuro-
logical science:
Baerwald, R. ZEITSCHRIFT FUR KRITISCHEN OKKULTISMUS UND
GRENZFRAGEN DES SEELENLEBENS. Vol. I, Heft 1. [Ferdinand
Enke, Stuttgart. ]
This is a new periodical to be devoted to a critical study of so-
called occult phenomena, metapsychic, as Richet would call them,
and to borderland problems of the soul. It will appear quarterly in
fascicles of 80 pages each, and the volume of 320 pages will cost $5.
The present initial volume contains much interesting matter.
Among its contributions there is to be found some amusing material
about Houdini’s claims and a large amount of space devoted to Coueé.
Riley, Woodbridge; Peabody, Frederick W., and Humiston,
Charles E. Tue Fairy, toe FALSITY AND THE FAILURE OF
CHRISTIAN ScIENCE. [Fleming H. Revell Company, New
Work etc |
We forbear making any extensive review of this timely book,
knowing how difficult it is to force evolution and that morons are
not alterable by anything but the invincible laws of survival of the
fittest. We therefore simply mention this volume as one of value
for those who are of an inquiring turn of mind and care to learn
thereby of this special form of dementia precox parading as a
religion. One important point, however, has been missed by the
authors. In the last words of the work we find a statement that
robbers demand your money or your life. Science puts it, your
money and your life. Unfortunately, this is not the only healing
pretension built along similar lines. Christian Science never would
have arisen if the regular medical profession had known more of
psychopathology.
Kleist, Karl. DIE GEGENWARTIGEN STROMUNGEN IN DER PSYCHI-
ATRIE. [Verlag von Walter de Gruyter & Co., Berlin and
Leipzig. | |
This is a reprint of some forty pages which most admirably pre-
sents the movement in psychiatry of the past twenty-five years.
Kleist first gives a rapid summary of the evolution of psychiatry in
the past century and then considers the developments of the present
day. He develops four trends which show themselves most strik-
ingly—the philosophical, the psychological, the neurological, and the
constitutional. The first seemed to spring from a discouragement
that arose out of the difficulties of clinical psychiatry in its possible
104 BOOK REVIEWS
overemphasis upon the “ einheit ” of the “ krankheitsbild,” first aris-_
ing through the work of Hecker, Kahlbaum, and Magnan, and carried
into prominence by Kraepelin. The ideas of Bergson, Driesch,
Jaspers, Husserl, and others have afforded a certain support to this
movement, which can be seen most saliently in the work of Schneider,
Kronfeld, and Hildebrandt. In the psychological direction one
encounters some of the previously mentioned workers, and more
particularly those allied to the psychoanalytic movement. The neuro-
logical method, which had its chief stimulus from Meynert,
Griesinger, and Wernicke, is represented widely in the work of Kleist
himself, the Vogts, Pick, and the syndromy “ lehre ” of much present
day psychiatry, and finally in the constitutional trend one encounters
the work of the geneticist, Rudin, especially Kretschmer and related
workers.
This is a very instructive little pamphlet, and coming from so acute
a worker as Kleist is entitled to serious consideration.
Jacobi, Mary Putnam. A PATHFINDER IN Mepticine. With
Selections from her Writings. Edited by the Women’s Medical
Association. [G. P. Putnam’s Sons, New York and London. |
Here is a work that defies reviewing. It is a review in itselfi—a
review of a life of unusual interest and one that stands out in the
annals of biography as unique and worthy of the highest praise.
In the Foreword we read the purpose of this book:
“The Women’s Medical Association of New York City desires
to perpetuate the memory of the work done by one of its founders,
one of the great pioneer women in medicine. She opened the doors
of a great university that women might equally with men obtain a
scientific medical education. All her life she was a zealous worker
for this advancement of the medical education of women. To con-
tinue this, her work, the Association has founded the Mary Putnam
Jacobi Memorial Fellowship, thus far awarded four times, to increase
the medical knowledge of the recipients. The Association in this
volume has collected some of her medical writings, illustrating her
studies on the medical problems of her day. With her writings as
with her other medical work, ‘she was never satisfied. There was
always a better than her best, a higher than her highest to be striven
for; and in this striving she was not influenced by personal ambition,
but by the higher object—the truth to be attained.’ ”’
And it is not without interest that George Haven Putnam, a
nephew, should say—for it is all true what he says:
“Here is the story of a rare American woman—a_ pioneer
scientist, a fine citizen, an admirable mother. Her life is a romance
of accomplishment and an inspiration to the women of to-day for
whom she blazed the trail of feminine independence. The book is
a cross-section of the finest sort of unusual American life and a
biographical contribution of real historic value and far-reaching
interest.”
For many years the reviewer knew and admired this courageous
and gifted woman not only in her professional capacity but in her
ac |.
BOOK REVIEWS 105
home and family life. She did not shine in the reflected glory of her
illustrious husband ; she was a personality as well as he.
Lipschiitz, Alexander. Ture INTERNAL SECRETIONS OF THE SEX
GuaNps. [Williams & Wilkins Company, Baltimore. |
We have commented most favorably upon this important mono-
‘graph elsewhere when it appeared in its original German edition.
The medical profession is to be congratulated upon this most excel-
lent English version with its short but interesting preface by Marshall
of Cambridge.
Lipschutz’s work is one of the most fundamental of those which
have appeared in the field of gonadal endocrinology and is cordially
recommended.
Bloch, Iwan, and Loewenstein, Georg. Dir ProsTiruTion. Zweite
Band. Erste Haelfte. [Louis Marcus Verlagsbuchhandlung,
Berlin. |
The senior author of this work, who died but a few years ago
(1922) at the early age of fifty, was internationally known as one of
the most alert minds dealing with the problem concerned in the direct
forms of sexual behavior in mankind. His contributions have been
numerous and marked by great literary merit as well as careful
observation.
The first volume of this great work on prostitution appeared in
1912 and was reviewed in this JourRNAL. ‘The present continuation
was interrupted by the Great War and then later by his illness and
death but fortunately carried through to a finish by Loewenstein.
This has been done in a highly meritorious manner and beginning
with Chapter IX takes up The First Occurrence of Syphilis and its
Significance for Prostitution. As is well known, Bloch wrote an
interesting and widely documented work upon the origin of syphilis,
the chief conclusion of which was its Central and South American
endemicity, chiefly in some of its lower animals, the llama classically,
whence through bestiality it was communicated to man and then
brought to Europe by the soldiers and sailors of Columbus. He here
goes over further evidence, discusses the objections raised and then
deals with the increasing taboo upon prostitution due to its dangers
and their relation to the development of sexual ethics.
Prostitution during the Renaissance, the Reform and Antireform
period (16-17 a.p.), covers three or more chapters. Chapter II is
especially informing regarding the courtesan of that period. Those
feminists who regard free-love as modern can read with profit this
chapter as to this aspect of sexual morality. The tenth and eleventh
chapters deal with the usual types, the twelfth with the locals and
variant types. Thus we can read of the famous “ houses” of these
centuries in most of the large cities of Europe. Bloch has collected
an enormous mass of information from the greatest variety of
sources. Chapter XIII deals with the efforts at suppression. The
reformer of to-day can read of these century-old efforts and learn
not what to do. Other chapters deal with the literary and artistic
106 BOOK REVIEWS
portrayals, prostitution at the present time, variations in the form of
prostitution, moral and ethical relationships and the final chapter
upon the efforts at state and communal regulation. A very complete
index finishes this most scholarly presentation of a situation for the
most vital part most hypocritically dealt with by Anglo-Saxons.
Bernfeld, Siegfried. SisypHOs ODER DIE GRENZEN DER ERZIEHUNG.
[Int. Psycho. Verlag, Vienna. | |
Had the results of Bernfeld’s certainly clever considerations been
more favorable he would never have chosen this title for a discus-
sion of education. This is a spirited and ingenious causerie on
method and organization in education. The psychology of the same
grows out of the psychoanalytic principles of the psychology of the
baby and the child. As a result he distinguishes between education
(upbringing) and pedagogy and leads the failures of the former
back to contaminations with the latter. Bernfeld is firmly opposed
to those who believe (with Melanie Klein, for example) that psycho-
analysis can be carried out effectually with the child, but he draws
many analytic postulates from objective studies.
O’Brien-Moore, Ainsworth. MapNEss IN ANCIENT LITERATURE.
[R. Wagner Sohn, Weimar. |
This is a Ph.D. thesis of Princeton University and although con-
taining more Greek than psychiatry it is a very remarkable production.
It has so much Greek that no one can really read it save perhaps a
few enthusiasts who have kept up this ancient and honorable tongue.
The author shows himself to be thoroughly conversant with the
literature of the ancient Greeks and has utilized every reference to
point out the representations of madness in the tragic and comic
productions of the period. He shows in a scholarly manner how the
poet and dramatist of that day kept in touch with social, legal and
medical thought and lead his own method of reading into the prob-
lems of life, of which madness was an outstanding faulty solution.
As to-day so then the word mad had many connotations but
he brings into relief certain interesting psychotic pictures, notably
one Dionysius of Syracuse who showed a typical paranoid evolution.
The broader character anomalies which to-day are frequently desig-
nated mad—crazy—nutty were used in those days much as now,
but the clearer cut situations of hysteria, fixed ideas, and psychoses,
the author states, were unknown to antiquity. We do not assent to
this, even for the dramatists, else we have misread the Mad Hercules
and Oedipus Rex.
But this apart, the thesis is an admirable one and our greatest
lament is that the great amount of knowledge of Greek necessary
has hampered our understanding but not diminished our enthusiasm.
Gerstmann, J. Dir MALARIABEHANDLUNG DER PROGRESSIVEN
PaRALYSE. [Julius Springer, Vienna, 1925.] |
In Vol. 55, 1922, of the JourNAL oF Nervous AND MENTAL
DisEASE there appeared the first discussion in English by Wagner- -
BOOK REVIEWS 107
Jauregg of the malaria method developed by him for the treatment
of general paralysis. Gerstmann has been Wagner’s constant assistant
in this work and presents in this volume a thorough summary of its
development in Vienna and its steadily increasing practice in other
countries. Gerstmann recapitulates the historical forerunners of the
malaria treatment, for a summary of which we refer to the afore-
mentioned number of this journal. The greatest space is given to a
systematic discussion of the technic, pathology, and clinic of the
treatment, a presentation which makes the volume a valuable hand-
book for the practice of this method.
It must be remembered that the inoculation malaria does not
increase itself by means of intermediate stages, a circumstance which
has proven to be of invaluable importance for its widespread use.
Nosologically the inoculation type differs from a natural tertian
malaria in its atypical fever periods, originating in atypical develop-
mental stages of the schizonts, its surprising lack of organ changes
or swellings, but most particularly in its thoroughly noninfectious
character and its great susceptibility to quinine even in small doses.
These latter characteristics are not only clinically but experimentally
verified in a special section. The noninfectiousness of the artificial
type is due to a paucity of gamete forms in the blood, with the result
that once effected anopheles stings do not lead in that host to
sporozont forms.
Although the Viennese clinic has treated far over 1,000 cases to
date, Gerstmann refers only to 400 of those cases which have been
treated two or more years ago. After a comprehensive survey of
his material a carefully sifted remainder of about 39 per cent cured
is left, whereby the criterion of the cure is the ability to return to
society and to work. Naturally the patient is not released until the
psychic and somatic symptoms have first largely disappeared. In
addition to his own material Gerstmann surveys the reports of other
clinics, particularly those of the Hamburg and other German clinics
where the treatment has been in widespread use. The favorable
results from Hamburg run to over 50 per cent, from Frankfort to
over 47 per cent but it must be remembered that none of the clinics
chose their material. Altogether the results amassed by the Viennese
and the German clinics are convincingly thorough and impressive.
The steady control of the liquor, serum and blood findings before
and long after treatment has led to the conclusion that these findings
bear no definite relation to the satisfactory results achieved. In one
case the findings were universally positive although the patient had
been in a responsible social and economic position for 714. years
after treatment. Gerstmann also reviews the pathological reports
of the clinic to show that malaria not only rids the nervous substance
of every trace of spirochetes, but that the infiltrations typical for
general paresis are transformed first into an acute plasma cell in-
flammation and then into a regressive type of fibrous meningitis with
only minimal signs of infiltration in the nervous tissue.’ The question
as to the effective principle by which artificial malaria factually cures
a disease long held to be incurable remains puzzling despite the
108 BOOK REVIEWS
several theoretic serologic considerations put forward by German
neurologists. Perhaps this question may be answered by the studies
with malaria in the treatment of other forms of syphilitic lesions,
a field already well spaded for further sowing by Kyrle’s favorable
reports on over 500 patients from the Vienna skin clinics. (The
very recent decease of this productive clinician early in his forties
is greatly to be regretted.) Despite Wagner-Jauregg’s and Gerst-
mann’s statements to the contrary, it remains for deeper experi-
mental study to show that the fever per se does not bring about the
changes recorded. That is still the most tangible assumption especially
in connection with some characteristic immunizing process.
It is not without interest to reflect that two classmates of the
Vienna medical faculty have produced such widely divergent and
ingenious therapeutic measures in neuropsychiatry as Wagner-
Jauregg and Freud.
Krabbe, Knud. Les Matapiges DES GLANDES ENDOCRINES.
[Libraire Le Francois, Paris. ]
What between the endocrines, pollen extracts and psychoanalysis
the present day physician is in a sorry pickle. But as to the first
of these, which has been as much exploited as the rest, in season
and out of season from Black Oxen through the entire range of
cure alls, occasionally we find a nugget of real value. This little
book of Dr. Krabbe’s is one of these.
It originally appeared as a chapter in the Scandinavian System
of Medicine which has been reviewed in these pages. It is now
available in a language which is more accessible and as such deserves
a wide reading. The author occupies a mid position between the
skeptic attitude of Swale Vincent and the optimistic touting of some
of the writers for the commercial manufacturers of these cure alls.
We still think the chapter upon the Endocrinopathies in Jelliffe and
White’s 4th Edition of Diseases of the Nervous System about the
best balanced discussion in this difficult field of medicine compressed
though it is.
Roback, A. A., et al. ProptemMs oF PERSONALITY. STUDIES PRE--
SENTED TO Dr. Morton Prince, PIONEER IN AMERICAN
PsyCHOPATHOLOGY. Edited by Drs. C. MacFie Campbell, H..D.
Langfeld, William McDougall, A. A. Roback, and E. W. Taylor.
| Harcourt, Brace and Company, New York. ]
The European custom of Festschrift preparation has not found
much following in the United States. This is to be regretted since it
is a type of appraisal of much intrinsic significance.
Therefore we welcome this volume which is a volume of this
type done in honor of Dr. Morton Prince, who in the quarter cen-
tury following the death of Beard has carried the torch of psycho-
pathology both valiantly and almost alone.
The collection of studies is a large and a singularly meritorious
one. From the opening words of G. Elliott Smith on the Evolution
of Intelligence and the Thraldom of Catch-Phrases to the bibliog-
BOOK REVIEWS 109
raphy one has almost a Lucullian banquet of good thnigs to read
and ponder over. Among the authors we find E. Jones, W. A.
White, E. Claparéde, G. M. Stratton, C. MacFie Campbell, A. A.
moback, P. Janet, ©. K. Mills, E! W. Laylor, T.. W. Mitchell, C. L.
Dana, J. R. Hunt, B. Hart;-K.-Dunlap, €.S. Myers, W. McDougall,
ee une. Wiliam-Brown, bia H. Goddard? S. EB. Jellifie, J: -T.
MacCurdy,:S. Langfeld, L!’ H: Horton.’ As for the titles of the
papers these must be left to the reader of the book itself. It will
well repay his effort.
It may be mentioned that the book belongs to that interesting
collection, the International Library of Psychology, Philosophy and
Scientific Method.
White, William A. Essays in PsycuHopatHotocy. Nervous and
Mental Disease Monograph Series No. 3. [Nervous and Mental
Disease Publishing Co., New York and Washington. $2.50. ]
These essays, all essentially modern in their outlook, direct and
straightforward in their statement and delightful in their style of
presentation, support a present-day platform in Psychopathology
which is of great importance.
While this volume makes no claim to systematic presentation
perhaps it is thereby all the more effective, for in spite of such an
effort at continuity the advance of the general theses is all the more
conclusive by its restatement from various angles.
We know of no more attractive and at the same time useful
collection of papers than these here presented.
Turpin, R. A. La T&ETANIE INFANTILE. [Masson et Cie, Paris.
16° tr}
Judging from a rapid survey of the literature of pediatrics as
revealed in the pages of the Index Medicus the problems connected
with infantile tetany are of very great practical importance. It is
not an insignificant chapter.
This small monograph then will come as a welcome addition to
this scattered literature, summarizing as it does the many studies
referred to and contributing some definite clinical and experimental
observations.
The entire problem is reviewed from the clinical and chemical
points of view with special emphasis laid upon the biochemical studies
of the blood, and, especially, as a departure from the older issues,
the author stresses the value of Lapique Bourguignon’s work on
chronaxia as a great advance in the electrical investigation.
The work of MacCallum upon the primary importance of the
calcium metabolism disturbances is essentially advanced by the newer
biochemical blood researches upon acid-base equilibrium, and thus
more explicit light is shed upon the therapeutic possibilities and their
more accurate application.
OBITUARY
BAN ei ana! igi 21a
EMIL KRAEPELIN
The death of Emil Kraepelin at Munich, October 7, 1926, is an
event which touches the entire world of scientific and social progress.
He was more than an eminent psychiatrist. A broad humanitarian
interest directed his attention to problems of mental welfare in every
form and guided his spirit of indefatigable research to very practical
results.
His name is associated throughout the world with two marked
achievements in the advance of psychiatry, both of which enlisted
his activity to the time of his death. The first of these is the publi-
cation of the fruit of his labors in his textbook of psychiatry, which
has appeared in eight editions in his own and other languages. It
embodies the principle of the classification of mental diseases, with
which he brought order into the vagueness and confusion in which
the older psychiatry groped. The most conspicuous service rendered
here was Kraepelin’s grouping of the “cyclic insanities,”’ including
those that were merely recurrent, under the term “ manic-depressive
insanity,” with the addition later of simple mania and most melan-
cholias. This classification has paved the way for further distinction
and regrouping, represented chiefly in the manic-depressive and
the schizophrenic group. Recent psychiatry has proceeded further,
and in some schools differently, to determine the underlying psycho-
logical background of the personality in which disorders of these
types are manifest. There has been effort to consider more funda-
mentally a functional situation involving emotional failures of adap-
tation upon a basis of predisposing tendencies rather than to accept
’
bd
an established constitutional disease.
These differences which have arisen in the course of psychiatric
progress do not however mark the decline of Kraepelin’s service to
his profession. Despite his seventy years, his mind was still actively
engaged upon these matters, and almost to the moment of his death
he was occupied in the preparation of the ninth edition of his text-
book. With a mind alert to the movements of the day and an energy
devoted to further research, he has doubtless provided in this just-
[110]
OBIT OARY 111
completed work fresh stimulus for the review of these important
questions.
The other great enterprise of Kraepelin’s life was the founding
and furtherance of the Deutsche Forschungsanstalt fur Psychiatrie at
Emit KRAEPELIN
Munich, later incorporated into the Kaiser Wilhelm Institut. <A
recent appropriation from the Rockefeller Foundation brings promise
of the realization of Kraepelin’s dream that a proper home should be
112 OBITUARY
built for the important work of this institution. The final fulfillment
of this dream also engaged his activities to the last. |
Another project was in preparation, a journey to India and Ceylon ~
for the purpose of investigating the effect of racial characteristics
upon psychic morbidity and the forms which mental diseases take
among different peoples. This journey of research was to have been
a continuation of the work which brought Kraepelin to America last
year to study negroes and Indians. Both of these undertakings were
preceded twenty years ago by a trip of a similar scientific nature
among the inhabitants of Java. The spirit of the self-forgetting
investigator is manifest in the urgent request that this plan would
still be carried out, although its originator had finally to yield to
inevitably approaching death.
Kraepelin, from his student days, which were spent under Wundt
of Leipzig as well as Gudden of Munich, was deeply interested in
psychology. He believed in the close relation of normal psychology to
that of the mentally diseased, and believed that the one would throw
light upon the other. This broader interest opened his mind to the
larger relations of specific problems. It led him, as early as 1900, to
advocate a criminal psychology and to lift the question of punishment
from the plane of mere retribution to purposive action of benefit to
society and to the criminal.
He was active also in advocating attention to the mental as well
as physical welfare of school children. He was an ardent opponent
of alcohol. His publications include writings upon these matters of
social welfare and also specific studies of disease problems in addi-
tion to his well-known psychiatric textbook.
Kraepelin’s professional associations have.been for the greater
part of his life with the University of Munich. His student days
were passed as Wurzburg, Leipzig and Munich. On graduation in
1878, he worked clinically in Leipzig and Munich. He entered into
the faculty of the University of Dorpat in 1886, passing on to Heidel-
berg in 1890. He went to Munich in 1903 and although his retire-
ment from the university was necessary because of an age limit, he
continued his work of investigation in the institute for research which
he had founded. .
N. B.—All business communications should be made to Journal of
Nervous and Mental Disease, 64 West 56th St., New York.
All editorial communications should_be made to Dr. Smith Ely Jelliffe,
Managing Editor, 64 West 56th St., New York.
VoL. 65 FEBRUARY, 1927 No. 2
The Journal
OF
Nervous and Mental Disease
An American Journal of Neuropsychiatry, Founded in 1874
ORIGINAL ARTICLES
Sek eA LON Oe EE CHREBELILUM..WHIGEH IT TO
THE TOTAL BRAINWEIGHT IN HUMAN RACES
AN DE INGSO MMA NIMALS >
By C. U. Arténs KaAPPERS
OF AMSTERDAM, HOLLAND
In the following pages I shall give some figures concerning the
total brainweight and the cerebellum weight in the Dutch, Chinese
and Japanese, adding some figures concerning the same relation in
animals.
I have been induced to this work amongst other things by the
fact that Topinard+ seems to consider the relation of the cerebellum
weight to the total brainweight (T.B.W.) of some value for an-
thropological studies.and, on account of the weighings of Clapham,?
thinks himself justified to the conclusion that the relative cerebellum
weight in the Chinese is less than in Europeans.
Another motive to examine this relation is that—in connection
with the somewhat different character of the Mongolian brain com-
pared with that of the average Dutch brain—it seemed not impossible
that the cerebellum in the Chinese might be different in its weight
relation to the total brain from the average Dutch.
Before entering upon the results of my researches, I will briefly
review the literature on the relative cerebellum weight in adult man.’
* Communicated at the meeting of the Royal Academy of Science, Amster-
dam, Proceed. 29, No. 1.
*Topinard. Eléments d’Anthropologie générale. Paris, 1885, page 578.
“Chez les hommes la plus forte proportion de cerveau se rencontre chez les
Chinois et les Caroliniens de M. Clapham et inversement la moindre proportion
de cervelet et de moélle allongée réunis.”
*Crochley Clapham. The brain weight of some Chinese and Pelew
Islanders. Journal of the Anthropological Institute of Great Britain and
Ireland. Vol. VII, 1878, page 89.
*T shall not discuss here the interesting results of Pfister on the relative
cerebellum weight in children (Das Hirngewicht im Kindesalter, Arch. f
Kinderheilkunde Bnd. 23, 1897, page 164).
[113]
Hite C. U. ARIENS KAPPERS
Krause,* examining this subject in Germans, stated the average
cerebellum weight percentage in men to be 1/9 or 11.1%, in womepr
1/8 or 1214%, giving an average absolute figure of 128 gr.
Parchappe ® on the contrary (in the French) found a larger cerebellum
percentage in men (11.8%) than in women (10.8%) and gives the
former an average absolute cerebellum weight of 160 gr., with an
average T.B.W=1352 gr., in women an average absolute cerebellum
weight of 133 gr., with an average T.B.W.=1229 gr.
Somewhat lower figures are mentioned by, Huschke®: in men between
10 and 80 years he found 10.95%, in women of the same age 10.69%,
so in the average 10.82%.
Figures similar to those of Parchappé were found by Boyd? (6 11.9%
and 2 11.44%) on account of 2,500 cases in St. Marylebone’s Infirmary
and the Somerset County Asylum.
Meynert § on the contrary found in men 10.5% only, in women 10.6%.
Crichton Browne,? examining 400 postmortems at the West Riding
Asylum, again gave a higher average: 11.33%.
The latest statistics concerning this matter are composed by Rey,
on account of the figures, registered by Broca in 273 men and 137
women.
Rey!® found the average to be in men 10.66%, in women 11.03%,
consequently a total average of 10.84%.
The most important weighings for my subject are those pub-
lished by Weisbach" for the different nations of the former Austro-
Hungarian monarchy, belonging with those of Boyd and Rey to
the most useful ones covering the largest material, and—in contrary
to those of Boyd and Rey (Broca)—concerning mostly neuro-
logically normal people. Weisbach’s figures are also important for
my purpose, since they include the Magyars, a race being largely —
Mongolian. |
*Krause. Handbuch der menschlichen Anatomie. Cited here after the
third edition 1879. Vol. 11, page 763. yt
° Parchappe. Recherches sur l’Encéphale, sa structure, ses fonctions. Iére
Mémoire, Paris, 1836, page 99.
® Huschke. Schade, Hirn und Seele der Menschen und der Tiere nach
Alter, Geschlecht und Race. Mauke, Jena, 1854, page 75.
“Boyd. Tables of weight of the human body and internal organs, etc.,
arranged from postmortem examinations. Philos. Transactions of the. Royal
Society of London, B. Vol. 151, 1861. I calculated these percentage figures,
given by Boyd on page 262.
®*Meynert. Das Gesamtgewicht und die Teilgewichte des Gehirns: Viertel-
jahrsschrift ftir Psychiatrie, 1867. Bnd. 1. Quoted after Ziehen; I could -not
obtain the original.
° Crichton Browne. On the weight of the brain and its component parts, in
the insane. Brain, Vol. I, 1879.
* Rey. Les poids du cervelet, du bulbe, de la protuberance et des hémis-
pheres d’aprés les régistres de Broca. Revue d’Anthropologie, 2iéme serie,
Tome VII, 1884, page 193.
™ Weisbach. Gewichtsverhaltnisse der Gehirne Oesterreichischer Volker.
Archiv ftir Anthropologie, I, 1867.
KELATTON. OF CEREBSELLUM-W EIGHT 115
Weisbach then found in the different populations of the former
Austro-Hungarian monarchy the following relations :
Number Aver. Aver.
examined Aver. weight per cent
Nations brains T.B.W. Cerebell. Cerebell.
| ESSA et es ne ee 46 1322.86 139.74 10.56
RCOUIMAIATICNSE 5.5) tec EY canis 13 1326.58 142.83 10.76
eealiahs ees a ee oe 40 1301.37 139.82 10.74
LAU: SE RR es i oh rN a 11 1320.59 140.08 10.60
PU ietiaticuersr a. « boa’ fc. 350: 18 1320.63 141.55 10.71
BIO Vedic baliS Bn ei ek ee 11 1310.74 142.56 10.87
CER hee SM 3 ee ae 2) 1368.31 146.28 10.69
Bouth- ociavoulaus ©. a «Ns. ass 8 1305.14 139.56 10.69
Sclavoman women °.:...<.:6: 14 1174.95 129.60 11.03
Gerinalcme ee ae. Sas est of 46 1314.50 142.20 10.81
terial women... .. carn foe 16 1180.15 125:56 10.63
In this table the Magyars have the smallest relative cerebellum
weight, a fact I shall return to later (see page 118).
Moreover Weisbach observes that he found great individual
differences in the relative cerebellum weight, even with approxima-
tively equal total brain weights.
According to him these differences may be explained only partly
by regressive alterations of the different brain parts with age (in
Germans in men the cerebellum diminishing relatively more than
the cerebrum, while in women the cerebrum should exhibit more
regressive changes in old age, according to him).
I need not say that the number of women, examined by Weisbach
is too small to justify this conclusion as a constant fact.
On account of one male cerebrum of 91 years and two female ones
of 92 and 93 years Topinard concluded inversively (1. c. p. 579). My
own figures show the value of such conclusions, as I registered a man
seventy-six years old showing a cerebellum percentage of 10.62 followed
by another, seventy-six years old, with a percentage of 8.98, followed
again by a man, eighty-seven years old, with a cerebellum percentage
of 12.12%. Amongst the women I have one seventy-six years old, with
a cerebellum percentage of 11.24 and another, eighty years old, with
9.72% cerebellum. We ought to view these cases individually without
generalizing. In this matter I absolutely agree with Rey, saying “les
poids absolus et les poids relatifs du cervelet, du bulbe, de la protubérance
et des hemisphéres présentent de continuelles oscillations ott il est difficile,
sinon impossible de saisir linfluence de l’age.”’
Moreover Weisbach (l.c. p. 316) supposes the height of the body
to influence the cerebellum more than the cerebrum. Generally in
larger men he found the cerebellum weight to be relatively larger.
My own matrial of human brains being too small, and containing
116 C. (UL ARIENS KAPPERS
too few cases, in which the body length’? was noted, I was unable
to verify this on human material.
On account, however, of my weighings of animal cerebella I shall
return to the influence of the stature.
Clapham’s figures on the Chinese are useful for our comparison
with a correction only (see below) since this author did not weigh
the severed cerebellum, but the cerebellum connected with the pons
and medulla oblongata (in 16 cases).
Owing to the above it is interesting to know the figures, found by
myself in 7 Northern-Chinese, 15 Chinese from the Dutch East-
Indies, totally 22 Chinese cerebra and in 8 Japanese brains.
Thanks to Professor Deelman, Dr. Dijkstra and Dr. Hammer I
have been able to compare these figures with those found in 25
Dutch brains (13 from Groningen and 12 from Amsterdam W.G.).
I must emphasize that all weighings were done by myself and
following the same method, viz., without pia and the ventricles being
emptied. Since Harvey’? determined the average total volume of
the ventricles to be 30.4 cm.?, the cerebral fluid would amount to a
weight of about 30.6 gr. Besides, this author found the largest
brains to have the smallest ventricles, the smallest brains having the
largest ventricles, the fluid increasing the T.B.W. in an inverse way.
The cerebellum was severed immediately above the emergence of
the VII and VIII roots.
My results in the Dutch are recorded in the two following tables:
MEN
Further
indica- Weight Per cent
Origin tion T.B.W. Cerebell. Cer. Age Height Causa mortis
Gr. y barseaCle
W.G. 15256 1452 1/7 TPO 11.81 9 i trauma
‘ 15283 1680 156 9.28 16 176 “3
Gron. Gor. 1470 164 eee 17, 165 empyem. pneum.
i Boe 1360% 117.5 8.63 18 178 peritonitis
W.G. 15297 1299 137 10.54 26 170 to Dac:
Gron. Gro. 1375 128 9.30 42 160 ca. ventr.
s Verh. 1224 136 Liou 45 170 ileus (perit.)
Ge ati thE CON ly 1401 143.5 10.24 62 181 carc. prostat.
i Siem. 1102 115 10.43 74 168 nephr. chron.
pr Hoog. 1054 114 10.81 74 165 carc. oesoph.
W.G. 15263 1365 145 10.62 75 170 care. recti.
: 15243 1124 101 8.98 78 163 carc. linguae
j 52/1 1278% 155 i2ele 87 155 ?
Average 1322 137.12 10.378
“Tn the average the stature of the Chinese (especially of the Northern-
Chinese) is not smaller than that of the Dutch. The Japanese only might be
useful in this respect. My number (8) being so small, I hesitate to make a
positive conclusion. Still the figures found here do not contradict Weisbach.
*% Harvey. The volume of the ventricles of the brain. Anat. Record,
Vol. V, 1911, page 304.
RELATION OF (CEREBELLOM WRIGHT ia)
Hence we see that I found the average cerebellum weight in the
men to be 10.378 per cent, in women 10.42 per cent, the total average
being 10.399 per cent, a figure almost equal to that of Meynert and
somewhat smaller than all the figures of Weisbach. Of course, I do
not conclude from my figures the cerebellum weight in the Dutch to
be smaller than in the races examined by Weisbach; I rather believe
the ways of severing and weighing, used by the latter, to be somewhat
different from my method. It is evident that the precautions in
WoMEN
Further
indica- Weight Per cent
Origin tion T.B.W. Cerebell. Cerebell. Age Height Causa mortis
Gr. Years CM.
Gron. Krijthe* 1502 137% 9:15 4 113s peritonit. (app. )
W.G. 15258 1369 125 9.17 1s 175 trauma
ic 15244 1238 140 Lig3l 26 160 abortus
Gron. Lenz 1103 117 10.60 28 145 anaemia
iH Water 996% 126 12.64 31 151 S
“f Smed. 1291 139 10.76 58 t54 Canc. OVvaril
ip Hamm. 1299 145 if-16 64 148 carc. ventric.
é: Bekk. 1102 88 8.00 67 157 vit. cordis
W.G. =: 15296 1087 cue ko 7 un 11656 71 POM REE it tip:
if 15310 1059 LIZ 10257 i2 155 nephr.) chron.
ia 15302 1210 136 ez4 76 ies, arterioscler.
. 152444 1265 123 9.72 80 155 scl. a. cor. cond:
Average 121001512672 10.42
Total average percentage in men and women, 10.399 per cent.
* This cerebrum shows a “corpus ponto-bulbare.”
weighing of two different authors are never exactly the same. This
is also the reason why for comparison with my Mongolian material I
used Dutch brains, examined by myself and did not confine myself to
figures found by others in Caucasian races. Duo cum faciunt idem,
non est 1dem.
My results in 22 Chinese brains, examined in identically the same
way as the Dutch brains, are the following:
Weight Per cent
Origin Further indication TP BsW. Cerebell. Cer. T.B.W.
Gr. Gr.
North-Chin. 3 Body No. 18 1090 128 11.74
‘ 4 3 4 hams 1130 115% 10.22
7 + 3 Autopsy 0949 1135 122 ene wel >
fe 3 Body No. 7 1256 13914 LEF10
- * 3 + 28 1277 110 8.61
ES #4 3 . ie) ee) 1342 128 9.53
“4 + 3 4 NEA, 1468 146 9.94
118 C..U. ARIENS KAPPERS
Further Weight Per cent
Origin indication T.B.W. Cereb. Cerebellum
No. Gr. Gr.
Chin. fr. D. E.-India 11 1014 124 12722
3 ‘ ‘ 9 1076 109 10.10
Hy 7 wy 3 1120 116 10.34
‘ a . 17 1085 115% 10.64
i ‘ vd 14 1170 130 11.11
. ye is 2 1161 131 11.30
« ae e 8 1171 129 IT 0!
“ x 4 1195 116 9.70
5 u 1 1228 143 11.60
5 i - 3 1261 141 11.18
i 8 7 1295 130 10.04
* + = 6 1261 116 9.20
er Ss e 15 1271 122 9.60
. 2 10 1344 134 9.97
‘ # % 12 1425 135 9.47
Average 1217 126.5 10.39
In addition I give the figures found for 8 Japanese brains for
which material I am greatly indebted to Professor G. Fuse of Sendai.
Further Weight Cere-
Average indication T.B.W. Cerebellum bellum Age Height C.M.
No. Gr. Gr. Percent Years CM.
Japanese ¢ 1 1284 13914 10.86 2s 146 vit. c.
of a 2 1239 12314 9.96 28 163 tubo
i 3 1061% 117 11.02 21 154 cel hh)
a Ag 4 1296 13814 10.68 28. 160-. eee
= : 5 1188 113 9.51 26 153 nephr.
te t 6 1214 119 9:80: 36. 153 carc. V.
~ . Z 1218 12214 10.05 36 156 t Dp:
a ¥ 8 1198 134 11°25 ZI 146 sa a
Average 1212751912500 10.383
The relative cerebellum weight in my Chinese (and Japanese)
differs so little from the Dutch, that I hesitate to draw a conclusion.
A much larger number of brains would be necessary to ascertain
such a conclusion.
I think myself qualified though in assuming the relative cerebellum
weight in the Chinese to be practically equal to that of the Dutch.
If any difference exists, the weight is perhaps slightly less in the
Chinese, especially in the Northern Chinese.
It is certainly noteworthy that in the tables of Weisbach the
Magyars show a slightly smaller cerebellum percentage than the other
races of the former Austro-Hungarian monarchy. This is interesting
on account of the fact that the Magyars are generally considered as a
largely Mongolian race and that also these weighings were done by
the same.
As mentioned at the beginning, Topinard on account of Clap-
RELATION OF CEREBELLUM WEIGHT 119
ham’s work thinks himself qualified to conclude the cerebellum per-
centage in the Chinese to be considerably smaller than in Caucasian
races.
Clapham himself in this article does not make this conclusion,
publishing only the figures of the total brain weight in his 16 cases
and the weight of the cerebellum connected with pons and medulla
oblongata.
Now there are two methods of using the latter figures for our
purpose. Both methods include a source of errors.
The first method is calculating the cerebellum weight from the
figures for the cerebellum, pons and medulla oblongata, given by
Clapham using the statistics made in Europe, the average weight of
the human oblongata + pons being, according to Boyd, 1.8% of the
T.B.W. (according to Crichton Browne l.c. 1.9%, to Rey, 1.99%).
A weak point in this method is our ignoring if it avails with the
same average of 1.8%-1.9% for the Chinese also. (I had no
pleasure in mutilating my material for controlling this).
A second method is, taking also in Europeans, instead of the
cerebellum weight, the weight of cerebellum + pons and oblongata
and comparing this weight (which we may call the metencephalic
weight) with Clapham’s results in the Chinese.
In the next table I used both methods reducing to grammes the
avoirdupois figures of Clapham.
From this appears that on account of the first calculation Topinard
is right in concluding from the figures of Clapham the average cere-
bellum percentage of his 16 cases to be less than in Europeans, the
average in the cases of Clapham being even less than 10 per cent.
Doubting this method of calculating the cerebellum weight from
the weight of cerebellum, pons and oblongata to be trustworthy, we
may compare the figures, found by Clapham for the whole meten-
cephalon with those found in the English by Thurnam."*
On account of 470 weighings (257 men and 213 women) Thur-
nam determined the metencephalic percentage to be 12.9 per cent in
men and 13.1 per cent in women; total average 13.0 per cent.
Now the total metencephalic percentage found by Clapham is
11.91 per cent, so that also this figure would be smaller in the
Chinese.
Still we have to be very careful with Clapham’s figures.
In the very meeting in which Clapham communicated his results,
“ Thurnam. On the weight of the brain and on the circumstances affecting
it. Journ. of Mental Science, Vol. XII, 1866, p. 1.
120 CUS ARIENS KAPPERS
Metenc. Metenc. Cereb. Cereb: Age
Hongkong T.B.W. Weight Percent Weight Percent Sex (approx.)
No. Gr. Gr. Gr. Years
1 1410.3 Wie 1356 151.8 10,77 3 30
Z 1417.4 163.0 1155 ti/cs 9.7 3 28
3 LotGa7 156.0 10.28 128.7 8.4 3 45
4 158700 184.2 11.61 155.4 9.8 3 40)
5 1410.3 170.0 12.06 25158 10.7 3 50
6 1360.0 138.0 10.94 1 Re, 8.2 3 40)
i 1318.0 156.0 LIS83 13260 10.05 3 25
8 1530.0 187.0 12.50 159.5 10.42 3 48
9 1403.3 170.0 j Rape b 144.8 10.32 3 55
10 1467.5 175.9 12.06 149.5 10.60 3 35
11 1311.0 138.0 Mag 114.5 Oe/, 3 30
12 1289.0 170.0 1318 146.8 11.4 Q 26
13 1389 .0 156.0 Linz 1310 9.43 2 i 38
14 1247.0 138.0 11393 115-6 9.27 2 30
15 1204.8 156.8 12.82 134-3 11.10 g 70
16 i351 180 156.0 11.89 132.4 10.10 2 18
Average 1385.8 11.91 137.4 9.91
Distant observed the T.B.W. figures of Clapham to be exceedingly
high and to exceed even those given by Barnard Davis for the
average skull capacity of the Chinese.
Though the average capacity mentioned by Barnard Davis? for
the male Chinese skull (47.87 ounces or 1357 cm.?) may be too small,
Distant’s criticism keeps its value even considering the average skull
capacity to be 1456 cm.? as found by Haberer?® in 28 men from
Peking. 3
The relation between skull capacity and brain weight with pia and
ventricular fluid determined by Welcker!’ for this category amounts to
93%. Bolk!®8 found in 40 years old Dutchmen figures varying from 90
to 96.5%, Manouvrier!® however in the French only 87%.
Taking the relation to be 92%, we should expect with an average
male skull capacity of 1,456 cm.? a brain weight of 1,380 gr. with ven-
tricular fluid and pia. Subtracting for the latter two 30.4 + 53.6= 83.5
* Barnard Davis. Thesaurus craniorum. Catalogue of the skulls of various
races~of man. London, 1867, and the supplement on this work, edited in 1875.
I regret this work not to be at my disposal.
** Haberer. Schadel and Skeletteile aus Peking. Verlag von Fischer.
Jena s.1902 (9,69.
™ Welcker. Die Kapazitat und die drei Hauptdurchmesser der Schadel-
kapsel bei den verschiedenen Nationen. Arch. f. Anthropologie. Bnd. 16, 1886.
* Bolk. Beziehungen zwischen Hirnvolum und Schadelkapazitat, nebst
Bemerkungen tiber das Hirngewicht der Hollander. Petrus Camper, Vol. II,
1902.
*® Manouvrier. Sur l’indice cubique du crane. Comptes rendus de I’associa-
tion francaise pour l’avancement des sciences. Congrés Reims, 1880. Quoted
after Martin. Allgemeine Anthropologie.
RELATION OF CEREBELLUM WEIGHT Aye
gr., we keep as netto brain weight 1,296.5 gr:?° (in a relation: of
90% = 1,275 gr., in a relation of 87% :1,240 egr.).
In my 7 Northern-Chinese I found the average netto brain weight
to be 1,243 gr. whereas Clapham in his Southern-Chinese—who according
to my experience have a smaller average T.B.W. than the Northern-
Chinese, stated the average male brain weight to be 1,430 grammes!
In my opinion we should be very careful with Clapham’s figures.
Apparently Topinard himself doubts the total weight figures
mentioned by this author saying (lc. p. 57) “La moyenne (des poids
de l’encephale) was Chinois de Cr. Clapham a étonné tout le monde.
Nous attendrons avant d’en tirer une conclusion.”’
Moreover we are confirmed in presuming Clapham to have made
errors in his weighings by the equally low percentage he found in two
Pelew natives and one Hindoo, published in the same article.
As appears from my tables the cerebellar percentage found in
the Chinese varies from 8.61 per cent to 12.22 per cent, in the Dutch
Prova UUsper cent tos) 2.12 per cent:
So the variation in the cerebellar percentage is about 4 per cent,
in the Chinese as well as in the Dutch.
As mentioned above, Weisbach also found large variations and 1s
inclined to correlate this among other things with the length of the
body, the increase of which should influence more the cerebellum
than the forebrain. |
Having at my disposal not enough human cerebra of individuals
whose body length was noted,?! I have tried to consider this problem
by determining cerebellum percentages in mammals of the same order
but of different size.”
The animals in this list are so arranged that the smallest specimen
of the order is always placed ahead.
Comparing in this list the large animals and the small ones of
the same order, we see in some groups (Rodents, Cetacea, Simiae)
the largest representants to have a larger cerebellum percentage per
BBV .
This, however, is not always, even not mostly so, especially not
in Insectivores, Ungulates and Carnivores (Felides), and while the
70 According to Harvey (1. c.), the average weight of the ventricular fluid is
we gr., while according to Rey (I. c.) the average weight of the pia (wet)
is 53.06 er.
74In the Dutch I found up to 160 cm., a larger average than in 160 cm.
and more, but in my Japanese the average does not conflict with this conception.
2 These four figures are taken from Ziehen (Bardeleben’s Handbuch der
Anatomie).
122 C. U. ARIENS KAPPERS
Whale and Elephant—two exceedingly large animals of different
orders—indeed show an enormous relative cerebellum weight, I found
on the other hand the small Choloepus didactylus having the very
considerable figure of 17.6 per cent.
Per cent
Weight —_Cere-
Order Species BW Cere. bellum Fixation
Gr Gr.
Marsupialia Didelphys m. Glia meacas 14 formal.
Macropus r. 55.00 heed 14 “s
Rodentia Mus dec"? 9" 3s eee Weds 13 fresh
Lepusi Can ee eee 1335 15 >
Insectivora ‘Lalpaceurs ae ee 0.17 13 fresh
Erindctens “saan eee eee 0.39 11
Ungulata Perissodact Tapirus ind. 265 .00 Do.UG 13.2. formal:
Equus cab. 468 .00 58.50 120 +
Artiodact Tragulus juv. 16.80 1.8 10.7 4
Oreas liv. 192.00 18.00 9.4 «
Proboscidea Elephas indic. 3860 .00 940.00 24.3 formal.
Cetacea Phocaena com. 390.00 58.00 15.0 formal.
Balaenopt. Sibb. 5676.0 ~~ 1076.0 18.95 ‘
Carnivora Felis dom. 23 .05 a5 13.66 formal.
Felidae Felis leo 197.5 21.0 10.60 ds
Felis tigris 208 .2 21.6 10.36
Canidae Vulpes lagopus Zoi) 3 .o0 1236 ".
Canis fam. box. Fone 6.0 8.9 a
Edentata Choloepus did. 34.0 6.1 17.6 -fornval:
Simiae Hapale ros.+ ae 0.62 7.8 fresh?
Callithrix py. 42.3 4.8 11: 3eetoemer
Semnopith. ceph. 65.0 8.0 12.5 +
Macacus rh. 70.0 623 9.0 ie
Hylobates synd. 105.0 14.0 1320 ¥
Simia satyrus 293.0 38.5 13.2 x
* This figure is taken from Flatau and Jacobsohn’s Handbuch der Vergi.
Anatomie des Centr. Nervensystems, 1899.
+ These weighings were also done without pia, the ventricles being emptied
and the brain was cut off near the calamus.
Without doubt other factors than body size influence this relation
and in a larger degree even than the latter. The most important
factor appears to be the habit of life, especially the manner of moving
and the peculiar use of the limbs for moving and grasping.
So, concerning the remarkable contrast between the two Insecti-
vores, probably the very different way of life of these two represent-
ants causes the cerebellum of Talpa to be relatively somewhat smaller
than in Erinaceus. Overlooking an eventual difference in favor of
the forebrain in the hedgehog? the larger cerebellum percentage in
*° Talpa is blind, Erinaceus is not.
RELATION “OF "CEREBELLUM Y WEIGHT 123
the mole may be explained by the movement of the extremities of
the latter. This animal is a very sturdy worker, who in his con-
tinually digging life, uses his extremities very much, strongly and
exactly. Its feet, especially the forefeet, are not only locomotor
organs, but also digging instruments, much more so than in Erinaceus.
That special functions of the limbs exercise a large influence on the
weight of the cerebellum—especially of the hemispheres—also results
from the high percentage of the cerebellum in the Sloth (Choloepus
didactylus), an animal that moves extremely slow and prudently and,
by the careful manner in which it finds its way in the trees, lays
great claims on the innervation of its extremities.
Whereas in the gait of most Quadrupeds bilateral symmetric in-
nervation acts the larger part, in this movement of the sloth careful,
slow, bilateral free motions and consequently antagonistic innervation
of the limbs are of the utmost importance. This motion is much
more complicated than the simple, rhythmic, bilateral symmetric
motion, as e.g. in Ungulates.
In my opinion the large size of the cerebellum in the Sloth may
be alleged in favor of the idea of Leiri** that the hemispheres of the
cerebellum are connected especially with inhibition of motions by
innervation of antagonists since it is supposed that in quick motions
the antagonists are activated chiefly in the end of the motion,
whereas in slow, searching motions they are acting nearly continually
(Wagner”>).
In still another way my table shows the influence of the function
of the extremities on the relative size of the cerebellum.
So the Whale, whose body and T.B.W. are much larger than
those of the Elephant, nevertheless has a smaller cerebellum per-
centage than the Elephant. This difference is certainly due to the
poor development of the extremities in the Whale and the exceed-
ingly fine motility (also unilateral) of the Elephant’s limbs and
trunk.
Consequently we find, for the relative cerebellum weight, the
motile capacities, not the size of the animal, to be the main point.
The facts confirm Bolk’s conception of the great significance of
the extremities, especially their asymmetric unilateral movements for
* Leiri. Le cervelet un organe servant a l’innervation des antagonistes
dans l’activité musculaire. Acta Oto-laryngologica, Vol. VI, Fasc. 34, p. 516.
Leiri’s conception agrees very well with Ingvar’s conclusions and seems to
explain very well the symptoms, described by Babinski, van Rijnberk, Barany
and Gordon Holmes and others in cerebellar insufficiency. See also Tilney and
Riley, The form and function of the nervous system, p. 475
7° R. Wagner. Ueber die Zusammenarbeit der Antagonisten bei der Will-
kiirbewegung. Iste Mitt. Zeitschr. f. Biologie, Bnd. 83, 1925, p. 59; 2te Mitt.,
ibid., p. 120.
124 C..U. ARIENS KAPPERS
the development of the hemispheres of the cerebellum, a thesis con-
firmed by the experiments of van Rijnberk and his collaborators,
further by Thomas and Durupt and even by Gordon Holmes, who
for the rest does not agree with Bolk’s theory of cerebellar
localization.
That, however, in some cases the cerebellum percentage increases
indeed in larger animals of the same order, is seen in Sharks, where
the cerebellum, not or hardly fissurated in the smaller representants,”®
shows a large amount of transverse convolutions in the larger speci-
mens of this class. In the larger sharks the greater increase of the
cerebellum may thus be demonstrated even ad oculos although it may
be expressed in figures also:
Name T.B.W. Weight Cer. Cereb.
Mgr. gr. Percent
Seyllitumitant 1s Sent eee 666 96.5 14.5
Galeus* canigyy esc ee ore ee 8750 1390 15.9
Lamnacornubins 327.450 eee 17110 3580 20.9
* These figures are the average of three weighings.
Though in some sharks which have a different way of moving
than the ordinary ones (f.1. Angelus Squatina) also contrary relations
may occur, the relative increase of the cerebellum compared to the
cerebrum in larger specimens is not surprising, the development of
the corpus cerebelli being largely a function of the musculo-sensory
system of all parts of the body, whereas the development of the
brain in these animals depends almost wholly on the senses of smell
and vision. Also the forebrain in mammals contains areas (smell,
vision, hearing), the development of which is no function of the body.
In the cerebellum of fishes this would avail only for the auriculus,
the development of which does not depend on impulses of the spino-
and olivo-cerebellar systems (ponto-cerebellar systems do not yet
exist in fishes), but on the NN. laterales (and N. VIII).
So in some bony fishes where the N. lateralis is very large
(Mormyrus) the cerebellum increases enormously by the huge de-
velopment of the auriculi and the associated valvula.
Finally I would like to point out that a determination of the rela-
tion between cerebellum weight and body weight and between cere-
bellum weight and the weight of the spinal cord without doubt will
cast more light on this subject.
Besides it would be interesting to examine the individual vari-
ations, so considerable in Homo, also in some of the mammalian
species of which a good many specimens may be obtained (as in
dogs, cats, etc.).
7° Confer Ariéns Kappers, Vergleich. Anatomie des Nervensystems, Part II,
page 647, and Voorhoeve, Het Cerebellum der Plagiostomen, Dissertatie,
Amsterdam, 1914.
DCG tS ON MOE te POS VERIO RG UN EHR R
CEREBELLAR ARTERY *
By Grorce Witson, M.D., anp N. W. WinKeEtMan, M.D.
PHILADELPHIA
The symptomatology of occlusion of the posterior inferior
cerebellar artery was first firmly established by Wallenberg (1) in
1895; since then many clinical cases and a few with necropsy have
been recorded. Hun and Van Gieson (2) in 1897 and Spiller (3)
Fic. 1. Medulla at maximum involvement “ A.”
in 1908 were the first Americans to report cases with necropsy.
Goldstein and Baumm (4) in 1913 reviewed the cases reported up to
that time, tabulated the symptoms and concluded from their statisti-
cal study that the most constant clinical sign was a loss of pain, heat
* From the Neurological Department of the School of Medicine of the
University of Pennsylvania, the Episcopal Hospital and the Laboratory of
Neuropathology of the Philadelphia General Hospital.
[125]
126 G. WILSON AND N. W. WINKELMAN
and cold in the area of the fifth nerve on the side of the lesion and on
the opposite side of the body. Since 1913 only an occasional article
has been written on the subject; one of the most recent and important
is the one by Foix, Hillemand and Schalit.(5) These authors con-
sider the vascular distribution of the medulla as follows: (1) The
paramedian artery supplying a triangular area which includes the
pyramid, fillet and part of the olive. (2) The artery of the lateral
fossa of the bulb which nourishes the lateral portion of the medulla
Fic. 2. Medulla at the summit of the inferior olive showing upper limit of
lesion “ A.”
except the restiform body which is supplied by (3) the inferior
cerebellar artery. They believe that the “artery of the lateral fossa
of the bulb” is the one that is usually involved in the “ syndrome
of the posterior inferior cerebellar artery occlusion” and not the
inferior cerebellar artery itself; but as will be seen from our illus-
trations the restiform body is also involved in the softening and this
case at least does not fit in with the rigid classification given by the
French authors. It is true that clinically there would be no differ-
ence in the symptomatology since the same cerebellar symptoms
could occur from involvement of the cerebellar tracts themselves
prior to their entrance into the cerebellar peduncles.
THE POSTERIOR INFERIOR CEREBELLAR ARTERY 127
The following cases, one with necropsy, are herewith reported:
Case 1—A white male, fifty-four, with a negative family history,
had smallpox in 1871 but denied syphilis. He drank as much as a
quart of whisky a day. On September 28, 1918, he suddenly felt a
sharp pain in the right occipital region which crossed to the left side
of the head and radiated down the left arm and leg. He became unsteady
on his feet, but managed to get home without assistance although he
was very dizzy. He developed difficulty in swallowing and his voice
was reduced to a whisper. He did not see double and did not vomit.
Fic. 3. Pons showing small lesion in superior cerebellar peduncle at “ A.”
He stayed in bed four weeks because he staggered like a drunken
man. The entire left side of the body felt numb and dead, and at times
he had the sensation of pins and needles there. The face was not involved
in this paresthetic phenomenon.
At the end of a month he left his bed for the first time although
he still had a tendency to stagger when walking. He noticed when
he touched a hot object with the left hand it did not give him the
sensation of heat but of tingling. He had been very drowsy since the
onset of his trouble. He never noticed any difference in the amount
of perspiration on the two sides of his body.
Examination——He was seen on June 2, 1919, nine months after the
acute attack. He walked with the base of support widened and he had
128 G. WILSON AND N. W. WINKELMAN
a tendency to stagger to both sides. He had a distinct sway with the
eyes open; when the eyes were closed he deviated to the left, although
he then actually fell to the right. The right pupil was smaller; both
were irregular and reacted sluggishly to light. The right palpebral
fissure was narrower than the left. The eye grounds were normal;
the vision was 6/25 in the right eye and 6/200 in the left. The ocular,
fifth and seventh nerves were normal. The uvula when moved was
drawn upward and to the left; stimulation of the pharynx on the left
produced gagging and on the right no response. The right vocal cord
was paralyzed.
Fic. 4. Showing lesion in middle cerebellar peduncle “ A.”
The Barany Tests (performed by Dr. Lewis Fisher) summarized
were as follows: The vestibulo-ocular tract from the horizontal canal
on the right side showed slight evidence of disturbance, because the
nystagmus produced was of the normal horizontal movement but was
mixed with an oblique movement. The vestibulo-cerebello-cerebral tract
for vertigo from the horizontal canal did not function at all, thus
indicating that something had interfered with it after it had become
separated from the vestibulo-ocular tract, most likely in the right resti-
form body. The absence of vertigo and practically no nystagmus from
the vertical semicircular canals suggested an interference with the vertigo
as well as in the nystagmus tracts from these canals. Dr. Fisher con-
Vii Gsd Cigo@iewiyPERIOR CERBEBEDLLAK ARTERY 129
cluded from his examinations that the disturbance was due to interference
with the circulation involving the brain stem on the right side about
its middle.
Muscular power was good in all four extremities. All the deep
reflexes were active and equal on the two sides with the exception of
the Achilles reflexes which were lost. Plantar stimulation produced
flexion of the toes on both sides. Slight adiadokokinesis was noted
in the right upper extremity.
Sensation: stereognosis, vibratory sense, sense of position and touch
were normal throughout, but pain, heat and cold were diminished but
not lost on the left side of the body. Sensation was not affected on
either side of the face and the corneal reflexes were normal. The
blood Wassermann, urine, blood pressure, and heart were normal.
The man made a good recovery but at the time of his last examination
still had the clinical evidence of his lesion.
Case 2—A white woman, forty-eight years of age, was admitted to
the Episcopal Hospital on March 15, 1924. Her husband had died
two years previously and had suffered for some years before his death
from tabes dorsalis. Ten years before her admission the patient had a
generalized skin eruption presumably due to syphilis. Her chief com-
plaint was inability to swallow. About one month before she entered
the hospital, she suddenly developed numbness and weakness in the
right arm and leg and thickness in speech. In three or four days she
entirely recovered and returned to work. Three days before admission
she suddenly developed difficulty in swallowing, numbness of the left
side of the face and difficulty in speaking.
Examination.—Distinct narrowing of the left palpebral fissure was
present, due to enophthalmos. The left pupil was smaller than the
right and was irregular; both pupils reacted well. The eye balls could
be moved freely in all directions. The corneal reflex was lost on
the left side. The nasolabial fold on the left was deepened and suggested
the condition seen in an old facial palsy, however, the movements of
the face were normal on both sides, and no changes in the electrical
reactions were present. Saliva continually ran from the mouth and
great difficulty in swallowing was noted. She could barely whistle but
could blow out a match at a fair distance from the mouth. The tongue
was protruded in the midline. The patient was too ill to stand or walk.
Both patellar reflexes were present, the right was exaggerated. Plantar
stimulation produced an atypical Babinski on the right and flexion of
the toes on the left.
Sensation: A marked impairment of pain, heat and cold was demon-
strable in the distribution of the left fifth nerve and on the right side
of the body. Sense of position and stereognosis were normal. An
ataxic tremor was present in the finger to nose test on both sides.
Laboratory examination: The blood Wassermann test was plus two
130 G. WILSON AND N. W. WINKELMAN
in the cholesterinized antigen. The routine blood examination was
normal and her urine showed the findings of nephritis. A bloody spinal
fluid was obtained due to local injury.
Clinical Course and Outcome—tThe patient lived twelve days after
admission to the hospital. In this time the tongue protruded to the
right and the temperature of the right side of the face was definitely
higher than on the left. She developed retention of urine and later
incontinence. She died suddenly.
Pathology—vVThe brain on gross examination showed moderate con-
volutional atrophy, haziness of the pia arachnoid and intense plaque
formation of the vessels, although no thrombosis could be made out.
Microscopic examination: A serial section study was made of the
brain stem and midbrain. On the left side of the medulla was an
area of softening (Figs. 1 and 2) which was quite recent and occupied
the region of the restiform body and all structures anterior to it up
to the inferior olive. The lesion was widest at about the middle of the
medulla and extended upward and downward in a cone shape. Other
small areas of softening were found, one involved the left superior
cerebellar peduncle (Fig. 3), another and larger area was found in the
left middle cerebellar peduncle (Fig. 4) and in the left lenticulo-capsular
region. The pyramidal system showed no degeneration by the Weigert
or Marchi methods. The vessels uniformly were thickened especially
the smaller ones.
CoM MENT
We believe that the two cases reported above are instances of
occlusion of the posterior inferior cerebellar artery. The one with
necropsy undoubtedly had this condition and in addition had other
areas of softening in the cerebrum and brain stem, the condition being
syphilitic in origin. The first case was unusual in that there was no
clinical evidence of implication of the descending root of the fifth
nerve. The involvement of the descending root of the fifth nerve
in the medulla is one of the commonest signs in this condition;
however, other cranial nerves were involved and helped to make the
localization possible in this case.
BIBLIOGRAPHY
1. Wallenberg. ‘Archiv f. Psych., 1895, Bd) 27, S. 504; Archiv WesPovere
1901, Bd. 34, S. 923; Deutsch. Zeitschr. f. Nervenheilk., 1911, Bd. 41,
S. 8; Deutsch. Zeitschr. f£. Nervenheilk., 1901, Bd. 19, S. 227. :
. Hun and Van Gieson. N. Y. Med. Jr., 1897, LXV, 513, 581, 613.
. Spiller. Jr. Nerv. AnD MEnT. Dis., 1908, 35, 365.
. Goldstein and Baumm. Archiv f. Psychiat., 1913, 52, 335-376.
Foix, sphiee and Schalit. Revue Neurolog,, IT. 1, No. 2, Feb, 3192s
p.
OBR WN
VERPIGOFAND FHE DEATH: WISH
By Ernest E. Haptey, M.D.
WASHINGTON, D. C.
Vertigo is a not unusual complaint of either primary or other
order and as a component part of certain well-marked symptom
groupings, entails no remarkable diagnostic acumen. While the pur-
pose of this paper does not include differential diagnosis, attention
may be directed to some of the more usual conditions giving rise to
what is termed in popular parlance, dizziness or giddiness.
Roughly, vertigo may result from any unusual alteration of the
afferent impulses to the cerebellar centers of coordination or from
lesions directly affecting such centers. Diseases of the ear occasion
rather frequent insults to the sense of equilibrium. Foreign bodies
or impacted cerumen in the external ear, irrigation of the external
meatus with hot or cold solutions (especially if there has been a per-
foration of the tympanic membrane) and sudden changes in pressure
are common causes of dizziness. Pressure affecting the stapes or
fenestra rotunda, inflammation or blockage of the eustachian tube,
chronic middle ear suppuration and inflammation or erosion of the
walls of the tympanic cavity may also give rise to vertigo. The most
common causes for aural vertigo arise from diseases affecting the
internal ear or labyrinth. Unequal pressure of the endolymph of
the semicircular canals, Méniere’s Disease (sometimes considered
due to a sudden increase of or hemorrhage into the endolymph) ;
lesions of one or more of the semicircular canals; syphilis of the
internal ear (more usually of congenital origin) and lesions of the
cochlear apparatus are the common offending agents. Those who are
susceptible to changes in the endolymph find rotation, swinging, fly-
ing, etc., extremely uncomfortable. Vertigo is a relatively minor
accompaniment of otosclerosis. Severe vertigo may be occasioned
by an increased intracranial pressure such as that due to cerebral or
cerebellar abscess or tumor. A neoplasm affecting the middle lobe of
the cerebellum is one of the best examples. An intracranial tumor
affecting the vestibular fibers in the auditory nerve may cause vertigo.
The so-called traumatic vertigo may arise from a fracture of the base
* Read at the February, 1926, meeting of The Washington Society for
Mental and Nervous Diseases, Washington, D. C.
[131]
132 EB. E. HADLEY
of the skull or from concussion. Conditions favoring fatigue of the
ciliary muscle or of the extraocular muscles, diplopia or near diplopia
are frequent exciting factors of vertigo. For this reason optic
neuritis should always be sought whenever dizziness is given as a
complaint. Sudden, repeated or rapidly changing visual impulses
such as looking from a near to a far object; gazing at an object
through the bars of a fence while passing or riding on a train stimu-
late dizziness. Variations of the blood pressure may cause a vertigo.
Increase of blood pressure as occurs in arteriosclerosis and nephritis
or a decrease as in anemic conditions, Addison’s Disease and chronic
or prolonged illnesses are the more commonly known causes. Mal-
nutrition, gout, digestive and gastro-intestinal disorders favoring the
liberation of toxins are as well known causative factors for vertigo
as alcohol, tobacco and certain drugs like the atropa group. Diseases
of the cord as in tabes dorsalis, multiple sclerosis, tumors, etc., and
alterations in cutaneous, joint and muscle sensibility may evoke sub-
jective states difficult to distinguish from dizziness. Endocrine 1m-
balance, disorders or stimulation of the pituitary, adrenals, etc., and
finally emotional tension states, fear, fright, anger, and conflicting
strivings in general are to be considered in an etiologic connection.
While this is an inadequate consideration of the various condi-
tions giving rise to vertigo the purpose of this paper has to do with
certain psychologic factors bearing fundamentally upon this as a
major complaint in a “neurosis.” The method of procedure will be
an attempt to unfold the problem as it was at first revealed to me with
some modification in view of the time element. Since the entire
therapeutic handling of the patient cannot be discussed here, the
selection, for the most part, of dreams hereinafter recorded, has been
made from the first stage of the analysis during which no explanation
of dreams or symptoms were offered to the patient. Liberal refer-
ence to remarks made by him during this period will be included and
no other historical material will be offered except that so kindly fur-
nished me by Dr. Kerr from whom the patient was referred. The
only modification in this report relates to tense and person.
” This report is to the effect that, the patient, then eighteen years of
age, was referred to Dr. Kerr by Dr. E. L. Morrison, March 7, 1921.
Dr. Kerr learned that the history, relating to the problem at that time,
“was of no importance up until a year before when he began to suffer
with headaches. Glasses were prescribed, but without relief. Two
months later he developed double vision which persisted for two months.
Shortly thereafter, he began having attacks of numbness on the right
side of his right foot which spread upwards and lasted a few minutes.
VERTIGO AND THE:-DEATH WISH 133
These attacks occurred about twice a month. In a short time, throbbing
in the right ear was noticed and has been continuous—not a true tinnitus.
Two months ago he commenced to have weak spells—a feeling of vertigo
on suddenly changing his position. His headaches continued throughout,
growing gradually worse.” During the month preceding his first visit
to Dr. Kerr he had “ vomited after breakfast. He consulted Dr. Morrison
who discovered a bilateral choked disc.’ On February eighth, one
month before Dr. Kerr saw the patient, “a lumbar puncture by Dr.
Hough showed clear c. s. fluid under increased pressure with increased
protein and three cells per cm. The Wassermann reaction was negative.
The blood Wassermann was also negative. On February eighteenth, Dr.
W. Cabell Moore made an exhaustive study of the case and found a
moderate coarse lateral nystagmus, a rather high blood pressure, absence
of the right abdominal reflex and marked increase of the red blood cells.
Otherwise the examination was negative.
“Dr. Dabney found hyperemic unhealthy looking tonsils with a thin
purulent discharge and a chronic granular hypertrophic pharyngitis.
Thinking that a possible toxic labyrinthitis from the tonsils might be
the cause of his vertigo, occasional nausea and nystagmus, the tonsils
were enucleated on the twenty-fifth of February without producing any
marked change in his condition.
(oneexatination, by er. Kerr on the: seventh of March,: “the
patient proved to be rather sparely built, of fair nourishment and
good color. The Romberg was negative. The finger to nose test was
‘negative and there was no adiadokokinesis. He could maintain station
on either foot, but not with eyes closed. There was a coarse lateral
nystagmus, more marked to the right. There was no spontaneous past
pointing. Of the cranial nerves, the first was normal. The second
showed a marked choked disc, bilateral. The pupils reacted to light
and distance. There was no extra-ocular palsy. The fifth was normal.
There was a good corneal reflex. The seventh and eighth were normal.
There was no pharyngeal reflex. The movements of the palate were
equal. The patient could not differentiate taste on the left side of the
tongue, front or back. There was no atrophy of the tongue. The
pulse was 100 at rest and 120 after exercise. The power in the trapezii
and sternocleido mastoids was normal. The cremasteric reflex on
the right was absent. The muscle power in the lower extremities was
good and equal. The knee and ankle jerks were equal and good. There
was no Babinski or clonus. Sensation to cotton, wool, pin pricks, heat
and cold was unimpaired. The joint sensibility was unimpaired. The
X-ray was negative except for faint convolutional markings throughout
“April 1, 1921—Under general anesthesia a small incision was
made behind the right ear with the idea of performing a decompression,
provided the patient did not have internal hydrocephalus. The dura
was incised. The brain needle was inserted to a depth of 4 cm. when
a large quantity of clear c. s. fluid escaped under pressure, demonstrating
134 EE Apres.
an internal hydrocephalus. The incision was closed and the patient
placed in the cerebellar position. With a typical crossbow incision
a subtentorial decompression was performed. The dura was found
tense and bulging. A dark area could be seen under the dura on the
left side. The dura was opened over both hemispheres. A dark red
mass presented in the middle of the left cerebellar hemisphere about
the size of a large egg, but not adherent to the dura. The mass was
well demarked from the surrounding brain tissue, though there was
not a very definite capsule. The bulk of the tumor was in the cerebellum -
but one-third of its circumference presented on the surface. After
ligation of several pial vessels the tumor was gently dissected out, with
very little hemorrhage. The muscles and muscle sheaths were sutured
back in place with chromic cat gut and the skin closed with silk worm
gut. There was no drainage. A plaster cast was applied which included
the head, neck and upper thorax.
“Convalescence was excellent, though a marked nystagmus persisted.
The patient was able to sit up after the fifth day. On the tenth day
after the operation the cast was removed and the sutures taken out.
There was primary union. <A few days later some clear c. s. fluid
escaped from the stitch hole intermittently for several days and then
ceased. The patient was out of bed the fifteenth day and able to walk
without assistance.
“May 20th, Dr. Morrison reported the eyes were about normal.
There had been no headache. There was some slight uncertainty in
walking. The Romberg was negative. There was no nystagmus to
the left. The deep reflexes were equal and active. The patient was
still unable to recognize taste on the left side of the tongue.
“The tumor was carefully studied by Dr. N. D. C. Lewis, who
summed up his report as follows: ‘Since the neoplastic cells are
unquestionably of endothelial origin, and as the vessels seem to belong
to the tumor process, in my opinion this tumor is an angitoendothelioma
of slow growth.”
Three years later this patient returned to Dr. Kerr complaining
of much the same subjective sensations as he had had prior to his
operation. Prominence was given to the subjective feeling of vertigo
and the patient thought he was developing another tumor. After a
careful examination Dr. Kerr was convinced of the absence of neuro-
pathology and referred him to Dr. Lewis. A few interviews with
Dr. Lewis relieved the patient somewhat, but after an interval of
several weeks he returned with an acute exacerbation of his com-
plaints. This was in December of 1924. Dr. Lewis was unable at
this time to see the patient and he was obliged to refer him to me.
When, after the introduction, Dr. Lewis left the office, the patient
was reluctant to speak of his condition. Quite frankly he objected
VERFIGO-AND THE DEATH WISH . 135
to the therapeutic handling of his problems by other than the one to
whom he had been referred. He appeared quite agitated, sat with
his head resting on the palms of his hands or walked about the room
with his hands pressed to his forehead. He said that he was too ill
to talk. But, finally, in response to my query about the nature of his
complaints, he responded by saying that he was quite certain he would
have to be operated upon for another tumor. He spoke of the
similarity of his present symptoms,—dizziness, clicking sounds in
his right ear, weakness, and nausea without vomiting, inability to
concentrate on his work and disturbing thoughts, to the sensations
that he had had prior to his operation something over three years ago.
The dizziness was of a subjective nature, the phenomenology of which
was not clearly described. Sometimes he felt confused, or just weak
with blurring and unsteadiness. He had not fallen and such sensa-
tions had occurred while standing, sitting or prone. Objects did
seem to move at times. He did not recall what direction, perhaps to
the right as he sometimes felt like turning or falling to the left. He
thought the sensation of dizziness had occurred without relation to
any sudden motion of his own and did not know but that it might
have some relation to his worries at home.
After considerable indecision he decided to return on the follow-
ing day when he thought that he might feel more like talking. The
second interview was scarcely more productive. He arrived twenty
minutes late, objected to the location of the office and the small size
of the room which gave him a “ closed-in feeling.”’ He was “ terribly
upset ’’ on seeing an excited patient in the hall, and could not sit or
lie down but paced the office making objections as indicated. He
complained of dizziness, thoughts which ran through his mind with-
out control, and thought he was going insane. He explained that he,
his mother and little sister lived together and that they rented a room
to a man to assist them, financially. He was afraid that his mother
might marry this roomer and because of his financial burden could
not “get rid” of him. He said that he was very much in love with
his mother and that any display of friendliness between his mother
and the roomer made him extremely jealous. He worried when away
from the house for fear the mother might commit some indiscretion.
[t pained him to distrust her. He was morally certain that the mother
would not execute a social error but such unwelcome thoughts oc-
curred to him. If he did not worry about this he was worrying about
a recurrence of his tumor. Worry stimulated this dizziness and he
could see no way of obtaining relief. Talking made him feel worse.
He blamed his father for his unhappy state. The father had “ told
ce
136 : Bah (Hae
a lot of lies’ about his mother during the divorce preliminaries and
later caused them to lose the home into which he, the patient, had
placed his savings.
Following this abbreviated interview, he returned for the third
hour with the following dream:
“T noticed a truck on a station platform—well loaded and
ready to be shipped to Washington. It seemed the station was
the one where my father used to be station agent and had to do
all that heavy work by himself. My father was in the dream ©
and he mentioned having seen me several times that day. I com-
pared him to our roomer and thought my father a better man. -
In the dream, there was a monkey on the truck, tied to a chain.
I played with the monkey in the dream and 1t made me dizgzy—
just like the dizzy spells I have in real life.
“There were two freight trains and two men—hoboes—
had a board which they were going to put under the car to take
a ride. One crawled under the wrong train and it pulled out
carrying him in the wrong direction.
“Then I was sitting in a room with my mother. She said
that she was thinking of my brother who drowned about two
years ago. It seemed that we were in this town where father
was station agent. Father was in this dream making bread.”
If we are to understand the meaning of these dreams, we must
first bear in mind the immediate situation. The patient has decided
to bring his problems to me, hence the well-loaded truck! on the
platform ready to be shipped to Washington. The starting point in
the dream, as in life, has to do with his father. While the patient has
said that the father is responsible for his unhappiness, the dream
expresses a favorable comparison of him over the roomer .and a
sentiment of sympathy for him on account of the amount of work he
had to do “all alone.” Such an identification with the father might
be seen to have motivation in the perceived affection of the mother
for the roomer since he is losing his mother’s affection as his father
lost it. This sympathy for the father in the dream on account of the
hard work he had to do is a reflection of his own situation. He must
now slave to support a mother who no longer loves him. There is
no joy in such a responsibility for he has to work “all alone ”—
without the reward of her love. The suspicions of the mother which
he strives to repress are almost identical to the allegations of his
father.
This brings us to a consideration of the patient’s associations to
* The patient’s associations to “truck” include the remark, “I have a
whole truck-load of troubles.”
BERTIGOMND THR DEAL AVIS H 137
“ father’ during the hour. He said, “ My father never provided for
the family. Ten years ago, mother and he could not get along. He
accused her of terrible things. Now mother is.my ideal. She is a
fine woman. Father never brought out in court the things he charged.
I really think the roomer is a nice man but he has a way I don’t like.
I really think she intends to marry him. In my dream I thought that
my father with all his meanness was a credit to this roomer. I really
had a sorry feeling for father. He was to be pitied in spite of the
way he treated us. I am sorry for him. I hated him for the way he
treated me—leaving everything on my shoulders—he drank—never
took care of himself—always looked shabby—couldn’t hold a job—
but after all father done to us I’d help him out if he was in trouble.”
Here, of course, it is the patient who is in trouble. Since the
death of his elder brother, he has held a position in the household of
relative importance. Not only has he been the sole male support and
the head of the family, but he has received a degree of affection of
an almost completely satisfying nature for one so young. Now into
this romantic arrangement there comes a foreign element in the guise
of a roomer. This gentleman is of, at least, moderate means and
what he pays in the way of room rent does help lighten the boy’s
financial burden. Regardless of the mother’s feelings which might
be quite contrary to the boy’s suspicions, a matrimonial arrangement
would, from the financial point ot view,. offer the patient complete
freedom of the support of the family. However, the possibility of
the mother transferring her affection to the roomer fills him with
alarm. Quite frankly, he states that he is tormented with jealousy.
He loves his mother and cannot endure even a manifestation of
friendliness between them. The assumption, that his troubles have
to do with his love problems, appears very well founded.
On the truck which was dramatized as being well loaded with
these problems, he was attracted to a monkey tied to a chain. Stroking
the monkey caused a dizziness similar to that of which he complained.
First of all it may be well to consider his associations to “ monkey.”
He said, “I liken this monkey to the roomer. He isa silly babyish
old fellow.. When I come in he goes out and when I go out he
comes in. I told mother that I liked a man who would face a fellow.
He isn’t friendly to me. I feel in my bones that mother intends to
marry him. He is just like a monkey and that makes me think of
anything foolish or insignificant. It seems to me like all that Dr.
Lewis told me vanished. I’m always trying to develop new symptoms.
We talked of my love for mother. I’ve always been tied down to
her. While I have girl friends, I’ve called none of them up, recently.
138 fH LADLE
To my mind I have never met a girl like my mother. One day I was
sick at home, but when she came near—well, it seemed better when
she stayed out. Now when I am out some force seems to get me
back into the house. Nevertheless I feel better when I am at work
if I can just keep my mind off of the things at home.”
The idea of the roomer as a silly, babyish old fellow comes up as
the first association to “ monkey.” Again a monkey may be “ any-
thing foolish.’ Further associations to “silly” and “ foolish”
ecphoriate the time worn admonition that masturbation causes silli-
ness, foolishness or insanity. ‘“‘ Monkey ”’ is later recalled as a col-
loquial term for the genitals, so that dream behavior in the form of
“stroking a monkey ” does not seem difficult to understand. Yet a
matter of primary importance has to do with its linking up to the
emotional background. A monkey heing considered somewhat lower
in the phylogenetic scale may very well symbolize the primitive nature
of that emotion. Perhaps we should say the “babyish” nature of
that emotion inasmuch as the roomer of which the monkey reminded
our patient was a “babyish old fellow.” This infantile attachment
to his mother is very nicely brought out in the expression that he has
“always been tied down to her.” Then the monkey in the dream
tied down by a chain is really a dramatization of himself. It is now
clear why the monkey reminds him of the roomer of whom he is
jealous since the intentions of the latter remind him of his own
secret cravings for her. In other words, he finds, though not as yet
consciously, an identification of his evil nature in the person of the
roomer. In the suspicion that the mother may have some sexual
relation with this roomer, the boy is merely stating in a less offensive
manner his own incestuous craving. The train carrying the hobo
in the wrong direction is a further symbolization of the above emo-
tional trend. A dramatization of the sexual act may be seen in the
use of the board which the hoboes placed under the car to take their
ride. The idea of the father and the roomer as the two hoboes does
not alter the significance of the dream to him. The latter dream of
the father “ making bread’ may be compared to the stroking of the
monkey in the first dream. Indeed, “it is not father who had to
make the bread, that was my job.” Neither was the brother obliged
to ‘make bread” since he was always away with the girls and oc-
casionally told our patient of his conquests. The full significance of
these thoughts about the brother imputed to the mother in the dream
is not entirely clear from the associations of the hour. However,
he said, “ When brother died some two years ago we all took it pretty
hard—although he did not stay around the house much. I had to go
‘6
VERTIGOMAND THE DEATMIMVISH 139
to Miami to take care of everything. Father did nothing, though I
believe he did pay the expenses at the time of the funeral. Then
I felt awfully important and when people came to view the corpse |
would say that I was his brother.”
Suffice it to say that these dream thoughts are of death. And,
we are aware of how upset—dizzy—the patient has become in view
of a possibility of an interruption of the mother relationship. Such
an interruption of a state of comfort must have its analogy in the
phenomena preceding birth so that the roots of vertigo must here be
found in the Death-Evil preconcept.?
To the next hour he brought a dream which we shall briefly
consider.
“T was standing ma road with a bunch of men, all of whom
were eating ice cream. I could see my mother and sister coming
down the road on horseback. I asked 1f the horse was all right.
Then I became mad and irritable because I had no ice cream
and took some from someone else. I then noticed the horse had
one shoe off. I did not want these fellows to see my mother on
account of the divorce proceedings which were going on.”
The affect reaction in. the dream is given as, “ Irritable, mad,
dizzy.’ And he says that “everything at the house gets on my
nerves—at the present time I seem to have more affection for my
sister and more mad toward mother. Sister is a lively kid and she
? Sullivan, in his clinical researches upon the motivation in schizophrenia,
has formulated a notion concerning certain primary constellary phenomena
which he calls preconcepts. The material of the last of these in the sequence
of events immediately precede the termination of the uterine state. To this is
given the apt designation, Death-Evil. A brief discussion of preconcepts is to
be found in his “ The Oral Complex” (The Psychoanalytic Review, 12:32,
January, 1925). Further elaborations of this appear in his other contributions.
Briefly, as I see it, the Cosmos preconcept. includes a felt pleasure—com-
fort—condition described by Sullivan as “a content of universal subjective
participation”? or a mental state to which the term omnipotence might be
applied. The interruption of this state of comfort is the beginning of the
Death-Evil perceptions, and, to quote the author, is brought about by ‘“‘ emphatic
changes in the fluid tension, hormone content of the blood and the foetal bio-
chemistry ’—the concomitants of the inception of labor (or surgical interfer-
ence). Impressions from the end-organs continue in ordinary labor up to the
period of foetal “unconsciousness ” occasioned during engagement of the head.
The functional activity of the sensory nervous apparatus and vegetative
systems give rise to experience which is, of course, devoid of meaning except
in so far as it has affective tone referable to the impulses making for the
continuation of life. Only by reflecting can we appreciate the ghastly and
cataclysmic nature of this event.
In the genetic sense, all post-natal experience involving “pleasure and
pain” would have relationship to these basic Cosmos and Death-Evil precon-
cepts. He believes that the affective aspects of experience are relatively little
differentiated in the course of life and that practically unmodified affective
radiations of the most primitive sort may appear in consciousness; for example,
in panic.
140 Fer ETT ADIGE
gets on my nerves. When I awake I hear mother getting breakfast
and talking to the roomer. I imagine they are talking about me. I
feel better if I am in the room where they are. One evening mother
walked into the room and made me unusually irritable. When I come
in the roomer goes out—or the other way. When he is friendly, I
feel somewhat relieved.”
Associations to “ice cream” were not very productive—yet he
said that he cared very little for cake or ice cream. Chocolate ice
cream, as in the dream, is the only kind he cares for. There he was
mad because the men had something nice which he alone did not have.
The anger, irritability and dizziness is occasioned in the dream be-
cause of his lack of ice cream—later understood as a sexual sweet—
and in reality because he feels that he is losing his place in his
mother’s affection. Then in the dream he obtains the ice cream by a
bit of trickery and in the waking state he feels more affection for his
sister, a sort of substitute love-object for the mother.
Now there is another element in the dream. The horse—his horse,
has lost his shoe. This brings to mind an old saying, “ For the lack
of a nail the shoe was lost, etc.’”’ His mother, we learn, is an ex-
cellent horsewoman, robust, vigorous and athletic. This brings to
mind his irritability about the house of late, his lack of ambition,
disinterest in calling up any of the girls and that temporarily he is
distracted from his ills by associations with some of the fellows. Cer-
tainly the affect of the dream, irritability, anger and dizziness, is quite
closely related with things not obtainable, losses, the castration com-
plex and the Death-Evil preconcept. The latter affect in the dream,
a feeling of shame on having the fellows see his mother during the
divorce proceedings, is stimulated by the allegations of the father
about the mother. Similar suspicions have entered his consciousness.
Since we have learned how such suspicions relate to his own secret
cravings, the feeling of shame is readily understood. Then the idea
of divorce brings up the thought of separation and the widening of
the mother’s personal interest in both the sister and himself.
The dream of the following hour is quite brief. He dreamed
that:
“I was on a ward with a lot of insane patients. I awoke
with a feeling of great fright.”
His associations, somewhat abbreviated, need no further explana-
tion. “ The first time I came to see Dr. Lewis, I told him that I
thought I was losing my mind. I can imagine myself as being a
patient here. This week I have been away from work, my thoughts
have been constantly on this roomer, my mother, home and the opera-
VERTIGO AND AOE UE Are WISH 14]
tion. I got to feeling I wasn’t wanted around the house. I felt |
couldn’t go home and was not at ease. I remember when I was a
child my mother would say, ‘ you must not have good sense,’ or ‘ you
must be crazy.’ She talked that way to sister and I told her not
to. . . . When father made those accusations about mother, people
said he must be out of his head. . . . The first time I came out here
I imagined my nerves might crack and I couldn’t get out of here.
I often wonder if brother wasn’t better off since he has missed
what I have gone through . . . I can’t stand it to see these poor
fellows (patients in the Hall). Mother used to say ‘if you read too
much you will go crazy. . .. [ remember one morning going down
on the street car that I saw my father walking along the street. He
looked pitiful, then at the same time I thought what a hateful fellow
he was. I ofen see middle-aged men walking with boys and I wish I
had a father to do that—to take an interest in me. Only once did
father take us two boys anywhere and that was to a bowling alley.
If I went any place it was with mother. The only pleasure I have
had has been through her. It just entered my mind that I might get
rid of all these responsibilities if I was insane.”
The fear-affect here exposed is the obverse of the desire,
which might be reworded as follows: “I wish that I might be insane
so that I might evade the problems of life.” This death wish is
expressed somewhat more clearly in a dream of the thirteenth inter-
view. However, before proceeding to it, we may consider a dream
impression of the seventh hour.
“Tt was a sort of an emotion or sensation in which I seemed
to be losing something. One moment it was almost unbearable
and the next moment it seemed to take a great load off of my
mind.”
The dream reminds him of “the home situation.” “ This roomer
is unbearable—yet in view of the rent he pays, I could scarcely get
along without him. Last night I got to talking with him and he did
not seem so bad. At first I was quite tense, but after talking a while,
eating some cake and drinking some wine, | went out feeling a great
deal better. Yet, I cannot keep this operation idea out of my mind.
It seems to blot out everything else. If I feel good for a minute
then I feel worse. I got terribly worked up on seeing that man out-
side (a patient in a panic state). I don’t know what might have
happened if I had not been admitted. He reminded me of my father,
even as to size, voice, etc.” There is a pause—then—‘‘After father
left, I used to have to sit around the house on Sunday. That was an
142 BE. Es HADLEY,
unbearable tied-down feeling. I used to say that I couldn’t stand
being head of the house much longer. One day, mother said that it
was hard for her too as she was still young. I had to buy things at
the store, take the man’s place and it upset me for I was not strong.
When these operation thoughts come on I get a sensation in my ear
which makes me dizzy and sick. If I get ina barber chair I get upset
and sick, especially if the barber gets to working around that scar.
I can’t remember, but I was very dizzy for some time after the
operation. Brother was the first to see me after I came out from
the ether. 1 don’t remember when I started to have dizzy spells
again but it was not until after brother died and I had that unbearable
feeling of having to sit around the house—being tied-down as head
of the house supporting mother and my kid sister. I felt tense all of
the time. Sometimes I think of myself as a sissy and the fellows
intimate that I am a home-loving baby. I have been that kind and in
talking to people they detect it. Once at a party a lively girl there
wanted to drink and we did. Something was said and she replied,
“Oh! you’re virtuous, your mother said so!’ That struck me hard.
Mother enters into everything . . . a fellow later said to me, ‘ Oh,
you're going to meet your mother.’ I met a girl friend of brother’s
at the hospital. She used to invite me over. I felt I couldn’t go out
with her (the brother’s mistress), or my mother. This girl was
passionate, and one time sitting on a couch . . . something disgusted
me. Later when I called her up, she had a date and then another
time she said she found out that my brother was not a gentleman and
I told her to go to Hell. When I go out alone it makes me think of a
kid the girls tease. He is a regular mamma’s boy. I hate to be that
way. That idea of mothers being so good, and living off alone
somewhere with them is foolish. I think this roomer is a fakir,
sometimes he seems all right. I can’t stand it to get her off my hands
that way. It is hard to think mother would marry him.”
Another dream in which a sensation of vertigo is experienced
will be included from the eighth interview. It is as follows:
“A bunch of fellows were on the street. One fellow was naked
and running around. We were all laughing and following him.
It seemed that he had an erection. He finally got on a bus and
left. I awoke but it seems that I had had another dream or
part of this one which had to do with my mother. I felt dizzy
and on awakening from this dream I continued to feel dizzy.
I was also convinced on awakening that mother was in some way
the cause of it or that something about my mother was causing
the dizziness.”
PERTIGO AND Wah DEAL WISH 143
The affect-reaction of the dream or dreams are given as “ dizzi-
ness about my mother, disgust at the sight of the (erect phallus),
and amusement on seeing him naked on the street.” Concerning the
dizziness he said, “I feel that this dizziness is caused by anxiety and
worry about my mother and that she is indirectly the cause of it.
One day at the office I was smoking a cigarette and a fellow said,
“IT guess your mother don’t know that you are smoking.’ I hate to
_ be considered small. Well, I didn’t feel dizzy any more to-day until
I got to thinking about this roomer and I got worked up. The blood
rushed to my head. If I am calm, I feel all right. If he is friendly
and I feel that way, I feel pretty much at ease. He says he likes
people who are genial and friendly but I think it is as much his fault.
It is so when he behaves as he does, avoids me, etc. Playing cards
with mother and I we all felt tense but after playing a while we all
felt better. There was a fellow at the office—a sissy—nervous kind
of fellow—showed me a picture and said, ‘that one is of mamma
and me standing under the tree.’ It sure sounded funny to me. One
day at the desk he fainted and they had to carry him out. He had
crying spells and I used to wonder how it felt to feel like that.”
The feeling of amusement at the nudity of the dream figure was
next considered. He said in part, “Laughing at this fellow. It
seemed a joke—funny he should be running around naked. He was a
young fellow. Well, I don’t know why but when anything is said
about girls or intercourse I get worked up. I’ve often thought I’ve
been inferior to most fellows. I’ve never been out with a woman
that way and I suppose most fellows have.” There is a pause and
when asked what had come to his mind said, “ Disgust, I was thinking
of how I felt in the dream—disgust at the boy’s running around
with (an erect phallus).’’ He was asked to proceed from this feeling
of disgust. “ We were all running after him. I have a perfect
horror of ac S When I was going for those treatments
(baths), a man next to me brought up the question of women, after
which he put his hand on my leg. I put on my clothes and beat it.
It seemed, to my mind, abnormal. When I walk along by myself, I
get the impression that other fellows would think that I was ‘ going
around by myself.’? One night I was watching a game of pool and
someone mentioned the word c s Then I thought that they
looked at me. I did have on a flashy necktie. This idea of disgust
reminds me of the way I felt with that girl I told I wouldn’t see
again. I was disgusted at the way I acted toward her. I often hear
8A nice remark made also of a girl of easy virtue,—‘‘ She goes around by
herself,” or “she runs around by herself.”
144 Bele aD ee
fellows my age brag about their intimacies, probably lies . . . as
this girl knew my mother I was afraid it would get back to her. She
was too passionate and irresponsible. . . . It is disgusting not to
get out and mix more with the girls. People appreciate a fellow
more if he has girl friends and can go out more and not be confined
to boy friends all the time. I feel sometimes that I] am handicapped
physically, have no ambition and I used to think it would be impos-
sible for me to get married. At the same time, I have a family to
support. Yet if mother did get married, I might have some future.
If she married somebody I liked, it would be easier.”
To return to the dream, we recall that one fellow was naked and
running around on the street. A bunch of fellows laugh and jeer at
this dream figure. That is the way they, his associates, would laugh
and jeer at him if they knew the nature of his secret cravings. That
is what the naked fellow represents. Then we know how “ funny ”
it seems to the other fellows that he should not have a girl and how
they tease and make fun of him. They even say, “He must be
going out to meet his mother.” As a matter of fact, during the
previous hour he remarked that he was much like this “ sissy fellow.”
He has even tried to put himself in the place of this fellow and
wondered how it would feel to faint and cry. When the “sissy”
referred to a picture and said “that is of mamma and me,” it gave
our patient a peculiar feeling which he described as “ funny.’ Then
at the office a fellow made fun of him, indicating that his mother did_
not know that he was smoking, that is to say, he was not old enough
to smoke. Instead, perhaps, he should have a nipple in his mouth.
Too, he hates being considered small, a sissy or a mamma’s boy. |
Quite understandable that he should consider his mother responsible
in some way for his dizziness. Actually, it is the strength of the
bonds of love for her, which, if running as wild-as the nude figure
in the dream, would make him an object of derision. We may observe
in passing, that the dream figure entered a bus. This fulfills two
motives. The bus is something in which one may ride for pleasure
and it is also a means of getting away. Entering the bus is first, the
fulfillment of incestual cravings—recall the marked manifestations
of libido and the statement that all the pleasure that he has had has
been through his mother, and secondly, the bus represents a means
of escape by way of regression back into the cosmic womb. Now,
when such strong barriers exist in the incest notion one might wonder
why there should be such a complete turning back if one did not also
understand the possibility of another and as equally strong a barrier
to going forward, away from the incest taboo. That barrier as re-
VERTIGO AND THE DEATH WISH 145
vealed is an homosexual one. To use his own expression, he is in a
vicious circle—between the devil and the deep blue sea, what with
worry over the mother and the roomer, with ensuing dizziness, which
makes him think he needs to be operated on for a tumor. The tumor
and the operative procedure which he needs is no longer surgical but
functional. The homosexual craving seems clear. He has been going
around by himself like the girls of easy virtue who go out alone to
attract the male. He is looked upon as a sissy, weak and feminine.
A boy at the bath placed a hand on his thigh in a suggestive manner.
He has a horror of a man who performs sexually upon another man.
He must have been suspected once as such an one since he heard a
common remark of such people, and the fellow looked at him. Quite
self-consciously he noted that he himself was wearing a flashy tie.
The secret wish from which he consciously recoils is that, as in the
dream boys run after a nude figure, he should be sought after by
boys in a sexual way. The feeling of disgust is the equal and opposite
reaction toward both the incestual and homosexual cravings. From
disgust to symptoms of nausea requires small stretching of the imagi-
nation and from confusion over conflicting cravings to dizziness
requires, if nothnig else is available, some inner reflection on the
feeling of confusion. However, in this adoption of the female role
an important concatenation of ideas should be mentioned, leading to
an understanding of the attitude of the patient to the roomer. He
has spoken of the feeling of jealousy, the comparison of the roomer
with the father, his own desire for a father who would take an
interest in him, his vacillation from ease to a state of tension with the
-roomer and how in thinking of the roomer he “ got worked up ”—
sexually excited, as was the nude figure in the dream. In this be-
coming “ worked up” over the roomer “blood rushed to his head.”
This is an important analogy to congestion in general, the idea of a
tumor—a swelling in the brain or tumefaction of erectile tissues.
The vasomotor disturbance bears a nice relation to dizziness * or
fainting spells, either through the “rush of blood to the brain” or
its opposite, a “rush of blood” to other parts of the body, e.g., the
genital zone. We may now reword a part of the psychological
mechanism by saying that, the patient, now realizing that he cannot
possess his mother sexually, identifies himself with her and through
such adoption of the female role diverts the craving from the mother,
whose part he plays, to the roomer. The fear that mother may com-
mit some social error may now be seen as a projection of his own
* Falling in a dizzy spell or faint bears a nice analogy to a moral fall.
146 Bett, WADIA
fear of giving in to his own desires. The evolution of the fellatio
fantasy is from the role of nursling with the mother to an analogous
position with the roomer.
Another aspect which merits certain consideration has to do with
exhibitionism as displayed by the nude figure in the dream. Ex-
hibitionism, as an overt feature, has been understood as a compensa-
tory manifestation of, sometimes dimly realized, feelings of im-
potence. In this particular instance, the patient has told us of his
lack of ambition, feelings of inferiority, disinterest in calling up any
of the girls with whom he is acquainted, ideas of physical handicap
and his lack of sexual experience with girls. He has not lacked op-
portunity. The bungling of a sexual opportunity with his brother’s
mistress, must have been motivated by rather potent taboos since his
own extremely weak rationalization was the fear that his mother
might learn of it. A very powerful attraction to and stimulation by
this girl was at a critical moment suddenly altered by overwhelming
disgust phenomena. Disgust moreover having its origin through
homosexuality in the incest craving. This girl was from his view-
point aggressive, passionate and, from his later remarks, possessed
of many masculine traits. As later demonstrated, she was for him a
confluent symbol par excellence for the satisfaction of all noncreative
libido strivings. It was of interest to learn at the close of this hour
that dizzy sensations occurred as a companion manifestation to ac-
tivity of the erectile tissues. Such occurrences as well as remotely
separated nocturnal emissions stimulated disgust. In fact, headache,
feelings of increased pressure within or about the head, extreme
lassitude, and a confusional attitude toward, and inability to con-
centrate on his work persisted for some time following a nocturnal
emission. He stated that he felt better when he could avoid all
sexual stimulation. The idea of suppressing or preventing genital
tumefaction, the need for an operation for cerebellar tumor, and the
relation of dizziness to both are exceedingly instructive psychological
events.
A dream of the eleventh hour dramatizes the nature of his interest
in girls.
“T was attracted to some extremely pretty girls—my mother
said they were unreal; on approaching them I found them to be
wax figures. I was then in a dance hall and dancing with this
girl I knew I started to kiss her but she turned out to be a
fellow I know.”
He said that all girls seemed unreal to him, that French girls are
less settled than American girls, These wax figures seemed to be
VERLTIGOVAND Tithe pig he Wisi 147
French. His brother showed him some photographs of very lovely
French girls, quite ethereal. The stories his brother told of the
diverse methods of sexual pleasure enjoyed by them did not seem
to fit in well with such nice pictures. The girl with whom he danced
reminded him of the one to whom his brother paid so much attention.
He regrets his lack of opportunity with girls and explains this
rather erroneous statement by the statement that he has always been
tied down to his mother. He says that he is always comparing girls
with his mother. So close a comparison has he made between the
mother and the brother’s mistress that censorship activity over incest
trends connects the object of such poorly disguised behavior as kiss-
ing over into that of a male. However, this boy is so easily compared
to himself that it is more like a manifestation of love for himself
than someone like himself—another male, that the idea of kissing a
boy was less offensive than kissing a girl who represents his mother.
Still he says, “when the girl changed into a boy it made me feel
foolish.” The boy reminds him of a youngster that never has a girl
and always goes out by himself. This youngster is popular with the
fellows as he would like to be; timid so far as the girls are concerned
and extremely good looking. He has compared this youngster to
himself and has a feeling of sympathy for him, because of what he
perceives to be a similarity of difficulties.
The dream of the thirteenth interview points a way out of all of
these difficulties. He said:
“I dreamed that I was standing by the grave of a man named
Free.”
He first recalled a recent trip to his brother’s grave and that while
standing there he thought that he would be better off if he could be in
the grave instead of his brother. Very likely, he might have to be
operated upon and this time he might “kick the bucket.” “Free”’
makes him think of being free from worry and responsibility. He
would be free if he were dead. Anyway, he might as well be dead
since he is as restricted as if he were “buried in a cave.”
“Home is like a tomb on Sunday.” Saturday, he begins to get
nervous, tense and dizzy and Sunday things become unbearable. He
is brought more into contact with the environment which makes him
dizzy and at such times death, he thinks, is much to be desired.
Time does not permit the utilization of further dreams and asso-
ciational material. Suffice it to say, the patient was enabled through
the ecphoria of affect trends to obtain expression of his instinctual
interests in a manner not offensive to the ego and more in keeping
148 A. E.=HADEES
with biological aims. Hitherto, he had sought comfort through a
conscious denial of the upsurging libido. It was only when he was
free from thoughts of a sexual nature that he experienced a feeling
of ease. At other times he was tense, ill-at-ease and if the unwel-
come emotions came near to crystallization in consciousness, the
summation of this vague feeling of dis-ease was experienced as dis-
tractibility and confusion up to a pronounced vertigo—even to a
panic state. By analogous thinking this alteration from pleasure to
pain may be compared to the phenomenology preceding birth which
has given form to the Death-Evil preconcept. These feelings of pain
experienced by our patient may therefore be seen as radiations of the
preconcept of Death. Vertigo has been seen as one of the major
radiations in this instance. Dizziness may be observed as a distrac-
tion from the painful stimuli in such manner as more obliterative
phenomena—fainting, states of unconsciousness, stupors, etc., are
seen to function. Death is conceived as a permanent solution of all
of these difficulties. However, we must look at this death-wish from
an angle which is after all a fear of death. It is not death but com-
fort which the patient desires. How else can one explain such
Herculean tasks as the suppression of that which appears to him as
sexual? Such comfort as he has found has been dependent upon a.
relatively nonsexual point of view, approaching as nearly as possible
the Cosmos preconcept. For him the consequences of forward direc-
tion of the libido have been decidedly unpleasant. It is the fear of
such pain—Death-Evil radiations, which mitigate an investiture of
interest in social constructive ends. In this connection, we may
remark that it is by means of the phenomenology of the transfer that
the patient is assisted from preoccupation with the cosmic mysteries
through what is ofttimes so allegorically described as the Valley of
the Shadow of Death, dark winding roads and unpleasant journeys.
to participation in the pleasure substitutes of reality.
THE COLUMNAR ARRANGEMENT OF THE PRIMARY
AFFERENT CENTERS IN THE BRAIN-STEM OF MAN *
By WALTER FREEMAN, M.D.
SENIOR MEDICAL OFFICER, ST. ELIZABETHS HOSPITAL, WASHINGTON, D. C.
(Continued from page 20)
A. Exteroceptwe System
(1) Light touch. Fibers for simple touch enter the root zone
by the ventral division of the sensory root and run partly to the
cornu dorsale within the space of a segment or two, partly directly
to the dorsal column nuclei by way of the funiculi. Secondary paths
are apparently widely distributed in the spinal cord for they are
said not to be destroyed except in very extensive lesions. It is pos-
sible that impressions of light touch reach the higher centers by a
number of relays.t
The discriminative elements of de sensation, such as the recog-
nition of the size or shape of the object placed upon the skin, the
texture and the hardness, are probably carried entirely by fibers
running in the dorsal columns.
| The cutaneous fibers subserving the function of touch (pressure
touch?), whose secondary course we find later represented in the
spinothalamic tract of the opposite side, enter in the ventral division
of the sensory root. According to Winkler, they divide immediately
into short descending branches and slightly longer ascending ones.
These form a fine meshwork dorsal to the substantia gelatinosa
Rolandi, and after passing around or through the stratum gelatinosum
go to make up another fine meshwork on the inner side. The tactile
fibers apparently run to the cellulae limitantes of the dorsal horn
where the impulses are then relayed to the higher centers by way of
the opposite spinothalamic tract. As was noted above, Winkler believes
*In examining for the sense of light touch it must be remembered that
_the touch of the finger or even of a light brush will often stimulate the deep
nerve endings. The need for delicacy in the examination for light touch was
shown by Head (7). upon his own arm. He also showed that the movements
of the hairs stimulated the deep sensory endings, for these movements were
perceived as touches in a part of the arm that had been rendered otherwise
anesthetic by section of all the nerves supplying cutaneous sensibility to that
part. Shaving the arm removed the interference. To gain an idea of the
proper stimulus to be used in testing the sense of light touch, the glans penis
offers a normal control. Head and others have shown that light touch is not
perceived on the glans penis.
[149]
150 WALTER FREEMAN
that fibers transmitting light touch may travel in a number of differ-
ent paths, and by several relays. Head (7, p. 401) states that tactile
impulses are gradually filtered off on their way up the cord from
the side of entry to the opposite side. When tactile sensibility is lost
in Brown-Séquard paralysis, it is lost on the side of the body opposite
the lesion, but it is lost only when the lesion is high up in the cord.
(2) Pain and temperature sensations are transmitted together as
a general rule, although in some clinical cases there is dissociation of
sensation, heat being perceived and cold not, or pain perceived and not
temperature. In general, however, it seems that the fibers trans-
mitting these impressions enter in the ventral division of the sensory
root, run up and down for a limited distance in the tract of Lissauer,
and find their end stations in the dorsal horn within two segments of
their level of entry. The entering fibers seem to connect with the
small cells of Gierke, by which the impressions are relayed to the
cellulae limitantes and thus by way of the opposite spinothalamic tract
to the brain. In either case the primary end stations for the fibers
conveying pain and temperature sensations are to be found in the
dorsal horn close to the level of their entry.
(3) Pressure sensations, although conveyed by fibers in the motor
divisions of the spinal nerves, are transmitted to the spinal cord by
way of the dorsal root and are probably relayed cephalad by cells in
the dorsal cornu as well as carried directly by the primary fibers run-
ning in the dorsal funiculi to the nuclei of Goll and Burdach. In
addition a series of short paths seems to be open to pressure impres-
sions, by which they may be relayed to the brain. Only very exten-
sive lesions of both halves of the spinal cord will abutish the sense of
deep pressure.
(4) Fibers subserving segmental reflexes and muscle tone prob-
ably enter by the ventral division of the sensory root and run directly
to the ventral horn on the same side.
B. Interoceptive System
~The afferent impressions from the viscera are carried by fine
fibers, presumably in the dorsal division of the sensory root, and find
their end stations in the pars intermedia in close relation with the
cells of origin of the visceral efferent system.
C. Proprioceptive System
IXinesthetic impressions, like those of deep pressure, are appar-
ently conveyed from the end organs in the muscles, joints, and tendons
bv heavy fibers which enter in the dorsal division of the sensory root.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 151
Two paths are open, one towards the cerebrum and one towards the
cerebellum. The former path is found in the dorsal columns and
their nuclei, and subserves the cognitive aspect of proprioceptive
sensibility. The latter is by way of the cells of the column of Clarke,
which forms their primary end station, to the cerebellum, and sub-
serves the automatic postural aspect of proprioceptive sensibility.
Deep pressure sense, including the sense of vibration, is probably
transmitted by the proprioceptive cognitive system, and has been con-
sidered apart, with the exteroceptive system, only for the sake of
convenience. Both systems belong to the somatic sensory system.
The Entering Root Fibers of the Cramal Nerves
The usual description accorded the roots of the VII, IX, and X
nerves is that the motor fibers lie mesially and the sensory ones
laterally, and that they enter the brain stem in a number of fasciculli
Haine one above the other. There has been no attempt to analyze
further the different fasciculi of the afferent roots. Using the dorsal
root fibers of the spinal cord as our example, let us see whether this
analysis is facilitated. In the spinal cord, according to Winkler. each
entering sensory root is divided into a smaller ventral portion and a
larger dorsal one. If the cranial nerves are examined it will be found
that the relationship is usually the same, but by no means constantly
so. For instance, the two divisions of the N. glossopharyngeus are
of about equal size. The dorsal divisions of the sensory roots of the
N. vagus are multiple; sometimes as many as five strands may be
seen penetrating the zona radicularis in the same section. ‘The dorsal
branches are always the larger. In the case of the N. trigeminus the
relationships are complicated, as we shall see later by the fact that the
nucleus sensibilis trigemini and the radix spinalis trigemini receive
divisions of the same entering fibers. Also in the case of the lower
branchial nerves the picture is often obscured by the entrance of
several afferent fasciculi one above the other, but this arrangement
does not disturb essentially the dorsoventral relationships of one to
_ another.
What is the destination of these various fasciculi? In the spinal
cord, as we have seen, the smaller ventral division of the sensory root,
carrying principally impressions of pain and temperature (and accord-
ing to Winkler, touch), runs in the zone of Lissauer and enters the
substantia gelatinosa Rolandi. The larger dorsal division of the sen-
sory root gives its fibers to the dorsal columns, to the column of
Clarke, and to the pars intermedia. The most dorsal fractions enter
the column of Clarke and the pars intermedia, the central fractions
12 WALTER FREEMAN
go to the dorsal funiculi, and those situated in proximity to or within
the ventral division run to the anterior horn as segmental reflex fibers.
Kicure 6. Pons of adult man, showing details of the entry of the sensory
division of the N. facialis. To the outer side of the R. spin. trigemini (V s)
are seen the entering root fibers of the N. vestibularis. Penetrating the spinal
root are numerous fasciculi of the sensory division of the N. facialis. Some
of the fibers apparently join the R. spinalis V, others continue dorsomesiad
to reach the viscerosensory nucleus A which is capped by the tractus solitarius.
Medially to this a large fasciculus can be seen which runs farther dorsad and
then bends proximad. The R. motoria VII is seen on the lower right.
Outline shows the area selected.
In a general way the same arrangement is found to hold good in the
brain stem.
Some of the dorsally placed fasciculi of the IX and X nerves
ARRANGEMENT OF PRIMARY AFFERENT CENTERS | 153
penetrate into the radix spinalis trigemini and apparently do not
emerge. ‘The probability is that they turn caudad in this cephalic
prolongation of the tract of Lissauer, a hypothesis that is confirmed
by Cajal’s researches. The ventral fibers of the main sensory divi-
sions of the N. trigeminus bend caudad in the R. spinalis V, thus
forming the tract at its commencement. In the case of the N. facialis
the relationship is apparently somewhat different. A large number of
small bundles making up the ventral division of the sensory root enter
and lose themselves in the spinal root of the trigeminus, but ventral
Ficure 7. Oblique section of re ons of a three months’ human embryo
stained with silver (author’s method). The entering fasciculi of the R.
sensibilis N. VII are seen penetrating the R. spin. N. V and running partly
to the tractus solitarius at c. and partly mesial to this. They can be traced
in a very definite series of strands to the neighborhood of the VI nucleus
where they engage the R. motoria N. VII.
to them all is a relatively large fasciculus that penetrates the R.
spinalis V, and runs dorsomesiad without apparently giving off any
fibers to the tract. This fasciculus may have crossed the other roots
to attain its position but I was unable to determine it in any of the
series. The fibers entering the R. spinalis trigemini in all probability
carry pain and temperature sensations to the nuclei accompanying the
root. It is very doubtful if even simple tactile impulses are relayed
by the substantia gelatinosa N. trigemini. (See Cases 2 and 3.)
The fasciculus of fibers which formed such a prominent part of
the sensory root of the N. facialis 1s also represented in the sensory
roots of the [X and X nerves, but here the fasciculi were found to be
situated centrally among the entering fibers. Fig. 6 shows this
fasciculus belonging to the N. facialis. Reaching the position shown,
to the mesial side of the tractus solitarius, the fibers bend forward
154 WALTER FREEMAN
and come into close relationship with the distal portion of the radix
motoria N. VII (Fig. 8). In a fortunate preparation giving an
oblique section of the brain stem of a human embryo, these fibers
could be traced almost to the midline at the level of the genu N.
facialis dorsal to the nucleus abducens (Fig. 7). (See also Appendix
A.) It is probable that they continued their course in conjunction
with the proximal portion of the radix motoria N. VII to end in the
Rami sens.
NW.
Ficure 8. fons of adult man a short distance above the section shown in
Fic. 6; showing the R. sens. N. VII engaging its gustatory nucleus. This
gelatinous nucleus is situated in the course of the incoming fibers somewhat
ventrolateral to the N. viscerosensibilis of the tractus solitarius. The full
stretch of the R. motoria VII is seen. The mesial bundle of segmental reflex
fibers which entered at a lower level may be seen in its vicinity as a loose
bundle of fibers cut transversely (A).
—
motor nucleus of the facial nerve. Homologous fibers belonging to
the IX and X nerves can be seen in some other sections (Figs. 9, 10,
15), lying to the inner side of the tractus solitarius at the margin of
the central gray matter. ‘These fibers are probably those subserving
segmental reflexes. Of their afferent nature we have no certain
proof. The peripheral course is with the afferent roots, however,
and there are homologous fibers in the spinal cord. Van Gehuch-
ten (27) considered the bundle to be an aberrant fasciculus of the
motor portion.
Of the dorsally placed sensory divisions, the most mesial usually
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 155
bends laterally, crossing the divisions situated farther dorsally, and
runs in the direction of the corpus restiforme. In the case of the
spinal nerves, the corresponding fasciculus is destined for the dorsal
funiculi. In the brain stem, however, instead of the dorsal columns
we have the main sensory nuclei, and it is apparently to these collec-
tions of cells that these fibers pursue their course. The nucleus
sensibilis trigemini is the best known of these groups and is homolo-
gous with the nuclei of the dorsal funiculi. The other nuclei will be
described below. ‘The fibers concerned probably carry superficial and
deep discriminative sensibility.
=a,
S Xe NUC.F Rane Vii
ES, See
a “
BLOOD VESSEL,
cone Ee he : Me e is
BF BSE 3 ae “> ;
le a es : ¢ ce ans e
Bf sé SEEN Se Nuc. vis¢eRo-
eee ¢ ae ‘ % : e SENSI BLIS IA,
oe ee if Ne : a
Rsens venti SOa\” BN CSUBSTCELW “<< Nuc cust Ie
| Nuc.vest. NOVI
Figure 9. Medulla oblongata of 6 months’ human fetus (silver impregna-
tion). The division of the entering root fasciculi can be seen clearly. Fibers
from both divisions of the afferent root turn outward and run in the direction
of the collection of large cells at the tip of the corpus restiforme. A large
mesial strand enters ‘the R. spinalis V and apparently joins it in its caudad
course. The dorsal afferent fasciculus engages a large pyriform gelatinous
nucleus (Nuc. gustativus IX) and the Nuc. viscerosensibilis IX of the tractus
solitarius. At “A” there are apparently some root fibers joining the R.
desc. VIII.
The large dorsal division of the afferent root often consists of sev-
eral subdivisions, and not infrequently they do not penetrate the
R. spinalis trigemini but skirt its dorsolateral border. ‘This 1s espe-
cially true of the N. vagus. In the case of the seventh and ninth
nerves this division engages nuclei that are believed to be the gustatory
nuclei, and in part this division runs farther dorsomesiad to make
up the fasciculus solitarius (Figs. 8 and 9). In the case of the
vague nerve it runs largely to the tractus solitarius with its accom-
156 WALTER FREEMAN
panying nuclei (Fig. 10). No collections of ganglion cells could be
identified as the nucleus gustativus X. The fibers taking this course
are those conveying interoceptive impressions, general sensibility
from the mucous membranes, and special sense (taste) from the
tastebuds.
Between the entry of the sensory root of the N. facialis and that
of the lower entering fasciculi of the N. vagus the tractus solitarius
lies in such intimate relation with the radix descendens VIII that no
Nuc.sene X (3).
“3 ae ih
ai Aeneid
Se coats
fear w.
wah
Ficure 10. Medulla oblongata of a 6 months’ human fetus stained with
silver, showing the entering root fibers of the upper portion of the N. X.
A few strands run in the direction of a collection of large cells near the tip
of the corpus restiforme. Another fasciculus apparently joins the R. spin. V
at b. Most of the fibers run to the tractus solitarius and its accompanying
nucleus. A few motor fibers are seen. SGR=substantia gelatinosa Rolandi.
OC = fibrae olivo-cerebellares.
adequate separation can be made, and indeed it seems that some
strands from the most dorsal division of the various afferent roots
penetrate among the descending fibers of this tract and lose them-
selves there. These fibers will be considered later when the great
proprioceptive system of the brain stem is described, the vestibular
nerve and its centers.
The interoceptive fibers of the N. trigeminus enter upon the outer
or dorsal side of the sensory root, and run to the visceral sensory
center which is the forward continuation of the tractus solitarius
(Fig. 11).
The known proprioceptive fibers of the N. trigeminus occupy a
different position from those in the spinal nerves possibly because
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 157
they enter the neural axis in primitive fashion without preliminary
relay in the Gasserian ganglion. At their entry into the pons, there-
fore, these fibers lie on the inner or ventral side of the main sensory
root. They can be traced as heavy fibers running far dorsally between
the motor and sensory nuclei of the fifth nerve, and close to the lateral
wall of the fourth ventricle, where they form the radix mesencephalica
trigemini (Fig. 12).
Tv vent.
Vim,
Figure 11. Pons of adult man, showing fibers situated in the lateral portion
of the entering R. sens. V, running to the cephalic continuation of the tractus
solitarius, the viscerosensory column. This nucleus is considerably larger than
it was at lower levels, and is surrounded by large number of fine fibers.
BP =—brachium pontis.
III. THt Primary RECEIVING CENTERS
The Location of the Sensory Columns
The entering fasciculi of the sensory roots in the brain-stem upon
allalysis are found to correspond more or less closely with the dorsal
roots in the spinal cord. The ventral division of the dorsal root
carries cutaneous fibers while the dorsal division ‘carries interoceptive,
158 WALTER FREEMAN
proprioceptive, and segmental reflex fibers. We now take under con-
sideration the arrangement of the reception nuclei for these various
fibers, and as in the previous chapter, the model presented is the
spinal cord.
In the spinal cord the segments are arranged one above another in
an orderly manner and resemble each other to a certain degree, so
that it is partly by a study of the differences of architecture at differ-
ent levels, always keeping in mind the specific functions known to be
Peo cor. SUR
Nuc. viSceRosEns.V
Nuc.sens. ¥-
&R.PONTIS.
\ LARS
KAN \ESS ANA
SORA
eA
HSS
Pe ih
R.seEnsV ~AN VW ics
Ficure 12. Pons of adult man, showing roots and nuclei of V nerve. Section
somewhat above the level of the last. The sensory and motor nuclei are well
developed. Between them run several strands of heavy fibers that come in
with the sensory root. At the level of the apex of the nucleus motorius V
they divide, some going dorsad to form the R. mesencephalica V, some mesiad,
and others to the locus coeruleus. Almost in contact with the R. mesencephalica
is the proximal end of the N. viscerosensibilis V, the forward termination of
the-tractus solitarius. This is a small gelatinous nucleus surrounded by a
large number of fine fibers. Some sensory ganglion cells of the radix
mesencephalica are seen at A.
exercised by these segments, that we arrive at a conception of the
meaning of the different grouping of the cells in various parts of the
gray matter. This in itself has led to the study of the spinal cord
from the point of view of the column. The segments have received
some consideration, especially where the diagnostic value of level
symptoms is considered, but the individual nerves and their centers
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 159
receive but scanty consideration—they are in general too much alike.
The anatomy of the cord may be expressed as that of the segment
and the column rather than that of the nerve. In the brain-stem it
has been otherwise. The individual nerves have from the first
received individual attention. ‘They are considered as individuals.
Resemblances of one to the other have been kept in mind, and for
some time past their segmental value has been understood, but in man
as yet no general attempt has been made to apply to the brain-stem
the doctrine of the columnar arrangement of the primary receiving
centers. By the recognition of this columnar arrangement I believe
PROPRIOCEPTIVE,
INTEROCEPTIVE,
VISCEROMOTOR
SOMATOMOTOR,
Ficure 13. Semischematic outline of the columnar arrangement of the
primary afferent fibers and centers in the spinal cord of man. Level about
IV thoracic. Exteroceptive (and proprioceptive cognitive) horizontal shading ;
the funiculus dorsalis and cornu dorsale. Interoceptive vertical shading; the
pars intermedia or nucleus parapendymalis. Proprioceptive crossed shading ;
Clarke’s column. Visceromotor dots; cornu laterale. Somatomotor circles;
cornu ventrale.
we shall arrive at a clear understanding of the fundamental anatomical
groups upon which this portion of the central nervous system is con-
structed. In military formations the rank and the file must be con-
sidered rather than the individual soldier. We must treat the brain-
stem similarly by considering the segment and the column rather than
the individual nerve.
It was shown at some length in the first chapter that each of the
cranial nerves under consideration (the V, VII, IX, and X), contains
all the components that go to make up a spinal nerve, and that the
160 WALTER FREEMAN
only differences are of degree, one component of one nerve being
greater than that of another, and another component smaller. With
the exception of the special senses all the components are represented
in each nerve. Since this is so, we should be able to find in the
medulla oblongata, and in the pons as well, certain primary reception
centers which maintain a similar relationship to one another and to
the relationship that exists in the spinal cord.
In constructing diagrams of the relationships of the various centers
in the medulla oblongata it is well to choose the thoracic portion of
the spinal cord as a model, for in both instances the interoceptive and
proprioceptive components are relatively more highly developed than
Exaferoceptive
Propricce pTive
I. :
Sag eee S&S (ne she 2 er rere ee r
WS ae eee a Unteroce pfive
Pont ee
Viscerormutor
V0009 Somalhamolor
ie IAF sat
Ficure 14. Semischematic section of the medulla oblongata, showing the
X and XII nuclei. The section has been rotated in order to bring the entering -
roots into the same relative position as is found in the spinal cord. Correspond-
ing to the dorsal cornu we find the R. spin. V and its substantia gelatinosa.
The dorsal column finds its Nuc. funiculi cuneati at this level. The extero-
ceptive system is shaded in horizontal lines. The interoceptive system is
represented by the tractus solitarius with its attendant nuclei, and the Nuc.
viscerosensibilis X. It is shaded with vertical lines. The proprioceptive
system (R. desc. VIII) from the vestibular nerve is shaded in crossed lines.
Visceral motor and somatic motor systems are represented by the motor
nuclei of the vagus and hypoglossus, distinguished by dots and circles
respectively.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 161
are the exteroceptive components. For general orientation also |
refer back to Fig. 1, in which the simplest relationships, as they occur
in Scyllium, are to be found.
In the thoracic portion of the spinal cord (Fig. 13) it will be seen
that the sequence of areas commencing at the dorsal septum, and
omitting from consideration all secondary and descending tracts, is:
1. Exteroceptive (dorsal column and dorsal horn).
Proprioceptive (dorsal column and Clarke’s column).
Interoceptive (pars intermedia or nucleus paraependymalis ).
Visceromotor (cornu laterale).
Somatomotor (cornu ventrale).
ee
Let us now apply this method of division to the medulla oblongata,
taking a level showing the nuclei of the tenth and twelfth nerves
(Fig. 14). The ventral fissure is replaced by the raphe against which
lies the somatic motor nucleus of the N. hypoglossus. External to
this is the dorsal motor nucleus of the N. vagus. The unfolding of
the medulla oblongata that accompanies the opening of the central
canal into the fourth ventricle has placed the primary centers in a
more or less horizontal row along the floor of the ventricle, but by
looking at the section rotated so as to bring the entering nerve roots
into analogous positions to those seen in the spinal cord it 1s easier to
trace the resemblance. External to the visceromotor column (the
dorsal motor nucleus of the N. vagus) lies the interoceptive or viscero-
sensory column represented by the Nuc. sensibilis vagi, the Nuc.
rotundus vagi, and the Nuc. tractus solitarii. Farther externally come
the proprioceptive centers as represented by the descending root of
the eighth nerve, and at the surface the nucleus funiculi cuneati and
the R. spinalis trigemini belonging to the exteroceptive system.
The relationships as they exist at the level of the primary reception
nuclei of the N. acusticus will be considered later (see also Fig. 21).
Farther proximal, where the primary receiving centers of the N.
trigeminus are situated, the relationships are again slightly different.
As I have already pointed out, the afferent proprioceptive fibers of
this nerve enter with the sensory root without preliminary relay in
the gasserian ganglion, and they run ventrally to the other entering
fibers of the main sensory root. Likewise the primary receiving
station for these fibers, the R. mesencephalica trigemini, is at this
point found closer to the ventricle than is the Nucleus viscerosensi-
bili N. V. This is shown in Fig. 12, and is also indicated in the
semischematic diagram Fig. 15.. An explanation for this is attempted
below.
162 WALTER FREEMAN
This study deals with the sensory or afferent primary fibers in the
brain-stem of man. It is limited in its scope to the mixed nerves of
branchial origin, but some side facts are noted which give promise of
clarifying the distribution of the other primary afferent fibers which
come into more or less intimate relation with the foregoing. As I
have indicated, I shall take up the study from the point of view of
the column rather than of the individual nerve.
The columns are in principle three, the exteroceptive, the intero-
ceptive, and the proprioceptive.
Pont is
Viscerumolor
Somafemslor
Ficure 15. Semidiagrammatic cross section of the pons at the level of
entry of the fifth nerve, showing the disposition of the primary neurones.
1. Exteroceptive in horizontal shading; 2. Interoceptive in vertical shading ;
3. Proprioceptive in crossed shading; 4. Visceromotor in dots; 5. Somatomotor
in circles. The relationships of the interoceptive and proprioceptive columns is
altered. See text. The section has been rotated to conform mwre to the direc-
tion of the entering dorsal roots in the spinal cord.
~~
A. The Exteroceptive Column
In drawing our analogy between the columnar structure of the
spinal cord and that of the brain-stem, we found that the exterocep-
‘tive column occupied the most dorsal portion of the spinal cord and
the most lateral portion of the medulla oblongata. In the cord it is
represented by the dorsal columns with their nuclei of Goll and
Burdach at the top, and by the dorsal cornu. It is in the substantia
AKRANGEMENT OF PRIMARY AFFERENT CENTERS 163
gelatinosa Rolandi and the dorsal column nuclei that the cutaneous
afferent fibers find their end-stations. The secondary tracts that relay
impulses in a cephalad direction commence here. In a general way
it may be said that pain, temperature, and a few tactile impulses are
relayed from the substantia gelatinosa, and that tactile and discrim-
inating impulses (for localization, discrimination of two points, etc.)
travel in the dorsal columns and are relayed from the nuclei of these
dorsal funicull.
— Nuc vent SE
S FLERE s
po Reocnieagis
RYH SENS.
RW cor.
Ficure 16. Brain-stem of 6 months’ human fetus at the level of the
cochlear division of the N. VIII. The motor and sensory roots of the
N. VII are seen outside the bulb. The Nuc. ventralis VIII is fairly well
developed but the tuberculum acusticum is immature. At the tip of the
corpus restiforme is a small compact group of large cells of the type found
in the Nuc. sensibilis V. It lies in the same relative position as that occupied
hv the upper pole of the Nuc. cuneatus. It is thought to be the Nuc. sensibilis
VII where one division of the cutaneous and proprioceptive fibers ends. The
interoceptive column is represented by the prevagal portion of the tractus
solitarius in the angle between the substantia gelatinosa Rolandi and the
R. desc. VIII. The separation between the two portions of the exteroceptive
division (the R. spinalis V and the Nuc. sens. VII) is probably due to the
large mass of fibers of the N. vestibularis which enters at a slightly proximal
level.
In the brain-stem the tract of Lissauer is represented by the
so-called Radix spinalis trigemini, and the substantia gelatinosa
Rolandi by the substance of the same structure and the same name
164 WALTER FREEMAN
that is found in the brain-stem. Nothing is more firmly established
than the homology and direct continuation of the substantia gelatinosa
Rolandi in the spinal cord and in the brain-stem. There are certain
superficial modifications that have taken place in this oral prolongation
of the tract of Lissauer, for instance the greater distance to which
the component fibers run caudad in it, but the modifications are due
to the principle mentioned before of usurpation and are superficial
only. The underlying more fundamental structures have retained
their primitive character. We shall discuss them shortly.
Fiber tracts homologous with the dorsal funiculi do not exist in
the brain-stem. The homologous fibers from the cranial nerve gan-
glia, the ganglion semilunare, ganglion geniculi, etc., end practically
at their level of entry into the brain-stem. For instance, the nucleus
sensibilis trigemini receives one part of the cutaneous fibers of the
N. trigeminus. Its structure is the same as that of the dorsal column
nuclei. Its cells are practically identical in size and morphology, and
moreover they undergo secondary atrophy after lesions of the ventral
nucleus of the thalamus, lesions which cause retrograde atrophy of
the lemniscus medialis and its cells of origin in Goll and Burdach’s
nuclei. Winkler has made a special study of this condition and has
even designated a trigeminal fillet with a termination more mesial in
the thalamus than the termination of the great band of sensory fibers
in the mesial lemniscus.
If we take the nucleus funiculi cuneati and the nucleus sensibilis
trigemini as examples of the exteroceptive primary centers (leaving
aside for the moment the proprioceptive cognitive function that they
undoubtedly exercise), we may locate them with respect to the struc-
tures that surround them and thus determine the position of the
exteroceptive column. Then we may attempt to find the correspond-
ing nuclei for the seventh, ninth, and tenth nerves.
At its proximal end the nucleus funiculi cuneati consists of a small
group of large cells situated close to and mesial to the dorsal tip of
the corpus restiforme, and lateral to the descending root of the ves-
tibular nerve. It is somewhat separated from the Radix spinalis
trigemini. This forms the caudal landmark of the almost vanished
exteroceptive column. The rostral landmark is formed by the caudal
tip of the Nuc. sensibilis trigemini. This is found dorsal to the fibrae
transverse pontis, and on the mesial border of the corpus restiforme
which at this level is diverging toward the cerebellum. It is in the
same relative location that we must look for the sensory nuclei of the
seventh, ninth, and tenth nerves.
At the level where the sensory division of the N. glossopharyngeus
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 165
enters the medulla oblongata there appears on the inner side of the tip
of the corpus restiforme, and external to the radix descendens N.
vestibuli, a group of large multipolar cells. This group is located in
precisely the same place as the proximal tip of the N. cuneatus and is
separated from it in the longitudinal axis by only a fraction of a
millimeter (in the six months’ fetus). It is as much a continuous
structure in the brain-stem as is the Nuc. ambiguus. From appear-
ances in the fetus it seems that the entering fibers from the ventral
sensory root of the glossopharyngeus bend laterally and run dorsally
toward the corpus restiforme (Fig. 9). In the relatively immature
brain that I have studied by means of silver impregnation of serial
sections, the root fibers stand out in prominent contrast to the sur-
rounding pale groundwork, and they appear to run to the vicinity of
the nucleus mentioned. Other investigators, notably Winkler, have
described radicular fibers in this nerve which run laterally from the
main trunk in the direction of the cerebellum, but it appears relatively
certain that in man no radicular fibers run directly to the cerebellum.
This nucleus, then, whose cells are large, occupies the same relative
position as does the nucleus cuneatus. I believe it functions as the
nucleus sensibilis glossopharyngei. This small collection of cells is
difficult if not impossible to locate in sections from the adult brain-
stem stained by Weigert’s method. The Nissl stain, however, shows
the cells in this location, and the group in the fetal brain is quite
evident.
The great entering mass of octavus fibers renders the location of
the homologous nucleus for the seventh nerve even more difficult.
The entering fibers of the dorsal division of the sensory root of the
N. facialis pursue an oblique course from behind forward in reaching
their interoceptive nuclei1. Some of the fibers of the ventral sensory
root however, apparently take an oblique course in the caudal direc-
tion to reach their exteroceptive nucleus. By close examination of
the region lying between the dorsal tip of the corpus restiforme and
the radix descendens nervi vestibuli, I have found a small compact
group of large cells situated at the level of entry of the cochlear
division of the N. octavus (Fig. 16). It 1s impossible in my prepara-
tions to trace the entering fibers of the sensory division of the N.
facialis to their termination 1n this nucleus, but at the level of entry
there is an aberrant strand of radicular fibers that runs in the direc-
tion of the restiform body. Appearances are suggestive, the location
of the nucleus is identical with the former, and the cells show the
same degree of development as do those of the known exteroceptive
nuclei. Further investigations are necessary to establish the function
166 WALTER FREEMAN
of this nucleus. as the receiving station for the cutaneous fibers of
the facial nerve. The same difficulties in distinguishing this nucleus
are encountered in Weigert sections from the adult as in the case of
the Nuc. sensibilis IX. For a study of the afferent division of the
N. facialis in the elephant see Appendix A.
Throughout practically the whole space of entry of the numerous
roots of the vagus nerve the nucleus funiculi cuneati is present. This
f NUCUENTTR.SOL.
~ NUC.COLLI, R DESC.VH, :
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—
NuC BURDA@CHI
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Ficure 17. Medulla oblongata of 6 months’ fetus stained with silver. The
tractus solitarius of the interoceptive column stands out prominently, sur-
rounded by a gelatinous nucleus, the N. interstitialis of Cajal, and bordered
dorsally by the G. descendens to which it gives many fibers of fine caliber.
Laterally to it» is the so-called N. ventralis tractus solitarii which is seen to
be in relation rather with the N. cuneatus than with the T. solitarius. It
is found to the outer side of the proprioceptive column as represented by the
R. desc. VIII. The N. ventralis T. solitarii is taken to be the exteroceptive
reception nucleus for the primary cutaneous fibers of the N. X.
nucleus grows progressively smaller and in its upper portion it has
ceased visibly to receive any fibers from the funiculus cuneatus which
has terminated some distance below. It is possible that. the long
forward projecting tongue of nucleus is the receiving station for
cutaneous fibers of the N. vagus rather than for fibers running in the
funiculus cuneatus. There is however another collection of cells to
be considered.
ARRANGEMENT -OF PRIMARY AFFERENT CENTERS © 167
In close relationship with the nucleus funiculi cuneati, at a level
where there are still some fibers of the funiculus cuneatus to be seen,
there is an interrupted column of cells of the same type lying more or
less ventrolaterally from the prominent tractus solitarius. This is
probably the nucleus ventralis tractus solitarii which is described by
von Monakow (70) as follows: “In the substantia gelatinosa of the
tractus solitarius are scattered (besides small and minute typical ele-
ments of the substantia gelatinosa) larger multipolar and spindle cells
which are assembled in a little group ventral to the tractus solitarius.
In the neighborhood of Burdach’s nucleus and the cell mass of the
substantia gelatinosa Rolandi the groups become more scattered,
cells lying singly or in pairs. Many of these examples lie rather
deep in the formatio reticularis, where they are again assembled.”
According to Winkler the tractus solitarius is surrounded on all sides
by arcuate fibers which leave open only the ventrolateral aspect. In
this location he finds the large cells of the nucleus ventralis. Cajal (2)
does not include this nucleus among those of the tractus solitarius
Kohnstamn and Wolfstein called it the Nuc. parasolitarius. By refer-
ence to Fig. 17 which is a drawing of the medulla oblongata of a six
month’s fetus, there is seen a compact group of fairly large cells
situated laterally or ventrolaterally with respect to the tractus soli-
tarius. This was the best example I could find in this particular series
of a collection of large cells ventral to the tractus solitarius. As will
be seen however, this nucleus lies some little distance from the
gelatinous nucleus (with the small elements), that lies strictly on the
ventral suriace of the tract.. Moreover the nucleus of large cells
lies in fairly intimate relationship with the Nucleus funiculi cuneati
and to the outer side of the R. desc. VIII. It lies in the path of some
of the-lower entering fasciculi of the N. vagus though none of the
fibers can be seen to lose themselves among the cells. These cells of
the Nucleus parasolitarius or the so-called Nuc. ventralis tractus solt-
taril, according to Tumbelaka and to Winkler, undergo atrophy in
cases of thalamic softening, so that they belong to the lemniscus sys-
tem. This nucleus, then, is probably the primary receiving station
for the exteroceptive fibers of the N. vagus. The long cephalic pro-
longation of the Nucleus funiculi cuneati may be a continuation of the
Nucleus ventralis tractus solitarii rather than the Nuc. fun. cuneati
proper. At the level of entry of the proximal roots of the N. vagus,
I could find no Nucleus ventralis tractus solitari1.
The bulbar portion of the exteroceptive column, homologous with
the nuclei of the dorsal funiculi of the spinal cord therefore lies
between the radix descendens nervi vestibuli and the corpus resti-
168 WALTER FREEMAN
forme. Its several parts, in relation to the nerves it supplies, are the
proximal portion of the Nucleus funiculi cuneati, the Nucleus ven-
tralis tractus solitarii, the Nucleus sensibilis glossopharyngei, the
Nucleus sensibilis factalis, and above, the Nucleus sens. trigemini.
These nuclei relay several forms of sensation, superficial and deep,
that might be classed together as discriminative in the spatial sense of
che: term:
The trigeminus system offers one of the best fields for the study
of the repartition of sensory impulses, because the main sensory
nucleus may be preserved while the spinal root is injured, or vice
versa, the main sensory nucleus may be damaged leaving the spinal
root apparently wholly intact.
Disease of the spinal root of the trigeminus causing a syringo-
myelic dissociation of sensation in the face is discussed in the follow-
ing section, but I can present here two cases showing the inverse
svringomyelic dissociation, that is, preservation of pain and tempera-
tus sensation with the abolition of touch sensation. In neither case
was there a necropsy to confirm the clinical findings, but the inference
is fairly conclusive from the clinical examination that the Nucleus
sensibilis trigemini was destroyed. The first case was reported by
Spiller (59).
Case 2. (Reported by Spiller.)
“The case was supposed to be one of multiple sclerosis. The symp-
toms which are of interest as regards sensation are as follows: The man
had entire loss of sensation for heat, cold and pain on the entire right
side of the body including the face as well as the limbs. He had slight
impairment of sensation for heat but not for cold over the left forehead.
Tactile sensation was entirely normal over the entire right side in the
parts in which temperature and pain sensations were lost, and sense of
position was promptly recognized in the right hand. Tactile sensation
was entirely lost in the left side of the face but only in the distribution.
of the fifth nerve; pain and temperature sensations were normal in this
region excepting for slight impairment of heat sensation in the left
forehead. The tactile loss did not extend over the scalp behind a line
This is not epicritic sensibility in the sense that Head used the term.
The dissociation of protopathic and epicritic sensibility occurs only at the
periphery and the distinction grows less and less marked even in the peripheral
nerves as the dorsal roots are approached. In the central nervous system
there is a repartition of paths by which impulses travel, and reintegration
again at higher levels. For instance in regard to temperature sensation, a
lesion at the periphery abolishing epicritic sensibility will prevent the percep-
tion of small differences of temperature, while the extremes of heat and cold
_will be felt correctly. In the spinal cord a lesion that interferes with tempera-
ture sensation will interfere with the extreme differences nearly as much as
with the slight ones. Moreover thermic sense may be abolished in spinal
lesions leaving tactile sensibility wholly unimpaired.
A0RANGEMENT “OF PRIMARY @ArPERENT CENTERS 169
drawn vertically to the ear, or into the distribution of the cervical nerves
on the left chin. Deep pressure was felt below the left eye, but it was
not felt above the left eye. When the mouth was opened the jaw deviated
markedly to the left. The left temporal and masseter muscles were
paralyzed.”
“It seems probable that the lesion in this case was in the left
tegmentum of the pons. It implicated the central fibers of pain and
temperature sensations coming from the entire right side of the body.”
In addition there was paralysis of the left external rectus muscle, and
other signs of multiple sclerosis. The full report of the case appears in
Rev.ew of Neurology and Psychiatry, February 1910.
A second case of inverse syringomyelic dissociation of sensation
in the tace has recently been studied by me in the Reale Clinica delle
Malattie nervose e mentali, Professor G. Mingazzini, Rome, to whom
1 am indebted for permission to report the case.
Case 3. A. L., male, aged fifty years. » Diagnosis: multiple sclerosis.
In December 1923 the patient noted weakness of the legs, staggering
gait and an impediment in his speech. Shortly afterward he suffered
from regurgitation of fluids through the nose, dysphagia and sialorrhea.
At one time he had diplopia. Examination disclosed nystagmus, scanning
speech and intention tremor, exaggeration of patellar reflexes, and aboli-
tion of abdominal and cremasteric reflexes. Examination of the cranial
nerves showed the senses of smell and sight intact. The eyeball was
moved freely and equally in all directions, but with nystagmus, especially
in looking to the left. Pupillary reactions were normal to light and to
distance.
V. Touch. There was anesthesia to light touch over the whole left
side of the face as shown in Fig. 18. The patient could not distinguish
the size or shape of an object that touched his cheek, forehead or lips.
For instance he frequently confused the dull point of a pencil with the
examiner’s finger. He could not distinguish between a marble, a ring
and a cube. He could not tell the difference between silk and wool when
they touched his lips, or between glass and leather. He could not dis-
criminate between the touches of one and two points of the compass,
even when they were separated a distance of 15 to 20 mm. All these
reactions were carried out with facility on the right side of the face.
In order to estimate more accurately the threshold of cutaneous sen-
sibility a series of tactile hairs was constructed and calibrated. Von
Frey’s directions for estimating the tension strength of the hairs were
followed. To arrive at this figure the bending strength of the hair is
measured on a fine balance, and then the thickness of the hair is measured
in its two diameters. The area of the elliptical cross-section is then
calculated, but the number used is the radius of a circle of the same area
as the cross-section of the hair under consideration. The pressure in
milligrams required to bend the hair is then divided by radius of the
170 WALTER FREEMAN
circle as calculated, and the figure obtained, expressed in grams per
millimeter, is the tension strength of the hair.
On the right side of the face the patient could feel a hair of 9 grm./mm.
(18 mg. bending strength) on his cheek, lip, and a side of the nose and
conjunctiva. A hair of 10.8 grm./mm. (45 mg. bending strength) tension
was felt on the right side everywhere. On the left side, touches with
these hairs upon the skin were nowhere appreciated within the area
outlined. The hair with a tension of 43 grm./mm. (80 mg. bending
strength), was nowhere felt. One with a tension of 66 grm./mm. was,
felt on the lips, conjunctiva and forehead, but was not felt on the upper
Ficure 18. Full face and ‘profile of the patient A. L. (CGasenjjeem
area anesthetic to light touch is outlined. The small area of diminished
temperature sensation in front of the tragus is shaded. There is diminution
of sensibility to pinprick over the upper portion of the face and the corneal
reflex is much diminished on this side. The jaw deviates slightly to the
left and the masticatory muscles are weak and hypoexcitable. The tongue
follows the jaw in deviation, there is no atrophy, and the left side reacts to
weaker faradic currents than the right side. The tongue, cheek and fauces
are anesthetic to light touch. There is ageusia on the anterior part of the
tongue. The facial musculature is weaker on the left side. Pain on deep.
pressure is reduced on the left side of the face.
eyelid, nose or chin. It was only when the next stronger hair was used,
one with a tension of 83 grm./mm. that touches were felt everywhere.
These last two hairs had bending strengths of 120 and 375 mg. respec-
tively. On application they produced evident deformation of the
cutaneous surface so that it seems that pressure nerve endings must have
been responsible for the sensation rather than simple tactile endings.
(To be continued)
oes wa —_ are
SD nti ee” aa eee
SOCIETY PROCEEDINGS
THE WASHINGTON SOCIETY FOR NERVOUS: AND
MENTAL DISEASES
DECEMBER 17, 1926, LAWRENCE KoLs, THE PRESIDENT, PRESIDING.
SEC hhiCy DIAGNOSIS AND-TREATMENT OF
BPIVEMIGsENCEPHALTTES
By WALTER FREEMAN, M.D.
DIRECTCR OF LABORATORIES, ST. ELIZABETHS HOSPITAL, WASHINGTON, D. C.
(Abstract )
Although a diagnostic triad characteristic of lethargic encephalitis
was promulgated by von Economo in the early days of the epidemic,
it was soon found that many other nervous symptoms and signs were
present in the disease, even though the triad might be absent. This
led in course of time to the abandonment of the term “ lethargic ”
and to the substitution of the term “ epidemic,” and in French hands
to the designation “neuraxitis.” It was gradually realized that the
mode of onset and the clinical varieties of the disease were legion.
The diagnosis, therefore, became increasingly difficult as more and
more forms were recognized by the clinician. The laboratory was
called upon for its contribution and yielded important studies in
pleocytosis and hyperglycorrhachia, with a nonspecific hump in the
colloidal gold curve. This phase of the disease (or was it the fashion
of the laboratory?) passed off; the findings were recognized to be
inconstant and nonspecific. The bacteriologic approach as a diag-
nostic problem in encephalitis was abandoned following the negative
report of the very comprehensive investigation by the Rockefeller
group into the specific etiology.
Until a specific etiology has been accepted for any disease, the
matter of specific diagnosis based upon these etiological considerations
is not to be thought of. Before the acceptance of the Koch bacillus
as the cause of tuberculosis, the finding of this bacillus was of no use
in the diagnosis of the disease. When its pathogenesis became recog-
nized, the diagnosis of tuberculosis from the laboratory standpoint
took a long step forward. The same story might be repeated in the
case of many diseases. When investigators can come to some agree-
ment as to the etiology of encephalitis, then specific diagnosis founded
upon the isolation of the pathogenic agent may quickly be established.
Miss Evans and I have dealt with the etiology of encephalitis *
* Evans and Freeman: Studies in the Etiology of Epidemic Encephalitis.
I. The Streptococcus. Pub. Health Rep., 41:1095 (June 4), 1926; Pub.
Health Repts., No. 1085.
[171]
172 WASHINGTON .SOCIETY
and are continuing our investigations along the same lines. We have
found microorganisms quite constantly associated with the disease,
and have compared our results with those reported in a large number
of papers published previously by others. There seems to be no
reasonable doubt that we are dealing with the same microorganism as
that described in at least ten other papers. We are attempting to
explain the finding of a filtrable virus by another large group of
investigators. To us a filtrable virus is merely a minute filter passing
form of the organism under discussion. If one takes a culture of the
streptococcus isolated from the cerebrospinal fluid or midbrain of a
patient with encephalitis and filters it through a porcelain candle
under careful control with B. prodigiosus, a water clear filtrate is
obtained that is rather weak in its effect upon animals. If, however,
the filtrate is inoculated into culture medium, larger visible forms
appear within twenty-four hours, and the culture becomes extremely
pathogenic for animals.
The negative results in the hands of other competent workers are
difficult to.interpret, for it seems sufficiently easy to obtain positive
cultures, although the first ones are often delicate, and after starting
to grow, sometimes recede and die off. Small amounts of inoculum
have worked best in our hands.
The forms of the organism observed under various conditions of
culture are quite numerous, and a full study of the life cycle is in
progress. In our first paper we mentioned large coccoid bodies and
minute filtrable forms as well as diplostreptococci and rods. The
variety of forms here resembles the pleomorphism of the Klebs-
Loeffler bacillus. Consequently any organism isolated from a case of
encephalitis 1s regarded with suspicion and tested for virulence by
amimal inoculation. All this work has been done by Miss Evans at
the Hygienic Laboratory, U-S.Rebie>:
We have isolated organisms virulent for rabbits and monkeys
from the blood stream in four cases of acute encephalitis, and one
recurrent acute. From the spinal fluid we have obtained it in three
acute cases and four chronic cases out of seven. In our necropsy
material we have encountered: it in the brain in one acute case, one
recurrence, and three chronic cases out of four. Incidentally we have
isolated it from the spinal fluid or brain of five out of seven cases of
“idiopathic ”’ paralysis agitans in whom there was no history of
encephalitis.
We believe, on the basis of our work so far, and upon its agree-
ment with the work of a number of others that the organism studied
by us is the specific causative agent, and that the diagnosis of encepha-
litis can be made by culture of the blood and spinal fluid.
When a case of suspected encephalitis comes under observation, a
few drops of blood and of spinal fluid are inoculated into six to twelve
tubes of meat infusion broth with the meat left in and titrated to
pH 7.4, or of the ordinary dextrose brain broth. Anaerobic cultures
are not necessary. Should a growth develop it is tested for virulence
by intracerebral injection into rabbits. If the culture is active, the
animal usually dies in eighteen to twenty-four hours. A mixture of
WASHINGTON SOCIETY 173
organisms is readily handled by filtration, the culture of the filtrate
yielding only those organisms associated with encephalitis. The
specificity and elective localization of the organisms may be tested
later, but it is sufficient for diagnosis to know that the inoculated
animal dies within 24 hours after a small intracerebral dose.
We have found organisms in the spinal fluid and in the brain at
necropsy from cases other than encephalitis, but in these cases the
virulence is so low that animals do not die after receiving an intra-
cerebral injection. Similar nonvirulent organisms have heen found
by Miss Evans in the brains of supposedly healthy animals. This
‘raises the interesting question of specific exciting cause from some of
the psychoses. Our control material for nonpsychotic individuals
has not been available up to the present, so that we can merely state
a hypothesis based upon the finding of a high percentage of positive
cultures from the brains of the insane. I am indebted to Winifred
Ashby, Ph.D., for this summary of the problem upon which she is
working in this laboratory. Her findings were recently reported at
one of our informal staff meetings.
We believe that an attack of encephalitis may underlie the develop-
ment of a number of forms of chronic psychoses that remit and
relapse with slow mental deterioration of the patient. If we examine
catatonic individuals by means of specific tests to bring out parkin-
sonian defects I believe we shall find a fairly large number of cases of
paralysis agitans among our chronic psychotics. I have picked up
half a dozen more or less typical cases in the course of an hour’s hasty
survey, and there are probably many more. Many of these patients
were admitted to the hospital, apparently in the same condition as at
present, years before the epidemic of encephalitis made its appearance.
In view of this and of the frequency of psychotic onset in
encephalitis, we suspect encephalitis in any acute mental disturbance
with fever.
During the past seven months we have had occasion to treat three
patients in the acute state of encephalitis with a specific antiserum
developed by the Mulford Company. Their culture was originally
obtained from one of our fatal cases. The use of the serum in each
case has been followed by gratifying improvement in the clinical
symptoms, and in one case it apparently was life saving. It is too
early to say whether the serum had a specific or a nonspecific action.
In one case the blood culture was persistently positive in spite of
several doses of serum, and two blood transfusions. It became nega-
tive under vaccine therapy.
After the recovery from the acute manifestations, autogenous
vaccine has been administered with the idea of raising the individual’s
resistance against persistent or recurrent infection. As I have pre-
viously shown,* the late complications and sequels of encephalitis are
evidence of continued infection, and I think we may best combat this
infection by the use of a specific, preferably autogenous vaccine. This
has been injected in ascending doses.
* Freeman, Walter. Chronic Epidemic Encephalitis. J. A. M. A., 87:1601
(Nov. 13), 1926.
174 | WASHINGTON SOCIETY
We have used this vaccine in several cases of chronic encephalitis,
but so far with very slight if any improvement. There has been no
progression of the symptoms in these individuals and it therefore
seems possible that the disease may be arrested by vaccine therapy.
It is too early to announce an opinion. Probably a good plan would
be to keep patients under rather close observation for a long period
of time just as is done in syphilis, being guided in the treatment by
culture of the blood or spinal fluid, and administering courses of
vaccine as indicated by a return to positive of the culture.
In summary it may be said that we accept the specific etiology of
epidemic encephalitis and are making use of the bacteriological “find-
ings in the diagnosis and treatment of the disease. We suspect that
the same organism will be found responsible for a larger proportion
of cases of mental disease than heretofore recognized. We suspect any
patient presenting acute mental disturbance Saks fever of having
encephalitis and we attempt to substantiate it by culture of the blood
and spinal fluid. If the bacteriological diagnosis is positive we inject
intravenously a serum prepared by vaccinating animals with this
organism and so far have had three satisfactory results. After the
acute stage is over we have treated patients by autogenous vaccine and
seen the virulence of the isolated organisms reduced, or the organisms
banished from the circulating fluids. We believe that by means of
vaccine we may prevent the development of the disastrous after-
effects of encephalitis or stop them in the course of their development.
We expect no considerable improvement in the motor manifestations
of those in whom the parkinsonian syndrome has developed.
Abstract of Discussion
Dr. Moore: I have not had much experience with the bacterio-
logical studies in psychiatry, but think that in encephalitis they may
lead to further advances. I have in mind a case upon which various
diagnoses have been made, and which Dr. Freeman is now studying.
The symptoms are certainly like those of hysteria, yet there is not the
proper background. Some neurologic signs have recently developed
that make me quite suspicious of encephalitis, and should Dr. Freeman
obtain positive cultures in the case I would be satisfied that it was a
case of encephalitis.
Dr. Wm. H. Hough: Dr, Freeman’s control material is notice-
able by its absence, and I do not think we can accept his work until
more thorough controls have been undertaken. As to the serum we
have a good example that Dr. McCoy called attention to not so long
ago. The individual reports are unfailingly good, yet the reports
from the public health officials condemn Dr. Rosenow’s serum as of
no use. I personally doubt very much whether the good results in
the cases reported by Dr. Freeman were specifically due to the serum.
Dr. Harry Stack Sullivan (Baltimore): It is not only infections
that give rise to attacks of mental disease, but many other things, and
I question whether an organism is responsible for any acute psychosis
with fever. Psychoses develop in pregnancy and in the puerperium,
for instance. There are, however, many patients whose symptoms
WASHINGTON SOCIETY 1/5
are far from clear cut, whom we cannot label with any of the well
known diagnostic terms, and whose psychoses tend to recover. I do
not doubt that some cases of illness in this mongrel type may be due to
infection, possibly encephalitis. Before the problem can be solved a
large amount of work must be done upon the chemistry of the body,
particularly the H-ion concentration, to determine the reason why the
brain is infected by the pathogenic agent. Dr. Freeman states that
this organism is found in the nasopharynx of healthy individuals.
The route of infection is presumably by way of the communicating
lymphatics, but why should the organisms penetrate to the brain?
What Dr. Freeman says about the number of parkinsonians among
our psychotic population should be carefully checked up. If his find-
ings are accurate it is a matter of great importance, and these cases
should not be overlooked. Finally, I would like to ask whether these
cultures can be made by any well-qualified technician, or whether it
requires professional skill.
Dr. Clarence H. Rice: I would like to ask whether any tests of
potency have been made for the serum, and whether any skin tests
have yet been developed.
Dr. Freeman (closing): The case that Dr. Moore mentioned has
yielded a positive culture from the spinal fluid, and we are about to
undertake serum treatment followed by autogenous vaccine. In this
instance a staphylococcus of very variable size has grown out. I
think that the serum referred to by Dr. Hough was that developed
against poliomyelitis. The encephalitis serum of Rosenow has not
yet attained the dignity of a public health problem. I admit that the
controls are far from complete, but the available cases for serum
therapy have been very few. Dr. Sullivan’s remark about the
psychoses brought on by other accidents, particularly pregnancy,
brings to mind the fact that chorea in pregnancy is sufficiently fre-
quent to be placed in a separate category. We are coming to believe
that chorea is a manifestation of some type of encephalitis. The cul-
tures could probably be made by an experienced technician, but the
animal experiments necessary would probably require more training
than is possessed by the usual technician. The work is too new yet to
be certain about the potency of a serum as determined upon experi-
mental animals, and no skin test has been developed. I think it
would be rather dangerous to inject intracutaneously any filtrate of
the organism associated with encephalitis on account of the filtrable
forms. The occurrence of encephalitis following vaccination has been
reported so often as to cause some concern. The rabbits inoculated
with material from healthy throats either did not react at all, or
developed a much milder affection with tendency to recovery. The
outbreak of the acute disease in 1917 is probably to be explained on
the war conditions of malnutrition and lowered resistance just as in
the case of influenza. Once the disease got started, repeated passage
through human hosts probably augmented the virulence of the
organism. Ordinarily the virulence is low.
CURRENT LITERATURE
I. VEGETATIVE NEUROLOGY.
i. VEGETATIVE NERVOUS SYSTEM.
Alvarez, W. C. Btioop Pressure Stupy. [Arch. of Int. Med., July,
Vol. (XCar oe Ble eer ee
An analysis was made by Alvarez of the systolic blood pressures of
6,000 men and 8,934 women freshmen entering the University of Cali-
fornia. The pressures of the women were more uniform than those of
the men, and averaged 11 mm. lower. Hypertension was very common
among the younger men, about 45 per cent having pressures exceeding
130, and 22 per cent having pressures exceeding 140 mm. Among the
women, about 12 per cent had pressures exceeding 130, and about 2 per
cent had pressures exceeding 140 mm. The average pressure for both
men and women drops gradually during the first years of adult life.
The pressures for the men are grouped mainly about 127 mm. at the
age of sixteen, and about 118 mm. at the age of thirty. The pressures
for the women are grouped about 118 mm. at the age of sixteen; about
111 mm. at twenty-four, and about 117 at forty. Alvarez says that
hypertension cannot be ascribed regularly to infections or to a strenuous
life. It seems to be an inherited peculiarity, the appearance of which
can be suppressed in women so long as the ovaries function well.
Hand, A., and Reilly, J. J. Raynaunp’s DISEASE IN CHILDREN. Coe
Med: ji. Aug.) 192372) A vie)
Three cases occurring in one family are reported by Hand and Reilly,
the patients being aged five, two and one-half and eight and one-half years,
respectively. Hereditary syphilis was suggested in these cases as both
parents had positive Wassermann reactions; with the exception of
snuffles in one case during infancy, none of the three children presented
signs of syphilis and the diagnosis was therefore made by the Wassermann
test.
Tigges, O. TREATMENT OF MIGRAINE. [Deut. med. Woch., May 25,
Vol. XLIX.]
The author apparently has had excellent results in this report of
three patients treated by nasal application of a mixture of 0.5 parts
cocain hydrochlorid; epinephrin 1 part (1:1,000) and distilled water to
10 parts. The application was repeated two or three times for three
months. After the first few applications the attacks ceased. Neither the
[176]
Ria+
VEGETATIVE NEUROLOGY 177
nature (etiology) of headache nor the rationale of results are sufficiently
discussed. [Psychogenic migraines (the majority) are often relieved
through transference, the drug or other procedure being but a rationaliza-
tion.—Ed. ]
Pavey-Smith, A. B. Causes oF HEADACHE. [Lancet sepia.s, 1925, |
This paper deals with a mixed type of classification of headaches. He
makes three main groups, as follows: (1) Intracranial, due to appreciable
somatic changes occurring within the cranial cavity. (2) Cranial, due
to processes affecting the cranial walls and their air spaces. (3) Extra-
cranial, due to somatic alterations outside the cranium. By “ process” is
meant the actual organic condition directly responsible for the head pain.
Thus, in an intracranial headache (Group 1) the pain arises as a result of
some intracranial change. This intracranial change may itself be due to
some extracranial and more general condition, but the headache is only
“extracranial” if the actual pain causing lesion is outside the skull.
These groups, in fact, refer to the starting point of pain, and not to
the condition with which that pain is associated. In supraorbital neuralgia
(Group 3, extracranial) the patient complains of a pain which shoots up-
ward into the forehead, and the maximum tenderness will be found over
the nerve. Pressure near the supraorbital notch will increase the severity
and area of the pain. In frontal sinus headache (Group 2, cranial)
the pain is fixed, dull, and may be throbbing; the maximum tenderness
is usually on the floor of the sinus under the inner third of the supra-
orbital margin. Superficial tenderness is not so marked, and pressure over
the supraorbital notch has no definite effect. In supraorbital headache
of intracranial origin (Group 1) there is no tenderness, though there
may be hyperesthesia to finer skin tests.
Moses and Warschauer. PATHOGENESIS OF PERNICIOUS ANEMIA. [Klin.
Beroct.. Wol. li; March 26,~ J.-A: “M.A: |
Moses and Warschauer injected extracts of feces prepared according
to Seyderhelm, who claimed that they have a hemolytic action in vivo,
though not in vitro. They found that these extracts cause only nonspecific
variable changes in erythrocytes and leukocytes, the same as other injuri-
ous substances. Seyderhelm claims to have found a pernicious type of
anemia only in rabbits injected with extracts of mesenteric glands from
persons who had died from pernicious anemia, but not from controls.
They found similar changes in a rabbit injected with an extract of rabbit’s
muscles.
Duane, A. OPpHTHALMOPLEGIC MIGRAINE AND RECURRENT PARALYSES
Meetteritve Mouscirs. [(Archeok Oph.,Sept:.,: 1923...B. M. J.]
A. Duane records three cases of migraine associated with ophthalmo-
plegia, and reviews the literature of this condition. He defines opthal-
moplegic migraine as a “ syndrome characterized by irregularly recurring
178 CURRENT Lita
migraine-like attacks which terminate in a complete or incomplete par-
alysis of one or more of the motor nerves of one eye, especially the third
nerve. The paralysis, at first intermittent, tends to become later remittent
and eventually permanent. Coincident affections of other nerves, especially
the fifth nerve, occasiona:!y occur.’ The condition is usually unilateral.
There are three types of recurring paralyses. (1) Recurrent nuclear
paralyses. These are most frequently associated with tabes, but may occur
in diabetes and in chronic progressive ophthalmoplegia. ‘2) Basal recur-
rent paralyses. The type form of these paralyses is ophthalmoplegic
migraine. In most cases the cause is very uncertain, intermittent com-
pression of the nerves at the base from tumor or inflammatory deposits
being the most probable etiological factors. (3) Cyclic paralysis. An
extremely rare condition in which there is an alternation of paralysis
with spasm. This rare condition is most common in females, and is
either congenital or acquired in very early life. The site of the lesion
is unknown. The typical attack of ophthalmoplegic migraine starts with
severe one-side headaches associated with nausea and vomiting, which
after lasting a few days disappear and are replaced by a unilateral
oculomotor paralysis usually on the same side as the head pain. After
a variable time the paralysis subsides, only to recur at some time later
in conjunction with another attack of head pain. Duane considers that
the condition cannot be due to a nuclear lesion, but rather to injury to
the radicles or trunk of the oculomotor nerve. This view is supported
by the results of post mortem examination. Such cases as have been
examined showed either benign tumor, an inflammatory exudate, or a
tuberculous mass involving the nerve. Treatment is most unsatisfactory.
Removal of all possible causes of infection and improvement of the
general condition, together with correction of any refractive error, is all
that can be done.
Hahn, L., and Stein, F. PATHOGENESIS AND THERAPY IN MIGRAINE.
[Ztsch. f. Nervhlk., Vol. LX XVII, Nos. 1-6.]
The latent migraine patient, the authors believe, is of a definite type
like the asthenic patient. The migraine attack itself is a cerebral vascular
crisis. This is attested by the fact that intravenous administration of
papaverin checked the attack in 90 per cent of the cases.
Roberts, F. Action oF VASOCONSTRICTOR SUBSTANCES ON ARTERIES OF
Brain, [J of Phys,, Aug, 1923:)
In this study upon animals pituitary extract, ergotoxin and barium
chlorid were tested out as to their vasoconstrictor action upon the cerebral
vessels. Diminution or complete stoppage of respiration could be caused
by each of them. Roberts argues that inasmuch as this effect occurs
when the blood pressure is prevented from rising, it may be referred
to anemia of the respiratory synaptic regions by cerebral vasoconstriction.
BEGETATIVE NEUROLOGY. 179
Pituitary extract causes two periods of apnea in rabbits. Of these the
second is proved to be related to cerebral vasoconstriction. Reasons are
given for believing that the first is due to a similar cause. The second
apnea is sometimes followed by Cheyne-Stokes respiration, the periods
of which are related to changes in blood pressure. The fact that these
substances all resemble epinephrin in their effect on respiration and
especially the close similarity which exists between pituitary extract and
epinephrin is confirmatory evidence for the view already expressed that
epinephrin is vasoconstrictor to the brain vessels.
Bigland, A. D. TREATMENT oF MIGRAINE BY CaLcrumM Lactate. [Brit.
Wed 1 Dears; 1923.)
A clinical study tending to demonstrate the value of thirty grain doses
of calcium lactate taken at the very first signs of a migrainous headache.
The results obtained are in the nature of mitigation rather than abortion of
an attack. [Since in the abstract statistical study of migrainous attacks
60 per cent at least rarely fulminate the reasoning of the paper is faulty. ]
Ramain, P. Acrion oF LIGHT ON THE Buioop. [Arch. Mal. du Coeur,
Coben lo239|
Immediately after exposing subjects for a few minutes to sunlight or
ultraviolet and infra-red rays phenomenon resembling the hemoclastic
crisis of Widal occur. The explanation suggested is of a vasomotor
reaction due to dissolution of leucocytes.
Redfield, A. C., and Bright, E. M. Hemotyric Action or RADIUM
Batanation, | Am. |l=ot Phys.,.July.1, 1923. ]
This study tends to show that the destruction of erythrocytes by
radium emanation is due chiefly to the alpha rays. The processes of
hemochromolysis and stromatolysis proceed independently of one another.
The electrical resistance of the suspension increases as hemochromolys:s
proceeds, and is reduced again when stromatolysis occurs. ;
Crawford, J. H. INFLUENCE oF Vacus oN Heart Rate. [Jl. of Pharm.
poo x, Ther, Aug, 1925). ]. A. M.A.)
The age incidence of maximum vagal activity in normal persons,
according to Crawford, is from ten to forty, being at its height from
twenty to thirty. After this it steadily. begins to decline, there being
a marked fall after fifty. There is considerable individual variation,
especially in young persons. There is no difference between the two sexes
in their reaction to atropin as studied by the increase in heart rate.
‘The increase in heart rate after atropin administration cannot be foretold
from the heart rate before injection. There is a diminished reaction
to atropin in all cases of chronic heart disease, in which the sinoauricular
node is in control, especially in aortic disease. Auricular fibrillation shows
an increased reaction to atropin but is not comparable to the other heart
180 CURRENT LIfLR arose
conditions as the normal pacemaker is not in control. Typhoid fever
and pneumonia during convalescence show a diminished reaction and
exophthalmic goiter shows the same to a less extent. In convalescence
from rheumatic fever and chorea the reaction to atropin is increased.
It is suggested that the varied results obtained are due to three factors:
(a) alteration of the tonicity of the cardioinhibitory center; (b) changes
in the vagal terminations in the heart itself, and (c) changes in the
cardiac muscle.
Strasburger, J. Tur TREATMENT OF MIGRAINE WITH LUMINAL. [ Klin.
Woch., Aug. 20, Vol. II.]
A clinical record of nine cases of migrainous headaches treated by
luminal in the last two years. Continued treatment of migraine with
luminal in a daily dose of 0.1 gram or a little less diminishes markedly
the number and severity of the attacks which relapse after dropping
the drug. The drug was given in the evening in one dose of 0.1 gram,
or half this quantity was given twice a day. Intestinal sluggishness re-
quires aperents. [Another source for drug forming habit. ]
Henry, A. K. RESECTING THE LEFT CERVICODORSAL GANGLION OF
SYMPATHETIC IN ANGINA Pectoris. [Irish Jl. of Med. Sc., April,
1924. J. A. M. A.]
Henry approaches the cervical ganglion by the posterior route, that is
to say, by a costotransversectomy at the level of the first rib. The seventh
cervical spine is the point of a sort of half circle incision which gives a
good exposure of the underlying muscles, trapezius, rhomboids and ser-
ratus posticus superior, whose origins are divided and the second rib is
found and divided from the costotransverse articulation. The sympathetic
cord can now be seen close to the vertebral body, lying on the pleura like
a tape. The sympathetic cord is divided between the cervicodorsal and
the second dorsal ganglion, also the communications between the back of
the ganglion and the eighth cervical and first dorsal nerves. The right
index finger is passed, nail down, into the interval between the ventral
face of the ganglion and the back of the vertebral artery, and by gentle
traction on the sympathetic cord the ganglion is lifted so that the branches
whtch pass to the artery come into view. These are divided. Next, the
cord which passes up to the middle cervical ganglion is cut. The resection
of the ganglion is completed by dividing the inferior cardiac nerve.
Adler, F'. H., et al. Tonic Errecr OF SYMPATHETIC ON OcuLAR BLoop
VessELts. [Arch. Ophthal., May, 1924. J. A. M. A.]
Adler et al. show that when the blood pressure is raised the intraocular
pressure is increased. ‘This increase, however, is kept in check by a local
vasoconstriction of the ocular blood vessels through the cervical sympa-
thetic. This mechanism is a protective one to the eye, and prevents
sudden changes in general blood pressure from causing harmful changes
VEGETATIVE NEUROLOGY 181
in intraocular pressure. This protective action is increasingly effective as
the blood pressure ascends. No effect on intraocular pressure is seen
when the cervical sympathetic is cut at normal blood pressure. In the
normal animal, as the blood pressure is raised, the intraocular pressure
rises in direct proportion to it.
Rockwood, R., and Barrier, C. W. CatctumM TREATMENT FOR EDEMA.
[Arch. Internal Med., May, 1924. J. A. M. A.]
Rockwood and Barrier have tried the effect of large doses of calcium
salts (from 12 to 18 gm. daily) in cases of massive edema of diabetic and
nephritic origin. In six of seven cases, most of which had been resistant
to other methods of treatment, edema disappeared completely. In one
case, edema disappeared, but the part played by the calcium is questionable.
In two cases of nephritis, edema recurred later. None of these cases
were complicated by significant myocardial damage, and in none was any
other diuretic given with the calcium. In the few instances in which
small doses of calcium (from 1 to 3 gm. daily) were used, little or no
effect was observed. In some of the cases, edema was reduced by calcium
lactate. In other cases, calcium clorid seemed more effective. Large
doses of calcium do not seem to increase the amount of serum calcium.
In one case of chronic glomerular nephritis, renal function was definitely
improved as the edema subsided. In one case of diabetic edema, the basal
metabolic rate rose during the administration of calcium from — 13,
April 21, to an average of + 57, May 9. A similar dose of calcium did
not produce a change in the basal metabolic rate of a normal person.
In the other cases of edema discussed, the administration of calcium had
no effect on the basal metabolic rate. The authors suggest that the high
calcium content of milk may explain its diuretic action, and thus its
popularity in the treatment of acute nephritis.
Stout, A. P. GANGLIONEUROMA OF THE CERVICAL AND THORACIC SYMPA-
THETIC Ganctions. [J. A. M. A., May 31, 1924.]
The first case reported seems to have been associated with the superior
and middle sympathetic ganglions. Six similar cases are on record. The
patient was aged two and a half years. At five weeks of age, a mass
thought to be a gland appeared on the right side of the neck. This had
increased with throat infections, and decreased in the free intervals.
When first seen, the mass extended from the right lower border of the
lower jaw to the lower third of the neck. It reached the midline anteriorly
and to the posterior border of the sternomastoid laterally. The left side
of the neck was normal. Examination otherwise was negative. The
clinical diagnosis was tuberculosis of the cervical lymph glands. At
operation a mass was seen filling up the submaxillary triangle and the
middle half of the neck from the thyroid cartilage to behind the sterno-
mastoid. Posteriorly, it extended to the vertebral column. It was re-
moved without much bleeding, being firmly adherent to the thyroid
182 CURRENT LITERATURE
cartilage and the fascia in the region of the tonsil. On microscopic
examination, it proved to be a ganglioneuroma. In the second case, the
tumor came apparently from the thoracic segment of the sympathetic
(six other cases from this situation are on record). This patient also
was aged two and a half years. Four months before Stout saw him, he
began to be unsteady on his feet and soon began to drag his right foot
when he walked. Then he grew so weak that he could not sit up. Five
weeks before he entered the hospital, he lost control of the bladder and
anal sphincters. Otherwise he was a normal baby with normal develop-
mental history. Physical examination disclosed marked dulness over the
left upper lobe, front and back. A roentgenogram of the chest showed a
dense shadow over the upper portion of the left lung which was thought
to be a new growth. There was marked anterior curvature of the thoracic
vertebre. The cervical vertebree were markedly fixed and rigid. The
child could not sit without support, but fell toward the left. Koenig’s
sign was present in both legs. The reflexes were all present and active.
The case was considered inoperable. Seven months later the child was
operated on in an attempt to relieve the pressure on the thoracic cord,
which had become progressively worse. At that time there was found in
the spinal canal, occupying the upper dorsal region and extending up
into the cervical region, a very long, encapsulated tumor, extradural
and continuous with the mass in the chest by an extension through an
intervertebral foramen. ‘The child died shortly after the termination of
the operative procedure, and no necropsy was obtained. Microscopic
examination of a piece of the tumor disclosed ganglioneuroma.
Pasteur, Vallery-Radot et al. VAGoSYMPATHETIC Tonus. [Presse Méd.,
Dec. 15, 1923.]
These authors assert that in urticaria the sympathetic plays a role,
and that in asthma the vagus conditions the attack. The participation of
the vegetative nervous system in the anaphylactic crisis is recognized by
all clinicians. Pharmacodynamic tests made in urticaria, asthma and
migraine showed such wide divergences, however, to explore the vago-
sympathetic tonus with such tests is still frought with many uncer-
tainties.
Wolfe, J. T. IteocecaL DELAY AND VaAGuS REFLEX AS ETIOLOGIC
Factors IN BRONCHIAL ASTHMA. [S. Med. Jl., April, 1923. J. AL
M. A.]
Wolfe contends that asthma can be relieved by locating and removing
the cause of the hypertonic state of the vagus nerve, and that a majority
of the causative pathologic factors will be found within the peritoneal
cavity, and that adhesions will constitute a large majority of these intra-
peritoneal conditions. The production of intestinal toxemia must always
be considered as a factor in keeping the patient’s health below par. For
two years Wolfe has been employing slowly distending enemas daily to
VEGETATIVE NEUROLOGY 183
distend the colon, following abdominal operations, to prevent the colon
from being bound again by adhesions. Under this method no case has
given trouble with adhesions following operation. Also he refrains from
feeding the patient till the third or fourth day.
Frey, E. K. THE Carprac Nerves ANp AstHMA. [Mtinch. med. Woch.,
Molla Xi eMay. 9. |
This warning note that cutting of one pneumogastric or resection of
sympathetic ganglions, as now being advocated by the surgically minded
in treatment of bronchial asthma, is dangerous if the heart is not perfect.
Digitalis also acts less effectively on a denervated heart. It is probable
that the twenty-year-old enthusiasms re glaucoma and sympathetic, hyper-
thyroid and sympathetic surgery will be recalled.
de Besche, A. StTupIES ON THE REACTIONS OF ASTHMATICS AND ON THE
PASSIVE TRANSFERENCE OF HYPERSUSCEPTIBILITY. [Am. J. M. Sc.,
Cixi 265.e oiled Sc. |
The author studied the cutaneous reactions of 86 asthmatics by means
of protein extracts of timothy pollen, substances from various animals
(horse, dog, cat, chicken, sheep, crabs, lobster, fish), substances like honey,
milk, potato, oats, rye, rice, strawberries, nuts, apples, pears, and various
bacteria. The most frequent reactions (23 out of 35 cases) were obtained
with extracts of horse proteins. It was also shown that several substances
may produce a reaction in one and the same patient. Thus one person
became asthmatic from pollen, on contact with horses, as well as on eating
fish or strawberries. A seven-year-old boy became asthmatic from eat-
ing eggs and apples, while his sister developed urticaria, but not asthma,
from the same foods. The author made interesting experiments to see
whether the serum of an asthmatic hypersensitive to a particular protein
can render guinea pigs anaphylactic to the same protein. From 1 to
5 c.c. of the serum of the patient was injected intraperitoneally in guinea
pigs, and after twenty-four to forty-eight hours they were injected with
horse or cat serum either intravenously or intracutaneously. A series of
experiments are given which indicate that guinea pigs can in this way
be rendered anaphylactic, and it is shown that by means of the serum of
asthmatics a local hypersensitiveness may be produced to horse serum in
the skin of previously normal persons. The author holds that certain
forms of asthma may be regarded as anaphylactic in nature.
von Gordon, L. THe NAtTuRE AND PATHOGENESIS OF BRONCHIAL
ASTHMA AND Its RELATION TO Hay FEVER AND TO OTHER DISEASES.
ie ocowamed. Woch., LITT, 1132.)
This study holds that bronchial asthma is based upon the equilibrium
of the vagus and sympathetic, in consequence of disturbances of the
vegetative nervous system. For some reason the threshold for stimuli is
lowered and this leads to disturbances. The sympathetic nerve is of great
184 CURRENT LITERATURE
importance in. the development of bronchial asthma, in the form of
decreased reactivity. The endocrine glands play a role in the develop-
ment of bronchial asthma. Some cases of the condition may be due to
adrenal disturbances, leading to sympathetic hypotonia, which is relieved
by the administration of adrenalin. This hypotonia may be associated
with increased reactivity of the vagus terminations following a decrease
in the blood calcium (disturbances of the epithelial bodies). Adrenalin
causes contraction of some muscles (uterus and blood vessels) and
relaxation of others (bronchial musculature and coronary arteries of
the heart). In cases in which adrenalin fails to relieve the asthmatic
attack, it must be assumed that the excitation of the vagus nerve endings
is so intense that even the adrenalin. stimulation of the sympathetic
nerves is insufficient to cause relaxation of the vagus nerves. A com-
bination of atropin and adrenalin may be effective in such cases. ‘The
atropin is first administered, to decrease the vagus tension, and then the
adrenalin to increase the sympathetic function. The equilibrium of the
vagus and sympathetic innervation is thus restored and the asthmatic
attack ceases. Decrease in the blood calcium, due to hypofunction of the
epithelial bodies is one of the most important causes of the underlying
lability of the vagus sympathetic equilibrium.
Bronchial asthma may be defined as an inherited or acquired neurosis,
based upon a functional disturbance of the vegetative nervous system,
leading to sympathetic hypotonia with or without vagotonia, and to lability
of the equilibrium of the vagus sympathetic nerves which react patho-
logically to normally inadequate stimul1.
2. ENDOCRINOPATHIES.
Maranon, G. Arcuivos pE ENpocrinotocia. [Jan., 1924.]
This newly founded monthly is issued by Maranon of Madrid, Pi y
Sufer of Barcelona, Houssay of Buenos Aires, and Novoa Santos of
Santiago, with Carrasco Cadenas of Madrid as editor in chief. The
annual subscription is 20 pesetas for Spain and Latin America, but 25
pesetas elsewhere.
Zondek, H., and Reiter, T. Hormones aAnp Cations. [Klin. Woch.,
Voleil autyelG.
Their earlier experiments along physicochemical lines show that tad-
poles treated with various hormones react not alone to the hormone, but
they require certain electrolytes before their specific action can occur.
The vegetative nervous system is the system regulating the electrolytic
factors. This maintains the hormone balance. Thus a syndrome may
be due to the gland producing the hormone or to defective functioning
of the regulating system alone. A hormone normal in amount may have
a pathogenic action from change in the electrolytes it encounters in an
VEGETATIVE NEUROLOGY 185
organ. In their [Zeit. f. klin. med., 1923] paper they report that the
inhibitory action of thyroxin on the growth was counteracted and inverted
by calcium. Growth was enhanced by potassium. Both ions changed
in a similar way the action of thymus. The vegetative nervous system
regulates the action of hormones by changing the constellation of electro-
lytes on the periphery cell membrane synapse, or secreting cell.
Kraus, F., et al. ELECTROLYTES IN THE ORGANISM. [Klin. Woch., Vol.
Li April 22.) -
Kraus, Zondek, Arnoldi and Wollheim present these considerations
relative to the significance of electrolytes in the body. An important role
in humoral processes in lower animals before the vegetative nervous
system develops is to be seen in ionic activities. Thus potassium produces
effects identical with those from vagus stimulation, while calcium has
an action similar to that of the sympathetic. They increase or reduce
the existing functional capacity of the cells, lactic acid production in
muscles being an illustration. The constellation of electrolytes is brought
about by the nerve stimulus. Changes of hydration then follow. Gly-
cogen now comes into contact with the ferment, which splits it into
lactic acid. The permeability of the surface systems is influenced by
the electrolytes, as well as the electric charge of proteins. Fatigue of
muscles can be increased or decreased. The fundamental reactions of the
cell to stimuli are thus determined, and here is another aspect of what
is called constitution. Without calcium digitalis cannot act and the
muscle action of guanidin is inhibited by it. Body fluid tests are not satis-
factory since local variations can exist. Thus loss of blood calcium is
not the cause of tetany, any more than azotemia is of a kidney lesion.
Orator, V. New Points oF VIEW IN ESTIMATING PHARMACODYNAMIC
PoNcrIONAL Less. [Mittl, a, d. Grzgb. d; Med. u. Chir, Vol.
XXXVI, Nos. 2-4.]
Orator gives results of experiments with adrenalin and pilocarpin.
Individuals with highly active thyroid (Basedow, diffuse parenchymatous
goiter, diffuse colloid goiter) showed rapid resorption and also strong
general reaction. Those with thyroids of lowered activity (rather old
nodular goiter) revealed distinct local reaction and weak general reac-
tion. After operation the situation was reversed, the general reaction
was strengthened in adenomata, weakened in diffuse goiters.
Ehrstrom, R. DERANGEMENT IN HorMoNE Function. [Klin. Woch.,
Vol. III, April 29.]
The suggestion is here advanced that certain poisons are capable of
so binding hormones as to paralyze their activity. The destruction and
new formation of hemoglobin, according to Ehrstrom in support of which
he states that extremely small quantities of Seyderhelm’s oestrin (0.08
mg.) can kill a horse. A grave anemia, which may be due to paralysis
186 CURRENT LITERAL URE
of a hormone which regulates the erythropoiesis results if smaller doses
of oestrin are given.
Gow, A. E. ENpocriINoLoGy FROM PuysicIANn’s Point oF VIEW. [Brit.
Med. Jl., April 19, 1924. ]
The majority of extracts of ductless glands administered by mouth,
as at present prepared, have no definite effects. Tissue extracts in
general, when injected intravenously, give similar effects as any foreign
protein, and are in no way specific with few exceptions. Thyroid or
parathyroid are alone absorbed as such from the alimentary tract. Epi-
nephrin nevertheless is valuable in shock, in asthma and other spasmodic
affections such as cardiospasm, urticaria and angioneurotic edema, and
pituitary extract is a stimulant to a failing myocardium, especially in
toxic myocarditis and in the third stage of labor. If any advances in
therapeutics are to be made with glandular extracts. the blunderbuss
method still so abundant in ordinary drug therapy in the hope that one
among the many may hit the mark must be abandoned.
Bauer, J. INDIVIDUAL CONSTITUTION AND ENDOCRINE GLANDS. [Endo-
crinology, Vol. VIII, May. J. A. M. A.]
Bauer stresses the importance and high power of the chromosomes
and their constituents, to show that the endocrine glands generally are
only, as it were, condensers or multipliers of certain chromosomal poten-
cies, and that not everything which may be attributed to pure endocrine
disturbances is, in reality, of endocrine origin. The interference of
general chromosomal (1.e., constitutional) and of incretory influences
is to be taken into consideration in the greatest number of cases in which
unsatisfying hypothetic suppositions of pure hormonal trouble usually
are to be met with. In a purely experimental way, Bauer is treating
cases of dwarfism and infantilism with extracts of fetal organs, partly
from fetal calves and partly from human fetuses. These experiments
seem to be yielding satisfactory results.
Zondek. RELATIVITY OF ACTION OF Hormones. [Deut. med. Woch.,
Vololn-Marchi2 ls)
This interesting paper deals with a number of important physicochem-
ical conceptions. Among other things he and his colleagues have shown
that the action of thyroxin on tadpoles may be increased or even reversed
by different ions. An expected increase in metabolism of dogs after
1.3 mg. of thyroxin by adding 0.3 gm. of calcium chlorid can be checked.
The action of pituitary extract can be enhanced by potassium chloride
and inhibited by chloride of calcium. The action of insulin does not
depend on the amount of the ions but on the difference between the
antagonists. Hormone action is thus reversible according to the con-
dition of the cells on which they act. Thus the paradoxical coexistence
of exophthalmic goiter with hypothyroid syndromes might be explained
VEGETATIVE NEUROLOGY 187
by a relatively high concentration of calcium ions in the organs which
show the hypothyroid syndromy.
Kamiga, Rikei. On Beripert Dis—EASE oF MAMMALIANS AND BIRDS
WuicuH DEVELOPS IN THE CONDITION OF PoTASSIUM DEFICIENCY AND
THERAPEUTIC VALUE OF POTASSIUM PREPARATIONS AGAINST BERI-
BERI. [Jl. Exper. Med., Vol. XXXVIII, Aug.]
In his previous communication, the author dealt with beriberi-like
disease caused by overfeeding of sodium salts, which would result in
potassium deficiency. The experimental animal was fed with usual ration,
with which no symptoms of beriberi-like disease developed. In the
present communication he deals with the experimental feeding of the
animals with polished rice alone and polished rice mixed with salts com-
bined with a large amount of sodium bicarbonate or sodium carbonate.
In the animal routine course of polished rice disease developed, but by
mixing a small amount of potassium bicarbonate into the polished rice
feeding, the development of the symptoms was markedly postponed.
In the excess feeding with sodium bicarbonate and polished rice, there
developed besides the genuine symptoms and pathological changes of
polished rice disease, other intercurrent symptoms, as well as the latent
paralysis developed earlier than in the control animals. In the sodium
animals or potassium deficit animals, the symptoms were ameliorated by
vitamin B. Organic paralysis ameliorates very soon by a liberal adminis-
tration of vitamin B and potassium. In sodium excess feeding, however,
the amelioration takes place very slowly and often resulted in chronic
course of the disease.
Bickel, G., et al. CarprAc INFANTILISM AND THE ENDOCRINES. [Rev.
fran. dae ndocrtit,«V Ol..1, Keb:|
The retarded development of the body in congenital affections of the
heart is here discussed. Changes in the pituitary, thyroid and suprarenal
glands were found and are causally related by them to the cardiac infan-
tilism. These as well as most authors are unaware of Lewis’ important
study on constitutional factors in dementia precox where may be seen
the beginnings of these aplasias much more logically elaborated than
by pointing a finger at this or that gland.
Engelbach, W. Diacnostic Enpocrtne Criinic. [Endocrinology, Vol.
VIII, May. | |
The author here divides endocrine anomalies clinically in seven
groups: (1) Bilobar insufficiency of the hypophysis, presenting four
cases of juvenile adiposity and emphasizing the diagnostic significance
of the distribution of fat and the necessity of early treatment to prevent
disastrous disturbances in later life in the sexual system; (2) thyro-
pituitary (posterior lobe) insufficiency, diagnosed by overweight at birth,
by retardation of dental development, of walking, and of speech; (3) thy-
188 CURRENT LITERATURE
ropituitary (anterior lobe) insufficiency, lacking the adiposity of group
II and showing physical underdevelopment; (4) thyroid insufficiency ; (5)
pluriglandular insufficiency with epilepsy, where the case presented
demonstrated the relationship of the internal secretions to the eyes and
to the teeth, as well as to the mental makeup or nervous system; (6) an-
terior lobe pituitary hypersecretion, which may stimulate overgrowth of
the osseous system; (7) Raynaud’s disease in a woman with secondary
hypothyroidism as shown by a high basal metabolic rate, in spite of which
she has been gaining in weight.
Korenchevsky, V. GLANDS OF INTERNAL SECRETION IN BeriBeri. [Jl.
of Path. andeBact. V dlexocy beiulya)
(a) Hypertrophy of the suprarenals; (b) atrophy of the thymus;
(c) atrophy of the spleen with persistence of the islets of the germ
centers, often accompanied by an increase in their number and size and
frequent hypertrophy: and hyperplasia of the islet cells. These were the
chief changes observed in pigeon beriberi.
Sansum, N. D., and Blatherwick, N. R. Sources oF Error IN OrRGANv-
THERAPY AS ILLUSTRATED BY REPARATION AND ADMINISTRATION OF
INsuLIN. [Endocrinology, Vol. VII, Sept.-Nov. J. A. M. A.]
Sansum and Blatherwick believe that organotherapy, in general, has a
wonderful future, but its future development will depend not on empirical,
haphazard methods of study but on the type of study which has led to
present knowledge of such products as epinephrin, thyroxin, pituitary
extract and insulin.
Kocher, A. CONSTITUTION AND SURGERY WITH ESPECIAL REFERENCE TO
THE ENpDOCRINE GLANDS. [Schweiz. med. Woch., LIII, 223.]
Hereditary and acquired constitution must first be distinguished. He
defines a normal constitution as one in which all the organs perform their
function in a manner adequate to the demands of the body, and in
which there is harmonious correlation between these organic functions.
The judgment of abnormal constitution is frequently only relative. This
article reviews many of the well known syndromes viewed from a narrow
endocrinological viewpoint so frequently seen in those surgeons unaware
of the intricacies of the “ body as a whole.”
Goldstein, Hyman. ROLE ofr THE ENDOCRINES IN THE GROWTH AND
NUTRITION OF CHILDREN. [N. Y. Med. Jl., Vol. CXX, Jan. 2.]
The ductless gland secretions play a great role in preparing the tissue
cells to utilize the food elements. Malnutrition in childhood is more than
a question of insufficient food or deficient vitamines. It is not rare to
find an excellent state of nutrition where the food supply is scanty and
vice versa. The malnutrition which is severe enough to be reckoned
as a factor in faulty development is usually the result of a hypoplasia ~
VEGETATIVE. NEUROLOGY 189
or endocrine insufficiency. There seems to be a close connection and
dependence existing between the functions of the vitamines and the duct-
less glands in which the hormones prepare the tissues giving them recep-
tive power to receive and properly utilize the vitamines. In the case of
rickets and to a lesser degree in marasmus, small doses of thyroid start
them on the road to improvement where other methods fail. We have
also certain types of children with a background of dyscrinism giving rise
to malnutrition. The hypo- and hyperadrenal; hypo- and hyperthyroid
and lymphatic or thymic types and malnutrition associated with blood
dyscrasias. In glycosuria and its complications the metabolic disturb-
ance may be traced to an abnormal thyroid, adrenals, pituitary or pan-
creas. Normal body and mental growth and nutrition are to a certain
extent dependent upon a normal set of teeth. The internal secretions
have a certain favorable influence upon the dental tissues in bringing
about eruption; in arresting decay; in preventing caries and resisting
caries. In the causation of caries of the teeth, ductless glandular balance
is upset in the direction of calcium hunger. The pituitary, thyroid and
to some extent the thymus are the glands usually involved. Aside from
the nutritive disorders and trophic lesions (skin) of children, develop-
mental anomalies and disturbances of growth must also be considered.
Laboratory investigations and clinical experiences have shown that defects
of the thyroid, pituitary, thymus and gonads are mostly responsible for
the anomalies of growth and morphogenesis. The difficulty in diagnosis
as well as treatment, lies in one’s ability to recognize these abnormalities
early, when our efforts are more likely to be effective. In the class of
growth dystrophies, many of the stigmata obviously are manifestations
of an organic nature and should not be expected to be remedied. But
since the underlying element is a disturbed function of some of the
endocrine glands, their remarkable responsiveness to hormone stimuli
may enable us to bring about some noteworthy organic changes. And
also the importance of giving early attention to the defective child should
be strongly emphasized. In discussing acromegaly and gigantism, the
Froehlich, Burnier, Cushing thymogenitopituitary, pluriglandular com-
pensatory thymuspituitary and the amyotrophic syndromes include prac-
tically all the possible dyspituitary types. A Wassermann should be
taken in these cases because of the close association of syphilis and
dyspituitarism. In conclusion, early diagnosis and treatment must be
emphasized and each patient individualized. The mode of living of the
patient should be regulated as to hours of sleep, recreation, food, regula-
tion of meals, cleanliness, care of the emunctories, etc. From the view-
point of diagnosis, symptomatology, pathogenesis and therapeutics in
nutritional and growth disorders of children, the ductless glands and their
internal secretions play an important role in solving many of the formerly
unknown problems as to the etiology of various complexes and syndromes.
[ Author’s abstract. ]
190 CURRENT LITERATURE
Serdjukoff. RecrprocAaL RELATIONS BETWEEN ENpocrInE GLANDS.
[Arch. f. Gyn., Vol. CXXI, May 12.]
The general attitude of this study is that the internal secretions are
a highly differentiated phase of general metabolism. An extreme instance
of the mutual relations between the endocrine organs is described in which
the thyroid, the suprarenals, and the uterus all shared in inducing the
severe clinical picture. The uterus presented a cavernous metritis, with
periodic erectile phases, and the whole clinical picture vanished as if by
magic after hysterectomy. More careful research on the internal secre-
tion of the uterus is demanded. :
Zondek, H. PLurRIGLANDULAR INSUFFICIENCY. [Deut. med. Woch.,
Volo X LD Marchal Ge ee
Zondek publishes several observations on pluriglandular insufficiencies
with the necropsy findings. He finds two opposite types: obesity and
cachexia, which may be due to opposite disturbances of the same endo-
crine organs. Cachexia may follow the obesity. He found high metabolic
figures in the obesity and low in the cachexia. The endocrine glands play
an important part in the accommodation of different animals to seasonal
changes, especially hibernation. He finds a similarity in human path-
ology: Persons with disturbances of the endocrine glands, especially
of the thyroid gland and vegetative nervous system, may have sudden
changes in weight and deposition of fat without changing their diet,
coincident with the seasons. He quotes the history of a young vagotonic
girl with distinct degenerative stigmata, who deposited fat regularly with
the beginning of the hot season and lost it in winter.
II. SENSORI-MOTOR NEUROLOGY.
3. SPINAL CORD.
Watanabe, T. Cyst FoRMATION IN THE SPINAL GANGLIA. [ Schweiz.
med. Woch., LIII, 407. ]
In a series of 150 cases examined on the suspicion of disease of the
spinal ganglia, cysts were discovered in forty cases. The cysts were
sometimes from 2 to 10 mm. in diameter. They were frequently filled
with a clear, aqueous fluid, resembling cerebrospinal fluid. In other
cases the cysts were so minute that they were discovered only on micro-
scopical examination. The dorsal and lumbar ganglia appeared to be
most frequently affected. The number of cysts varied greatly in indi-
vidual cases; some patients presented involvement of only one or twa
ganglia, while in other cases practically all the spinal ganglia contained
cysts. ‘The lesions were found mainly in the intervertebral ganglia, or
at the border between the ganglia and the posterior roots, or were con-
fined to the posterior roots. The histological appearance was strikingly
SENSORI-MOTOR NEUROLOGY 191
uniform. They were covered by one layer of flat epithelium surmounted
by a narrow layer of loose, avascular or poorly vascularized connective
tissue, containing occasional lime nodules and lymphocytes.
The cases affected twelve men and 28 women; in thirty-six cases the
patients were over the age of forty years. Apparently young indi-
viduals are rarely affected. There were no clinical manifestations which
suggested the presence of cysts. The condition is not responsible for
scleroderma or Raynaud’s disease.
Guillain, G., and Alajouanine, Th. THe Semei1oLtocicaL VALUE oF D1s-
SOCIATION OF THE ABDOMINAL AND CRURAL RESPONSES OF THE MEDIO-
PUBIAN REFLEX IN LOCALIZATION OF THE HEIGHT oF A MEDULLARY
Peston. §| Compt Kend Soc) de Brol., EX X XIX; p. 12154
The writers’ medio-pubian reflex is a periosteal reflex, obtained by
striking the symphysis pubis with a hammer, the patient lying on his
back, completely relaxed, with lower limbs slightly separated from each
othe: and thighs in slight abduction and external rotation. Normally the
reflex gives two responses, an upper abdominal, chiefly of the recti, and a
lower, of the pectineus and adductors of the thigh. In a case of flaccid
paraplegia due to acute poliomyelitis, medio-pubian percussion no longer
gave the normal adductor response, while the abdominal response was
absolutely normal. ‘The dissociation of these two responses enabled the
writers to localize the upper limit of the lesion below the eleventh and
twelfth dorsal segments at level of the first and second lumbar segments.
The fact of the dissociation of the medio-pubian reflex may have a double
localizing value; for, (1) if it be totally abolished, the lesion is in the
lower dorsal medullary lesion, and (2) if it be dissociated, an upper lum-
bar lesion is indicated. [Leonard J. Kidd, London, England. |
Barre, J. A. PyrAmipaL LESIONS AND VERTEBRAL ARTHRITIS. [ Méde-
cine, February, 1924. |
Barré records that chronic vertebral arthritis may cause pyramidal
symptoms. This may lead to mistaking them for incomplete forms of
multiple sclerosis or Pott’s disease.
VanderHoof, Douglas. Tur EtroLtocic RELATION oF ACHYLIA GASTRICA
TO COMBINED SCLEROSIS OF THE SPINAL Corp. [Archives of
Internal Medicine, XX XII, pp. 958-971. ]
In a recent clinical study of 451 patients with achylia gastrica, there
were twenty-nine individuals with definite evidence of combined sclerosis
of the spinal cord. Of these twenty-nine patients, fourteen had pernicious
anemia, one had pellagra, in seven the observations were incomplete,
leaving seven patients that form the basis of this report. Combined
sclerosis of the spinal cord has been regarded as a disease of obscure
etiology and hopeless prognosis. The study of these seven cases woul
seem to show, however, that achlorhydria not only precedes and accom-
192 GURRENT, LITERATORE
panies the development of this nervous disorder, but that it is in all proba-
bility an essential predisposing cause. Achylia gastrica thus appears to be
as constant a finding in combined spinal sclerosis as in pernicious anemia.
In one instance neurotoxins, in the other hemolytic toxins, are evidently
produced in the intestinal tract of the individual whose stomach lacks the
protective or inhibitory action of the normal hydrochloric acid secretion.
The outlook in patients suffering from combined spinal sclerosis, not
accompanied by pernicious anemia, appears to be very favorably influenced
by persistent treatment with full doses of hydrochloric acid. Of these
seven patients, one is subjectively cured, two are apparently well and one
is greatly improved. The author is firmly of the opinion that every
individual with true achylia gastrica is a potential case of either pernicious
anemia or combined spinal sclerosis. He also emphasizes the great
importance of adequate hydrochloric acid therapy as an essential prophy-
lactic measure in every case of achylia gastrica. The dose of dilute
hydrochloric acid recommended by the author is one dram to one and
one-half drams, well diluted, with meals. [Author’s abstract. ]
Estapé, J. M. Ascenpinc Mye itis in Acute PoLiomye itis. [Arch.
Lat -Am.cd2 Peds May. 19235)
Ten days after the onset of acute poliomyelitis a diffuse myelitis cf
the Landry type developed in this boy, twelve years of age.
Jaroschy, W. Late INjJuRY oF SPINAL Corp FROM Sco_tiosis. [Beit.
z. klin. Chir., CX XIX, 245-482, 1923.]
In the two cases here reported upon the severe spastic paraplegia of
the legs developed at the ages of fourteen and seventeen years respec-
tively. The paraplegia in one case was completely relieved by laminec-
tomy, and materially improved conditions in the other, in which the
paraplegia had been present a long time.
Jarlov, E., and Rud, EH. ExpPreRIMENTAL MULTIPLE ScLeErRosts. [Hosp.,
August 1, 1923. J: A. M, A.)
Jarlov and Rud say that a “right interesting” clinical picture de-
veloped in the seventeen animals after they had been injected intraperi-
toneally with blood or serum or spinal fluid from a woman with typical
sclerosis in patches. She had been healthy until 1920. The disease in
the animals ran a more rapid and a severer course.
%?
Griinewald, E. A. PATHOLOGICAL ANATOMY OF “ LANDRY’S PARALYSIS.
{ JourniPsychman, Neureey ol xk 1 a)
Grtinewald considers Landry’s paralysis as a clinical concept which
reveals nothing definite as to etiology or pathological anatomical involve-
ment. The clinical course and the anatomical findings are often widely at
variance. Grunewald reviews the literature, forty cases with autopsy, and
then describes a case of his own where extended investigations of the
SENSORI-MOTOR NEUROLOGY 193
nervous system were carried out. There were marked changes in the
peripheral nerves (myelin degeneration, proliferation of Schwann’s cells,
infiltration of lymphocytes); changes in the central nervous system, in
the spinal cord, medulla oblongata, brain stem and even in the cortex
(nerve cell alterations, proliferation of neuroglia, medullary degenera-
tion, locally, also secondary lymphocyte infiltration and necrosis).
Achard, Ch., and Thiers, J. CEREBROSPINAL FLUID IN MULTIPLE
ScLEROsis, [ie WMéd., 1923, p. 330.)
Multiple sclerosis is very well defined by its lesions: that may be
indicative of a specific cause; and as no visceral lesion is found by
anatomical examination but in the nervous system, the cause seems to be
a neurophil virus.
Indeed many authors have described a specific spirochete. In France,
A. Pettit has found it in several occurrences. Professor Achard refers
three cases: in two of them the parasite has been made conspicuous by
A. Pettit in the cerebrospinal fluid of the patients or in the liquid of
inoculated animals (rabbits and guinea pigs).
It is not infrequent to find in the liquid of the patients a positive or
subpositive reaction of the colloidal benzoin, according to the Guillain
technic, which is always positive in syphilis, another spirochetic infection.
But the Wassermann reaction, on the contrary is generally negative in
sclerosis. Achard points out this opposite result and he thinks it is a
worthy sign for the diagnosis of the multiple sclerosis.
Dowman, C. BE. CoMPpLETE TRANSVERSE LESION OF THE SPINAL CorRD
WITH RETENTION OF SUPERFICIAL REFLEXES. [Arch. Neur. and
Peycne Ns p,/33: |
Dowman reports three cases, with necropsy, in which there was com-
plete severance of the spinal cord at the levels of the fourth and fifth
cervical segments, sixth and seventh thoracic segments, and third thoracic
segment respectively. In spite of this there was retention of the following
superficial reflexes in the parts below the level of the lesion: Cremasteric
reflexes on both sides; epigastric, abdominal, cremasteric and plantar re-
flexes (flexor type) on both sides; abdominal and cremasteric reflexes on
both sides. The deep reflexes below the level of the lesion were absent in
all cases. The cases were all the result of shell fragment wounds obtained
during the World War, and these were not the massive fracture dis-
locations seen in the usual traumatic cord cases of civil practice. Other
observers have noted the retention of superficial reflexes in complete
lesion of the spinal cord due to war injury. Guillain and Barré in fifteen
cases noted that the plantar cutaneous reflex and cremasteric reflexes were
often preserved. Head calls attention to the fact that when the spinal
cord has been completely divided, without widespread destruction or
septic infection, the lower end may under favorable conditions, regain
its tonic influence and reflex excitability. It would seem, therefore, that
194 CURRENT JATERATURE
as the result of such clinical observations, that part of Bastian’s law
regarding the superficial reflexes must no longer be accepted. [Author’s
abstract. |
Achard, C. CEREBROSPINAL FLuIp AND MULTIPLE ScLERosis. [Bul. d.
YAc d. Méd., May 22, 1923-55 Jae ve
Achard obtained a positive reaction to the benzoin test of the cerebro-
spinal fluid of a woman who had had multiple sclerosis for nine years,
and in twenty other cases out of a total of twenty-five, under his own
or others’ observations. The Wassermann test was constantly negative
in all. The benzoin reaction was pronounced in some of the cases in
which the clinical picture was far from complete at the time. It may
prove instructive to supervise the benzoin reaction during a course of
treatment, especially with spirillocidal drugs, to gage the effect. The
spirochete found by Pettit and by Guillain in several cases of multiple
sclerosis was never discovered outside the nervous system, even at
necropsy. In discussing Achard’s communication, Guillain stated that
he had obtained a positive reaction to the benzoin test in the spinal fluid
in six out of ten cases of multiple sclerosis, but the colloidal gold and
mastic reactions were positive also. It indicates a progressive lesion, and
becomes negative as the progressive wave subsides.
Muller, C. Priapism. [Bruns’ Beitr. z. kl. Chir., Vol. CXXVIII, No.
an
Muller discusses the etiology and pathogenesis of priapism and re-
ports several cases. Priapism occurred in a patient forty-seven years
old, suffering from spondylarthritis ankylopoetica with whom incision in
the erectile tissue produced extensive improvement but with chronic loss
of the capacity for erection. Priapism occurred in another patient after
a myeloma in the first thoracic vertebra with pressure upon the spinal
cord. The history is given of a case of so-called idiopathic priapism and
mention is made of a phenomenon exceedingly rare observed by the
author, a priapism continuing after death.
Rehbein, M: OssiFICATION oF MuscLe AFTER SPINAL Corp INjuRY.
[Do Zschr. t..Chirwy ol io LL Niossainecel
“Rehbein presents a case analogous to one described previously by
Israel. The patient was.a soldier, twenty-three years of age, shot
through the spinal cord in the cauda equina at the second lumbar vertebra.
There was almost complete paralysis of the pelvic and leg musculature.
Four months later the X-ray confirmed the clinical picture of ossification
of the muscles of the thigh and pelvis, also in the lower third of the
femur and within the knee joint. The patient took his own life after four
years. Autopsy showed that the iliopsoas musculature and that of the
upper third of the sartorius were intact with degeneration elsewhere.
Ossification of the inferior iliopsoas, of the pectineus, of the medial,
SENSORI-MOTOR NEUROLOGY 195
deep gluteus minimus division and of small portions of the adductors
existed in close association with the femur. In the region of the knee
joint the pes anserinus, vastus med. and lat. and the articularis genu were
ossified. The bony neoplasia corresponded in structure to the longitudinal
direction of the muscle. Beside the trophic neurosis which would pre-
. pare the way for the ossification a mechanical cause for its origin is
probable, the stimulus of the muscular pull. The upper third of the gen-
erally ossified muscles was intact and capable of function. The force of
this portion would be carried over the paralyzed portions to the insertion
at the bone and so give the stimulus to the bony formation.
Schuster, J. Scierosts MULTIPLEX AND DiFruse Scuerosis. [D.
Pischieet. Nervhik; Vol; EX X Vi Nos. 1-6:]
Spirochete-like forms were found in three cases of the multiple
sclerosis syndrome in permanent preparations.
Viets, H. R. Acute Ascenpinc Meninco-MyYeE.itTis, Possisty RESULT-
ING FROM ARSPHENAMIN THERAPY. [Bost. Med. and Surg. Jl.,
Gi XX VHT 895.
The patient was an outdoor telephone worker, thirty-eight years old,
whose illness began suddenly with malaise, sore throat and muscular
weakness followed in a few days by complete paralysis of both legs
with loss of sensation up to the ribs. The condition was rapidly progres-
sive. When examined on the fourth day of his illness, breathing was
almost entirely diaphragmatic because of paralysis of the intercostals.
Anesthesia was absolute up to the fourth cervical segment. There was
incontinence of both urine and feces. There was complete paralysis of
the legs and no movement of the arms was possible. Tendon jerks were
uniformly absent. The spinal fluid had a pressure of over 300 mm., was
cloudy, showed a fine clot on standing, had a cell count of 675, two-thirds
of the cells being polynuclears, contained three times the normal amount
of protein, and gave a negative Wassermann and a gold sol curve of
1222344322. The patient died of respiratory paralysis about thirty
minutes after the lumbar puncture. The patient had received two injec-
tions each of 0.5 gram salvarsan, the first twelve days before death and
the second four days before death. This case was probably an acute
spreading myelitis ascending in character with definite meningeal in-
volvement. A possible etiologic factor is suggested in an arsphenamin
reaction somewhat analogous to encephalitis hemorrhagica.
Curschmann, H. FamitiaAL Spastic SPINAL ParRAtysis. [D. Arch. f.
Paevied.. Vel, CXETI. Nos, 172.1]
Curschmann presents cases of the rare combination of hemolytic
icterus and familial spastic spinal paralysis. In one case the spastic
spinal paralysis was hereditary though this is one of the rare heredode-
generations. There is here probably not a typical combination of two
196 CURRENT LITERATURE
disease conditions nor a clinical picture due to one single agent but an
accidental coincidence of two quite different diseases arising on the
basis of a constitutionally weak germ plasm. On this assumption splenec-
tomy which otherwise would have been resorted to was rejected since it
could have no beneficial effect upon the spinal process. Late eunchoidism
in the form of eunuchoid distribution of fat, shrinking of penis and
testicles and alteration of the sella turcica were observed as signs of dis-
turbances of internal secretion. ‘Two other cases of hemolytic icterus
manifested marked infantilism, hypogenitalism and an unusual hypo-
plasia of the skeleton. The signs of endocrinous disturbance with hemo-
lytic icterus are coordinated symptoms of degeneration.
Platt, H. Earty MECHANICAL TREATMENT OF ACUTE ANTERIOR POLiIo-
MYELITIS. [Brit. Med. Jl., February 16, 1924.]
The treatment outlined by Platt consists of complete rest; the pre-
vention of deformities by the adoption, from the moment immobilization
is effected, of certain standardized positions of the limbs—positions which
are known to be antagonistic to the occurrence of the common contrac-
tures, and relaxation of the paralyzed muscles.
Flatau, E., and Sawicki, B. Spinat Tumors. [Lyon Chir., February,
1924. J. A. M. A.]
In two of Flatau and Sawicki’s three cases the tumor was in the
vertebra and had invaded the spinal cord. In the other case, the tumor
was in the cord and had invaded the vertebrae. The tumor was excised
and the region was exposed to the roentgen rays. ‘The patients are in
comparative good health now, five and nine years since the operation.
In the third case, the primary tumor was in the ilium and was inaccessible.
The metastasis in the spine, five years after the first symptoms, had in-
duced total spastic paraplegia of the legs, with edema and eschars, and
the consultants warned against operative intervention. But the paralysis
and edema subsided after removal of the tumor, plus irradiation, in 1922,
and the man, now fifty, has regained his earning capacity.
Finzi, A. NEUROLOGICAL EXPERIENCE WITH PHLocGETAN. [W. kl.
W sehr. No, 22,1924 |
Two paretics and one case each of spastic spinal paralysis and multiple
sclerosis among seven cases treated with phlogetan showed subjective and
objective improvement.
Royle, N. D. New OPERATIVE TREATMENT OF SPASTIC PARALYSIS.
[ Med. Jl. Australia -january.20, 1924 = 5) An Wie
Experiments were made by Royle to determine the function of the
sympathetic fibers going to voluntary muscles, and whether that func-
tion had any relationship to the abnormal muscular condition seen in
spastic paralysis. He found that removal of the left abdominal sympa-
SENSORI-MOTOR NEUROLOGY 197
thetic trunk did not interfere with the animal’s ability to control the left
lower limb, but the animal when placed on its back was not able to
maintain the limb in an extended position and the amplitude of the tendon
jerks was diminished. The hypertonicity and the flexion following trans-
verse section of the cord were profoundly altered. In contrast to the
right lower limb the left limb fell into extension and abduction under the
influence of mechanical factors, while the knee and ankle jerks were less
active. On the basis of his findings Royle considered it justifiable to
test the therapeutic value of the observation and to endeavor to find some
relief for the rigidity accompanying spastic paralysis in the human sub-
ject. A willing patient submitted to operation. The white ramus from
the second lumbar nerve was divided and the grey rami going to the
second, third and fourth lumbar nerves were avulsed. The sympathetic
trunk was divided immediately below the fourth lumbar ganglion. By
this means the grey rami communicantes to the fifth lumbar nerve and
to the sacral nerves were divided. Fifty-four days after operation the
patient improved to such an extent that he relaxed the formerly spastic
limb almost in a normal manner when walking. The knee jerks were
practically equal on both sides. The ankle clonus was still present in a
definite form on the left side, but was not present on the right side nor
' was there any sign of abnormal tone in the muscles of the right lower
limb. A second patient who had had spastic hemiplegia on the right side
for fourteen years was also operated on. The upper limb was useless.
The grey rami to the whole brachial plexus were avulsed. Since the
operation (two weeks) there has been a remarkable gain in voluntary
control in this useless hand and there appears no reason why improvement
should not continue when the structural deformities become lessened.
The name given to this operation is sympathetic ramisectomy.
Christiansen, V. THE CervicAL SPINAL Corp. [Annales Méd., Janu-
ary, 1924. ]
Christiansen deals with affections of the cervical spinal cord and its
roots. Careful examination of a supposedly peripheral neuritis may
reveal one of the four typical radicular syndromes, and thus allow an
early operation. Arthritis of the cervical vertebrae may produce symp-
toms similar to those of tumors. It is, however, usually unilateral, does
not compress the cord, is favorably influenced by extension of the
patient, and causes no changes in the cerebrospinal fluid.
Friedman, E. D. INCREASED INTRACRANIAL Pressure. [N. Y. Med. Jl.
& Med. Record, October 3, 1923. J. A. M. A.]
In the examination of about 3,000 cases, of which 750 were examined
for evidences of injury or pathology, evidences of intracranial pressure
were observed by Friedman in about 75 per cent. Roentgenologically,
intracranial pressure can be divided into acute, subacute and chronic.
The acute type can readily be interpreted by observing a peculiar mottling
198 CURRENT TITERAT GRE
of the skull field, better described as areas of increased illumination with
intervening spaces of the normal brain shadow. This appearance justi-
fies the diagnosis of a diffuse mild form of edema of the brain. This
edema may arise not only from injury, but also from laceration of the
brain which occurs in concussion. In every case in which lumbar punc-
ture was performed shortly after an injury, bloody spinal fluid was found
even though there was no evidence of a fracture. The subacute type of
intracranial pressure is observed at a more remote period after an acci-
dent and is accompanied by certain subjective symptoms such as headache
and vertigo.
Schall, L. Ture Tusincen Epip—emMic oF HerrtnrE-MEpIN’s DISEASE.
[Miinchen. med. Wchnschr., LX X, 763-765. Med. Sc.]
Schall, of the Tubingen University Children’s Clinic, describes an
epidemic of 139 cases of Heine-Medin’s disease which occurred in the
Tubingen district during 1922 at the same time as similar epidemics in
Hesse, East Prussia, Baden, and the Rhine district. During the period
January to May six prodromal cases occurred, but the actual epidemic
did not begin till the middle of May, and the great majority of the cases
occurred in the summer months. Among 90 cases in which details of
the onset were available 83 commenced like an acute febrile disease with °
a high temperature, 44 had a frequent cough, 40 headache, 15 opistho-
tonos, 13 general hyperesthesia, 9 pain in the limbs, and 8 pain in the
back. Meningeal symptoms were pronounced in 13 cases. Gastro-
intestinal manifestations occurred in only 2. Paralysis developed in 107,
3 were examples of the purely meningeal form, and 2 of the cerebral form
characterized by general convulsions. There were 25 abortive cases, in
which the diagnosis of Heine-Medin’s disease was established by their
association with paralytic cases. The paralysis as a general rule, affected
the limbs; one extremity was affected in 40 cases, two extremities in 31,
three in 10, and all four extremities in 9. The nuchal muscles were in-
volved in 7, the abdominal in 5, and the back muscles in 2. The bladder
and rectum were affected in 4 cases during the paralytic stage. In the
bulbar cases the facial nerve was paralyzed 7 times, the hypoglossal 4
times, and the spinal accessory once. The eye muscles were involved
twice, and the speech center once. Fourteen cases were fatal, including
two of the purely meningeal and one of the cerebral form. As the
mortality was reckoned only on the paralytic cases, the last three cases.
were excluded, so that there were 11 fatal cases, or a mortality of 10.3
per cent. The principal feature of the epidemic was the influenza-like
character of the initial symptoms, viz. fever, headache, and dry cough,
not only at the onset of the epidemic but throughout its course. In
abortive cases in which paralysis did not develop the diagnosis from in-
fluenza was impossible. In this connection an outbreak of the disease in am
infant’s home at Tiibingen is of interest, especially as epidemics of Heine-
SENSORI-MOTOR NEUROLOGY 199
Medin’s disease in institutions are uncommon. In the course of a month
14 children, 3 of whom subsequently developed paralysis, showed more
or less considerable rises of temperature associated with symptoms of
influenza, such as redness of the fauces, cervical adenitis, and frequent
cough. Schall agrees with Wernstedt that the form of Heine-Medin’s
disease accompanied by paralysis constitutes a relatively small propor-
tion of the total number of cases, and points out that the predominance of
abortive cases accounts for the spread of the disease, although he does
not deny the possibility of dissemination of the disease by healthy carriers.
He recommends that in epidemic times the public should be warned of
the danger of the apparently harmless “influenza” case. [J. D. Rolleston. ]
Barré, J. A. Tue PAINS WITH COMPRESSION OF SPINAL Corp. [Presse
Méd., May 19, 1923.]
A comprehensive discussion of the significance of pains above and
below the lesion, and the interpretation of those for which the cord itself,
the sympathetic nerve, or the roots are responsible.
Wideroe, S. DisLocaTION oF THE FirtH LUMBAR VERTEBRA. [ Norsk.
Mag. f. Laeg., July, 1923.]
Five cases of traumatic displacement of the body of the fifth lumbar
vertebra in relation to the sacrum are here recorded. In three treatment
by extension was sufficient to effect partial or complete recovery. In
the remaining two cases he performed Hibb’s bone-grafting operation,
securing the last lumbar vertebra to the sacrum by bony union. Complete
restoration to health was achieved in both cases. Referring to the litera-
ture of spondylolisthesis, the author notes that as early as 1890 Neuge-
bauer was able to collect 101 cases, only 47 of which were correctly diag-
hosed during the patient’s life. Hitherto this condition has been much
neglected, and while obstetricians have long been familiar with it as a
cause of obstructed labor, surgeons have not paid it the attention it de-
serves. Yet by the aid of a bone-grafting operation, such as Hibb’s or
Albee’s, the distressing pain and general invalidism of this condition,
which is often due to a sudden strain or fall, may be completely banished.
Levick, G. Murray. ELrectricAL TREATMENT OF INFANTILE PARALYSIS.-
[The Journal of Bone and Joint Survey, April, 1923.]
Dr. Levick contends that the most important factor in the electrical
treatment of muscles affected by anterior poliomyelitis has escaped notice.
This factor is the preservation of contractility in the muscles. If ade-
quate electrical treatment is not given, the atrophy of the muscles is
greater and is usually accompanied by loss of contractibility of some
degree. The author contends that his observations are supported by the
accepted theory of muscle contraction which has been put forward by
Shaffer. When a muscle contracts, the clear contractile substance passes
into the tubes of the sarcous element which are elastic and are dilated by
200 CURRENT LITERATURE
its entry. As long as a muscle remains in a state of complete relaxation,
the tubes remain constantly contracted. It appears to the author that
the atrophy following paralysis, besides causing absorption of the con-
tractile substance, is accompanied by a loss of elasticity of the sarcous
element and the tubes can no longer dilate to a proper extent for the
contraction of the muscle. The author admits, however, that relaxation
of the paralyzed muscle is far more important even than electrical treat-
ment. Directions for giving adequate electrical treatment are supplied
and the author illustrates these by reference to patients whom he has
treated.
Kohlbry, C. O. Birth HEMORRHAGE INTO SPINAL Corp. [Am. Jl. of
Dis. of .Ghildren, Sept, 1923.)
In this breech presentation case hemorrhage took place into the cervical
cord. There were no other evidences of hemorrhage. The phrenic nerves
functioned. The child showed the typical picture of cervical cord injury.
The breathing was entirely diaphragmatic, there being paralysis of the
thoracic and abdominal muscles. The legs were paralyzed. As a result
of bladder paralysis with back pressure, the child developed double hydro-
ureters and hydronephrosis. Infection of bladder and kidneys resulted.
Necropsy revealed a complete degeneration of the cord in the lower
cervical region.
Caprioli. “HE SuRGICAL TREATMENT OF INFANTILE ParRA.ysis. [La Ped.
ADIL ete oe
Caprioli says the aim of treatment in postparalytic equinovarus is
(1) to reestablish the equilibrium of the antagonistic muscles, and
(2) to bring the foot back into the best possible position. Whereas
many surgeons prefer to straighten the deformity first and then deal
with the muscles by transplantation of tendon, or otherwise, the author
says that he gets better results by first treating the muscles and tendons,
and then, three or four weeks later, he proceeds to forcible straightening.
This is done in four stages: (1) Dorsiflexion of the foot, (2) external
rotation with the os calcis fixed, (3) forcible pronation, and (4) straight-
ening of the plantar arch. Photographs are given of the various
manceuvres, and details of 8 cases so treated are added, with bibliography
of 36 references to recent literature on the subject.
Etienne, G. SrEROTHERAPY IN AcuTE Myeritis. [Bul. d. l’Ac. d. Med.,
July 24, 1923.0 JcAe Mea]
Etienne reports extremely favorable results from the poliomyelitis
antiserum prepared at the Paris Institute Pasteur, and administered in
eight cases. Myelitis in adults seems to be prevailing in epidemic form,
and in his two fulminatingly acute cases the serotherapy arrested the
disease and the symptoms began to subside the next day. In the less
acute cases the diagnosis was not made so promptly, and treatment was
SENSORI-MOTOR NEUROLOGY 201
not begun till the fourth day or later. The effect was good, but slower
in becoming manifest. The interval in three cases was 18 days, 2 months,
or 11 weeks after the onset, but the benefit was unmistakable, although
not apparent for 6 or 7 days. He gives the details of a number of other
cases in which no serotherapy had been given. They all ran a very
severe course, testifying to the gravity of the disease in the present
epidemic. In one woman the myelitis had been ascribed to syphilis and
treated accordingly, and she now has complete paraplegia.
Regan, J. C., Litvak, A., and Regan, C. Tur CoLttoipaAL GoLtp REACTION
IN ACUTE PoLioMyeEtitis. [Am. J. Dis. Child, XXV, 76-84. Med.
Se.]
The writers studied the cerebrospinal fluid in 42 cases of acute polio-
myelitis at the Kingston Avenue Hospital, New York, by the colloidal
gold test, 132 spinal fluids being thus examined at intervals from the
fourth to the eighty-fourth day of disease. The results were as follows:
in no instance was a normal reaction obtained in any poliomyelitic fluid
taken during the first three weeks, which corresponded to the very acute
period of the disease. The reduction was constantly in the zone of low
dilutions or so-called syphilitic zone. In 88 per cent of the fluids examined
the reaction occurred in the first six dilutions between 1: 100 to 1: 320.
In 14 spinal fluids from patients, who showed more or less marked
polyneuritic or meningeal symptoms or pronounced paralysis, the reaction
extended to the seventh dilution (1:640). The average curve was
highest in the first and second weeks and then gradually declined, reaching
an almost normal level by the eighth week. Cases with an early sub-
sidence of the positive reaction from the third to the seventh week were
with types of the disease in which polyneuritis, if any had been present
at all on admissions, rapidly disappeared; convalescence occurred early
and complete recovery took place. On the other hand, in the more severe
cases with extensive paralysis the curve remained high till the eighth week
or later. The type of reduction in the spinal fluids of the fatal cases
closely resembled that found in the nonfatal cases, so that the reaction
did not possess any prognostic value. As regards a relationship between
the cytology and chemistry of the spinal fluid and the gold colloid reaction
it was found that the amount of globulin bore no relation to the height of
the colloidal gold curve. A high curve was often associated with a low
or absent globulin reaction, or vice versa, a high globulin reaction was
found with a low curve. Nor was there any definite relation between
the height of the gold chloride curve and the number of cells per cubic
millimeter in the spinal fluid, the gold curve remaining high for several
weeks after the cell count was normal. The subsidence of the colloidal
gold reaction was usually associated with improvements in the general
condition, the paralysis, meningeal symptoms, and polyneuritis. In con-
junction with the history, symptoms, and other laboratory data the colloida!
202 CURKENT *LITERALURE
gold reaction may be of diagnostic value, especially as it is far more
constant and persistent than either the cell or globulin increase.
Williams, Tom A. A GrowtH WITHIN THE SPINAL CANAL Com-
PRESSING THE Corp AND Roots LocALIzED: OPERATION: RECOVERY.
[W. Va. Med. Jl., 1923.]
A woman of thirty-nine had a progressive loss of power in the legs with
gradually increasing severe pains for three months. Pain in the back,
and tingling as high as the lower abdomen was also present. A uterine
cancer(?) had been removed by radium three months previous to this.
The same surgeon had reopened the abdomen in November because of
the intensity of pain, after finding nothing abnormal with the X-rays,
but nothing pathological was found. Patient was wasted, moved the
left leg with difficulty and the foot not at all. There was marked atrophy
of the left calf, and the lower part of the left thigh. The left toes could
be flexed but dorsiflexion was almost absent. Reflexes of the left leg
were feeble, and on the right the patellar reflex was much exaggerated,
and there was ankle clonus, although the toes flexed on stroking the sole.
Abdominal reflexes were overactive. Some indefinite hyperesthesia in
the left groin. The diagnosis made was an extramedullary neoplasm
implicating the third, fourth and fifth lumbar roots on the left, and
compressing the spinal cord at a level as high as the third lumbar segment.
In view of the history, this was of course believed to be a metastasis
from the uterus. Operation was performed and revealed the dura mater
bound down by a mass the size of a large bean at the level of the third
lumbar segment. Neither roots nor cord were infiltrated and no xantho-
chromia appeared in the spinal fluid below.
The growth proved to be a hemorrhagic pachymeningitis. In part of
the first lumbar vertebra, which appeared soft to the surgeon, no abnor-
mality was found. Sections from the small discolored piece of tissue show
chronic inflammatory reaction with some hemorrhage and necrosis. Care-
ful search fails to reveal any evidence of a primary or metastatic malig-
nant condition. No evidence of any infectious agent could be demonstrated
in the tissues. Recovery is still progressing. [Author’s abstract. ]
Beériel, Branche, J., Devic, A., Viret and Wertheimer, P. INTRASPINAL
~ Tomors., [Lyon, Chir cA prill923. 9 J Avie At
Bériel and Viret discuss, with illustrations, two cases of polyneuromas
which show that the nervous tumor spread exclusively by nerve tissue,
and lingered for years in the spinal roots before entering the spine.
When it invaded the spine, it affected only the intradural tissue in the
free space between the bifurcation of the two roots, and could easily
have been shelled out. The mother tumor in the root could have been
excised, and thus have forestalled the invasion of the spine. Neuromatous
bunches in the neck had been noted for 13 years in one of these cases.
In the other, the right arm had been weak since childhood.
SYMBOLIC NEUROLOGY ~* 203
Bériel and Wertheimer explain that mestastasis in the spine of cancers
or hydatid cysts in viscera, bones, etc., is almost invariably extradural.
One woman, fifty-four, with paraplegia after a year of vague motor symp-
toms, recovered after the removal of an extradural tumor in the dorsal
spine; it proved to be thyroid tissue. When the metastasis induces
pachymeningitis, operative measures are generally contraindicated, but
under other conditions they should be considered. The intraspinal
metastasis may be long in developing; in one woman, aged 46, there was
a destructive process in vertebrae from metastasis after mammectomy
for cancer, but the paralysis was the work of a circumscribed extradural
nodule.
COMPLICATIONS OF INTRASPINAL ‘TUMoRS.—Besides the symptoms
from compression, Devic and Wertheimer analyze the anatomic com-
plications in cord, meninges of vertebrae, and multiple tumors. In Claude’s
case there was paraplegia at seventeen, then fatal recurrence after a remis-
sion for five years. Necropsy revealed six intraspinal sarcomas.
Flexner, M. Durat EpiITHELIOMA. [Ky. Med. Jl., July, 1923.]
Clinical history and autopsy findings of a man of fifty-seven. He had
a low blood pressure, glycosuria, and difficulty in walking with loss of
power in the legs. Wassermann + inc.s.f. Neoarsphenamin was given.
In about five weeks the patient died, with evidence of cerebral involve-
ment three days before death. The course was atypical for a brain tumor,
but it proved to be a case of dural endothelioma.
III. SYMBOLIC NEUROLOGY.
3. PSYCHOSES.
Mott, F. W. and Hutton, I. HE. Brtoop Pressure IN DEMENTIA PRECOX.
Nese Meds hy Jul 21923) AM. AL]
In their blood pressure studies in 143 cases Mott and Hutton found
that in 10 of the cases of katatonic dementia precox, and in 4 of the
27 cases of hebephrenic dementia precox the blood pressure was under
100; whereas in 12 cases of epilepsy, in 15 cases of general paralysis,
and in 9 of the 10 cases of congenital imbecility there was not a single
case in which the blood pressure was under 100; moreover, in 5.of the
10 cases of katatonia, and 2 of the 4 cases of hebephrenia, the blood
pressure was very low, under 90. In not one of the cases of general
paralysis was it under 120. The Goetsch test was made in fifty dementia
precox cases. Two cases only gave a normal reaction; these had a
systolic blood pressure of 122 and 128, respectively. One was a katatonic
and the other a simple dementia precox case with congenital defect.
Eighteen cases gave a moderate reaction; in 13 of these the blood pres-
sure was 120 or under (minimum 104); in 5 it was over 120 (maximum
130). Thirty cases reacted only faintly; in 25 the blood pressure was
204 CURRENT LITERATURE
120 or under (minimum 98); in 5 it was over 120 (maximum 136).
The test was repeated in cases with a high blood pressure which gave a
faint reaction, and the same result was obtained. In several cases it
was found that a faint reaction might be intensified by administration
of thyroid extract, but without material alteration in the blood pressure.
Zierl. Brain TUBERCULOSIS IN Mentat Diseases. [Beit. z. patho.
Anal? VolsAlerlextise|
Tuberculous lesions of the brain were noticed in five out of 370
patients suffering from mental diseases who died of lung tuberculosis.
In one of the five cases there was a tubreculous hemorrhagic encephalitis
secondary to a miliary tuberculosis; in the other four one or more solitary
tubercles were observed. In four cases the clinical picture of the mental
disease was unaffected by the brain tuberculosis; only in one case
symptoms of brain tumor became associated with the catatonic condition
of the patient. In general the existence of a solitary tubercle of the
brain should be suspected when in a catatonic patient with lung tuber-
culosis, epilpetic fits, vomiting, and other symptoms of brain tumor
make their appearance. [C. Da Fano.]
Lewis, Nolan D. C. KipNEY MALFORMATIONS IN THE MENTALLY DiIs-
ORDERED WITH A REPORT OF A CASE OF CONGENITAL Cystic KIDNEYS
AND Liver. ={ Amer: Jr. Psych. Volo lie ih, | uly
Congenital malformations in general such as developmental peculiari-
ties of skull, ears, teeth, etc., are universally conceded to be common
among the mentally disordered. However, malformations of the kidneys
have been very infrequently reported from psychopathic hospitals and
since these organs belong to one of the most important eliminative sys-
tems of the organism, it was thought worth while to direct the attention
of pathologists and psychiatrists to some of the interesting findings in
this field.
This account deals with the pronounced kidney malformation dis-
covered among four thousand four hundred and fifty autopsies on the
mentally disordered and examples with numerous illustrations are given
of fetal lobulated kidneys, multiple ureters, pelvic kidneys, solitary
kidneys, horseshoe kidneys, aplastic kidneys, single kidneys and types
of congenital cystic kidneys. Since these autopsies had been performed
by several pathologists, the interests of whom were varied, undoubtedly
many cases of congenital kidney malformations, particularly those with
less prominent defects such as fetal lobulations, multiple ureters, vessel
anomalies, etc., were overlooked or escaped mention; therefore a statistical
presentation was impossible. After examining the few available statistical
accounts from general hospital material, the impression was gained by
the author that there is a notably higher percentage of these abnormalities
among the insane. .
In addition to general considerations one case of psychosis asso-
SYMBOLIC NEUROLOGY 205
ciated with tabes dorsalis and bilateral congenital cystic kidneys and
liver was reported in full with microscopic findings, thus adding to the
literature another case of this rare combination in which the bile capil-
laries of the liver share with the tubules of the kidneys in a congenital
cystic dilatation of massive dimensions. This man had lived sixty-one
years with his abnormality which according to the history had not
seriously interfered with his mental and physical health, thus. escaping
for a long period of time the ever present danger of uremic develop-
ments, as the functioning kidney tissue is impaired developmentally by
pressure and also by secondary irritative and sclerotic changes.
Emphasis was laid upon the possibility of gaining valuable informa-
tion on the behavior of the human organism as a whole by a thorough
analytic survey of the individual’s mental and physical functions when
the diagnosis of congenital abnormalities or arrests in development of
such fundamental organs as the kidneys and liver can be established dur-
ing life. A series of correlative studies of mental dynamics associated
with arrests in the physical development of organs should be of con-
siderable interest, and it is hoped that this paper will initiate such
investigations. (Author’s abstract. )
Greene, Ransom A. DEMENTIA PRECOX AND SyYPHILiIs. [Amer. Jr.
Psych Vol. 1, No: 3, January. |
In 2,117 admissions, 495 of which were dementia precox, there were
12 cases of dementia precox with positive Wassermanns and negative
spinal fluid. (Menninger.)
Ludlum, Seymour Dewitt. PuysioLocic CoNpiITIoNS UNpER WHICH
INSANITY Occurs. [Am. Arch. Neur. and Psych., Vol. XI, March. ]
The argument is that there can be observed in the separate parts
of the involuntary nervous system variations that show a physiologic
pattern corresponding to the type of mental disorder, and causative
factors can be sought, having in mind those portions of the involuntary
nervous system that are changed in tone, using observations of smooth
muscle function as the index. Following Gaskell, there are three out-
flows of involuntary nervous elements, with motor and inhibitory func-
tions controlling all the smooth muscles of the body. They are: (1)
thoracicolumbar (sympathetic); (2) midbrain (third nerve); (3) bul-
bosacral (vagus system, vagus nerve and pelvic nerve). The integrative
action can be observed in numerous ways. In 100° cases we used the
three physiologic symptoms that are easy to demonstrate, one for each
outflow: (1) blood pressure variation (sympathetic); (2) pupillary
variation (third nerve and cervical sympathetic); (3) peristalsis, by
roentgen-ray pictures of the intestines (tenth nerve and pelvic vagus).
This gives physiologic information from all three outflows of the involun-
tary nervous system. More symptoms with this innervation can be
correlated such as red hands, sweaty skin, etc.
206 CURKENT LITERATURE
The neuromuscular mechanism of the bowels should be correlated
with the blood pressures, also the pupillary conditions, examination
of the urine, and of the stool. The determining cause may be any type
of irritant, such as bacterial or metabolic disturbances, sufficient to upset
the physiologic equilibrium of the vagus or sympathetic nervous system.
The vast majority of the cases are primarily somatic, the mental symp-
toms obscuring the origin of the somatic lesion. (Author’s abstract.)
Frets, G. P., and Overbosch, J. F. A. Earty JUVENILE FAMILIAL
Amaurotic Iprocy. [Nederl. Tijdschrift voor Geneeskunde, LX VII,
Sept. 15, p. 1091.]
The writers record a case of the early juvenile form of familial
amaurotic idiocy. The family consisted of five brothers and one sister.
Three brothers were affected with this disease: it began at the third.
year of life, and the children died at the ages of five, five and a half, and
six years. There was an hereditary taint, and possibly the three affected
children were of less good intellectual constitution than the nonaffected
ones. Clinically. the disease was manifested by epileptiform attacks,
dementia, muscular weakness, blindness, and a progressive course: in
one there was atrophia retine pigmentosa. Anatomically, there was a
general swelling of the cell body of the cortical nerve cells: there was
also degeneration of the nucleus and of the fibrillz, a fibril degeneration
allied to that of Alzheimer. The retinal neuroepithelium had disappeared.
There were great changes in the cerebellum: the granule cells are absent,
and the molecular layer is too small: there is increase of the glia fibers.
The Purkinje cells show swelling of their cell-body and also swellings
of their dendrites and occasionally also of their axons. ‘The case here
described corresponds to the type described by Spielmeyer-Vogt. [Leon-
ard J. Kidd, London, England. |
Morse, M. E. THe DucTLess GLANDS IN DEMENTIA Precox. [Jl. of
Neur. and Psychopath., Vol. 3, May.]
M. E. Morse has studied the pathological anatomy of the gonads,
pituitary, thyreoid and adrenals in twelve male and fifteen female
patients with dementia precox who died under forty-five years of age.
From the pathological side there is very little evidence of a primary
atrophy of the gonads in dementia precox, with the possible exception
when the disease develops on a basis of mental defect. The fibrosis
which is sometimes found in the sex glands, is not an isolated change,
but is frequently present also in the hypophysis and occasionally in
the thyreoid. The atrophy, when present, can be accounted for by the
somatic diseases from which the patient suffered. This explanation is
not only simpler and less hypothetical than that of a primary atrophy,
but it is more in accord with the facts, if they are critically studied. It
agrees also with recent experimental and pathological work on the
SYMBOLIC NEUROLOGY 207
ductless glands, particularly the gonads. The condition of the endo-
crines in dementia precox requires more study, but the authors state
that there is no one uniform condition of the gonads or other endocrines
dependent on the disease process. The main factors which determine
the condition of the glands at autopsy, are the nature and duration of the
terminal disease, the state of the nutrition and possibly in some cases
an underlying defect of development which is expressed in feebleminded-
ness or the hypoplastic constitution.
Uyematsu, Shichi. Tue PLaterer Count AND BLEEDING TIME IN
Catatonic DEMENTIA Precox. [Amer. Jr. of Psych., Vol. I, No. 1,
July.]
The author carefully reviews literature in regard to variations in
platelet count and bleeding time, tending to show that these are closely
related and vary inversely. Fifty normal individuals were selected
and average platelet counts and bleeding time determined. The results
were 296,000 platelets per c.c. and 5.2 seconds bleeding time. Forty-five
cases of catatonic dementia precox were then studied carefully and the
average platelet count was found to be 573,000 and the average bleeding
time 3.3 seconds. This the author points out is comparable to the
results found in hypothyroidism which is then discussed together with
some pertinent literature. [ Menninger. ]
Halbertsma, T. MoncoLtism IN ONE oF TWINS AND THE ETIOLOGY OF
Monecorism. [Am. Jl. Dis. Children, XXV, 350.]
A study of the literature of mongolism reveals that almost nothing
is known about the causation. Several authors have regarded the affec-
tion as dependent upon diseases of the mother, or as acquired during
pregnancy through the operation of other influences injurious to the
embryo. Halbertsma describes five cases of mongolism in one of twins,
and says that if the condition of the mother during pregnancy were
related to the etiology, one should always expect the identical pathologic
condition in both twins. Hence an acquired origin of mongolism is
declined and the author shows that in all probability mongolism is
germinal of origin; he therefore draws the attention on the type of
twin birth (one egg or two egg). If mongolism were not germinal
of origin, then the occurrence of mongolism in one of twins would
be a surprise; a review of the literature revealed fifteen such cases
(author’s case included), and only two cases of mongolism in both twins.
If, however, mongolism is due to defects inherent to the germ plasm,
then the occurrence of mongolism in one of twins is comprehensible,
but it will only be possible in a two-egg pregnancy. In accordance
with this theory the author was able to show, that in all cases from
the literature the two-egg pregnancy was evident (no,data about two
cases).
208 CURRENT LITERATURE
If we now consider the cases of mongolism in both twins, the
germinal theory makes the birth of these twins possible only in case
of one-egg pregnancy. Although a two-egg pregnancy in these cases
is imaginable, as the result of the coincidence of two separate eggs both
doomed to mongolism, this will occur very seldom, as mongolism in
more than one child of the same mother is almost never reported. In this
connection, it was interesting that in the only two cases reported the
twins were of the same sex. Cases of twin mongols of different sex
do not exist. (Author’s abstract.)
Heveroch, A. Narcouepsy. [Cas. lek. ceskych., Oct. 11, 1924. J. A.
M. A.]
Heveroch’s patient becomes quite sleepy every day at certain hours.
He does not lose consciousness, but is unable to move. Laughing im-
mediately produces a weakness of the lower extremities. The author
localizes the disturbance in the grey matter of the third ventricle.
Psychologically there is a faulty connection between the psychic per-
sonality and the static motor functions.
O’Brien, J. F. Epirepsy anp Hysterta. [Boston Med. & Surg. Jl.,
January 15, 1925.]
In this presentation a rapid survey is offered of 100 cases, in which
many exciting factors are found to take part in producing convulsive
seizures and unconscious states. Fright and craniocerebral trauma in ~
his statistics were predominant, exciting causes, but many convulsions
were related in some way to infection in persons who were constitutionally
defective. He says that phenobarbital and bromids render patients less
convulsive and hence more hopeful, and in a small number of cases
apparent recovery has followed.
Juarros, C. ErroLtocy oF Epitepsy. [Siglo Médico, July 26, 1924. ]
A fairly complete historical résumé of the various hypotheses put
forth with reference to the epilepsies in which 262 publications of the
last decade are analyzed. Sifting them all merely confirms that almost
any cause is liable to induce convulsions, but for the convulsions to be_
epilepsy, there must be some constitutional mental predisposition, and
this he ascribes to some developmental defect in the brain.
Schou, H. I., and Stubbe, H. P. Fastinc 1n TREATMENT OF EPILEPSY.
[Hospitalstidende, January 22, 1925. J. A. M. A.]
Two to six days of fasting on the part of Schou and Teglbjerg’s
thirteen patients with genuine epilepsy, mostly severe, resulted in a com-
plete temporary suspension of the seizures, fewer attacks of petit mal,
and consistent mental improvement. In several cases the effect of the fast
SYMBOLIC NEUROLOGY 209
persisted for some time. The ammonia regulation of the acid-alkali
balance in six of these patients during the fast showed a marked rise in
the regulation curve with wide variations. This quickly ceased when
food was given. Large amounts of ammonia were excreted during the
fasting period. Charts and the data of each case are included.
Belloni, G. B. Traumatic Epitepsy. [Riv. d. pat. nerv. e. ment.,
A OVI Io]
The patient had received a penetrating wound of the right temporal
region of the skull when three years old and had contracted syphilis at
the age of thirty. Thirty-one years after having been wounded and four
years atter the syphilitic infection, he had a fit of Jacksonian epilepsy.
From that moment the epileptic attacks became frequent and later were
associated with symptoms of G. P. I. The patient died in status epilepticus
a few years afterwards. The macro- and microscopical examination of
his brain revealed the presence of mild, though characteristic, lesions
of G. P. I., and of an old scar with considerable destruction of the
nervous tissue in the inferior portions of the right frontal and parietal
ascending convolutions. According to the author this lesion was the
cause of the epileptic fits, which, however, might never have appeared
if the patient had not contracted syphilis. [C. Da Fano. ]
Felsen, Joseph. LaAsorAtory STUDIES IN EpiLtepsy. 1. FRACTIONAL
Gastric ANA.tysis. [Arch. Int. Med., Vol. 34, August. |
Complete absence of free hydrochloric acid in the fasting and sub-
sequent specimens obtained over a period of two hours was found in
15 per cent of a series of 53 cases of epilepsy. Of the so-called “ non-
epileptic ”
of free acid, and further investigation made it seem quite probable that
control group (37 cases), 19 per cent showed complete absence
all of these patients were epileptic. The absence of free acid in one
patient closely observed for more than one year, seemed to be associated
with rapid deterioration. In one patient, the absence of free acid did not
seem to be associated with the onset of an epileptiform attack. Defects
in the central nervous control of gastric secretion are more likely than
local lesions if one is to consider our findings of significance in epilepsy.
A replacement gliosis may follow small hemorrhages occurring in the
spinal cord during an epileptiform attack. Several authors have reported
an absence of free hydrochloric acid in the fractional gastric specimens
of cases suffering from combined spinal sclerosis. If true epilepsy
should really be due to sclerotic changes in the spinal cord I am of the
opinion that the lesions would in all probability be found in the lateral
horns of the gray matter in or above the thoracic region of the spinal
cord. [Author’s abstract. ]
210 CURRENT LITERATURE
IV. SOCIAL. NEUROLOGY, RELIGIOUS PSYCHOLOGY,
MEDICO-LEGAL, ETC.
3. MEDICO-LEGAL.
Burt, Cyril:.. Juvenite Crimes. [Br}-Jl. Med. Psych, Vola ii Rie
Dele
These notes represent observations gathered (a) as expert for magis-
trates, school officers, and other organized groups coming in contact with
juvenile delinquents; (b) material gathered in an educational survey, and
(c) single cases specially met with, The author summarizes his general
paper as follows: 1. Nearly 200 cases of juvenile delinquency, and, as a
control series, 400 normal cases, have been individually investigated in
parallel inquiries; and the various adverse conditions discoverable in
their family history, in their social environment, and in their physical,
intellectual, and temperamental status, have been ascertained and tabulated
for each group. 2. The tables show a lengthy list of contributory causes.
Delinquency in the young seems assignable generally to a wide variety,
and usually to a plurality, of converging factors, so that the juvenile
criminal is far from constituting a homogeneous psychological class.
3. To attribute crime in general to either a predominantly hereditary or a
predominantly environmental origin appears impossible; in one individual
the former type of factor may be paramount; in another, the latter;
while with a large assortment of cases both seem, on an average and in
the long run, to be of almost equal weight. 4. Heredity appears to
operate, not directly through the transmission of a criminal disposition as
such, but rather indirectly, through such congenital conditions as dullness,
deficiency, temperamental instability, or the excessive development of some
single primitive instinct. 5. Of environmental factors those centering in
the moral character of the delinquent’s home and, most of all, in his
personal relations with his parents, are of the greatest influence. 6. Psy-
chological factors, whether due to heredity or to environment, are supreme
both in number and strength over all the rest. Emotional conditions are
more significant than intellectual, while psychoanalytic complexes provide
everywhere a ready mechanism for the direction of averpowering instincts
and of repressed emotionality into open acts of crime.
Wittermann, E. Criminat Psycnopatus. [Mutinch. med. Woch., Oct.
3, 1924; J. A. M. A.]
Wittermann declares only 17.5 per cent of his criminal cases as
insane, while his predecessors had so declared in 76 to 62 per cent. He
also believes that a too rich inner life of the expert is a source of danger,
because he tunes himself in too easily with the psychic condition of the
delinquent. Only results are important, and the inhuman treatment of
war hysteria had excellent effects. It also has thrown light on the nature
of hysteria.
SORIAL NEUROLOGY, RELIGIOUGeES YCHOLOGY, ETC. 211
Rogers, L. Atconot 1n Tropics. [Practitioner, October, 1924. ]
The use of alcohol in the tropics is to be condemned, this paper
‘states, also that the health of white people in the tropics would be mate-
tially benefited if they would abstain from the use of alcoholic drinks.
Stevenson, T. H.C. Morrarity or Arconorism. [Practitioner, October,
1924. | :
This paper would show that in England and Wales during the four
years of compulsory temperance, from 1914 to 1918, there was a decline
of 84 per cent in convictions for drunkenness, and a decline of 88 per cent
in the mortality ascribed to alcoholism.
Powell, R.D. AtcoHoL in RELATION To Lire INSURANCE. [ Practitioner,
October 1924; J. A. M. A.]
One of the liabilities which in Powell’s opinion may account for the
greater safety of life for a total abstainer from alcohol is that an amount
of the drug far short of intoxication may inhibit restraint of elemental
passions and lead to indiscretion often resulting in venereal disease.
Mott, F. W. AxtcoHoL IN RELATION To INSANITY. [Practitioner, Octo-
ber, 1024. |. 940 M7 A4]
Mott’s paper is based largely on investigations previously reported on
by himself and others. He says: If alcohol is the essential factor in the
production of insanity, there will be certain specific indications pointing
to the more or less specific action of the alcohol. Even in the absence
-of a history of alcoholic indulgence, the physical signs and symptoms
which point to alcoholism and the cause of the symptoms are much more
valuable than any statement made by the patient or even by the friends or
‘nurse. The more definite the signs and symptoms of neuritis, associated
with mental symptoms, the more certain can we be that the cause is
removable, and the more hopeful is the prognosis. These signs and
symptoms of alcohol as the cause per se associated usually with microbial
toxemia, are found most pronounced in the two conditions of mental and
‘nervous disorder which occur in hospital practice, viz., delirium tremens
and polyneuritic psychosis.
Deutsch, Helene. On Patuotocicat Lyine. [Int. Zeit. f. Psa., VIII,
BY Gia Z|
Psychoanalytic explanations for pseudologia phantastica are sought by
the author. She defines lies of this form as daydreams told to others
as reality. All that which is found in the content of the daydream,
voluptuous wishes of ambitious or erotic character, is the stuff patho-
logical lies are made of. There is one moment, however, which distin-
guishes them from daydreams; daydreams are assiduously concealed as
something to be ashamed of, while there is an intense urge to communi-
cate pathological lies to others. It is as though there were a plus of
212 CURRENT LITERATOGKE
psychic tension which is relieved by communication. Pseudologica phan-
tastica is compared with poetic creation: the close connection of poetic
creation with the daydream has been explained by Freud; the purpose
of both is to supply what reality fails to give; both are fulfillments of
wishes whose origin is in the unconscious. The author finds that, like
pathological lies, poetic creations differ from daydreams, in that at their
root is the urge for expression. Besides, the element of aesthetic enjoy-
ment as a mode of adjustment is present only in poetic creation.
From the analysis of a young girl in whom the symptom of pseudo-
logia presented itself at puberty, Dr. Deutsch arrived at the conclusion
the phenomenon represents the attempt to divert the phantasy life into
channels of reality. The patient related that between her thirteenth and
seventeenth years she had lived out a remarkable love romance. The hero
was a young man with whom she imagined she arranged rendezvous; she
passed hours in weeping at his imagined cruelty; kept a detailed diary
of imaginary incidents which she persuaded herself were real. ‘The
author analyzes this behavior as arising from the patient’s infantile
fixation on a brother. At adolescence the patient changed her love object
in keeping with the repressed brother image (she steadfastly refused to
meet the hero of her remarkable phantasy). It may be said the object was
a condensation of the repressed and real object, her hero in the actual
world being responsible for the circumstance that she lived her phantasy
as real. The pseudological content is a direct derivative of the repressed
element which has been mobilized by the newly arising sexual require-
ments and which has assumed a form acceptable to the censor.
Deutsch gives an explanation of this temporary pseudologia of
puberty, which she believes is justified by empirical material: The experi-
ences of the infantile sexual life are discarded because of their incom-
patibility for the new demands of reality, but there still remains a pressure
to continue the old forms of adaptation in the form of new experiences.
Pseudologia will make its appearance in those situations in which the
adolescent individual experiences energetic and real urges to become free
of the earlier conditions; the memory traces of past experiences are
revived but are now associated with the transference tendencies which
have become strong. The wish phantasies thus acquire the character
of real experiences. A _ biologically useful function may perhaps be
ascribed to pseudologia; this office is to gradually free the adolescent from
the burden of remembrances. Our organism is ceaselessly engaged in the
effort to free itself from tension, to bring about an “ abreaction”’ in some
way; pseudologia then represents the completion of a psychic process,
that is to say the reliving of the reminiscences to relieve the psychic
tension—a catharsis it might be called with greater propriety.
The author compares the mechanism of pseudologia to that of hysteria.
In both there is return to an infantile experience and the fulfillment of
a forbidden wish and in both there is unsuccessful repression. The
Pou NEUROLOGY, RELIGIOUS oY CHOLOGGY, EYC. -213
repressed wish, in conversion hysteria, takes the form of somatic symp-
toms, while the affect disappears; the repressed wish, in anxiety hysteria,
is displaced and the affect is converted into anxiety; the repressed ma-
terial returns, in pseudologia, but is attached to a new object not rejected
by the censor and the original affect thus secures gratification. It repre-
sents a middle stage between psychic health and a neurosis and indicates
a vacillation in making the decision between an escape to reality or to a
neurosis. While not all cases of pseudologia are pathological, strictly
speaking, yet where there is gross and constant pseudologia, continuing
throughout life, it may be assumed that there has been an unsuccessful
attempt at adjustment and that a neurosis has stabilized itself in this
form. The swindler probably belongs to this picture. There seem to
be far-reaching analogies between pseudologia and myth formations, as
Rank has noted in his “ Myth of the Birth of the Hero.” *
Newsholme, A. Socrat Aspects oF ALCOHOL PRoBLEM. [Practitioner,
Octin 1924. S] A-sM: As
Newsholme concludes his paper as follows: If medical and hygienic
advice were adopted by every member of the community, compulsory
action would not be called for, but this ideal is not attainable in an
average population. Even in present conditions so-called restrictive
measures imply no serious restriction for the majority of the community,
but only for those who are injuring themselves, their families and the
nation, in the absence of such compulsion. It is only by increased com-
pulsion in the form of restriction on the sale of alcoholic drinks, backed
by the hygienic persuasion of physicians and others, that we can secure
reduction more rapidly than at present of the alcoholism which is still
a chief cause of crime, disease, destitution and neglect and impoverish-
ment of families in our midst.
Park, 8. TREATMENT OF INEBRIETY AND DruG Hasits. [Lancet, Sept.
6, 1924. ]
In this paper the McBride method is favorably reported upon. It is
a method of the combined use of atropin and strychnin, not as a cure but
only a help. Given by the mouth, frequently, in small doses, he found
the following extremely useful: nux vomica, cinchona, kola, damiana
and gentian. Nux vomica by the mouth often gives better results than
strychnin hypodermically. With regard to general treatment, ambulatory
treatment nearly always fails and institutional treatment is essential. In
treating this class of case it is not only a question of what drugs to use,
but how to use them, and there is no doubt that the successful treatment
of inebriety depends a good deal on the experience of the physicians and
the technic employed. ‘
* Translated in Nervous and Mental Monograph Series No. 18.
BOOK REVIEWS
Hamilton, G. V. An INTRODUCTION TO OBJECTIVE PsycHo-
PATHOLOGY. [C. V. Mosby, St. Louis, Mo.]
It is a long time since we have read so big a book and found so
little in it except words.
The book cover tells us that the book is meant to “ reflect the
importance of effecting psychopathological studies by scientifically
formulated methods of research as an essential supplement to the
always useful but never quite trustworthy methods of field and
clinical observation.” This reminds us, as does the book proper, of
the desk worker’s approach to practical problems, he tells you what
he thinks they ought to be instead of observing what they are.
We are inclined to the suspicion that the author is a doctrinnaire;
he is evidently not a psychiatrist in the sense of one acquainted with
current or past psychiatric experience. Far from sharing Dr. Yerkes’
enthusiasms as to the author’s commanding place in psychopathology,
as evidenced in a very gushing Introduction, from the evidence set
forth in this book we would be inclined to call him a fourth rater
who deals out a lot of hokum.
Thus his case histories are for the most part a joke. They are
glibly worded but as for so-called objective findings there is nothing—
everything is put in terms of “conclusions ’—judgments, impres-
sions—and such meaningless phrases as “ Indirect responsiveness to
inhibited urges ’—much as an internist might say that a patient’s
“gastric pain’ was due to his “stomach’s failure to adapt itself to
its environmental contents ’’—corn bootleg for instance. ‘ Mal-
adaptive habits of response to personal problems or difficulties,”
this is another wise crack. The book is full of this pompous kind of
nothingness. Case 200 is a scream. “ Female—Fifth Decade.” All
of the patients are designated in “ decades ’’—we are not told their
actual age—so whether this blushing damsel was just entering fifty
or about to pass sixty we are unaware. She is diagnosed as
“malingering.” This spicy bit of Sherlock Holmesians acumen is
offered us (p. 198). “A silly woman who sought to start an intrigue
by feigning a most unconvincing collection of nervous symptoms.
She was charged a stiff fee and treated with much formality—and
never: returned to my office.” Prunes and prisms! ‘This is a worthy
gem for Professor Mencken’s Americana. Can we not see this
‘Adonis ” spotting this poor old lady in one interview in her attempt
to seduce him. As we gather from the dedication the author is
married—what naughty women there are in Santa Barbara or in
the Mississippi valley town in which two places these “surveys ”’
were made.
[214]
BOOK REVIEWS 215
The more one reads the more irritating the false statements
become, every page contains some obvious nonsense.
In the first place, in any large polyclinic service in New York
City—such as at the Mt. Sinai, Neurological Institute, Post Graduate
or Vanderbilt Clinic, nearly 200 cases of the types envisaged in this
book can be seen in a week or at most ten days. Much better case
records are obtainable in these clinics than any presented in this
book. They may not contain so much language but they will be
more “objective.” From this comparatively insignificant material
almost farcically investigated we learn among other things that “ the
3d, 4th, 5th, and 6th decades represent the periods in which nervous
disorders are especially apt to develop”—why omit the prevalent
disorders of childhood and adolescence—and as for senescence we
are blithely told (p. 203) “after sixty, death’ and the natural tend-
ency of elderly persons to become less responsive to personal limita-
tions and baffling personal problems are important factors in the
reduction of the incidence of the so-called functional nervous dis-
orders.”’ This sentence contains one of the few statements we have
found in this book with which we are disposed to agree—namely
that “death ” is an important factor in the reduction of the incidence
of functional nervous disorders. Maybe, however, Mr. Conan Doyle
would say it was only the beginning of who knows what functional
nervous disorders can take place judging from the profundity of the
remarks we are offered from those who have tried this adventure.
We have devoted some space to this book because we hate to
see such an undisgested and self-contradictory medley of academic
psychology, behaviorism, mental measurement doctrinairism, bad
neurology, lay psychanalysis, unblushing exhibitionism and puerile
endocrinology, posing as a serious contribution to psychopathology.
Two more bits of rubbish (such are found on almost every page)
before we close: (p. 243) “ Their cell bodies (1.e., autonomic vegeta-
tive nervous system) lie outside the cord, brain, spinal ganglia,
cranial nerve root ganglia and sense organs.” What about the vege-
tative ganglion cells in the ventral horns (Jacobsohn), in the medulla
(Onuf and Collins), in the diencephalon (Malone), etc., etc.a
Then read this bit of ambiguity (p. 245) : “ The heart, the gastro-
intestinal apparatus and probably the endocrine glands are to an
extensive but as yet not exactly determined degree self-regulatory,
and by this I mean that they are self-regulatory independently of
impulses received from the cranial autonomic, sympathetic and pelvic
nerve divisions of the autonomic division of the nervous system.”
These are but a few of many illustrations of the author’s igno-
rance of the whole subject which would be amusing rather than
annoying if the whole thing were not written with such a fatuous
assurance of superior knowledge. He even quotes the German titles
for translated works, the citations from which are plainly taken
from their Englished forms for in some instances later German
editions are available if he could read them. A farmer from Kansas
1 Italics ours.
216 BOOK REVIEWS
could hardly: have done worse; this is why, perhaps, Birnbaum in
the Mtinch. med. Woch., calls this work “ primitive and naive.”
Weigeldt, Walther. STUDIEN zUR PHyYSIOLOGIE UND PATHOLOGIE
DES LIQUOR CEREBROSPINALIS. [Gustav Fischer, Jena. |
This masterly small monograph of about 130 pages is specially
devoted to a consideration of variations in cell and albumin content
in different parts of the c.s.f. system. It thus deals with more than
the general problem of the c.s.f. but also with special situations
and variations which are of unusual clinical importance and which
are usually not known from the run of studies with which we are
familiar.
These specific studies dealing with local differences in cell count,
albumin content, variations in specific gravity, in Wassermann and
gold-sol reactions and in bacteriological findings are all taken up
after a thorough consideration has been given to the questions of
c.s.f{. formation, distribution, mechanics of the fluid and its circula-
tion, its cell elements and its chemistry.
With Greenfield’s monograph and this equally excellent treatise
one is well equipped to survey the present-day horizons concerning
thesc.S. i
Kraepelin, Emil. ARBEITEN AUS DER DEUTSCHEN FoRSCHUNGS-
ANSTALT FUR PSYCHIATRIE IN MUNcCHEN. Zehnter Band.
[Julius Springer, Berlin. | |
This admirable collection of papers, 32 in number, indicates the
great activity of the workers associated with Kraepelin in his gradu-
ally developing Research Institute. With this record of 10 volumes
no one can for a moment doubt the immense service to psychiatry
that the Institute has done and can do in the future if its future can
be made certain.
Peters, W. DIE VERERBUNG GEISTIGER EIGENSCHAFTEN UND DIE
PSYCHISCHE KONSTITUTION. [Gustav Fischer, Jena. Mk. 14.]
The initial stimulus for this work came from the author’s Referat
before the Eighth Congress of Experimental Psychologists at Leipzig,
and it has grown into a book of some 400 pages done in the style that
only Fischer of Jena has been famous for for many years.
It is not, however, of interest for its good paper or excellent
printing; it has intrinsic merits as a scholarly production.
If eye color, skin structure, bodily form, and Hapsburg noses have
come down through many generations in stereotyped form, why may
not there be the same principles operative for psychological characters
just as Galton, Pearson, Davenport, and many another have shown
or attempted to show. Ziehen and Heckel have worked upon musical
talent and innumerable studies have developed this or that type of
special aptitude, and certainly we as neuropsychiaters are not entirely
oblivious to the genetic relationships of color blindness, hemophilia
and maybe certain schizoid or cycloid temperamental inheritance
possibilities.
BOOK REVIEWS Al7,
The author builds much upon Johanson’s application of inheritance
principles, a formulation which has clarified many abtruse situations
as they have been offered in human genetics. In general the author
is fully en rapport with the entire literature; in one point only have
we sought to find a consideration of what may be called false
heredity, 7.e., in the factors of imitation of psychical characteristics
which makes such a large chapter in contemporary study of human
personality seen from the standpoint of conditioned reflexes, which
operating from childhood are of so much significance in the analytic
investigation of character formation.. The author touches upon this
field but does not do justice to it, in our opinion.
Eldridge, Seba. Poritican Action. [J. B. Lippincott Company,
Philadelphia and London. |
Politics does not always center about the village drug store, except
possibly on election day, but it also dwells in high places. The factors
producing some of its results are of sufficient interest for a group
of individuals termed sociologists to attempt to analyze them and
thus possibly influence mass behavior, much as physicians might
hope to influence a mass collection of leucocytes and other things
known as a pneumonic consolidation.
Thus the author subtitles the work “ A Naturalistic Interpretation
of the Labor Movement in Relation to the State”’ and we have read
it with much interest, even though our ideas along these lines are
more or less impressionistic, and more derived from theoretical con-
siderations of mass psychology rather than from any study of actual
politics.
From one point of view we welcome the author’s laying low on
the theory of instincts, especially as advocated in certain quarters.
Such are great words in the professional chairs but not of much
direct application in the subway, and this work impresses us as having
been written by some one who has gotten down to brass tacks and
seen the gang on its job. At all events it is a readable book, even
if at times a trifle pedantic.
Berkeley, W. N. THE PRINCIPLES AND PRACTICE OF ENDOCRINE
MepicInE. [Lea & Febiger, Philadelphia and New York. |]
A somewhat labored but yet possibly useful summary of very
restricted aspects of endocrine medicine in which the author rests
still upon older and now historically interesting hypotheses only.
He is strangely unacquainted with the recent literature of the vege-
tative nervous system as outlined in such works as Lewy, Brugsch, |
Dresel, Jelliffe and White, Laignel-Lavastine, Pende and others and
is content to quote Bayliss, Langley and others as authorities. Pio-
neers they were, but for some time past pushed aside in the forward
rush of a great mass of interesting material. As we read of the
various endocrine glands we are struck with the hodge podge char-
acter of accumulated statements of various workers in the field with-
out any synthetic point of view, quite in the older style of Sajou’s
218 BOOK REVIEWS
scissors clipping accumulations of material. The author flounders
about in his quotations apparently without any sense of what it is
all about. In short he misses the essential thesis that the “ body
as a whole” in its purposive seeking utilizes its organs for its ends.
He hardy does more than catalogue the various organs as disparate
types of activity. He never gets them all running together. It seems
to us like Ford’s shop in Detroit when the belt is not running. In
short the author is rich in quotations but he shows no synthetic
capacity. The chapter upon paralysis agitans is almost a farce, so
little is the author acquainted with the nervous system as studied
by Lewy, Jacob, Vogt, Magnus and others.
We would like to say something nice about this book, but the
more we read it the worse it seems. It is a mess.
Foix, Ch. et Nicolesco, J. Les Novaux Gris CENTRAUXSeii
REGION MESENCEPHALO-SOUS-OPTIQUE. Suivi d’une appendice
sur l’anatomie pathologique de la Maladie de Parkinson. [Mas-
sonjet Gig, Paris.)
This is a classical production both in content and in form which
follows the best French traditions. Nothing just like it in the neuro-
logical field has appeared since Dejerine’s well known Traité or
Azoulay’s translation of Cajal’s well known work.
Two aims have been set forth—the one which occupies the major
portion of this 600-page work, namely the anatomy, and the histology
of the basal ganglia, subthalamic region and the tuber cinerium while
in an appendix the authors discuss the anatomical pathology of
Parkinson’s syndrome. All this is done in the most minute and com-
plete manner with the most advanced of mechanical aids in the way
of excellent bookmaking, fine paper, beautifully illustrated plates in
black and white and in colors.
The authors approach the main theme of their work in three
sections. They first outline the general anatomy, topography and
relations of the regions under discussion; they then give an extended
and well-illustrated series of sections in all three planes of the various
nuclei and pathways under investigation. Finally they correlate the
cytotectonic and mayelotectonic features and offer much matter
of physiological interest. All of this is done in a manner a trifle
didactic but unusually comprehensive. The bibliography is ample
at the end of the chapters, but does not form any part of the dis-
cussion, hence it is of value only as reference. It does not con-
tribute to enlarge the vision of the student. ‘This is a feature to
be somewhat regretted. In spite of this no worker in neuroanatomy
can afford to neglect this really very valuable contribution.
The appendix deals only with the senile type of the Parkinsonian
syndrome. Others are recognized but the senile type is discussed
in the limited frame of reference to degenerative changes although
the possibilities of early types of senile alterations producing a
Parkinsonian syndromy from unknown infectious origins links up
the encephalitic with the senile types. Lewy’s thorough studies are
BOOK REVIEWS 219
mostly confirmed regarding the pathological anatomy. Here also
a fairly complete bibliography is to be found.
The volume as a whole is of the highest merit.
Kraepelin, E., et al. ARBEITEN AUS DER DEUTSCHEN ForSCHUNGS-
ANSTALT FUR PSYCHIATRIE IN MUNcHEN. [Elfter Band.
Julius Springer, Berlin. |
Again we have a reminder, and an important and valuable one,
of the activities of Kraepelin and his coworkers in the appearance
of this eleventh volume containing the results of researches con-
ducted at the Research Institute for Psychiatry in Munich under the
leadership of this indefatigable and master spirit of psychiatry.
It is a doughty volume and contains not only reprints of studies
already published but also a large number of original contributions
not available elsewhere by such well known workers as Spielmeyer,
Plaut, Jahnel, Matsuo, Mulzer, Lange and others. There are 40
papers in the volume upon a vast variety of subjects connected with
neuropsychiatry. One cannot list them all but they deal with prob-
lems of structure as well as of function. Cerebral fat embolisms,
miliary necroses and treponema pallida, morphinism, spinal cord
necroses, hereditary degenerations, CO» poisoning and nervous sys-
tem, fatigue and work, metabolism and the nervous system, epidemic
encephalitis, melancholia, exogene reaction types, clinical psychiatry
and heredity, multiple sclerosis, histopathology in the last 50 years,
these are but a few of the subjects dealt with.
| This series of studies is of inestimable value to all workers in
neuropsychiatry.
Roger, G. H., Widal, F., Teissier, P. Nouveau TRAITE DE MEDE-
CINE. FAscICULE, XIX, PATHOLOGIE DU CERVEAU ET DU CER-
VELET. [Masson et Cie, Paris. |
In this monumental new Traité de Médecine, vols. 18, 19, 20 and
21, are devoted to diseases of the nervous system, speaking in the
narrow sense of sensori-motor and vegetative neurology. The plan
apparently does not as yet include the psychoses, 1.e., diseases of
man’s symbolic mechanisms. The volume before us is the first to be
completed, save that upon the endocrinopathies which has already
been reviewed in these pages. The present volume is a very com-
prehensive one—it is nearly 1,000 pages.
A quick glance at its contents will reveal what it stands for.
Klippel and Monier-Vinard discuss the chief Pyramidal Syndromes,
or Hemiplegias; Roussy and Cornil have an elaborate chapter upon
Cerebral Hemianesthesia; Velter and A. Weill write upon Hem1-
anopsia; Klippel, upon Jacksonian Epilepsy; Lévy-Valensi, a very
thorough discussion of Cortical Syndromies; Klippel and Lhermitte,
one upon Subcortical Disturbances. Cerebral Trauma is written
upon by Marchand, while Comte contributes the chapter upon Infec-
tious Processes of the Brain. Circulatory Disturbances are written
upon by Comte and Klippel, and Roussy and Cornil offer a chapter
220 BOOK REVIEWS
upon Brain Tumors. Gougerot bas the section upon Cerebral
Syphilis, and Lépine that of Paresis. The Encephalopathies of Child-
hood is written by Lévy-Valensi. André Thomas has a very full
section, 150 pages, upon the Cerebellum, and Hautant’s contribution
te Labyrinthine Syndromes draws the book to a close.
This is a noble list of contributors, most of whom have inter-
national reputations.
The reviewer is at a loss to know where to distribute praise or to
apportion criticism. The whole work is conceived in the best of
French neurological style. Some of the material consists of care-
fully elaborated, enlarged, and rearranged communications already
classical, such as the masterly handling of Roussy and Cornil upon
Cerebral Hemianesthesias and Brain Tumors. These are notable
contributions to neurology which lie outside of textbook presentations.
Thomas’ many contributions to Cerebellar Disorders are classical.
Here is no repetition of his older work but a most masterly handling
of the entire cerebellar situation which is an entirely new monograph.
Lévy-Valensi’s touch is always of interest. Here is a master of
diagnostic acumen with rare qualities of precise and valuable formu-
lation. Klippel and Lhermitte’s discussion of the pallidal and other
subcortical syndromes is profound without being heavy, and does
justice to the newer interests awakened concerning the many prob-
lems of these complicated brain structures and brain functions.
The bookmaking is as worthy of praise as are the contents. Alto-
gether this neurological volume is one that will prove of great service
to the student as well as to the specialist. It is easily on a par with.
the best of the German systems and for the most part superior to all
others. It has certain inequalities incident to all systems and here
and there falls short of certain monographic presentations. The
specialist could point out a large number of deficiencies in certain of
the chapters, but these—such as, for instance, the omission of Willis’
observations on general paresis—are of but minor importance and
do not in any sense detract from the value of the volume as a whole,
and only in minor degree from the respective sections.
Eliasberg, Wladimir. PsyCHOLOGIE UND PATHOLOGIE DER ABSTRAC-
TION. Beiheft 35 zur Zeitschrift fiir angewandte Psychologie.
Johann Ambrosius Barth, Leipzig.
The relationships of thinking to speech constitute a most fertile
field for investigation in that highly complicated series of evolution-
ary developments which are incident to man’s utilization of symbols
as tools. For some years the author has made a number of note-
worthy contributions to this general aspect of the thought processes
and here presents a useful résumé of his researches. These have
dealt with children before the ages of entering school, with so-called
normal adults, with academically cultured and developed individuals,
aphasics, dements, and, of special import, with patients suffering
from brain injuries.
The goal has been to determine the various stages in the develop-
BOOK REVIEWS VGA
ment of the powers of logical abstraction and to learn in what sense
and by what means such evolutionany syntheses are capable of ana-
lytic interpretation in the light of disease dissociation.
It is a monograph of nearly 200 pages and is of special value for
all who are able to get into complicated problems of logical construc-
tion of thought processes. It is not easy reading and will not appeal
to the simpleminded who, unaware of the complexities of the issues
involved, are content to follow the empty phrases of the scholastic
textbooks of their college days, especially those who are wrapped up
miei Weriniantile \beliet that: ~ tests "sof ~ intelligence: are ofgmuch
significance.
ipernard, L: LL. Instinct: A Stupy In Soctat PsycHoLoey.
Henry Holt and Company, New York.
Of all the useful generalizations introduced into biological science
by the Darwinian discipline, that of “instinct” has been the. most
fertile as well as the most baffling.
No one mortal can possibly read all of the many discussions rela-
tive to the meaning of this phrase, so widespread has been the interest
in the thought and so discursive have been the points of view
expressed upon the problems raised.
Here we find, however, a sincere and valiant, as well as scholarly
effort to disentangle the many meanings which have been attached to
the conception, especially as it has been applied to the social sciences.
The author expressly states that he was dissatisfied with the
McDougall concept. This concept, as is fairly well known, permits
of a multiplicity of instincts, which, logically speaking, are not care-
fully differentiated from simpler syntheses of behavior reactions
which are more rigorously regarded as habits. The author quotes
Dunlap, who, scholastically immersed in etymologies, says he cannot
distinguish between instincts and habits. Here Bernard prefers Her-
rick’s effort at distinction, which, as neurologists, we also prefer.
The reader will here find an excellent digest of all of the various
points of view, chiefly taken from English students of the problem.
In our opinion he demolishes the McDougall conception and gives at
the same time a better working series of formulae ie the meaning
to be applied to the conception of Instinct.
This is the best book we have met with in recent years dealing
with this complicated generalization and one which can orient the
intelligent reader as no other work of its kind in English.
Miiller-Freienfels, Richard. Das DENKEN UND DIE PHANTASIE.
Band II. Grundztige einer Lebenspsychologie. Zweite Auflage.
Johann Ambrosius Barth, Leipzig. 12 marks.
The ‘ foundations of a living psychology ”—this is an attractive
program, especially to neuropsychiatrists. The author has already
presented an earlier volume dealing with this situation under the
title of “ Das Gefiithls und Willensleben,’ which has received atten-
tion in an earlier volume of the JoURNAL.
Ventas BOOK REVIEWS
Here he would deal with those mental manifestations which may
be subsumed under the titles of “ Thinking” and “ Phantasy ’—or
as in general already partly presented to psychiatrists as “ directed
thinking’ and as wish-fulfilling or autistic thinking, as Jung and
Bleuler have designated them and here termed “ phantasy.’ Not
that our author would be satisfied with these signposts, for he here
presents a very systematic analysis of the entire scheme of thought
processes, more or less in the orthodox regimes.
Thus he sets forth in his Introduction the notion of the “ Ego”
and the intrinsic patterns of the strivings for self-preservation and
for development in which environmental circumstances play a neces-
sary and important role. Hence arise “ pleasure and pain” and the
idea of “values.”
Coming to grips with his problem, he discusses “ perception ”’ in
its analytic and then in its synthetic function. Thus arises “ idea-
tion’ and “ presentation,” which finally build up conceptual thinking.
These questions occupy the first section of 250 pages.
He then advances in the second section, chapter 1, to “ construc-
tive activities”? of “ Thought” and “ Phantasy,” in which he dis-
cusses, among other themes, the free movement of consciousness,
dissociation, impulse, and goes on to diifferentiate the chief types of
“Thinking” and “ Phantasy,” “Conscious and Unconscious)”
Chapter 2 deals with the impulse to thought and the setting of the
thought “ object.”
Further chapters deal with the constitution and elaboration of
the thought object and the solution and verification of the problem,
while a final section deals with considerations of the theory of
knowledge.
The whole volume is filled with provocative ideas, and apart from
difficulties of a foreign language presentation is one well qualified
to be of distinct service in psychology.
‘
‘
Winterstein, H., Grund, G. MErETHODEN zUR UNTERSUCHUNG DES
UEBERLEBENDEN ZENTRALNERVENSYSTEMS.—- METHODEN ZUR
FUNKTIONSPRUFUNG VON MUSKEL UND NERVEN BEIM MEN-
SCHEN MITTELS DES GALVANISCHEN UND FARADISCHEN STROMES.
[Urban & Schwarzenberg, Berlin u. Wien. |
Abderhalden is editor of this Handbook of Biological Methods, of
which these two sections constitute No. 188. It is a gigantic scheme,
this work of at least 600 coworkers.
The present volume contains two sections, one upon animal experi-
mental methods working on various parts of the animal body sepa-
rated from the living animal. Artificial circulation is dealt with first,
then study of isolated functions of the nervous system, and the study
of body fluids of necessity for nervous functioning. These are taken
up in detail.
The second two-thirds of the volume deal with functional nerve
testing. It is an excellent short summary of the usual tests made
by galvanic and faradic electrical currents. The newer French work
of Lapicque and Bourgignon is dealt with in about three pages.
BOOK REVIEWS 223
Garcia-Diaz, Guillermo. ETUDE ANALYTIQUE ET SYNTHETIQUE
DE LA SYMPATHECTOMIE PERIARTERIELLE APPLIQUEE AU TRAIT-
MENT DES ULCERES CHRONIQUES DES MEMBRES INFERIEURS.
[Libraire Le Francois, Paris. |
An Argentine-Republic surgeon, a graduate of the Paris faculty,
has written this very interesting and elaborate monograph upon the
treatment of chronic ulcers of the leg by periarterial sympathectomy.
From its dedications we infer that it is his “ doctor” thesis, but
it evidently is the work of one who has had more experience than the
usual medical graduate.
The thesis follows the usual lines, taking up the history of the
operation, the morpho-physiology of the vascular innervation, opera-
tive technic, immediate and after effects of operation, risks and acci-
dents, the study of the mechanisms involved in the operation, and a
final chapter on the therapeutic value.
There are those who think of this type of work as having origi-
nated with Leriche and Jaboulay, but the attack upon the vegetative
nervous system began back in the middle of the 18th century. In
the latter part of the 19th, cervical sympathectomy “ cured every-
thing,’ and now the end of the rope—.e., the periarterial vegetative
network—has come and the surgeons offer a new millennium. This
historical chapter gives a quick orientation to the work done. The
histology of the nerve net is not very satisfactory. It is so much
more complicated than figured or conceived of by the author. The
néwer Spanish work is not thought of, and this is the most unsatis-
factory chapter in this very excellent thesis.
There is a large amount of clinical material put under discussion
and a very conservative attitude is taken; in fact, the author comes
to the general conclusion, after having studied about 500 cases, that
periarterial sympathectomy is not a good procedure; in fact, surgical
interference of this type is to be deprecated.
He would substitute certain forms of electrotherapy or actino-
therapy in order to bring about the needed vascular dilatation and
stimulus to cicatrization.
Henning, Hans. PsyCHOLOGISCHE STUDIEN AM GERUCHSINN.
[Urban & Schwarzenberg, Berlin u. Wien. Marks 4.50. |
There is no greater authority to-day upon the sense of smell than
Hans Henning of Danzig. We have had occasion to call attention
to his monumental monograph published in 1924, and Abderhalden
in this No. 189 of his Handbook of Biological Methods has been
fortunate in getting this very condensed and well written chapter
upon the psychological methods of studying the sense of smell.
NOTES AND NEWS
Tue Fifth Annual Convention of the Central Neuropsychiatric
Association was held at Cincinnati, Ohio, on October 29 and 30.
Clinical presentations, pathological demonstrations, and addresses
were made by neurologists and psychiatrists in Cincinnati. The presi-
dential address was delivered by Dr. Albert M. Barrett, of Ann
Arbor, Michigan, on Neuropsychiatric Interrelationships. Dr.
August Wimmer, Professor of Psychiatry and Neurology of the
University of Copenhagen, was the guest of honor and delivered two
addresses, one on the Clinical Aspects of Kleptomania, and one on
Epilepsy in Chronic Encephalitis. 3
Officers for the ensuing year were elected as follows: President,
Dr. Walter D. Shelden; Vice-President, Dr. Alvin T. Mathers;
Secretary-Treasurer, Dr. Karl A. Menninger; Counsellor, Dr. Albert
M. Barrett.
The Annual Meeting of the American Neurological Society will
be held May 24, 25, 26, 1927, at the Hotel Ambassador, Atlantic City.
Titles of papers must be in by March 31,, 1927.
On) tly 25)120, 6272/5) the American Neurological Soe will
hold a joint meeting with the Section of Neurology of the Royal.
Society of Medicine in London, England. Dr. C. L. Dana of New
York will give the Hughlings Jackson Lecture July 27, 1927, Mem-
bers of American Neurological Society are redes ter to hand in titles
of papers before March ay 1927.
N. B.—All business communications should be made to Journal of
Nervous and Mental Disease, 64 West 56th St., New York.
All editorial communications should be made to Dr. Smith Ely Jelliffe,
Managing Editor, 64 West 56th St.. New York.
[224]
VoL. 65 MARCH, 1927 No. 3
The Journal
OF
Nervous and Mental Disease
An American Journal of Neuropsychiatry, Founded in 1874
ORIGINAL ARTICLES
Pie MAL ARTA TREATMENT, OF GENERAL PARESIS
By ArRMANDO FERRARO, M.D., AnD THEODORE C. C. Fone, M.D.
ST. ELIZABETH S HOSPITAL, WASHINGTON, D. Cc:
The favorable influence of infectious diseases on the course of
the psychosis, and presumably on general paralysis, was well known
imine gactuhall century. Keuss’ Rosenblum, Jacobis, lL. Meyer,
Sciamanna, and others were already acquainted with the beneficial
influence of high temperature accompanying infections and a treat-
ment so directed as to produce an increase in the temperature was
established by Wagner v. Jauregg and Pilcz, who used injections of
tuberculin, while Donath, Fischer, and others used natrium nucleinate.
The idea, however, of producing artificial infectious diseases in men-
tal patients was first tried in 1875 by Rosenblum, who inoculated
patients affected by different types of psychoses with relapsing fever
organisms. It is doubtful if among these patients there were any
paretics, and Plaut and Steiner, who have reviewed the cases, deny it.
The results obtained by v. Jauregg, Pilcz, Donath, and Fischer were
found satisfactory, as Pilcz reported 60.3 per cent of remissions with
the tuberculin therapy and Donath 47.6 per cent with the sodium
nucleinate treatment.
We are, however, indebted to Wagner v. Jauregg for his original
experiment of inoculating paretics with malaria, the results of which
were reported in 1887 in the Jahrbiicher fiir Psychiatry, Bd. 7. In
1917, v. Jauregg started a new experimental work by inoculating nine
patients, four of whom were beneficially influenced by this new mode
of treatment. The attempt of the Viennese school to treat paresis
with malaria was followed up by that of the school. of Monaco
(Plaut and Steiner) (1919), who treated general paresis by artificial
infection produced by the spirochetes of the relapsing fever.
[225]
226 AL HPERKARO ANDET C2O FONG
Encouraged by his first results, v. Jauregg instituted this treatment
on a larger scale. In other cities of Austria,.in Germany, in Eng-
land, and in other countries additional contributions were made, deal-
ing with the efficacy of this new type of treatment. To-day this
method of treatment has become widespread and in many large
institutions extended experiments have been carried on. In this
country, St. Elizabeths Hospital was among the very first to adopt
this new form of therapy, and the results of a first series of cases
so treated have already been published by Dr. Eldridge and his
coworkers. This paper will consider the results of this treatment on
the entire series of cases, considering them mainly from the clinical
point of view, the serological results having already been described
in a previous paper.
A careful survey of the literature on the subject has given us
statistical data reported by many authors who have studied this
subject, and we have incorporated this data in the accompanying
table :
DTABEE SI
Results of Malaria Treatment of General Paresis According to Various
Authors
Year of pub- No. Very Incom-
Author lication of of goodre- pletere- Unim-
the paper cases missions missions proved Deaths
Jo Jo Yo To
Wagner
v. Jauregg 1917 9 44
Gerstmann 1920-21 25 28 44
Delgado 1921 5 40 60
Kirschbaum 1922 39 2 17
Weygandt 1922 68 20 12
Gerstmann 1922 L1G Boat 30.96 22.36 ~ 10a
Pitez 1923 141 Sa, 12.6 39.9 10.5
Drought and Beccle 1923 14 ZA 56.8 14.2
Aguglia and
.d’Abundo 1923 4 50
Scripture 1923 141 43.4
Gans 1923 jf 23.2 5.8 40.6 5.8
Herman 1923 40 20 ZH
Grafe 1923 19 62.4
Gerstmann 1923 294 38.08 30.60 Slee
Kirschbaum
and Kaltenbach. 1923 ie Sit 31.4 22.9 14.2
Grant 1923 40 22.5 Files 120 15
Nyiro Gyula 1924 30 Zo 40 20 6.6
Artwinski 1924 70 46 40 14
Herzig 1924 100 15 12
Schulze 1924 250 44 12 6.9
Horn 1924 58 58
THE MALARIA TREATMENT OF GENERAL PARESIS — 227
Year of pub- No.
Author
Askgaard
Reese and Peter
Bratz
Kirschner and
ve Loon
Jansen and Hutter
Untersteiner
Modena and
De Paoli
Jossman and
Steenarts
Schuster
C. Meyer
Yorke and Macfie
Plehn
Scherber and
Albredst
Grant and
Silverston
McBride and
Templeton
McAlister
Grossman
Kihn
Scarpini and
Befani
Lilly
Davidson
Wizel and Prussak
Eldridge
Gerstmann
Sagel
Mingazzini
G. M. deRudolph
Graham
Hermann
Cortes
Donner
Bunker and Kirby
Nonne
De Paoli
Pastrovitch
Fribourg-Blanc
Grimme
Nicolle and Steel
Bosch and A. No
O’Leary
Nerancy
Bunker and Kirby
H.and A. McIntyre
lication of
the paper
1924
1924
1924
1924
1924
1924
1924
1924
1924
1924
1924
1924
1924
1924
1924
1924
1925
LOZ
1925
1925
1925
1925
125
125
£925
1925
1925
1925
1925
1925
1925
1925
1925
1925
1925
1925
1926
1926
1926
1926
1926
1926
1926
of
Cases
on
236
40
4
2
40
106
40
Very
good re-
missions
Incom-
plete re-
missions
%o
Zi
50.6
50
29.6
40
Unim-
proved Deaths
To To
32.4
29 10.6
44 22%
225
2 Za
39 12
23.80 16.6
53
14
22 16.5
5 12.5
34 20.4
28.4
40.5 8.1
9
29.4
5:5
30
15
8-12
Zz, 8.8
RS)
28.5 13
20.58 ne
40 10
24.5 10
17:5 10
There are several points concerning the clinical course of arti-
ficially induced malaria which must be taken into consideration before
disclosing the results of the treatment.
the period of incubation of the artificial infection.
that the period of incubation of naturally acquired malaria (benign
One of the first points is
It is well known
228 A, PFERRAKROVANDAI Cac. LONG
tertian) is from nine to twelve days, according to Castellani and
Chalmers. The incubation period of artificially induced malaria
is somewhat different and varies with the method of incubation,
depending on whether it be subcutaneous, intravenous, intramuscular
or by mosquito-bite inoculation.
According to Gerstmann (1924) the period of incubation by sub-
cutaneous means of inoculation is from four to twenty-eight days.
Scripture (1923) states that the period is from six to thirty-one
days. Donner (1925) reports from five to twenty-one days, while
York and Macfie (1924) says the incubation requires from eight
to fifteen days but with considerable variations. Pijper and Russell
(1924) state a period varying from nine to eighteen days and
McAlister (1924) gives from nine to thirty-two. Grant and Sil-
verston (1924) in a series of forty-three cases noticed that the initial
rise in temperature occurred from one to eighteen days after the
inoculation whereas parasites were first found in the blood stream
from six to twenty-two days. After infection Kirschbaum and
Kaltenbach found the incubation period varying from eight to
fourteen days to a maximum of four weeks. Dattner and Kauders
occasionally found a period of twenty-one days while the average
was from six to eight days, Nyssen found the average to be eleven
days, and Fribourg-Blanc ten days. The work of Wizel and Prus-
sak shows that from seven to twenty-one days of incubation are
required and Eldridge’s cases from seven to thirty-four days. The
longest incubation period was reported by Muhlens and Kirschbaum
and was fifty days.
By the intravenous method of inoculation, Ronald Ross cites the
details of six intravenous inoculations with benign tertian malaria.
In these cases, fever first appeared in from three to twelve days
following inoculation. Templeton (1924) found in twenty cases
of dementia precox inoculated intravenously with 2-3 c.c. of malarial
blood that the temperature rose the day following inoculation. Mac-
Bride and Templeton found that pyrexia usually developed on the
second or third day in a series of eighteen general paretics. David-
son (1925) in a series of sixteen cases found that the incubation
period varied from four to nineteen days. Muhlens and Kirschbaum
found the incubation period varied from three to twelve days. The
incubation time of Nyssen’s cases averaged four days and that of
Fleck three days. Dattner and Kauders state that intravenous
inoculation shortens the time from one to three days.
According to de Rudolph, if the same strain of parasites are used,
JHE MALARIA TREATMENT OF GENERAL PARESIS . 229
there is a tendency for the incubation period to be slightly shorter
with the intramuscular type of inoculation than with the subcuta-
neous. Davidson, however, finds that the differences are very slight,
the time being essentially the same for intramuscular and sub-
cutaneous inoculations.
For malaria artificially induced by means of the mosquito bite,
de Rudolph found that in thirty-seven cases the incubation period
varied from seven to twenty-five days if measured by the first rise
in temperature, and in thirty-four cases from seven to thirty days if
the first appearance of parasites in the blood was regarded as the
measure.
The technique initially employed at St. Elizabeths Hospital was
to inject into the subscapular connective tissue by means of a hypo-
dermic syringe 2 c.c. of blood withdrawn from the donor patient
shortly after a paroxysm. ‘The recipients were then sent to a ward
which was well screened, and confined there until the treatment was
completed. Lately, the intravenous mode of inoculation has been
used and at present patients are inoculated by this means. The
donor patient is always one with a negative blood Wassermann and
with no syphilitic history.
Our data concerning the period of incubation as found in the
entire series is as follows:
Subcutaneous inoculation. The period varied from a minimum
of two days to a maximum of forty-eight. Of the entire series,
seven cases showed an incubation period of more than thirty days,
while ten showed an incubation period of less than ten days, two of
which were respectively two and three days. The average incuba-
tion period by subcutaneous inoculation was sixteen days.
Intravenous inoculation. The period varied here from a mini-
mum of two days to a maximum of twenty-four days. The cases
had a period of incubation of fifteen days or more while seventeen
showed a period of incubation of less than ten days; in six cases
it was five days or less. The average period of incubation by the
intravenous mode of inoculation was found to be ten days. The
onset of the incubation period was calculated from the appearance
of the first paroxysm and not from initial appearance of parasites
in the blood.
A point which might be discussed is the amount of malarial blood
to be inoculated. According to G. M. deRudolph, the volume of
blood in itself bears no relation to the incubation period, but the
number of parasites present in the blood is the important factor. In
fact, the cases that received the smaller doses gave the higher incu-
230 ADP FERRARO ANDES CG GenOn G
bation periods as determined by the first appearance of parasites
or by the first elevation in temperature. The patients that received
the greatest number of parasites showed the longest incuhation
periods if the first rise in temperature was the factor regarded, but
the shortest if the first appearance of parasites in the blood was the
feature considered.
Our data show that the intravenous method of incubation shortens
the incubation period to an average of five days. As the intra-
venous mode prevents loss of time, Nyssen advocates it, not only
from this standpoint but because in agitated patients in precarious
somatic conditions, this method of inoculation prevents the develop-
ment of a too advanced debilitated state and assures the reduction
of the period of hospitalization.
Another point of a practical interest is the question of natural
or acquired immunity to malaria inoculation. In our series, a few
cases showed an apparent total immunity so that even after three
or four inoculations no paroxysms were obtained. A few other cases
developed malaria after the third inoculation. A total of twenty-
eight cases failed to develop malaria at the first inoculation. Of
these, fifteen were not reinoculated whereas the remaining were
reinoculated two or three additional times, the latter developing the
infection after the second, third or fourth inoculation.
The partial or total failures in producing artificial malaria sug-
gested to York and Macfie the existence of evidence that man
exhibits some degree of immunity to malaria although his natural
immunity is but slight, and in the vast majority of cases insufficient
to prevent the development of the infection. On the other hand,
there is evidence that the malaria parasites readily develop an immune
body resistance which, however, does not confer a similar protec-
tion agaifist the other species. This point is of practical interest, as
in cases where inoculation with a special strain fails to produce
results, an attempt could be made with other strains or even with
other types of parasites. This point is also of interest in cases where
reinoculation is advisable and where the reinoculation with the former
strain fails to act. Following this line of thought attention has been
called by Kirschner and v. Loon to the natural immunity which
appeared to exist among the patients who were born in the tropics.
These authors found that many of these patients failed to be infected
while others showed signs of partial immunity, the fever developing
after the second or third inoculation.
Another point which must be emphasized is the different clinical
course between naturally acquired and artificially acquired malaria.
Pie AN Lic Al MENT OPriGeNERAL PARESIS” ~ 231
The observations of previous writers that artificially inoculated
malaria is easily cured by comparatively short courses of treatment
with quinine or salvarsan have been confirmed by our results. In
thirty-eight cases of our series the malaria subsided spontaneously
before any quinine was administered. On the other hand, only a
very few cases of our series have had relapses of fever after the
routine treatment had been completed and the patients sent back
to their wards.
Various hypotheses have been advanced to explain the remarkable
sensitiveness of the inoculated strain to quinine treatment. Accord-
ing to York and Macfie, the explanation of the success of the treat-
ment in these induced infections is to be sought in the fact that we
are concerned here with the early treatment of the disease or, in other
words, with the treatment of primary infections and not, as in the
war or as frequently in practice, with old-standing relapsed cases.
The influence of the malaria treatment on the blood cell count
has been studied by several authors and among them are Bunker and
Kirby and Pijper Skolveit and Russell. The latter found that a sub-
cutaneous injection of from 0.5 to 10 c.c. of blood containing benign
malaria parasites is quickly followed by a rise in the red cell count,
amounting to somewhere between 10 and 30 per cent. This rise lasts
several days, with minor daily variations, and is followed by a fall
which constitutes the malaria anemia. As an injection of malaria
blood cannot very well lengthen the life of the red blood corpuscles,
the rise can only be explained as an increase in production of red
blood cells. Normal blood has no such effect. An injection of
malarial blood is a direct stimulus for the red bone marrow towards
increased activity. Incidentally the authors state that the stimulus
might be applied for therapeutic purposes (forms of anemia, espe-
cially chlorosis). The outbreak of fever can always be prevented
by an injection of neosalvarsan as soon as the increase in red cells
is well established. The whole process could then be repeated.
Skolweit, in the clinic of Prof. M. Nonne, has examined blood
of paretics before and after the fever period. It is well known that
lymphocytes play a material role in syphilis and the other infectious
diseases. In the usual case of late syphilis Skolweit found in the
cerebral type, lymphocytosis; in paresis, lymphopenia. He also
found that at the end of the malaria attack there immediately
occurred a strong lymphocytosis in the blood which continued for a
long time, then gradually diminished; and that in parétic patients
with a remission the lymphocyte value was similar to that in cerebral
syphilis. He, therefore, gained the impression that from intercur-
232 AV PERRAKOAN DAT COLC eon
rent malarial infection the relation between virus and organism
received an impetus that paretics reacted more like late syphilitics.
Abroad, the idea is prevalent that no hazard is to be feared from
the propagation of the infection (Fleck, Gerstmann, Kirschbaum,
Kaltenbach, Mithlens, v. Jauregg, etc.) and even experimental
studies on this subject (Barzilai-Vivaldi and O. Kauders) have
proved that artificial infection is not transmittable by means of the
anopheles. However, the conclusions of these two authors have not
been confirmed by Bravetta or by v. Engel. The latter has succeeded
in transmitting the infection by anopheles bite when the passages
have not been numerous and the circulating strain is rich in gametes.
Bravetta has found that through different passages the fundamental
type of the plasmodium vivax keeps itself constant and no differences
can be noted even from the morphological point of view.
In this institution, the wards in which the patients are treated
are well screened, and with this precaution no propagation of the
infection has been reported.
Another important point in countries where malaria is not endemic
is the transportation of the malarial organism for purpose of inocu-
lation. Several methods have been suggested by Kirschbaum,
Muhlens, O. Kauders and others. The methods suggested by the
latter author is as follows:
(a) Method of sodium citrate. 5 c.c. of malaria blood are
mixed in a sterile tube with 5 c.c. of 0.5 per cent sodium citrate
solution. The tube is closed with.a rubber cork and hermetically
paraffined. The level of the fluid must not reach the base of the cork.
(b) Method of agar blood. 10-15 c.c. of malaria blood are defibri-
nated with small glass balls. The defibrinated blood is then trans-
ferred to a tube containing agar blood distributed on an inclined
plane. Agar blood, which contains agar and blood in the proportion
of three to one, must be freshly prepared and homogeneous. Closure
of the tube must be done as in the previous method.
(c) Method of gelatinization. 2 c.c. of malaria blood are put
in 10 c.c..of sterile gelatin—chemically pure. The gelatin must be
dissolved at 30° centigrade in a water bath. The blood and gelatin
must then be shaken for a few minutes, after which the gelatin is
left for solidification. The infectious properties of the malaria blood
so treated are preserved for at least forty-eight hours and at times
up to three days. These tubes can be mailed.
The average number of chills that every treated patient should
be allowed to have is twelve, according to the majority of authors.
However, Muhlens and Kirschbaum have permitted their patients
THE MALARIA TREATMENT OF GENERAL PARESIS — 233
to have seventeen and even twenty chills when no complications arise
such as anemia or icterus. In our institution many patients have
been permitted to have from twelve to eighteen chills and a few of
them even more than this. We have as yet to find any hazard
attached to this although Fleck suggests a limit of from eight to
ten paroxysms.
In order to better understand the results of malaria treatment,
we believe that we should outline the scheme that we have followed
in the valuation of our results.
We have considered as remissions, cases exhibiting remissions
even after six months’ standing.
In Table No. 12 we have divided the cases according to the dura-
tion of the remission and the reader will be able to note the duration
of remission in each group.
We have not included in our conception of remission the time
factor. In other words, we have considered as remissions, not only
those of long standing but those of short duration, six months
and over.
In itself the time factor is irrelevant as far as remissions are con-
cerned, but will be of value in the future when the duration of
remissions are considered. In other words, we have taken into
consideration patients from a cross-sectional point of view, but have
placed a minimum limit of six months in cases that we have grouped
as in remission. A future survey of these patients will inform us
of the exact nature of their outcome.
We felt that it was necessary to include as remissions those of
six months’ duration, as well as those lasting from twelve to eighteen
months, for the following reasons:
(1) The high percentage of these remissions as compared with
those occurring spontaneously (average 10 per cent) and those fol-
lowing the usual course of treatment (3 per cent, according to
Furman ).
(2) The changes in the serology which follow malaria treatment.
The serology has improved 36.32 per cent within twelve months
and 52.8 per cent within twenty-four months.
(3) The pathological changes occurring in cases dying at various
intervals following malaria inoculation.
In all cases examined microscopically (see paper of Dr. Freeman
in the course of publication), those cases which exhibited partial or
total remission during life showed a corresponding improvement in
the pathology. Even after the brief period of four months, one of
the cases examined revealed almost complete arrest of the patho-
234 AUPE RRAROSCAN DeleCr- Ce Qi
logical process and in two cases lasting ten and seventeen months
respectively not only was there complete disappearance of the inflam-
matory and degenerative lesions, but there was also considerable
repair occurring in the cortex.
On the other hand, we feel that if we had to take into considera-
tion the time factor and regard as remissions only those cases extend-
ing over two or three years, our conception would then lead to an
error, as the intermediary cases with remissions extending from six
to twelve months, and even up to eighteen months, would not be
regarded as due to the malarial treatment. This would lead one to
a false conclusion and it would impress upon one that malaria played
no part in the resulting improvement or remissions; the remissions
would then be considered as occurring during the normal course of
general paresis. This cannot be true as the percentage of remissions
following malaria treatment is very high as compared with the one
occurring spontaneously, or following other forms of treatment.
RESULTS OF THE MALARIA TREATMENT
Of the 120 cases successfully inoculated with malaria, the general
results obtained were as follows:
AABLEA II
Total Very Slight Deaths
number at good Partial improve- Unim- Acute Other
cases remissions remissions ment proved Malaria causes
120 31 29 6 34 6 14
If we now add to the living cases those who died after the
malaria treatment from other causes and group them as to their
mental conditions at the time of their deaths, the ultimate results
will be found to be as follows:
TABLE III
Total Very Slight Deaths from
number of good Partial improve- Unim- acute
cases remissions remissions ment proved malaria
120 31 oe 10 40
Of the total number of successfully treated cases 25.73 per cent
have shown very good remissions, 27.39 per cent a marked improve-
ment (incomplete remissions), while 8.3 per cent exhibited slight
improvement. The total degree of improvement following malaria
treatment amounted to 61.45 per cent. If, however, we wish to
exclude the ten cases showing slight improvement and confine our-
THE MALARIA TREATMENT OF GENERAL PARESIS 235
selves to the cases exhibiting a real appreciable improvement (good
remissions and partial remissions), the total percentage of improve-
ment is reduced to 53.12 per cent.
Very good remissions. In this class we have included all the
cases that we have considered as socially recovered. We do not
speak of recovery in general paresis as we have noticed that even
in the most striking cases when a detailed and careful examination
is performed, there can always be detected a slight degree of defective
judgment or insight, and also emotional instability. The patients,
however, can be considered as “socially recovered,’ meaning by
this term a relative degree of mental and physical recovery which
will enable the patient to function socially and even to return to his
previous occupation or to some other form of labor which will assure
him a living. The mental conditions of these patients, although
slightly impaired, permits them to normally adapt themselves to their
environment.
Partial remissions. Under partial remissions cases we grouped
those who have shown an incomplete remission. Their physical and
mental conditions are so benefited that these patients show a surpris-
ingly good: adaptation to the hospital environment. Many of these
patients are allowed privileges such as ground parole and city parole,
privileges that the patients use very satisfactorily. Although their
mental condition is fairly good, defects can be detected in the emo-
tional sphere and judgment as well as in memory for both past and
recent events. So far as the course of improvement is concerned,
some of these patients have been stationary since the onset of their
improvement while others are still improving so that in the near
future some very good remissions are hoped for. As regards the
working capacity (Arbeitsfahigkeit of the German authors) these
patients are capable of performing ward work or other routine
hospital work even though their improvement is not sufficiently
advanced to adapt to positions outside of the institution. However,
if the relatives of some of them were willing to assume the responsi-
bility of their maintenance, we feel that many of them could make
a satisfactory adjustment outside. Undoubtedly some of them could
even earn a partial living if conditions necessitated.
Very slight improvement. In this category we have placed those
patients who have adjusted themselves fairly well to routine hospital
life. Although of no value in the routine work of the wards, these
patients have become tidy, neat in dress and habits and as a rule
cooperative in the routine examinations. Some of them have
236 A. FERRARO AND T. C. C. FONG
exhibited no further changes since the time of the treatment while
a few others have shown a slight tendency towards a more pro-
nounced improvement.
Unimproved. Among the unimproved cases we have classed
those who have remained stationary for a long period of time fol-
lowing the malaria treatment. Whether this prolonged stationary
period is to be regarded as the result of the treatment it is difficult
to say although some of the patients actually show a prolongation
of the disease which is far longer than the usual duration.
As a matter of fact we have to consider that following the
malaria treatment many of the unimproved cases show at least a
subsidence of the stormy phase, becoming more quiet, cleaner, less
careless and, as a rule, not bedridden as is usually expected with
ordinary cases—and, as a whole, they are less burdensome to the
institution.
Deaths. The total number of deaths was twenty. Of these only
six died during the acute stage of malaria, and the percentage of
death risks with this new form of treatment is then only 4.9 per cent.
The figures of our results are not very far from those of Reese
(2.9 per cent) and Fleck (3.6 per cent). The other fourteen cases
died at different intervals after the malaria treatment. One of them
died two months afterwards (no autopsy performed), two after five
months (no autopsy), two after six months (bronchopneumonia),
one after eleven months (cardiovascular disease), two after twelve
months, one after seventeen months (ruptured aneurysm), one after
eighteen months (spontaneous rupture of the bladder), two twenty-
five months after (bronchopneumonia), one after 37 months (no
autopsy) and one thirty-eight months after (bronchopneumonia).
> K oK oK ok > ok
As the type of paresis seems to exert a certain influence on the
result of the malaria treatment, we have in the following tables
divided all the treated cases in relation to the type of paresis and to
the result of the treatment.
TABLESLYV
Cases showing very good remissions
Total
number Demented Expan- Tabo- Juve- Schiz- Sta-
of type Depressed Manic sive paresis nile oid tion-
cases paranoid ary
31 3 8 8 la | — — —— ee
THE MALARIA TREATMENT OF GENERAL PARESIS 237
TABLES.
Cases showing partial remissions
Total
number Demented Expan- Tabo- Juve- Schiz- Sta- '
of type Depressed Manic sive. paresis nile oid _ tion-
cases paranoid ary
a fi 1 1 1 Z 1 1
PABIEE VE
Cases showing slight improvement
Total
number Demented Expan- Tabo- Juve- Schiz- Sta-
of type Depressed Manic sive’ paresis nile oid tion-
cases paranoid ary
10 3 — 1 4 i — 1 —
TABLE VII
Cases stationary or unimproved
Total
number Agi- Expan- Tabo- Juve- Schiz- Sta-
of Demented Depressed tated sive paresis nile oid tion-
cases paranoid ary
40 21 3 3 6 — 3 3 1
By studying these tables, we can easily see how the different
types of paresis react to this new form of therapy. Leaving out of
consideration acute cases of malarial deaths, only three cases of the
demented type of paresis of the thirty-four showed very good remis-
sions, while seven were improved, three slightly improved, and
twenty-one remained stationary. Undoubtedly the highest percentage
of the unimproved cases is in the demented type, which represents
52.5 per cent of the unimproved cases and 55.44 per cent of the
whole group of demented cases. The greatest number of very good
remissions is in the expansive-paranoid type, as out of a total of
thirty-one cases of good remissions eleven were of this paranoid
type. Considering now the total number of the expansive-paranoid
cases, we see that eleven have shown very good remissions (29.04
per cent), thirteen partial remissions (34.32 per cent), and four
(9.56 per cent) slight improvement. Of the sixty-four cases showing
very good or partial remissions, twenty-four, or 37.44 per cent, were
in the excited-paranoid group.
Next to the expansive-paranoid type, the depressed type shows
the greatest number of very good remissions. In fact, 25.6 per cent
of the very good remissions were of this type. The same percentage
was shown by the manic type, which is also represented by eight
cases of the very good remission series.
But if we consider the percentage of very good remissions of the
238 APPAR RRARO SANGO AC Ovar Oly:
depressed type in comparison with the entire group of this type, we
soon find that the depressed cases are those which offer the highest
percentage of very good remissions. In fact, of the twelve cases
which constitute the entire group, eight, or 66 per cent, have shown
very good remissions. Of the manic cases, 41.6 per cent of the
group have shown very good remissions, 36.4 per cent partial remis-
sions, 5.2 per cent slight improvement, while 15.6 per cent are
unimproved.
The schizoid type, as well as the juvenile type, offers marked
resistance to improvement. Of the four cases of the juvenile type,
only one has shown any improvement, while three (75 per cent of the
eroup) has shown no improvement. Of the five schizoid cases, two
have shown improvement, while three (60 per cent) have been
stationary.
TABLE Vill
Rerults of treatment in the different types of paresis
(Percentage of results in each type)
Sta-
Result of De- Ex- De- Juve- Schi- tion-
of pressed Manic pansive mented Tabo- nile zoid ary
treatment type type type type paresis type type type
Jo 0 Jo 0 Yo 0 Jo Yo
Very good
remissions 66 41.6 29.04 7.92
Partial
remissions Si 36.4 34.32 28.68 66.6 20 20 50
Slight im-
provement 52 10.56 7.92 20
Unimproved 25.9 15:6 15.84 55.44 RIES: 75 60 50
The figures of Table 8 show that the type of paresis which offers
the highest probability of success for the malaria treatment, as shown
by the combined number of good remissions and partial remissions
cases, is the manic type of paresis (78 per cent). This is followed
by the depressed type (71 per cent) and then by the expansive-para-
noid type (63.36 per cent). The dementing type, the juvenile, and
the schizoid are next in sequence, these showing marked resistance to
this special form of treatment, as the percentage of the unimproved
cases is respectively 55.4, 75 and 60 per cent.
Our data do not correspond entirely with those of other authors.
Gerstmann, for instance, found that the highest percentage of remis-
sions is found in the simple demented type and in the cases of tabo-
paresis. Conversely, Kirschbaum states that the demented type
offers the smallest percentage of the remissions, whereas the manics
are those who contribute largely to the good remissions. Pilcz states
the best results are obtained in cases of the maniacal form, and in
TA ee VATARIA TREATMENT OF GENERAL PARESIS © 239
the simple demented type, the hypochondriacal, presenile, and cata-
tonic forms of the disease offering a less favorable prognosis. Herzig
and Jossmann and Steenaerts also claim that the manic patients are
the ones most influenced by the treatment, while the simple dement-
ing type, according to the two latter authors, show the most unfavor-
able results. The data given by Fleck are as follows: Remissions:
18.8 per cent of the dementing type, 62.5 per cent of the expansive
type. Unimproved: 33.3 per cent of the expansive type, 59.3 per
cent of the dementing type. According to Bunker and Kirby, 12
per cent of cases of the simple demented type achieved full remis-
sions, whereas 55 per cent of the expansive type and 67 per cent of
the manic type attained therapeutic results.
k * 2 * x x
As the age factor has been considered by some authors as being
.of importance in the prognosis of the treatment, we have in the fol-
lowing table divided all the patients successfully inoculated according
to their age at the time of the treatment:
TABLE 1X
Division of the malaria treated cases according to the age of the patient
Result AGE
NN EEE ES ————E—E————eE—eEEeEEE——————————————EE
ment 15-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 66-70
Very good
remissions 1 9 yi, 5 5 2 1 1
Partial
remissions 1 5 9 7} vi 4
Slight im-
provement 2 5 3 1
Unimproved 2 7 5 5 TZ 6 5 3
Although the results are not very striking, it can, however, be
seen from this table that the greatest number of very good remissions
are found between 26 and 40 years. In fact, twenty-one of the
thirty-one cases are between these two ages, sixteen (more than 50
per cent) being between 26 and 35. The same can be said of the
partial remission cases, as twenty-one of the thirty-three improved
cases are from 26 to 40 years, fourteen (42.42 per cent) being
between 26 and 35 years. If we consider now the proportion of
the unimproved cases which are between 26 and 40 years, we find
this proportion to be lower than for the cases in the first two cate-
gories: 55 per cent as compared with 69.69 per cent of the partial
remission and 67.2 per cent of the very good remissions. On the
other hand, twenty-six out of the forty of the unimproved series are
240 ANFERRARO- AND Wie CeG ONG
between 36 and 55 years, viz., 65 per cent as compared with 41.6
per cent of the very good remissions and 54.54 per cent of the partial
remissions cases.
On the whole, it would seem that the older the patient is the less
probability there is of benefit from the malaria treatment. Impressed
by these facts, some authors, as Jansen and Hutter, suggest that
patients over 55 years of age should not be treated.
Another point of interest is the result of the treatment as com-
pared with the duration of the disease before the malaria treatment.
Some foreign authors are inclined to attribute considerable impor-
tance to the time factor that has elapsed between the onset of the
disease and the date of malaria inoculation. Among the many, Joss-
mann and Steenaerts, Gerstmann, Kirschbaum, Fleck, Lilly, and
Bering have especially emphasized this point. According to Lilly,
it is probable that cases exhibiting a long history of mental symptoms
are not so likely to improve as those whose disease is of more recent
origin, although a patient with a short history has not necessarily a
hopeful prognosis. The degree of mental abnormality at the time
of treatment is no criterion of what is likely to happen after the
malarial fever.
The accompanying table shows the number of cases in each cate-
gory divided according to duration of the disease before the treatment. —
In a few cases it has been impossible to establish the exact time of
the onset of the disease. We have considered as the onset the
appearance of the first abnormal signs in the mental activity of the
patient, as reported by the relatives, the date of admission to this
institution being an unreliable factor.
TARDE &
Result of treatment as compared with the duration of the disease
before treatment
Duration of disease before the malaria treatment
Result Within Within Within Within Within More
of treat- first 12 18 24 36 than
ment 6 months months months) months months 3 years
Very good
remissions 5 4 5 8 4 2
Partial
remissions 4 i 5) 5 5 8
Slight im-
provement 0 4 1 z 0 3
Unimproved 9 1 2 10 Z 16
THE MALARIA TREATMENT OF GENERAL PARESIS 241
Table X shows that while cases in the very good remission class
treated within the first eighteen months following the onset of the
disease represent 47.6 per cent of the entire series, the partial remis-
sions series represent 46.2 per cent, while the unimproved represent
only 30 per cent of the cases.
On the other hand (and here the results are more striking), while
the cases successfully treated three years or more after the onset of
the disease represent 15 per cent of the very good and partial remis-
sions cases, those unsuccessfully treated after three years from the
onset of the disease represent 40 per cent of the entire series. If
we consider now all the cases of two or more than two years dura-
tion, we find that these cases represent 40 per cent of the very
good remissions and 70 per cent of the unimproved.series. From
this table we may conclude that the old standing cases (over two
years) offer less probability of successful treatment with the malaria
inoculation.
We cannot quite agree with the conclusions of Nyiro-Gyula and
Sandor Stief that none of the incipient cases treated within the first
six months fail to show remission.
Comparing now the result of the treatment with the time elapsing
from the date of malaria inoculation, we find the following data:
Pen hr
Result of treatment
Time of Very good Partial Slight Un-
inoculation remissions remissions improvement improved
More than 3 years before 13 2
18-24 months before.... 6 8 Is 13
12-18 months before.... 2 Zz 1 &
6-12 months before.... 9 9 * 7
xf x x x x 2 x
How long do remissions persist? .This point is of real practical
interest inasmuch as it might be argued that remissions following
malaria therapy are of short duration and that relapses might easily
occur, as in the cases of spontaneous remissions.
DEE eg OY Se Gp |
Duration of remissions (very good and partial remissions cases)
6-12 1228 19-24 25-36 * More than 36
months months months months months
18 4 14 2 24
242 AN PERRAKOAN DT HCA rn G
Table XII shows that the duration of remissions is surprisingly
long when we consider that twenty-four of the cases show a remission
lasting now more than three years, while forty-three show a remission
of almost two years or longer.
What is the average percentage of spontaneous remissions in
general paresis? In the Hamburg clinic, over a period of eight
years of admissions, the average as reported by Kirschbaum was 11
per cent. Tophoff found that the occurrence of spontaneous remis-
sions in general paresis was only 4.8 per cent with the very good
remissions and 14.9 per cent with partial remissions. W. Raynor,
covering a period from July, 1911, to June, 1918, during which 1,004
paretics entered the Manhattan State Hospital, found a total number
of eighty-five patients who were improved, thirty-three of which had
good remissions. The author concludes that spontaneous remissions
in patients with untreated cases of G.P. occur, but are not frequent,
and that at least in more than one-half of the cases they are not
permanent.
Furman, who has studied the occurrence of remissions in the
usual treated cases of G.P., has found that in 503 patients only
twenty-one showed spontaneous remissions, viz., almost 4.2 per cent.
The percentage of spontaneous remissions in G.P. as given by
different authors are: Acker (1888), 14.3 per cent; Behr (1900),
4.08 per cent; Hoppe (1901), 16.8 per cent; Gaupp (1903), 10 per
cent; Pilcz (1908), 21 per cent; Joachim (1912), 4 per centyeipiis
(1916), 13.5 per cent; Kirschbaum (1923), 11 per cent. Comparing
these percentages with those of our results, we find that the total
percentage improvement in our cases amounts to 61.45 per cent, 53.12
per cent of which show real appreciable remission.
If we now consider the duration of the remissions in our malaria
treated cases with the duration of spontaneous remissions as given
by Raynor, we see that the author reports nineteen deaths in thirty-
three cases, showing very good remissions. Of these nineteen, thir- —
teen died within the first year of remission, one after three years, one
after four, one after five, one after seven, and one after eight years.
In our series of thirty-one cases of very good remissions, none died,
seventeen of them show a remission of more than two years, and
fourteen a remission of more than three years. Of the thirty-three
partial remissions cases, only four have died, one thirteen months
after the treatment, one seventeen months after from a ruptured
aneurysm, one twelve months after from sepsis following a prostatic
abscess, and one twenty-nine months later from paresis and broncho-
pneumonia. , % < x x * X*
THE MALARIA TREATMENT OF GENERAL PARESIS 243
Has the treatment any influence at all on the unimproved cases?
Even in these cases the beneficial influence of the malaria treatment
can be noticed as it seems to us that the treatment, as a rule, prolongs
the life of the patients. In fact, if we take into consideration only
the unimproved cases who have received malaria treatment in 1923,
more than three years ago, we find that of the fifteen patients only
four have died. Of the remaining, the duration of the disease,
including both the periods previous and following the malaria treat-
ment, 1s reported in the accompanying table.
Ais Bld, 2.05 gl
Total duration of the disease in the unimproved cases.
Duration of the disease Duration of the disease Total duration
before the malaria treatment following the treatment of the disease
6 months 41 months 47 months
“c“ 4? (79 45 6é
# “c“‘ 45 6c 48 6é
60 : 40 a 100 %
48 4] = 89 *
5 ce 39 ce 44 ce
48 ; 40 pe 88 <
24 a 38 « 62 “
48 > 40 $i 88 .
il 6é 40 “ce 41 6c
60 40 * 100 “f
It may be seen from Table XIII that the duration of the disease
is increased, the patient living longer than 2-3 years, this being the
average period of life for untreated cases of G.P. It must be added,
however, that these patients although unimproved from the mental
point of view, have on many occasions exhibited certain degrees of
physical improvement or have been stationary.
Is there any parallelism or relationship between the result of
the treatment from the clinical point of view and the number of
paroxysms experienced by the patient? Table XIV shows the per-
centage of improvement or unimprovement as compared with the
average number of chills.
TABLESALV
Relationship between clinical results and number of paroxysms
Number of chills
Result of treatment 1-6 7-12 13-18 More than 18
Very good remissions 3 eh EVA s 15 S12 % 1 e290
Pertial remissions °° 3" ‘ Se 24 24% 1-195 257.52 3. 9.09%
Slight improvement 2 22.2% Zee i eas
Unimproved 8 Tee 2 iaoe 19 47.5% 1 2.5%
244 A; FERRARO AND I. CoC) FONG
From this table, the only striking point is the large percentage
of unimproved cases who have had from 1 to 6 chills. While the
percentage of the very good remissions and improved cases who have
had from 1 to 6 chills are respectively 9.6 per cent and 9.09 per cent,
the percentage of the unimproved cases who have had only a few
chills is higher, viz., 20 per cent. The percentage of unimproved
cases who have had from 13 to 18 chills is slightly less than the
number of very good remissions, but is evidently lower than the
partial remissions cases who had the same number of chills.
Comparing now the clinical result of the treatment with the
highest temperature reached during the paroxysms, the following
results were found.
TAB Rex
Relationship between the clinical results and the highest temperature
Result of Highest temperature
treatment 103 104 105 106 107
Very good
Pata aee 4131690: A ORO Ton meGe eee 9 30:69 7/4 eae
artia
remissions Lima leo 9.3% 9 27.9% 15 46.599 aie
Slightly
3
12.5% 4 50% BST e096
2 13% 18 .46.48% 12 31.2% | Lo zeeee
improved
1
Unimproved, °22. 5.2%
The point revealed in this table is the high percentage of cases
showing good or partial remissions, those having highest temperature
showing greater improvement. In fact, the unimproved cases who
have had a rise in temperature of 106° and 107° were only 33.8
per cent of the unimproved series. The good and partial remissions
cases who had the same rise reached respectively 44.2 per cent and
58.9 per cent of the total cases of the series.
Unfortunately, we have no complete record of the duration of
fever in terms of number of hours during which a given height of
temperature was maintained so that we cannot add to the contribu-
tions of Kirby and Bunker, who have taken into consideration the
relation of height and duration of fever to the clinical outcomes
of malaria treatment.
SEROLOGICAL CHANGES FOLLOWING THE MALARIA TREATMENT
In a previous paper we discussed in full detail the serological
changes following the malaria treatment in general paresis.
We studied ninety-three cases who had several spinal punctures
following the malaria inoculation and divided them according to the
THE MALARIA TREATMENT OF GENERAL PARESIS — 245
time elapsing from the malaria treatment. The following table taken
from our previous work shows the serological changes as_ they
occurred in periods varying from six months to three years following
the malaria treatment.
BN Be Vek
Serological changes following malaria treatment
Blood Cerebrospinal fluid
Number ee $$$
of Time Colloidal
cases intervals Wassermann Wassermann Cells Globulin Gold
25 Within 6 months
Unchanged bl 20 8 8 20
Improved 7 4 12 14 5
Negative 7 ] 5 + 0
14 Within 12 months
Unchanged 5 5 7 4 7
Improved 4 6 3 8 7
Negative i 3 4 2 0
20 Within 18 months
Unchanged 3 6 5 8 8
Improved 6 7 10 10 iz
Negative 11 tj 5 2 0
11 Within 24 months
Unchanged 0 0 0 5 1
Improved 1 o 6 5 10
Negative 10 6 5 t 0
23 Within 36 months
Unchanged Pa 2 1 4 3
Improved 1 5 6 5 10
Negative 20 16 12 7 2
In order to establish a percentage of the improvement in relation
to the time elapsing from the malaria treatment to the last spinal
puncture performed, we have not included cases of less than a
month’s duration, but have included the cases of eighteen months’
standing in the series of twelve and twenty-four months. The
results so obtained are the following:
§ Serologically improved, 3: 15%
Serologically unchanged, 17: 85%
Serologically improved, 8: 36.32%
Serologically unchanged, 14: 63.68%
Serologically improved, 8: 52.8%
Serologically unchanged, 7: 47.2%
Serologically improved, 25: 86%
Serologically unchanged, 4: 14%
Within 6 months: 20 cases
Within 12 months: 22 cases
Within 24 months: 15 cases
Within 36 months: 29 cases
These figures show that the percentage of serological improve-
ment increases grossly from a minimum of 15 per cent within the first
six months to a maximum of 86 per cent after a period of three years.
246 AD PERRAKROQ CAND I AGe Co PONG
The period that has elapsed from the date of the malaria inoculation
to the time of the last spinal puncture is then very important and
certainly explains the discrepancies of our results compared with
those reported by other authors who have neglected the time factor.
Analyzing the result of our findings in the cases of thirty-six
months’ duration, we see the astonishing serological findings in both
the blood and the cerebrospinal fluid. In fact, twenty of the twenty-
three cases reported in Table XVI show negative blood Wassermann
and sixteen negative spinal fluid Wassermann. ‘The cell count
became normal in twelve of the twenty-three cases and the globulin
negative in three of them. ‘The colloidal gold improved in twenty
cases, being negative in two and changing from a paretic type into
a syphilitic type in the others.
More accurate details will be found in our previous paper. How-
ever, it seems useful to report some of the conclusions we arrived
at in our investigations:
(a) The first serological element which improves following the
malaria treatment is the pleocytosis, which is reduced within a few
days following the treatment. Of the cases of more than twenty-
four months’ standing 95.7 per cent show great improvement, while
50 per cent show a complete reversal to the normal number of cells.
(b) The globulin content, although gradually improving, shows
less pronounced changes than the cell content.
(c) The Wassermann reaction of the cerebrospinal fluid is third
in order of improvement. ‘The rate of improvement within the first
six months is 20 per cent, increasing to 90 per cent within thirty-six
months; 68 per cent of the cases of thirty-six months’ standing
show a complete negative reaction.
(d) The colloidal gold reaction is the element most resistive to
the treatment, as within twelve months only twelve of the thirty-nine
cases show signs of improvement. ‘The improvement then increases
gradually although the reversal to an absolute normal curve is rare.
(e) The blood Wassermann rapidly improves and within the
first six months 28 per cent of the cases already show a negative
reaction. After thirty-six months the percentage reaches 86.
(f{) No parallelism was found between the serological improve-
ment and the maximum of temperature, while parallelism is evident
between the number of chills and the percentage of improved cases.
Comparing, in a series of cases, the clinical with the serological
improvement, we found that in the early stages there is absolutely no
parallelism between the clinical and the serological improvement. But
as time elapses, a higher correlation may be noticed, and within
THE MALARIA TREATMENT OF GENERAL PARESIS 247
twenty-four months following the malaria treatment the percentage
of the improved cases, both from the serological and clinical point of
view, 1s practically the same. Within thirty-six months the parallel-
ism is still more striking, as all the clinically improved cases have
also improved serologically. But, conversely, not all the serologically
improved cases show clinical improvement. A comparative -percen-
tage of the clinical and serological improvement as reported in our
paper on the serology shows that the clinical improvement is 61.2
per cent, as compared with 36.32 per cent of the serological improve-
ment. The percentage is highly modified in the subsequent period, as
within thirty-six months the cases clinically improved represent 65.2
per cent, as compared with 85 per cent of the serologically improved.
There is then no absolute parallelism existing between the clinical
and the serological improvement, even in the later period. But while
in the earlier stages the lack of parallelism is absolute, in the later
period a partial parallelism exists in the sense that all our improved
cases from the clinical point of view show a concomitant serological
improvement.
From the clinical point of view, we will now consider some
changes in the mental reactions following malaria treatment. Gerst-
mann has called attention to this special subject in a careful study
of the acute transitory or permanent changes following this new
method of treatment.
Some of the reactions immediately follow the onset of the
paroxysms, assuming the type of the “ amentia ” which occasionally
accompanies infectious diseases. At other times the reaction is that
of a simple delirium accompanied by hallucinations, and finally at
others the mental reaction is that of a precox type with hallucinations
and paranoid ideas. These mental reactions may last a long time,
and in these cases the patients even show typical catatonic and
manneristic symptoms.
We have no data concerning the mental reactions in the acute
stage of malaria, but in our series of 126 cases we have found four
patients who, following the malaria infection, have developed typical
precox reactions with auditory hallucinations, paranoid ideas, man-°
nerisms, and a more or less pronounced negativism. ‘The clinical
picture presented by these patients would certainly cause an error of
diagnosis if the previous history and serology were unknown. A
detailed study of these cases will form the subject of a separate note.
At present we wish only to call attention to these schizoid reactions
which may constitute a clue for research on the relationship between
svphilis and a few cases of dementia precox.
248 AN FERRARO VANDEL C. TONG
Neurological Changes Following the Malaria Treatment
Not all the treated patients have been considered from this point
of view, as in their records not all the patients have satisfactory notes
regarding their neurological conditions before the malaria treat-
ment. Our data comprises only those cases which have been carefully
examined from the neurological point of view preceding and fol-
lowing treatment. |
Pupils: Table XVII, on page 249, shows the modifications occur-
ring in the pupillary reactions divided as to the results obtained by
treatment.
Of the thirteen cases of the very good remissions, showing slug-
gish reaction to light before the malaria treatment, only one case
has manifested improvement, the reaction to light in this case becom-
ing normal. On the other hand, another case with sluggish reaction
lost all reaction, the pupils being immobile following the treatment.
The reaction to accommodation seems to be more susceptible to influ-
ence, as out of the ten sluggish reactions four improved, acquiring
again a normal reaction, while only one became aggravated.
No appreciable modification in the regularity of the pupils fol-
lowed the treatment, and the same held true for the equality. There
is rather a tendency to aggravation, as in two cases with equal pupils
an aniscoria was recently noticed.
In the partial remission group no record of improvement is
reported as regards the reaction to light and accommodation, nor is
there for the regularity. In this series, also, one of the cases with
equal pupils showed aniscoria following the malaria treatment.
In the unimproved series, the reaction to light became worse in
two cases and the reaction to accommodation worse in one case.
Two of the cases even lost their previous equality.
Deep Reflexes of the Upper Extremities
(a) Radial. In the very good remission series, two cases show-
ing hyperactive radial reflex and one showing sluggish radial reflex
reversed to normal following the treatment, while of the partial
remission series only one of the hyperactive group reversed to
normal and another became sluggish. Of the unimproved series,
three of the normal cases became sluggish during the further course
of the disease.
(b) Cubital. In the very good remission series, two cases have
shown improvement reverting to normal from a previous hyperactive
249
THE MALARIA TREATMENT OF GENERAL PARESIS
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250 As PERRAKOGAN DG Cr re
condition. Conversely, however, two of the hyperactive became
sluggish. In.the partial remission cases one case reverted to normal,
while another changed from hyperactive into sluggish condition.
In the unimproved series, two cases reverted from a normal reaction
to a sluggish one.
(c) Bicipital. The bicipital reflex improved in one case of the
very good remission series, while it became worse in the partial
remission series, changing from a normal condition into one of slug-
eishness. ‘The same changes occurred in two of the cases of the
unimproved series.
(d) Tvictpital. Improvement has been noticed in one case of the
very good remission series, while one case of the same series changed
from a condition of hyperactivity into one of sluggishness. In the
partial remission series, three cases changed from hyperactive into
a sluggish condition, while one case improved, the reflex being slug-
eish, whereas before the treatment it was absent. In the unimproved
series two cases changed from a normal condition into a pathological
one (hyperactive and sluggish).
In terms of percentage, the changes occurring in these reflexes
following the malaria treatment may be rated in this way: Unim-
proved series: Aggravation of the previous conditions: Radial
reflex in 75 per cent of the normal cases, cubital reflex in 50 per cent,
bicipital and tricipital, respectively, 66 per cent of the cases. Very
good and partial remission cases: Improvement of the rada‘l reflex:
18.75 per cent for the good remission series and 7.6 per cent for the
partial remission series. Improvement of the cubital reflex was
respectively 12.6 per cent and 7.6 per cent for each of the good and
partial remission series. Improvement of the bicipital reflex: 5.8
per cent for the very good remission series. Improvement of the
tricipital reflex: respectively, 5.8 per cent and O per cent. Con-
versely, there is an aggravation of the bicipital reflex in 33 per cent
of the partial remission cases.
These figures show that while there is an evident, although slight,
tendency toward improvement of these neurological conditions in
the cases of the very good remissions as well as of the partial remis-
sion series, a comparatively high percentage of aggravation is seen in
the series of the unimproved cases.
Deep Reflexes of the Lower Extremities
(a) Knee jerks. In the very good remission series two of the
previous normal cases showed sluggish reaction, while one case lost
NEPAL ARIA TREATMENT Of GENERAL PARESTIS 251
the reflexes which were present previous to the malaria treatment. In
the partial remission series, one case lost the previously normal reac-
tion, while two others of the hyperactive group became respectively
sluggish and absent. No changes were noticed in the unimproved
"series.
(b) Ankle jerks. Three of the normal cases belonging to the
very good remission series and one belonging to the partial remission
cases lost their previously normal reflexes. In the unimproved series
three cases changed from a normal into a sluggish reflex.
In terms of percentage, we see that 75 per cent of the normal
cases of the very good remission series show an aggravation of the
condition of the knee jerks and 50 per cent an aggravation of the
ankle jerks. Twenty per cent of the normal cases of the partial
remission series show the same aggravation of the knee jerk reflexes
and 42.6 per cent of the ankle jerk. Conversely, no aggravation has
been noticed in the unimproved series in regard to the knee jerk,
while 50 per cent of this same series show an aggravation of the
ankle jerks. :
The percentage of aggravation of the ankle jerk is then slightly
higher in the unimproved series than in the partial remission cases.
Superficial Reflexes
Abdominals. In the very good remission series these reflexes in
three of the normal cases became sluggish. In the partial remission
series, two of the normal cases became sluggish in their reaction,
while in one the previously normal reflexes disappeared. In the
unimproved series two cases changed from normal to sluggish in
their reactions.
Cremasteric reflexes. Two of the hyperactive cases belonging to
the very good remission series reverted to a normal condition, while
three of the partial remission series changed from a normal condition
into a condition of sluggishness. Of the unimproved series four
cases changed from normal to sluggish.
Plantar. The only change in regard to this reflex was found in
the unimproved series, in one case of which the normal response to
plantar stimulation was lost.
In terms of percentage, 42.6 per cent of the normal cases of the
very good remissions, as well as of the partial remission series, have
shown aggravation of the abdominal reflexes, while 33 per cent of
the unimproved series have shown the same changes. ~
Of the cremasteric reflexes, 27 per cent of the very good remis-
sion series have shown an improvement, while 33 per cent of the
252 A. FERRARO AWN De?) CaO On
partial remission cases and 66.6 per cent of the unimproved cases
showed an aggravation of the condition.
Of the plantar reflex, 10 per cent of the unimproved series have
shown a condition of aggravation.
Babinski sign. In the very good remission series, two cases -
showed Babinski sign previous to the malaria treatment, but in one
the pathological reflex was afterwards lost. The Babinski sign also
disappeared in the four cases of the partial remission series, as well
as in the only one of the unimproved series in which the reflex was
present previous to the treatment. ,
Coordination. ‘This test shows a marked improvement in the
very good remission series, as all the six impaired cases have shown
a reversal to the normal condition (100 per cent). In the partial
remission series the three impaired cases have shown the same
changes (100 per cent), while in the unimproved series one of the
three cases became aggravated (33 per cent).
Ataxia. There was improvement in both cases of the very good
and partial remissions (100 per cent).
Tremors. The facial tremor, as well as the tremor of the
extremities, have been markedly influenced by the malaria treatment,
as seven of the fifteen cases (46.2 per cent) of the very good remis-
sion series, three of the thirteen cases (22.8 per cent) of the partial
remission series, and four of the unimproved series (36.04 per cent)
have shown a disappearance of the tremors which were present prior
to the malaria treatment.
Speech defect. The typical speech defect of general paresis was
also evidently influenced, as this trouble has disappeared in nineteen
of the very good remission series (77.9 per cent) and in eleven of
the partial remission cases (47.5 per cent).
Seizures. The seizures have disappeared in both cases of the
very good remission series, while in three out of the four cases of
the partial remission series no marked influence on the seizures has
been. noticed. ;
Focal lesions (Cranial nerve involvement—pyramidal or extra-
pyramidal signs). The focal lesions have been beneficially influenced
in only one of the two cases belonging to the very good remission
series. ,
From the results of these data, there can be seen that no defini‘e
conclusions can be drawn, as the improvement in the neurological
conditions are noticed in the unimproved series as well as in the
THE MALARIA TREATMENT OF GENERAL PARESIS. 253
improved cases and in those with very good remissions. On the
other hand, an aggravation in some of the neurological conditions
can be also seen in the partial and even in the very good remission
cases, while on the whole there is a tendency toward improvement
following the malaria treatment.
Among the neurological signs showing the most marked improve-
ment in the course of the malaria treatment are the speech defect,
the coordination test, and the tremors. The convulsions are appar-
ently uninfluenced, our data disagreeing with those of certain German
authors.
Weight. From a general point of view we have noticed in many
of our patients a gain in weight which sometimes has been consider-
able. We do not agree with G. M. de Rudolph, who found that in
the majority of patients the weight remained stationary. Our data
agree much more with those of Bunker, who found a gain in weight
in 80 per cent of his cases above the pretreatment level. Unfortu-
nately, we cannot discuss the weight factor as a prognostic indicator
as our data bearing on this topic are not sufficiently complete.
How does malaria act? This question has been debated at length,
but no satisfactory answer has as yet been furnished. Many authors
claim the rise in temperature is the real factor responsible for the
beneficial reactions. The organism of the patient responds to the
rise of temperature by humoral diffuse changes which permit a more
successful fight against the disease. The exact mode of action of
the high temperature is, however, unknown. Weichbrodt and
Jahnel, on the basis of their experiments, have found that by placing
a rabbit infected with syphilis in an oven at a temperature of from
107.6° to 110° F. (42-43 C.) for an hour, and repeating this not
less than three times, a complete disappearance and death of spiro-
chetes present in the scrotal chancre of the animal resulted. It is
known, on the other hand, that the spirochete fails to grow at a
temperature from 104° to 106° F. (40 to 41 C.).
In the course of our investigations, we have found that from the
serological standpoint a parallelism exists between the number of
chills and the improvement. Thus we are inclined to believe that
the temperature presumably plays an important role in determining
the disappearance of the spirochetes, as well as in influencing the
inflammatory changes.
254 A, PERKARO CAND We Gi NG
Some other authors believe that a sort of antagonism exists
between the malaria parasite and the spirochete of the G.P. But
whether or not the antagonism is directly or indirectly produced by
antibodies which are injurious to the spirochete is still a debatable
question. It is a fact, however, that in malarial regions the percen-
tage of syphilitics becoming paretics is very low. Bercovitz, for
instance, reports that in Hainan (China) 90 per cent of the popula-
tion is infected with malaria, syphilis is practically universal, and
yet in eight years he has not seen a case of G.P. and only two or
three of tabes. De Bellard (Gazette med. de Caracas, 1925), who
sees On an average of one thousand patients a month, 50 per cent of
whom have syphilis, has as yet never encountered a case of G.P.
In Sardinia (Italy), which is still a markedly malaria infested
region, the number of paretics seen at the clinic of the Nervous and
Mental Diseases of the University of Sassari or in the local insane
asylum is really surprisingly low as compared with those found in
other regions, and the type of paresis appears to be quite different
from the classic expansive or manic type, the patients being usually
of the simple demented type.
The idea of an immunity reaction due to malaria has been
advanced by Plaut, Kirschbaum, and recently accepted by others,
among them Wizel and Prussak. Following the same line of thought,
Veichbrodt infected a paretic patient simultaneously with malaria
and relapsing fever. This latter infection did not become manifest
until after the malaria had been cured with quinine. The author
thinks then that a similar depressive immunity may be the explana-
tion of the action of the malaria treatment on general paresis. _
Other authors believe that the favorable results obtained by the
malaria treatment are due to the leucocytosis which follows the infec-
tion. However, Weichbrodt and Jahnel disregard this view, as they
report that in some cases of typhoid fever, for instance, which pro-
duces a leucopenia instead of a leucocytosis, there has at times been
exerted a favorable influence on the course of the general paralysis.
Besides the already mentioned factors, Bunker and Kirby are
unable to divest themselves of the impression that a satisfactory out-
come in the treatment of general paralysis may depend not only o1
_ the absence of irreparable and irrevocable anatomic changes, but also
on the capacity of the organism to react to the stimulation which the
malaria treatment as apparently a form of foreign protein therapy
is potentially capable of furnishing: the absence of such response
THE MALARIA TREATMENT OF GENERAL PARESIS = 255
rendering impossible in certain cases this mental improvement, which
the organic damages alone might have not precluded.
BUbeloOGRAPHY
E, Aguglia e E. d’Abundo. Tentativi di terapia con innesti di malaria
terzana nella p. p e nelle sindrom: parkinsoniane. Rivista Italiana di
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E. Artwinski. Uber die Behandlung der progressivon Paralyse mit
Malaria. Polska Gaseta lekarska, Jg. 3,.No. 5, 1924, p. 800.
V. Askgaard. Vorlaufige Resultate ein jahriger Malariabehandlung von
Paralytikern. Ugeskriit F. laeger, Jz. 86, No. 15, 1924, p. 307.
G Barzilai-Vivaldi und O. Kauders. -Die Impf. Malaria experimentell
durch Anophelen nicht tbertragbar. Wiener Klinische Wochen-
schrift, No. 41, 1924, p. 1055.
Bering. Discussion on the paper of M. Nonne: Die Behandlung der Spat
und Metalues. Allgemeine Zeitschrift fir Psychiatrie, Bd. 81, 1925,
p. 141.
W. Bohnig. Uber die Fieberbehandlung der progressiven Paralyse durch
Milchinjection. -Archiv. fur Psychiatrie, Bd. 71, 1924, p. 701.
G..Bosch and A. No. Malaria Treatment of General Paresis. Semana
Medica, 1926, p. 25.
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THE EXPERIMENTAL STUDY OF PACHYMENINGUTES
HEMORRHAGICA *
By Tracy JAcKson Putnam, M.D.
AND
{RMA KELLERS Putnam, M.D.
OF BOSTON, MASS.
Definition and Terminology: The term pachymeningitis hemor-
rhagica interna has been used rather loosely to designate various:
types of hemorrhagic exudation on the inner surface of the dura
mater. Virchow (17), who introduced the name, employed it to:
describe a progressive lesion, in which the formation of a very vascu-
lar subdural membrane was apparently followed by larger or smaller
ecchymoses, or by a subdural hematoma. In the cases which he
studied, there was no history of trauma, and no definite evidence of
‘a preceding hemorrhage, so that he believed the process represented
the organization of an inflammatory fibrinous exudate. ‘This inter-
pretation of the histological appearances has been questioned by other
' observers, and a large number of cases has been reported in which a.
somewhat similar histological and clinical picture has been the
undoubted result of trauma to the head. The subject has been
reviewed at length in a recent paper, from the clinical, surgical and
pathological point of view (12). In general, two chief types of
hemorrhagic membrane are seen. In one, the nontraumatic, idio-
pathic, or vascular type, the membrane is composed of a network of
large blood vessels, which have the structure of capillaries, although
they may reach a diameter of 40 micra or more. Such membranes
are frequently seen in chronic alcoholics and in the insane, without.
a history of trauma. The rarer type, sometimes called traumatic,.
but-perhaps better reactive, is oftenest seen following injury to the
head, and is characterized histologically by the presence of irregular
giant capillaries”
a3
blood-filled spaces, much larger than the
described above, which anastomose with each other and with the:
apparently normal capillaries seen elsewhere in the neomembrane..
The reactive type of membrane is apparently always preceded by a
subdural hemorrhage, but the vascular type may be found either with.
* From the Laboratory of Surgical Research, Harvard Medical School.
[260]
STUDY OF PACHYMENINGITIS HEMORRHAGICA 261
or without hemorrhage. Both are remarkable clinically for the
reason that a well-developed and apparently old lesion may be
found at operation or autopsy on a patient whose symptoms are
of very recent date. Illustrations of both types of membranes, and
further particulars concerning them, are given in the paper just
referred to (12).
Other types of subdural membrane are seen, but need not be con-
sidered here.
Methods of Study: In addition to pathological, clinical and sur-
gical studies of subdural membranes, a number of attempts have been
made to elucidate the mechanism of their formation by experimental
means. The simplest and most obvious experiment is the subdural
injection of blood or of irritating substances. A similar means of
investigation is the examination of a series of duras from patients
dying at various intervals of time after intracranial operations.
Finally, the frequent concurrence of pachymeningitis and chronic
alcoholism has suggested the study of the duras of animals fed
alcohol over long periods.
The Subdural Injection of Blood: This experiment was first
tried by Serres (15) in 1819. He tore the longitudinal sinus sub-
durally, and found that the animals developed convulsions and hem1-
plegia within a few hours, and when they were sacrificed a day or
so later, a mass of fluid blood contained in a fibrinous sac was found
adherent to the dura. Similar experiments were performed by
Laborde (6) and Wilks (19), but in none of these cases was there
any histological examination.
The most important experiments were those of Sperling (16). In
his experiments, performed apparently without particular regard to
asepsis, he rongeured away the skull of rabbits, and injected blood
beneath the dura with a syringe and blunt needle. He states that
injury to the arachnoid was avoided because the dura was bulged out
by fluid; it is possible, therefore, that his cannula was sometimes
subarachnoid rather than subdural. The wounds seldom suppurated,
and when the animal was sacrificed a few days to a month later, in
almost every case the inner surface of the dura was covered by a thin
brown membrane which was vascular. The author gives no illustra-
tion of the membrane and it is not possible to be sure from his
description whether the appearances he found coincided with those
seen in human cases or not. His experiments were repeated by
van Vleuten (18) who was already committed to the .opinion that
traumatic subdural effusions did not lead to a hemorrhagic pachy-
meningitis. Van Vleuten’s experiments were conducted under aseptic
262 T. J: PUTNAM AND Ie Roi Ua ae,
conditions, and he found the subdural injection of blood was some-
times followed by the formation of a membrane. He states that the
same result was seen, however, after simple trephining, without
injury to the dura, and denies that the pachymeningitis was produced
by the blood. He also fails to illustrate or describe the microscopic
appearances produced. The same criticism may be directed at the
experiments of Marie, Roussy, and Laroche (9), in which the injec-
tion of blood alone failed to reproduce a pachymeningitis 1n nine
animals. Injection of blood and an irritating mixture of fatty acids
produced a laminated hemorrhage in one animal and thickening of
the dura in several others; but no histological descriptions are given,
and the operative technique is described only briefly. As may be
seen below, similar gross appearances can be produced by the sub-
dural injection of blood alone, in a comparable proportion of cases,
and it does not seem necessary to suppose that the fatty-acid mixture
had much to do with the result.
Repetition of Previous Experiments: As similar experiments
have led to diametrically opposite conclusions in the hands of various
observers, it seemed worth while to repeat them under as rigid
control as possible.
Technique: Fifteen cats and three dogs were operated upon.
One cat and one dog succumbed the day of the operation, and may be
excluded from the series.
The operative procedure was essentially the same in all cases.
Ether was used as anesthetic. The temporal muscle was turned down
from its origin and a trephine opening 1 to 2 cm. in diameter was
drilled-in the angle between longitudinal and transverse sinus. Blood
was sucked from the wound with a 1 or 2 c.c. paraffined syringe. A
19 gauge needle was fitted to the syringe, and its point inserted
obliquely through the dura. In three cases at least, and perhaps in
others, the needle was inserted into or through the arachnoid, and no
trace of the blood was found subdurally at autopsy, but only an
adhesion of the dura to the cortex. This is a point where mistakes
are~ easily made and they may explain some of the discrepancies
between previous reports. The blood was injected as promptly as
possible, causing the dura to bulge through the trephine opening.
Sometimes the needle-hole had to be plugged with muscle to prevent
the blood from escaping, as it would spurt out with some force if not
clotted. The wound was closed carefully in layers. In spite of pre-
cautions, several of the animals became infected. This appeared to
make no difference in the lesion produced. They showed no definite
neurological symptoms, and ophthalmoscopic examination revealed
Sty aor PACHY MENINGITIS, HEMORKHAGICA 203
no choked discs. Conjugate deviation of the eyes was seen in one
animal whose cortex had been damaged by the needle.
Owing to the difficulty of keeping fluid blood beneath the dura,
washed fibrin in amounts up to half a gram was inserted through a
tiny slit in some of the later animals. This proved a more satisfac-
tory technique, and the lesions produced were similar. Defibrinated
blood was also injected beneath the dura in several experiments, on
the opposite side of the head from the fibrin. It showed a great
tendency to leak out through the tiniest rent in either arachnoid or
dura, and even when the puncture made by a fine needle was plugged
with a bit of muscle, no trace of the blood could be found at autopsy.
Injection of Subdural Spaces: In several experiments, an attempt
was made to identify the implanted clot or fibrin by mixing it with
Prussian blue or India ink. The resulting histological picture was
not greatly clarified, but a definite injection of the subdural space
occurred. The dye or ink diffuses over the entire hemisphere, but is
arrested at the border of the longitudinal and transverse sinuses, and
along the basal sinuses. None of it crosses the midline or reaches
the tentorium. ‘The ink becomes collected in small aggregations.
The animals were sacrificed at intervals varying from one day to
three months, usually by etherization. Paraffine sections were taken
through the center of the membrane, and stained with hematoxylin or
methylene blue and eosin, and in some cases with Perdrau’s silver
connective tissue stain, and Weigert’s stain for elastic tissue. In
several experiments, a capillary injection with India ink was made
and pieces of dura were cleared by Spalteholtz’ method. In two dogs,
specimens of the membrane were removed at a second operation
seven and eight days after the first, the defect was closed with fascia,
and the animals sacrificed ten and eight days later respectively.
Result of Experiments: In five of the eighteen cases there was
no trace of a membrane, or at most slight injection and roughening
of the dura. In three of these it seemed evident that the blood had
been injected beneath the arachnoid. In all cases, much less clot was
found than might have been expected from the amount of blood intro-
duced. Even the collections of fibrin inserted beneath the dura
appeared to have diminished. The coagulum was always adherent to
the dura, and bound to it by a thin membrane fading out over the
dural surface. Adhesions to the arachnoid were rarely seen.
Microscopic Examination: Within five days after the injection
of blood a thin neomembrane of fibrous tissue covered with meso-
thelium is usually found covering the surface of the clot toward the
arachnoid. Traces of it can still be made out in sections from a cat
264 tf. J. PUTNAM AND TAK EULA
sacrificed fifty days after the injection of blood, but it has begun
to become fused with the organization tissue growing up beneath
it (Fig. 1). The mesothelial covering over a scar is all that is left
of it after three months. It was never found vascularized. The
neomembrane covering the clot is, then, a much less constant and
Fic. 1. A cat was trephined, and 2 c.c. of whole blood were injected
beneath the dura. The animal was sacrificed 50 days later. The section shows
the entire thickness of the dura and subdural membrane (at the top of the
photograph). The free surface of the fibrous scar is covered by a mesothelial
membrane. The boundary between the dura and the new-formed tissue is
marked by an arrow. A series of lined spaces, filled with serum, cells and
debris lies along the dural surface. A small bit of muscle placed to control
operative hemorrhage is seen at the bottom of the picture. Hematoxylin and
eosin. X80.
striking feature of the microscopic picture than that seen in the
human cases, but is perfectly comparable with it.
The clot itself shows the usual regressive changes. Fibrin is laid
down mainly along the surfaces, and in coarse columns traversing the
mass. Rounded spaces are often seen in its meshes. They are
usually empty, but may contain cells or serum.
STUDY OF PACHYMENINGITIS HEMORRHAGICA 265
The distinction between the clot itself and the subdural membrane
of granulation tissue is less definite than in the human cases, where
the two are readily separated. But in animal experiments the clot is
.so thin that it is usually found completely traversed by connective
tissue, if it is organized at all. The membrane is composed of fibrous
tissue whose density increases with its age. Leucocytes or newly
Fic. 2. Specimen removed at secondary operation, 8 days after the subdural
injection of 4 c.c. of blood in a small dog. Tortuous, dilated, thin-walled capil-
laries are invading the thick clot (Cf. Figure 3). Perdrau’s stain. 300.
extravasated red cells are rarely found. Vessels are seldom seen in
specimens taken a week or less after the injection, but coarse, tortu-
ous capillaries were found in a membrane removed at a secondary
operation eight days after the first in one dog. At the second opera-
tion a greenish, gelatinous coagulum about 0.5 cm. .in thickness,
between two thin friable membranes was found beneath the dura.
This lesion resembled that of spontaneous pachymeningitis more than
any of the others produced (Fig. 2). Only a small section of it was
266 Ti J; PUTNAMSAND LR ee UI Aa
removed, but at autopsy 10 days later, it was found firmer, paler,
reduced almost a half in thickness and distinctly less vascular than
before (Fig. 3). Usually the vascularity is not striking (Fig. 4).
An almost constant feature of the experimental subdural mem-
branes is the presence of mesothelial lined spaces, usually empty,
Fic. 3. The same dog from which the previous specimen (Fig. 2) was
taken. The present section was removed at autopsy 9 days after the secondary
operation. Capillary injection with India ink. The tissue is much denser, and
the vessels, filled with ink, are smaller. The lining of a typical empty space in
the center of the photograph is well demonstrated. Hematoxylin and eosin.
X 300.
sometimes containing a little blood or debris (Fig. 1). They are
similar in appearance to some of those seen in human cases, excepting
that they may occur anywhere throughout the membrane, and that
they have not been observed to connect with blood vessels. Ink was
never found in them, even after a successful capillary injection
(Figs. 3 and 4). They appear to occur wherever a pocket of serum,
cells or air is enclosed by fibrin. The fibrin becomes organized and
pi Pea ACHY MENINGITIS -HEMORKHAGICA 267
the space is left. A sort of mesothelium appears to be formed from
the fibrous tissue (Fig. 3). There is sometimes a row of them along
the surface of the dura as in the human cases, suggesting either that
this is a favorite location for such lakes of fluid, or that the dural
mesothelium has something to do with their formation (Fig. 1).
Fic. 4. Specimen removed at autopsy 10 days after the insertion of washed
fibrin beneath the dura of a dog. Capillary injection with India ink. To show
the general appearance of the lined empty spaces, and their relation to the ink-
filled blood-vessels. Dura and capsule not shown. Hematoxylin and eosin.
x80.
Such spaces probably have a special significance in the pathology of
true vascular pachymeningitis. Comparable spaces are rarely found
in hematomas elsewhere in the body, as for example, in those seen
external to the dura.
Bacteria was never found in the sections stained with methylene
blue. The Perdrau connective tissue stain sometimes showed the
presence of fibrous tissue and vessels before it could be detected by
268 T. JOPUTL NAM ANDER aN Ae,
other methods, and demonstrated the fibrous framework of the large
empty spaces. Elastic tissue was never found in the new-formed
membrane, and indeed was seen only in the vessels of the dura.
To sum up, we may say that experimental subdural hematomas
are distinguished from those seen elsewhere by (a) the presence of
a thin mesothelial neomembrane between the clot and the arachnoid,
(b) by rather unusual vascularity in some cases, and (c) by the
presence of large, empty, endothelial-lined spaces. These peculiari-
ties are also seen in traumatic subdural hematomas. Subsequent
spontaneous hemorrhages did not occur in any of the experiments.
It is probable that they do occur in traumatic cases in human beings.
Attempts to: Produce Secondary Hemorrhages in Experimental
Hematomas: In many of the histories of patients with traumatic
hematoma of the dura, the appearance of secondary symptoms
appears to follow some unusual exertion, after a latent period of a
week or longer. Thus, a patient who has been comfortable for two
weeks in bed after a trauma to the head, will develop headaches, con-
vulsions, or hemiparesis on getting up. It is difficult not to suppose
that in such a case a rise of blood pressure with a simultaneous fall
of intracranial pressure has been sufficient to rupture a capillary or
dislodge a small thrombus, as has often been suggested. A reduction
of cerebrospinal pressure can be produced by spinal puncture, or
more conveniently in cats, by the intravenous injection of concen-
trated (30 per cent) saline solution. The latter procedure was the
one employed in three experiments, without, however, producing any
definite change in the condition of the membrane at autopsy a few
hours later. An attempt was also made to raise the blood pressure
in the head by mechanical means, by rotating etherized animals on a
_ turn-table, a method similar to that used by Mendel (10) on dogs,
and by Forel (3) on human subjects. Mendel believed that he pro-
duced a pachymeningitis as well as chronic degenerative changes in
the brain by this maneuver. A subarachnoid hemorrhage occurred
in one of our animals, but no fresh hemorrhage in a hematoma, or
from the under surface of the dura.
Pachymeningitis with small hematomas is sometimes seen during
the course of hemorrhagic diseases, such as pernicious anemia,
leukemia and purpura. Two cats in which experimental subdural
hematomas had been produced were bled, and the blood defibrinated
and reinjected progressively until it came uncoagulable from the
artery; but when sacrificed an hour later, they showed no fresh
hemorrhage in the granulation tissue lining the dura.
The Subdural Injection of Irritating Substances: A considera-
STUDY OF PACHYMENINGITIS HEMORRHAGICA 269
tion of the course and pathology of human cases of pachymeningitis
makes it seem improbable that any local irritant plays a part in its
etiology. A great variety of irritating substances has been injected
subdurally by various experimenters, among whom may be men-
tioned Sperling (16), van Vleuten (18), and Marie, Roussy and
Laroche (9). The injection has almost invariably been followed
either by suppuration or by a fibrous scar and adhesion. Van Vleuten
believed that he produced a mild pachymeningitis by the injection of
acetic acid, but he gives no histological description of it, and evidently
no hematoma was formed. A criticism of the experiment of Marie,
Roussy and Laroche has already been given. It did not seem worth
while to repeat these investigations.
The Fate of Subdural Hemorrhages in Human Beings: Van
Vleuten (18) made a study of the process of organization of subdural
hematomas in patients dying within a few days after a fracture of
the skull. He always found organization. of the clot by tissue which
was usually vascular, but less so than the membrane of spontaneous
pachymeningitis. He found no tendency to progressive hemorrhage,
and observed a fibrous scar at the probable site of a subdural
hematoma in a man dying fourteen years after a trauma to the head.
He mentions the presence of mesothelial-lined spaces and of a meso-
thelial covering over the free surface of the hematoma, but did not
have the opportunity of comparing such membranes with those found
in patients dying after a progression of symptoms following trauma.
He concluded that pachymeningitis did not result from a simple
subdural hemorrhage. Bockmann (2) examined the duras of fifty-
seven patients dying after various intracranial operations in which
blood was presumably extravasated beneath the dura. The patients
died at intervals of.a few hours to two months post-operative; there
was local sepsis in several of the cases. In two cases, the remains of
a hematoma was found, but with little vascularity. He made no men-
tion of lined spaces or of a membrane over the free surface of the
clot. He agreed with van Vleuten in believing that a subdural hemor-
rhage does not lead to pachymeningitis. Neither of these authors
give any illustrations.
Material from the Surgical Service of the Peter Bent Brigham
Hospital afforded an opportunity to repeat Bockmann’s investigation.
Specimens were taken from the preserved duras of eighteen patients
who had died at various intervals after intracranial operations during
the past three years. Only those cases in which the dura’ was opened
were taken, but the cases were otherwise unselected, and represent a
majority of the post-operative fatalities during that: period. The
270 1. J, PUTNAM, AND Sie ODN AM
interval between operation and death varied from a few hours to
three months, with an average of about twenty days. Meningitis was
present in one case of brain abscess. Extradural hemorrhage of
greater or less extent was found in almost all cases dying within a
fortnight after operation. Shreds of fibrin or tags of clot were fre-
quently seen in patients dying a day or two post-operative, but the
amount was always surprisingly small. Rarely a definite pigmented
scar was found, but never a lesion of significant size. Thus little
positive evidence was obtained from the gross appearance of the dura.
Blocks were taken of whatever clot was present, or from the
vicinity of the operative wound. They were embedded in paraffin,
cut transversely and stained with hematoxylin and eosin, with
Weigert’s elastic tissue stain and with Perdrau’s stain for connective
tissue.
In three cases no definite subdural exudate was found. In nine
small amounts of fibrin and red cells were seen without any evidence
of organization; in one case as long as four days after operation. A
definite mesothelial covering over the free surface was found in this
case before any growth of granulation tissue from the dura could be
detected. Four cases showed organization, but vascularity was never
marked. A mesothelial neomembrane over the surface toward the
arachnoid was seen in only two instances; it is possible that it had
become rubbed off in specimens which had been preserved for a long
time.
Definite mesothelial-lined spaces, such as described and pictured
above as occurring after the subdural injection of blood in animals,
and in another paper (12) as occurring in human cases of pachymen-
ingitis, occurred in seven of the eighteen cases. They were usually
much smaller than those seen in animal experiments, but were unmis-
takably similar. Occasionally they contained a few red cells, but
they never appeared to connect with blood vessels. An illustration
of a post-operative subdural clot, with spaces and a mesothelial mem-
brane, is given in the paper just referred to (Lc., Fig. 8).
Our findings agree with Bockmann’s then, in that the subdural
clots in our cases were always small, and never showed evidence of
progressive or repeated hemorrhage. On the other hand, they did
show the mesothelial-lined spaces which apparently play an important
part in the etiology of recurrent bleeding, and which are rare in
hematomas elsewhere in the body.
Pachymeningitis in Experimental Chronic Alcoholism: The pro-
duction of chronic alcoholism in animals is an old experiment which
has been repeated many times under rigid control. A summary and
criticism of the entire question is given by Saltykow (14). Valuable
STUDY OF PACHYMENINGITIS HEMORRHAGICA Zi
references may be found in this article, but there are some inac-
curacies in the figures quoted. Huss (4) speaks of Dahlstrom’s
production of an “ ausschwitzung”’ between dura and pia in dogs, by
feeding six ounces of alcohol daily for eight months. Kremiansky(5),
who was well acquainted with the appearance of pachymeningitis in
human subjects, produced a similar picture in three out of four
puppies by feeding them an ounce of brandy (45 per cent alcohol)
daily for two to five months. Neumann (11) and Lewin (7) each
saw only one case in a number of experiments which is not definitely
stated. Lewin’s case was that of a large rabbit fed 380 c.c. of 95 per
cent alcohol during sixty-six days; the membrane was the thickness
of an egg-skin. Magnan (8), Ruge (13) and Afanassijew (1) were
unable to produce a subdural membrane in a long series of com-
parable experiments, but often saw a hyperemia of the vessels of the
dura. |
It is evident from a survey of the literature that there is consider-
able disagreement as to what constitutes pachymeningitis, but that a
subdural hematoma has not been produced by chronic alcoholic
intoxication. These experiments were not repeated in the present
study.
SUMMARY AND CONCLUSION
Apparently a true, progressive chronic hematoma of the dura has
never been produced experimentally. The lesions seen after the
subdural injection of blood and in patients after operation resemble
the progressive lesion in appearance, but not in behavior. It was
suggested in a previous paper that the progressive nature of the
lesion seen in human beings was due to the establishment of connec-
tions between the blood vessels and the empty spaces which occur
commonly in subdural hematomas; but there appears to be no way of
testing this supposition experimentally.
If we accept a sufficiently broad definition of what constitutes
pachymeningitis, we can find examples of it following various experi-
mental procedures in animals. The most important of these are the
subdural injection of blood or fibrin, and chronic alcoholic poisoning.
But there is no evidence that the lesion so produced is progressive.
Experimental studies have so far added little to the knowledge
of progressive subdural hemorrhage which has been gained by clinical
and pathological observation.
Grateful acknowledgment is due to Dr. Harvey Cushing for
pathological material from patients on his service, for permission to
work in his laboratory, and for help in many other ways.
272
DT, J ORUT NAM VAN DI Fi tA
REFERENCES
. Afanassijew. Zur Pathologie des Alkoholismus. Beitr. z. path. Anat.,
10 :443, 1890. Re a.
Bockmann, E. Ein Beitrag zur Aetiologie des Pachymeningitis interna
haemorrhagica. Arch. f. path. Anat., etc., 214:380-388, 1913.
. Forel, O. L. Contribution a l’étude des traumatismus cérébraux. Schweiz.
Arch. f. Neurol. u. Psych., 4:170, 1919.
Huss, M. Alkoholismus chronicus. Leipzig u. Stockholm, 1852.
. Kremiansky, J. Ueber die Pachymeningitis interna haemorrhagica bei
Menschen u. Hunden. Arch. f. path. Anat., 42:129-161, 321-351, 1868.
. Laborde, J. Contribution a l’étude des conditions pathogéniques des kystes
sanguines de l’arachnoide; recherches expérimentales sur les animaux.
C. r. Soc. de biol., Paris, 1864, p. 70.
. Lewin. Ueber die Wirkung des Alkohols, etc. Centralbl. f. d. med.
Wissensch., 1874, p. 593.
. Magnan. Gazette médicale, Paris, 1869, No. 5.
. Marie, Roussy and Laroche. Sur la réproduction expérimentales des
pachyméningites hémorrhagiques. C. r. Soc. de biol., Paris, 74:1303,
1913.
. Mendel. Syphilis u. Dementia paralytica. Klin. Wochenschrift, Berlin,
1885, No. 34, p. 549.
. Neumann, E.-A.O. Ueber die Pachymeningitis hemorrhagica bei der
chronischen Alcoholvergiftung. Konigsberg, 1869, 8°.
. Putnam, T. J. Chronic Subdural Hematoma. Arch. Surgery, 11, 329-393,
1925.
. Ruge, P. Die Wirkung des Alkohols auf der thierischen Organismus.
Arch. f. path. Anat., etc., 49:252, 1870.
. Saltykow. Alkoholismus chronicus (Referat.). Centralbl. f. allg. Path.,
22 2849, 1911.
. Serres, A. Nouvelle division des apoplexies. Annuaire méd.-chir. des
hop., Paris, 1:246, 1819.
. Sperling, H. Ueber Pachymeningitis haemorrhagica interna. Inaug. diss.
Konigsberg, 1872. (Summarized briefly in: Centralbl. f. d. med.
Wissensch., Berlin, 9 :449, 1871.)
. Virchow, R. Haematoma durae matris. Verhandl. d. phys.-med. Gesells.,
Wiirzburg, 7 :134-142, 1857.
. Van Vileuten, C. F. Ueber Pachymeningitis haemorrhagica interna
traumatica. Inaug. diss., Bonn, 1898.
. Wilks. Med. Times and Gazette, London, 1868.
fee NE UROPATHOLOGICAL FINDINGS IN@A CASE OF
ACUTE SYDENHAM’S CHOREA
By Lioyp H. Zircier, A.M., M.D.
COLORADO PSYCHOPATHIC HOSPITAL, DENVER
New interest has been aroused in chorea in the last decade despite
the discouraging diversity of reports concerning its pathology. This
has undoubtedly come about as a result of the possible relationship
which chorea may have to epidemic encephalitis and other diseases
causing involuntary motor disturbances. Because of the relative
infrequency of opportunity to study the neuropathological findings
in acute Sydenham’s chorea, the following case should prove of
interest.
Clinical History of E. L—A high school girl, seventeen years of
age, was admitted to the clinical service of the Colorado Psychopathic
Hospital on April 8, 1925, in an unconscious condition. Her family
history was apparently negative. She had always been well except
for occasional tonsillitis. Two months previous to admission she had
had a severe tonsillitis from which she made a poor recovery. Occa-
sionally after that attack she had rheumatic pains in her extremities,
was irritable, and felt that she could not concentrate on school work
as well as before her illness. Two weeks before admission she began
to show irregular, incodrdinate, purposeless movements. These appar-
ently increased up to two days before admission, when she became
unconscious. On admission she was in coma. Her temperature was
106.4° F. (rectal). She showed considerable loss of flesh. Muscle tone
was poor. There were many irregular, purposeless, jerking movements
over the body. The jaw, face, and neck muscles were especially involved.
The elbows were excoriated from restlessness. ‘The tendon reflexes
showed no abnormality so far as could be determined. The Babinski
sign was negative. There were no muscular atrophies. The pulse
was 120. The heart was enlarged. A loud systolic murmur was
heard in the mitral area. Blood pressure was 100/60. It was impossible
to see the tonsils. The teeth were dirty. A clinical diagnosis of acute
Syndenham’s chorea and acute endocarditis was made. Laboratory
studies of the blood gave hemoglobin, 90; red cells, 4,390,000; leucocytes,
15,200. The differential count showed polymorphonuclears, 73 per
cent; small lymphocytes, 13 per cent; large mononuclears, 14 per cent.
The spinal fluid studies showed 2 cells per cu. mm.; globulin negative;
sugar normal; Wassermann 00 with .6; gold curve, 3455544450. A
[273]
274 LOH eZee
urine specimen was not obtained; the patient was incontinent. Blood
chemistry and blood culture were not done. The patient’s temperature
varied between 106.4° F. and 100.2° F. (rectal), falling as she ap-
proached death. She remained comatose and died on April 11, 1925,
three days after admission,
Autopsy Findings——Unfortunately the autopsy was limited to the
brain, which was removed about nine hours after death. The brain was
fixed in 10 per cent formalin. Grossly the brain and meninges presented
no pathological features whatsoever.
For microscopic study blocks were taken from the motor cortex,
calcarine cortex, corpus striatum, cerebellar cortex and dentate nucleus,
cervical cord, pons, and medulla. Sections were stained with hematoxylin-
eosin, cresylechtviolett, Van Heuman’s modification of the Weigert stain,
phosphotungstic acid-eosin, and Sharlach R.
Sy
Pirate I. 100. Photomicrograph showing small fresh petechial hemor-
thages into medulla near dorso-medial aspect of the restiform body.
High Cervical Cord—The microscopic sections presented few, if
any, pathological features. By the hematoxylin-eosin stain no hemor-
rhages or cellular infiltrations were seen. By the cresylechtviolett stain
there was a mild degree of chromatolysis. Nuclei were slightly swollen.
By the Van Heuman stain no tract degenerations were seen.
Medulla—Sections stained with hematoxylin-eosin presented a small
area of petechial hemorrhages near the dorsal and medial aspect of the
restiform body. (Plate I.) No areas of leucocytic infiltration were
seen. By the cresylechtviolett stain the nerve cells presented alterations
similar to those of the cervical cord. By the Van Heuman stain there
were no tract degenerations.
Pons.—Sections of the pons stained with hematoxylin-eosin were
ACUTE SYDENHAM'S CHOREA 275
free from hemorrhages or cell infiltrations. By the cresylechtviolett
stain the nerve cells showed markedly swollen nuclei and moderate
chromatolysis. Marked chromatolysis of the cells of the sixth nerve,
nuclei had disappeared and the cytoplasm stained palely. (Plate II.)
Marked neuronophagia was apparent in about one-third of the cells
Bene pons. (Plate III.)
Cerebellum.—By the cresylechtviolett stain the Purkinje~ cell nuclei
were swollen and moderate chromatolysis was apparent. Cells of the
dentate nucleus presented swollen nuclei.
Pirate II. X400. Photomicrograph of the nucleus of the sixth nerve
showing chromatolysis, swelling and eccentricity of the cell nuclei and complete
destruction of some cells.
Upper Edge of Red Nucleus——Sections at this level, stained by
hematoxylin-eosin, showed no hemorrhage or cell infiltration. By the
cresylechtviolett stain the cells showed moderate chromatolysis and neu-
ronophagia was present around one-third of the cells. There were no
apparent glial fiber proliferations by the phosphotungstic acid-eosin stain.
By Van Heuman’s stain no tract degeneration was seen.
Corpus Striatum—By the hematoxylin-eosin stain no hemorrhages
or infiltrations with leucocytes were seen. By the cresylechtviolett stain
moderate chromatolysis was noted. The nuclei were swollen and eccen-
tric. These changes were seen in the large and small cells of the
pallidum. Neuronophagia was very definite in about one-third of the
276 L. H. ZIEGLER
cells. By the Sharlach R. stain droplets of fat were seen in the large
cells of the pallidum. Fat was also seen in some of the small pallidal
cells and in some perivascular spaces. There was no apparent glia fibril
proliferation by the phosphotungstic acid-eosin stain. .
Lateral Nucleus of Thalamus.—Sections stained with hematoxylin-
eosin showed no hemorrhages or cell infiltration. By the cresylecht-
violett stain the cells showed moderate chromatolysis and swelling of
the nuclei. The nuclei were eccentrically placed and neuronophagia
Piate III. 800. Photomicrograph of the pallidum showing neurono-
phagia, swollen and eccentrically placed nuclei. Some of the large cells and
perivascular spaces show fat when stained with Sharlach R.
a
was seen in about one-third of the cells. By the Van Heuman stain
no tract degenerations were seen. Sections stained with phosphotungstic
acid-eosin showed no proliferation of glia fibrils.
Motor and Calcarine Cortex.—By the hematoxylin-eosin stain no
hemorrhages or cellular infiltrations were seen. By the cresylechtviolett
stain all cell layers of the motor cortex showed markedly swollen nuclei
and much chromatolysis. Neuronophagia was seen in about one-third
of the cells. By the Sharlach R. stain some of the cells, chiefly of
the sixth layer of the motor cortex, contained fat droplets and some
ACUTE SYDENHAM’S CHOREA 277
of the perivascular spaces contained fat. The calcarine cortex by the
Sharlach R. stain showed marked destruction of neurons in all layers
with much chromatolysis in those that remained. The glia nuclei were
greatly proliferated and fat was seen in some perivascular spaces.
Discussion
The outstanding findings in nerve cells were chromatolysis, swell-
ing and eccentric location of nuclei, complete destruction of some
See
Pirate IV. 400. Photomicrograph of motor cortex showing swelling of
nuclei, chromatolysis and neuronophagia. When stained with Sharlach R.
some of the cells of layer six and perivascular spaces show fat granules.
cells (especially the sixth nerve nuclei. and neurons of calcarine
cortex), neuronophagia, deposit of fat droplets in the cytoplasm of
nerve cells and in some of the perivascular spaces, and a few small
hemorrhages into the medulla near the restiform body. The glia
cells were proliferated especially in the calcarine cortex. The swell-
ing of the cell nuclei and chromatolysis and even the destruction of
‘cells with deposits of fat within them might be explained as post-
278 Te eG BE
mortem changes. The perivascular fat, hemorrhages into the medulla,
neuronphagia, and proliferation of glia cells, must be explained
otherwise.
Since Sydenham’s original description of chorea minor the eti-
ology and pathology have been variously explained. The relationship
of chorea to endocarditis and rheumatism has long been noted.
Choreiform movements have also been observed in association with
other diseases and the question has been raised as to whether Syden-
ham’s chorea is a disease or a symptom. It is sometimes seen in
pregnancy or the puerperium. It. has been seen in the course of
gastrointestinal diseases.(1) It has occurred with exophthalmic
goiter.(2) It has been observed in cases of polycythemia.(3) The
differential diagnosis between acute epidemic encephalitis and Syden-
ham’s chorea has been puzzling in not a few instances.(4) Choreic
manifestations have been seen in individuals with proved thrombotic
softenings in the basal ganglia.
The pathological findings in acute Sydenham’s chorea have been
so various that it may well be said thére is no proved and definite
lesion. Oppenheim (5) mentions reports of findings such as hy-
peremia of the brain, small hemorrhages into the brain, foci of .
softening and inflammation especially in the basal ganglia, disease of
the blood vessels with thrombosis, inflammation of the cerebral
membranes, occlusion of smaller vessels and capillaries with emboli
(especially in basal ganglia), sinus thrombosis, cell infiltration of
motor cortex, encephalitic processes, colloid corpuscles, changes in
cerebellum and superior cerebellar peduncles. At least in some in- —
stances such reports doubtless represent the pathology of coexisting
complications or associated diseases. Osler (6) said in 1911, “ Endo-
carditis is by far the most frequent lesion in Sydenham’s chorea.”
Wilson,(7) by his extensive studies on the anatomy and physi-
ology of the basal ganglia, has tended to focus attention on that
portion of the brain as a seat of pathology in chorea.
Trétiakoff,(8) in 1919, reported the pathology of a case of acute
chorea in which the basal ganglia were carefully examined. The
case was severe and the patient died on the ninth day of the disease.
Histologically the base of the brain showed a marked polioencephalitis..
The cortex showed some inflammatory areas. The substantia nigra
was involved with perivascular and parenchymatous infiltration.
Nerve cells were swollen and edematous. There was neuronophagia
and much increase in neuroglia.
Marie and Trétiakoff,(9) in 1920, reported the pathology of a.
case of acute infectious chorea, the patient dying on the tenth day of
ACUTE SMDENHAMS CHOREA aie
her disease. The corpus striatum, thalamus, pons, and cortex showed
lesions of an acute nature similar to those found in epidemic
encephalitis.
Lewy,(10) in 1923, reported the pathology of eleven cases, one
of which showed evidence of acute inflammation and bacterial emboli.
He felt that the corpus striatum was not the only seat of involvement
in Sydenham’s chorea, but that the cortex was also involved. In
some cases he found rather acute changes in the cells (chromatolysis )
with fatty degeneration and a tendency to destruction of the cells.
He found neuronophagia. He thought the degree of cell damage
was in some degree comparable to the severity of the chorea. The
neuronophagia was characteristic of the most acute process. He
found much siderophilic material in the perivascular spaces in cases
that had been ill a longer time. He thought that the small cells of
the striate body were damaged more than the large cells. In the older
cases rod cells were seen. He said that Spielmeier found similar
acute changes in typhus patients sick only two weeks. In one case
cell disintegration was found in the substantia nigra and body of
Luys. In one case some infiltration of the pia of the cord was
observed. Ina case of chronic progressive chorea (not hereditary)
the patient was observed for twelve years, during which time he had
no symptoms of an acute infection. Such a case raised the question
of factors other than infection in chorea. Lewy thought chorea was
a manifestation of toxins on a brain that had poor resistance, espe-
cially in its motor elements.
Jakob (11) reported a case of chorea gravidarum in which there
were areas of focal necrosis of varying age in the corpus striatum
with marked glia proliferation.
From such reports one may gather that lesions in acute chorea
vary from toxic cell changes to destructive lesions, The brains from
cases dying of delirium, or exophthalmic goiter, or other severe
toxemias may show changes similar to those of the case here re-
ported. In these diseases, as in chorea, the patients may recover
from the acute manifestations of the disease, which fact is in agree-
ment with the type of pathology found in the case of acute Syden-
ham’s chorea reported herewith. Only a relatively few cases of
endocarditis or acute rheumatic fever have chorea. It is only oc-
casionally associated with other diseases. These facts, together with
a pathology that varies in degree from acute toxic changes in the
brain cells to destructive lesions, give evidence of an individual
factor. This factor may be a lowered resistance of the motor ele-
ments (motor cortex, corpus striatum) to toxins or infections, or
280 EXHeCIPGhEen
the elective action of toxins or infections on certain portions of the
brain as in the case of progressive lenticular degeneration. (12)
Hunt,(13) in discussing the different syndromes of encephalitis,
said that a lesion of the pallidum produced a paralysis agitans syn-
drome, while a lesion of the putamen and caudate produced a
choreo-athetoid syndrome. Though he does not state definitely, it is
presumed he refers to destructive lesions and with such lesions there
are usually persistent residuals. ‘The writer has observed a certain
amount of awkwardness after recovery from the acute manifestations
of Sydenham’s chorea, which raises the question as to whether the
motor system had ever developed properly and might thus be more
amenable to toxic insults, or whether there were true residuals. These
questions suggest room for much investigation.
SUMMARY
1. The neuropathological findings in a case of acute Sydenham’s
chorea, with acute endocarditis, were chromatolysis of practically all
cells of the central nervous system, with swelling of nuclei and
eccentric displacement; destruction of some neurons, especially sixth
nerve and calcarine cortex where glia cells were much proliferated ;
neuronophagia; fatty deposits in the large cells of the motor cortex
and pallidum; fat in the perivascular spaces; and petechial hemor-
rhages in a small area near the dorso-medial aspect of the restiform
body of the medulla.
2. Reports of pathological findings in acute Sydenham’s chorea
represent a wide variety of lesions, but recent work points especially
to toxic changes in brain cells and to destructive lesions of the
corpus striatum, some of which resemble the lesions of epidemic
encephalitis.
3. In acute Sydenham’s chorea some of the elements of the brain
may be less resistant to toxins or infections, or the toxins or infec-
tions.may have an elective action (irritating to destructive) on certain
areas of the brain. Though the disease is recoverable, certain awk-
ward tendencies observed in chorea patients after recovery make it
apparent that the motor system has never developed properly, or
that there are slight residuals.
Nore: From the Department of Neuropathology of the Colorado Psycho-
pathic Hospital and University of Colorado Medical School. The writer is
indebted to Dr. Hugo Mella, Associate Professor of Neuropathology, for
helpful suggestions.
—
jan R\o)
Oo NAM # Whe
ACUTE OY DENEAAM'S CHOREA 281
REFERENCES
. Oppenheim. Textbook of Nervous Diseases. Foulis, 1911.
. Sutherland. Chorea and Graves’ Disease. Brain, 1903, 26.
. Pollock. A Case of Chorea and Erythremia. Jr. Amer. Med. Assn., 1922,
[on fee:
Alfaro. Epidemic Encephalitis and Chorea. Arch. Latino. Ann. Pediatri.,
Nov.—Dec., 1921, 546.
Ibid.
. Osler. The Practice of Medicine, 7th Edition, 1912.
. Wilson. The Anatomy and Physiology of the Corpus Striatum. Brain,
1914, 36.
. Trétiakoff. Contribution a l’Etude de |’Anatomie Pathologique du Locus
Niger de Soemmering. Paris, 1919.
. Marie and Trétiakoff. Rev. Neurologique, 1920, 428.
. Lewy. Die Histopathologie der Choreatischen Erkrankungen. Zeitschr.
f. Gesamte Neur. and Psych., 1923, 85.
. Jakob. Die Extra Pyramidalen Erkrankungen. Berlin, 1923.
. Wilson. Progressive Lenticular Degeneration. Brain, 1912, 35, 296.
. Hunt. Symptoms and Syndromes in Encephalitis. Amer. Jr. Med. Sci.,
1921, 162, 481.
THE COLUMNAR ARRANGEMENT OF THE PRIMARY
AFFERENT CENTERS IN THE BRAIN-STEM OF MAN *
By WALTER FREEMAN, M.D.
SENIOR MEDICAL OFFICER, ST. ELIZABETHS HOSPITAL, WASHINGTON, D. C.
(Continued from page 170)
The cornea was carefully tested on each side. On the right side the
finest hair produced smarting and stinging pain upon the least application.
On the left cornea this hair (18 mg. bending strength, 9 grm./mm. ten-
sion) was distinctly felt every time it was applied, but it caused no. pain.
The same was true of hairs of bending strengths of 45, 60, 80, and 120
mg. bending strength, tensions of 10.8, 24, 43 and 66 grm./mm. respec-
tively. The contacts of these hairs on the left cornea were accurately
appreciated, yet no pain was produced. It was only when a hair of
bending strength of 375 mg. (tension of 83 grm./mm.), was applied, that
the patient experienced pain.
The inference is that the corneal fibers which apparently run wholly
in the radix spinalis trigemini will also serve to transmit tactile stimuli
when the mechanism for the transmission of pain is interfered with. It
is possible however that the mechanism for the conveyance of pressure
stimuli from the tunics of the eyeball is very highly developed, responding
to the touches of delicate hairs. The cornea made analgesic with cocaine
remains sensitive to light pressure. No satisfactory explanation of the
phenomenon is known to me at the present time.
Pain. Puinprick about the mouth was felt equally readily on the two
sides. There was diminution of sensibility to pinprick below the left eye
and in the region of the temple, and on the forehead there was marked
hypalgesia. The cornea was rather insensitive, and the corneal reflex
diminished. Back of the hair line pain sensibility was diminished as far
as the vertex.
Pressure. Pressure was felt everywhere, but pain was produced
more readily on the right side. With Catell’s algometer the following
readings were obtained:
Right Tete
Forehead Zane 4 kg
Cheek 2s Ra
Chin Sei Se
Temple Onis See
Masseter ae Cu
ARRANGEMENT OF PRIMARY AFFERENT CENTERS — 283
Pressure upon the eyeball produced pain equally readily on the two sides
although there was no change in pulse rate in either case. Traction upon
the hairs of the moustache or scalp was accompanied by pain on both
sides, although on the left side slight displacements of the hairs of the
moustache were not perceived. Similar displacements were felt on the
right side. The patient was able to localize in a general way the region
that was pressed upon although his incoordination made exact localiza-
tion diffcult for him. The vibration of a tuning fork was perceived on
all bony parts although it was not perceived on the left cheek where no
bony prominence was encountered. ‘It was perceived on the right cheek.
Temperature. Small variations were named accurately in all parts
except for a small area in front of the tragus (shaded in the photograph).
Mouth. The left side of the tongue on both dorsal and ventral surfaces
was anesthetic to light touch. So also were the gums, cheek, hard palate
and anterior pillars of the fauces. Objects placed in the left cheek
(marble, cube, ring), were not recognized until the tongue tip was brought
to them. Pinprick was painful equally on the two sides, and small differ-
ences of temperature were readily perceived.
Pressure was acutely felt on both halves of the tongue.
Motor division. The jaw deviated slightly to the left on opening the
mouth and the patient experienced fatigue in mastication. The masseter
and temporal muscles were noticeably smaller on the left side. No
reaction to the faradic current was obtained from the left masseter muscle,
and the masseter and temporal muscles reacted only to stronger galvanic
currents than those on the right side. (5 M.A. left; 3.5 M.A. right.)
As was noted above, pressure upon the masseter region was felt much less
acutely on the left side than on the right.
VII. Touch. Light touch was immediately perceived over the inferior
portion of the helix and lobe. The root of the helix and part of the
tragus were insensitive to light touch on the left side. All other parts,
including the anterior wall of the external auditory canal were normally
sensitive.
Pain. Pinprick was everywhere perceived acutely in the neighborhood
of the left ear.
Temperature. Warm and cold objects were sometimes confused when
applied in front of the left tragus. In all other parts the sensation was
immediately and correctly perceived.
Pressure. Deep pressure was everywhere recognized and well local-
ized in the neighborhood of the left ear. Pain was produced by deep
pressure equally on the two ears at less than 2 kg. The readings for
pressure upon the facial muscles are given above.
Mouth. Light touch was not felt on the left side of the soft palate,
the anterior pillar of the fauces and the tonsil. Pain was somewhat
reduced in the same area and there was practically no reaction on the left
side to stroking the soft palate. Taste was very much delayed on the
284 WALTER FREEMAN
left side of the tongue in its anterior portion for all the solutions used,
and absent for sweet. Quinine was perceived, with a certain element of
parageusia.
Motor. There was very slight weakness of the facial musculature as
expressed by diminished force of closure of the orbicularis palpebrarum
and orbicularis oris. That it was not marked can be seen from the
photograph. The stimulation by the galvanic and faradic currents showed
slight but distinct hypoexcitability on the left side (left 6 M.A.; right
4 M.A.,). |
VIII. There was tinnitus on the left side with slight diminution in
hearing. Air conduction was better than bone conduction. The Weber
test was localized to the right. Caloric and galvanic tests for vestibular
function showed diminished excitability on the left side, though this was
not marked.
IX. Touch, pain, heat and cold, and pressure were accurately per-
ceived in the mastoid regions of each side and in the external ear.
Sensation in the pharynx was diminished but slightly to touch, and pin-
prick was readily felt. The gagging reflex was elicited slightly more
readily by touching the right side of the pharynx. Sweet, sour, bitter
and salty solutions were quickly perceived on both sides of the posterior
portion of the tongue although there was some parageusia, sweet being
called sweet but with bitter after-taste.
Motor. The patient complained of dysphagia especially for solids, and
of regurgitation of liquids through the nose. Speech was somewhat nasal.
During phonation the palate and uvula were elevated more completely on
the right side. The gag reflex showed a definite curtain movement of the
posterior wall of the pharynx to the right.
X. Sensation was normal in the distribution of the posterior auricular
nerve. There was hypesthesia of the larynx and rima glottidis on the
left side.
Motor. The patient was dysphonic. The left vocal cord was weak in
movements of abduction. There were respiratory irregularities such as
sighing, hiccough, etc., from time to time. The pulse averaged 85 with
some irregularities. |
XI. The power in the sternomastoid muscles was equal on the two
sides and there was no atrophy. Elevation of the arms to the sides
showed no suprascapular hollow, and the muscle mass of the trapezius
was equal on the two sides.
XII. The tongue deviated slightly to the left on protrusion, but this
was probably due to the deviation of the jaw. No atrophy could be
determined; there were no fibrillary tremors. The left side of the tongue
reacted to a weaker faradic current than the right side (left 117 mm.;
right 112 mm.). Pressure was felt acutely on the two sides of the tongue,
pain being produced equally on either half. The vibration of a tuning
fork was felt on the right side but not on the left.
=
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 285
II C. Normal in all respects.
It seems that in this case we are dealing with two lesions, one in the
medulla oblongata causing symptoms referable to the N. vagus and N.
glossopharyngeus, and probably the N. facialis; and another situated more
orally involving the Nucleus sensibilis and Nucleus motorius trigemini.
Careful tests for various forms of sensibility carried out, upon the body
and the extremities revealed no impairment at any other location than the
face. As in Spiller’s case we can say fairly certainly that the lesion
involved the Nucleus sensibilis trigemini, both on account of the sensory
disturbance and> because of the fact that the masticatory muscles were
markedly weakened on the left side. The motor and sensory nuclei of the
fifth nerve are located in such close proximity that one could hardly be
completely involved without the other also being affected.
As will be noted also, the hair sensibility was lost. This does not mean
that pain could not be produced by traction upon the hairs of the mous-
tache, but that the displacements that could be felt upon the right side
were not perceived upon the left. Here we have an indication that the
fibers supplying these hairs, which Head has shown to belong to the deep
sensory system, travel in the sensory division of the trigeminus. It is
the N. trigeminus that supplies the moustache hairs and Edinger (5)
has shown a special development of the nucleus sensibilis trigemini in
animals in-which these hairs subserve an important exploratory purpose.
This portion of deep sensibility, then, is rather a function of the N.
trigeminus than of the N. facialis. That the radix spinalis trigemini is
involved in its lower portion in the case reported is suggested by the
relative analgesia over the forehead and cornea on the left side.
The “ Radix Spinalis Trigemini”
The entering fibers of the posterior root of the Gasserian ganglion
divide upon entering the pons. One division goes to the main sensory
nucleus, the other turns caudad in the tractus spinalis trigemini.
It has been shown in a large number of observations that the spinal
root of the N. trigeminus carries fibers for pain and temperature.
If it carries touch fibers at all, they are not numerous, and of no
practical import. The observation of Spiller (Case 2), and Case 3
here reported showing the inverse syringomyelic dissociation of sen-
sation in the face, where only painful and thermic impressions could
be appreciated, and where simple touch was not felt, would suggest
that fibers for ordinary touch sensation do not run in the spinal root.
The evidence in regard to the grouping of pain and temperature
fibers in the spinal root is derived chiefly from clinical sources,
although among others (notably Wallenberg (62)) Gerard (50)
has adduced some experimental evidence. She sectioned the spinal root
in rabbits below the entry of the fifth nerve and tested the residual
286 WALTER FREEMAN
sensation. In her experiments the sneeze reflex was taken as evidence
of the integrity of general sensibility, and the corneal reflex for pain
sensibility. The deep sensibility of the face could not be relied upon
for information, because it was found that even after total transection
of the posterior root of the Gasserian ganglion, stimulation with
needle electrodes was followed by struggling and other manifesta-
tions of pain. This is in accord with the work of Davis. Transection
of the radix spinalis trigemini was followed by loss of the corneal
reflex, with preservation of the sneeze reflex. It is possible, however,
or even probable that this test does not prove the point conclusively,
for sensation from the interior of the nose 1s probably rather visceral
than somatic. More convincing are the experiments of nature upon
man, and the two principal conditions in which the root of the trige-
minus 1s destroyed are occlusion of the posterior inferior cerebellar
artery and syringobulbia. In both of these conditions pain and
temperature sensibility are abolished over a more or less extensive
territory on the face and head, whereas touch sensation is diminished
very little, if at all. This proves conclusively that pain and tempera-
ture sensations are carried by fibers running in the descending spinal
root of the trigeminal nerve. Gerard has collected a large number
of cases.
This tract is so predominantly a product of the fifth nerve that
other fibers entering into its composition are not generally considered.
Marburg and others describe fibrae concomitantes of the tract that
do not degenerate when the root of the fifth nerve is sectioned. He
claims that these fibers are ascending in direction and consist of sec-
ondary paths. They apparently lie mesial to the root, are most numer-
ous in the middle portion, and have a somewhat paler staining reaction,
particularly in the immature brain. Aside from this however, Gerard,
by actual count of the fibers in the radix spinalis trigemini, noted a
relative increase in their number in the caudal portion of the tract.
Also, as Cajal has shown, in the lower portion of the root a not incon-
siderable portion of the fibers, a sixth to a seventh of the total number,
come frem the ninth and tenth nerves. They occupy the dorsal por-
tion of the tract.
His illustrations are convincing in this regard (Fig. 19). He
denies the existence of similar fibers from the facial nerve, but Kap-
pers has shown that such fibers exist in the lower fishes and in the
amphibia, and in the case of a three months’ fetus where the spinal
root of the trigeminus was darkened only a short distance below the
entry of the fifth nerve, I was able to observe a portion of the entering
fibers of the seventh nerve, blackened at their origin, enter this other-
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 287
wise pale tract. The evidence in preparations of older brains was
unsatisfactory because in transverse sections it is impossible to be
certain that fibers are really joining the tract. But in a careful com-
parison of the entering fibers of the N. facialis, with those of the N.
glossopharyngeus, and N. vagus which are known to give fibers to
this root, I could find locations of precisely similar aspect tending to
show that a few fibers of the sensory division of the facial nerve
turned caudally in the spinal tract, or as it deserves to be called the
nociceptive division of the exteroceptive column. This would be in
keeping with our original conception of the facial nerve as mixed
nerve carrying cutaneous fibers.
The Segmental Representation in the Somatic Sensory Column and
the Principle of Usurpation.
The entering root fibers which run caudally in the exteroceptive
column, commonly known as the radix spinalis trigemini, take up
definite positions with respect to one another in the root. This was
shown long ago by the experiments of Bregmann who performed in-
complete transection of the posterior root of the Gasserian ganglion.
According to his ‘findings (Winkler, Vol. 7, pp. 29 and 61), the
mandibular nerve sends its fibers in the dorsal portion of the tract
and the ophthalmic nerve into the ventral portion of the tract. These
fibers do not all run caudally to the same level. A low section of the
spinal root will abolish the corneal reflex in animals whereas the
reflexes elicited by painful stimuli applied to the region about the
mouth are fully preserved. More definite and characteristic results
are obtained in the examination of patients suffering with cavitation
of the substantia gelatinosa in cases of syringobulbia. The gradual
progression of the disease may be traced by the extension of the anal-
gesic area upon the face. This has been done by Dejerine, Brouwer,
Head and others. ,
The analgesic zone in the neck is prolonged first up over the scalp,
then in front of the ear and to the root of the nose, then narrowing
gradually toward the mouth. This is indicated in the diagram taken
from Dejerine (Fig. 3). He delimits five zones while Winkler con-
siders only three, but the principle is the same.
As Brouwer (16, p. 275 ff.) has shown, it is not accurate to say
that the fibers of the ophthalmic division run the farthest caudal and
that those of the mandibular division end at superior levels.
There is an entire redistribution in the nervous axis, and fibers
from each division end at each level. This is shown by a comparison
of the areas subserved by the various divisions of the N. trigeminus
288 WALTER FREEMAN
Ficure 19. Medulla oblongata of fetal cat. (Cajal, Vol. II, Part 1, p. 67.)
Some of the entering root fasciculi of the vago-glossopharyngeal complex
joining the radix spinalis trigemini. A. Corpus restiforme. B. Descending
portion of the trigeminus. C. Fasciculus solitarius. D. Vestibular nucleus.
E. Trigeminal portion of the vagoglossopharyngeal. e. Motor fibers of the
ninth and tenth running to the nucleus ambiguus.
(Fig. 2-a) with the line of advance of the sensory dissociation
(hiagero)
ARRANGEMENT OF PRIMARY AFFERENT CENTERS — 289
The area above the ear which is supplied by the third division is
among the first to become analgesic whereas the area about the tip
of the nose which is supplied by the first division is among the last
to become analgesic.
From the point of view of the sensory disturbances in syringo-
bulbia there is very definite segmentation shown centering about the
mouth. In this respect the segmentation may be likened to that which
is found about the anal orifice. The two orifices are the original
rostral and caudal ends of the body. The cutaneous surfaces sur-
rounding the eyes have an innervation that is derived from a region
farther caudad than the innervation for the region surrounding the
mouth. ‘This is shown even in the lower fishes.
The cutaneous area supplied by the N. trigeminus in the higher
vertebrates is relatively much larger than that so supplied in the lower
ones. In some fishes and in the amphibia the seventh and other nerves
have a considerably larger cutaneous representation than we find to
be the case in mammals.
How does it happen, then, that the fifth nerve has taken over the
field which was originally innervated by segments further caudal?
The N. trigeminus has apparently encroached upon the cutaneous
areas formerly supplied by the other cranial nerves, and even by the
first cervical nerve which has lost its dorsal root. Winkler (14, Vol.
7, p. 1) regards the Gasserian ganglion as a “collection of spinal
ganglions belonging to the segments from C 1 to the most proximal
of those which are concerned in the innervation of the skin.” The
fusion of these ganglia has caused the N. trigeminus to preside over
this greatly enlarged area and has led to the large representation of its
fibers in the spinal root. This idea, however good it may be from
the standpoint of function, is not borne out by anatomical findings.
The only fusion that is known to have taken place with respect to the
N. trigeminus is that between the ganglion of the ophthalmic nerve
which is found in amphioxus and in the embryo, and the maxillo-
mandibular ganglion, into the semilunar or Gasserian ganglion.
Moreover the posterior root ganglia of the other nerves, although
relatively reduced in size in comparison with that of the N. trigeminus,
are to be found, and seem to have cutaneous fields, however small and
poorly known they are.
We know how, during the course of a few months, the nerve
fibers from the regions surrounding an anesthetic area (for instance
in the face after trigeminal neurectomy), will encroach upon this
area and reduce it considerably. Cushing (17) demonstrated this
twenty years ago. The extension of the adjacent nerves has been
290 WALTER FREEMAN
augmented, they have undergone compensatory hypertrophy in re-
sponse to the demand for function, just as is the case with so many
other organs.
In the long course of vertebrate development, the trigeminus has
become predominant, its ganglion has undergone true numerical
hypertrophy, not from migration of ganglion cells from the other
ganglia, but due to unknown reasons, of which free blood supply
from the neighboring carotid artery may play a part. Changes take
place less readily in the central nervous system however. The systems
as they are laid down in the lower vertebrates undergo only partial
modification. Especially the primary centers and the secondary tracts
shift their position but little. Hence it comes about, probably, that
the origin of the secondary system of fibers remains in its primordial
position, and the primary fibers, although they arise in a different
ganglion must travel farther in their intramedullary course before
they form connections with them. If we consider with Herrick
(9, p. 197) that the spinal root of the N. trigeminus represents a
phylogenetically old structure, that it 1s concerned with the trans-
mission of impulses of pressure, pain and temperature, and that in
its internal structure it has a strictly segmental arrangement, whereas
the main sensory nucleus is of later origin and has to do more with
the transmission of the discriminative forms of sensation, then the
trigeminal nerve must have usurped the fields formerly supplied by
other cranial nerves. This usurpation must begin very early in the
vertebrate series, for the R. spinalis trigemini is already somewhat
developed in the cyclostomes although its importance is increased in
other fishes. The tract is well established long before the appear-
ance of the main sensory nucleus which occurs only in the reptiles and
higher classes. When this nucleus (and its homologous nuclei per-
taining to other cranial nerves), is developed, it is concentrated in one
place at the level of entry of the nerve, and receives the collaterals
from the radicular fibers that then bend caudally in the spinal root.
There are certain structural differences between the upper and
lower portions of the nucleus accompanying the radix spinalis tri-
gemini. The upper portion shows greater resemblance to the base of
the dorsal horn of the spinal cord, and the lower portion a construc-
tion more like that of the substantia gelatinosa proper. In speaking
of the spinal cord Winkler attributes to the base of the dorsal horn
the interoceptive sensations together with temperatuve sensations.
Pain and thermic impulses are sometimes dissociated in spinal lesions,
and quite frequently in lesions of the radix spinalis trigemini, e.g.
Cases 2 and 3. Whether the nucleus described by Winkler, situated
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 291
in the middle portion of the tract, receives and transmits thermic
stimuli, and the nucleus gelatinosus the painful impressions is not
certain, but is suggested as a possibility.
In summary, then, the cutaneous sensory fibers, those of the
exteroceptive system, enter the brain-stem chiefly by the sensory root
of the N. trigeminus, but also by the sensory divisions of the seventh,
ninth and tenth nerves. They divide upon entering, one portion run-
ning to an interrupted column of large cells of the type seen in the
nuclei of the dorsal funiculi. Representatives of this column are the
nucleus sensibilis trigemini and the small exteroceptive nuclei of the
seventh, ninth, and tenth nerves. The other portion runs caudally
to varying levels in the nociceptive division of the exteroceptive
column, commonly called the tractus or radix spinalis trigemini. In
this column the segmental arrangement of the origin of the secondary
tracts has remained, as is shown by studies of the advance of the
analgesic area in cases of syringobulbia. The segmentation about
the oral end of the body is shown to center about the mouth. In the
course of development the N. trigeminus has encroached upon the
fields supplied by the other nerves, but because there has been no shift
in the primary receiving centers for these pain fibers, the communica-
tions of the cells of the Gasserian ganglion with the cells of origin
of the bulbothalamic tract must be established by a prolongation of
the axones of the cells of the Gasserian ganglion; and this gives rise
to the so-called spinal root of the trigeminal nerve.
B. The Interoceptive Column
The interoceptive or visceral sensory column is represented by the
tractus solitarius with its attendant nuclei. This tract is made up of
some large fibers and of a great number of fibers having only very
thin myelin sheaths or none at all. It is very early in development,
and in sections from the brain-stem of a three months’ human fetus
impregnated with silver, it is by far the most prominent tract in this
part of the nervous system. It is most noticeable from the level of
entry of the N. glossopharyngeus to the point where the fourth
ventricle closes to form the central canal. Here is situated a nucleus
of small cells, the nucleus commissuralis, described first by Cajal
2, p. 733), and there is good physiological evidence (see Pike and
Coombs, Science, 1923), to show that this constitutes the true
respiratory center of the bulb.
Examining the tractus solitarius from the rnd yoint of the
column, we find that it occupies the portion of the medulla oblongata
that corresponds to the pars intermedia, the interoceptive column of
292 WALTER FREEMAN
the spinal cord. It is indeed a direct continuation of this column into
the brain-stem (Fig. 20). From the lower end of the fourth ven-
tricle as far as the nucleus of the fifth nerve, the interoceptive column
can be traced in serial sections. Boettiger remarked this long cephalic
prolongation though Van Gehuchten denied it.
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Ficure 20. Lower end of the medulla oblongata of a 6 months’ human
fetus (silver impregnation). The nuclei of Goll and Burdach are beginning
to send out the internal arcuate fibers to form the lemniscus medialis. There
is still a part of the dorsal funiculi remaining. The large pale area situated
laterally is the substantia gelatinosa Rolandi lying within the lower end of
the radix spinalis trigemini. The lower end of the inferior olive is to be
seen, bordered by its medial and dorsal accessory bodies. In the dorsal portion
of the~central gray matter, dorsal to the canalis centralis is the lower end
of the nucleus commissuralis represented by a few cells. The caudal extension:
of the tractus solitarius is to be seen external to the fibrae acruatae internae,
and immediately to the outer side of this lies the radix descendens N. VIII.
They have come to occupy the positions of the pars intermedia and Clarke's
column in the spinal cord.
As far up as the level of the IX nerve it stands out prominently.
At this point it lies at the dorsomesial angle of the descending root
of the VIII nerve, and in this same position we find it at the level
of entry of the sensory root of the facial nerve. It is clearly distin-
guishable as far proximal as the level of the nucleus sensibilis.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 293
trigemini, and loses itself in the triangle between this nucleus and the
radix mesencephalica trigemini (Fig. 12). It undergoes alterations
in size and shape, its appearance is changed by the advent of the
gustatory nuclei, but its continuity and constancy are outstanding
peculiarities.
The interoceptive column, of which the tractus solitarius is the
most prominent part, receives fibers from all the mixed nerves of the
brain-stem. From the N. trigeminus come fibers supplying the bucco-
Hasaiemucosa, and: the orbit (Winkler, Vol: 7, p:61). From the
seventh nerve come fibers supplying the middle ear, eustachian tube,
and palate with general visceral sensation, and the anterior two-thirds
of the tongue with special gustatory sensation. From the ninth nerve
come fibers supplying the pharynx and middle ear with general
visceral sensation and the posterior third of the tongue and the
pharynx with gustatory sensibility. From the vagus come fibers sup-
plying the rest of the alimentary canal and its appendages, the
respiratory system and the cardiovascular system with general visceral
sensibility, and the region of the epiglottis and larynx with gustatory
sensation. The vagus component is so large that it brings the column
into great prominence, and the multiplicity of nuclei occurring in the
lower bulbar portion of the column point to its great importance.
The nucleus accompanying the tractus solitarius and subserving
common visceral sensation is continuous. It consists of small cells
fairly closely grouped, separated, however, by a fine meshwork of fine
fibers, and in its supravagal portion it is covered on the dorsolateral
surface by a crescentic mass of fibers of fine caliber that are derived
from the most dorsal portion of the entering afferent nerve roots.
These roots run to the column fairly direct from the point where they
penetrate the marginal neuroglia layer. A part of them penetrate the
nucleus from its ventral aspect; most, however, go to make up the
overlying crescentic bundle of fibers that is found cut transversely in
frontal sections. Not all of these fibers run far caudally, however.
The band becomes noticeably diminished between the fifth and the
seventh nerves, and again between the seventh and the ninth, where
in preparations from the adult brain-stem it almost disappears. From
experimental investigations (Van Gehuchten, 65), and according to
Cajal, it would appear that fibers from the N. vagus are the only ones
represented at the level of the nucleus commissuralis.
Cajal (2, p. 733) describes two nuclei accompanying the solitary
tract, a small one situated externally, the cells of which are also found
among the fibers, which Cajal calls the nucleus interstitialis. This is
apparently not the ventral nucleus described by v. Monakow and
294 WALTER FREEMAN
others, of which Cajal here makes no mention (I have already given
reasons for believing that this nucleus belongs to the exteroceptive
system). Situated on the inner side is a large nucleus which Cajal
calls the ganglion descendens. The tract gives a small number of
fibers to the nucleus interstitialis, and a large number to the ganglion
descendens. The nucleus commissuralis is formed by the fusion of
these two latter ganglia in the midline at the lower angle of the fourth
ventricle. The fibers running to it are best seen in fibrillar prepara-
tions for they have very thin myelin sheaths or are wholly unmyelin-
ated. Where the ganglia descendentia of the two sides come together
to form nucleus commissuralis, a large portion of the fibers of the
tractus solitarius cross to the opposite side in the decussatio infima.
This is well developed even in the fetus of three months. A small
part of the fibers, as Cajal further notes and as I have been able to
confirm, continue uncrossed to lower levels, as far as the pyramidal
decussation. “‘And when the Nucleus cuneatus disappears, the tract
can be seen penetrating the internal portion of the base of the dorsal
horn of the spinal cord, that is to say, in the region of the posterior
commissure’ (Cajal, 2, p. 733). (see also His. 20:) | liitsseniamam
then is the cephalic continuation of the pars intermedia of the dorsal
horn, or better, the interoceptive column.
Two other nuclei situated in the interoceptive column are deserv-
ing of special description, the collections of cells existing at the level
of entry of the seventh and ninth nerves. At the level where the
motor root of the facial nerve penetrates the corpus trapezoides and
the formatio reticularis grisea, a number of filaments of the sensory
root are seen penetrating the substantia gelatinosa of the radix spinalis
trigemini, converging on the interoceptive column which lies just to
the inner side of the descending root of the octavus (Fig. 8). Here
the dorsal divisions of the sensory root come into relation with a fairly
large rounded gelatinous mass, almost without fibrils, and containing
a few small rather widely scattered cells. Dorsal to this is a triangu-
lar more compact collection of small cells which also receives fibers
from the dorsal divisions. The gelatinous nucleus disappears a few
sections in each direction, but the smaller triangular or oval nucleus
of compactly arranged small cells remains constantly in relation with
this upper end of the tractus solitarius proper. The Nucleus gus-
tativus described by Nageotte (31) appears to have extended over
ainuchManrgenared:
Where the glossopharyngeus nerve enters in two divisions of about
equal size, the lateral root encounters a pyriform gelatinous nucleus
with scattered small cells before it reaches the more dorsally situated
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 295
tractus solitarius with its attendant compact small-celled nucleus
(Fig.9). The gelatinous nucleus is encountered only in this vicinity.
These nuclei are relatively considerably larger in the fetus than they
appear in the adult.
No structure of sufficiently notable similarity was encountered in
connection with the vagus nerve. The reasons for believing these
gelatinous nuclei to be the gustatory nuclei are several. In the first
place they are situated in the viscerosensory column, and the taste-
buds, as Johnston (8) has shown, are derived from the entoderm and
not from the ectoderm. Secondly, these somewhat peculiar nuclei
are found only at the level where the principal nerves of taste arrive
at the specified column. The negative side of the question is con-
sidered somewhat in detail by Kappers (43, 44) from the standpoint
of comparative anatomy.
The tractus solitarius, which in the past has been considered by
many anatomists to convey gustatory impressions, is practically unde-
veloped in the cyprinoid fishes. In these fishes the taste-buds are
distributed not only in the mouth, but over the head, the fins, and
even a large part of the body. The seventh and tenth nerves are
very large. The large collections of gray matter at the level of entry
of these nerves are so prominent that they are called the vagal or
facial lobes. It seems probable that these structures have to do with
the relay of gustatory impressions.
The tractus solitarius as such first becomes noticeable in amphibia,
that is, with the change from gill breathing to lung breathing, and it
increases progressively through the vertebrate series. In birds it is
_developed to a great degree, whereas the gustatory sense in birds
appears to be only rudimentary. Kappers compares the tractus soli-
tarius of the cassowary with that of the rabbit. The bird has prob-
ably less than one hundred taste-buds altogether, while the rabbit has
17,000. The tractus solitarius of the cassowary is as large if not
larger than that of the rabbit. Finally a comparison of the number
of fibers supplied to the tractus solitarius by the several nerves, and
their known relation to the sense of taste of these nerves, shows that
the smallest number is supplied by the N. facialis and the largest
number by the N. vagus, whereas the gustatory representation in the
nerves is the exact reverse. In truth we may well agree with Kappers
(I, p. 311) when he states that of all the IX and X fibers, those in
the tractus solitarius have least to do with taste. The tractus soli-
tarius probably transmits stimuli that provoke the reflexes connected
with air breathing, and it is composed of fibers transmitting impulses
of general visceral sensibility, chiefly from the upper respiratory pas-
296 WALTER FREEMAN
sages. According to Kappers this tract well merits the name formerly
applied to it of fasciculus respiratorius.
To sum up, then, the interoceptive column is practically continuous
from the base of the dorsal horn of the spinal cord to the area lying
dorsomesial to the nucleus sensibilis trigemini. It receives fibers
from all the mixed nerves, being in relation with the lateral roots of
the entering nerves. It is developed very early in fetal life. Its most
prominent part, the tractus solitarius, conveys not gustatory but gen-
eral visceral sensation. It forms the afferent path for impulses from
the respiratory passages that bring about the reflex acts concerned in
the breathing of air. The special interoceptive component fibers of
taste find their nuclei in this column at the level of entry of the
seventh and ninth nerves. No Nuc. gustativus N. X could be
identified.
C. The Proprioceptive Column
The proprioceptive system is no less complicated than the other
afferent systems. From the functional point of view there are two
main roles that it plays. The first is to inform our centers of con-
sciousness of the location in space of the various segments of our
body, so that we are able to form what Head has called a schema of
our relations in space. This might be called the cognitive function
and enables us to perform that complex act of the recognition of the
form of objects through the sense of touch, in other words stereog-
nosis. ‘The other part played by the proprioceptive system has to do
with the maintenance of equilibrium and the adjustment of tonus, and
is carried out automatically, through the mediation of the cerebellum.
The end-organs of the proprioceptive system are situated chiefly in
the muscles and tendons. The afferent fibers apparently run by way
of the motor nerves and find their ganglion cells in the dorsal spinal
ganglia and the corresponding cranial ganglia. In the substance of
the cord there is a redistribution of these impulses, one element being
shunted to the automatic proprioceptive centers which are strictly
segmental, and find their expression in the cells of the column of
Clarke. The fibers subserving the cognitive function run cephalad
in the dorsal funiculi to end in the nuclei of Goll and Burdach. The
latter is the more recently developed system in the phylogenetic series.
The close relationship of the proprioceptive cognitive and the
exteroceptive discriminative systems is apparent at a glance, and what
I have said concerning the exteroceptive discriminative system applies
equally to the proprioceptive cognitive system. The same nuclear
systems subserve both functions, therefore this latter one will be
discussed only incidentally in the sections below. We have found
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 297
the centers subserving the cognitive function in the brain-stem. ‘They
are the main sensory nuclei of the various cranial nerves and have
already been described. As was shown, these nuclei form an inter-
rupted column of cells comprising the nucleus funiculi cuneati, the
nucleus sensibilis trigemini, and the smaller intermediate nuclei. The
secondary pathway is found in the lemniscus medialis.
The proprioceptive system as expressed in the spinal cord by the
column of Clarke has not yet been accounted for in the brain-stem.
There is physiologic evidence strongly indicating the automatic control
of tonus in the muscles supplied by the cranial nerves. Such control
is obviously needed and exercised, for example, in carrying out the
function of speech, of eating, and of facial expression. Moreover,
these functions are disturbed to some extent in cases of disease of the
cerebellum which tend also to disturb the maintenance of equilibrium.
What is the connection therefore between the cranial nerves and the
cerebellum °
Many years ago Edinger (5) described a bundle of fibers entering
the brain-stem with the afferent divisions of the cranial nerves, par-
ticularly the N. trigeminus, and running directly to the cerebellum,
the direct sensory cerebellar tract. This appeared evident because
in the immature brain such fibers were myelinated at an early date.
Comparative studies have shown direct afferent fibers entering the
cerebellum in fishes, and here they form an important component of
the various nerves. ‘There is also some experimental evidence of the
existence of such fibers in mammalia. Winkler among others, in a
few rabbits in whom he had sectioned the posterior root of the Gas-
serian ganglion, described a few degenerated fibers running toward
the cerebellum. These findings were confirmed by some observers
and disputed by many others, until finally Winkler (14, Vol. 7, p. 41)
is much in doubt as to the existence of such a tract, and Edinger
(5, p. 230) himself has retreated from his original stand and states
as his opinion that these fibers are efferent ones from the tectile nuclei.
In serial sections impregnated with silver from the brain-stem ot
the human fetus, three, four, and six months of age, I have been able
to find no convincing proof of the existence of entering root fascicul1
running directly to the cerebellum. The evidence was not conclu-
sively negative, however, and in some sections there was an appear-
ance of fibers running towards the cerebellum (Figs. 8 and9). As I
have shown, however, the sensory nuclei situated at the tip of the
corpus restiforme lay in their path, and these may have been their
destination. On the whole there is no convincing evidence of a direct
sensory cerebellar pathway from the cranial nerves. Leaving aside
298 WALTER FREEMAN
the question of the cerebellar connection of the ordinary mixed nerves
for the moment, we take up the consideration of the great propriocep-
tive system of the medulla oblongata, the labyrinthine system.
I. The Octavus System
The nervus acusticus occupies a rather special position among the
cranial nerves. It is an unmixed sensory nerve (excepting some
efferent autonomic fibers said by Winkler to come from Bechterew’s
nucleus), resembling in this regard the optic and olfactory systems.
Unlike them, however, it does not arise directly from the neural tube
as an individual system. The ganglia of the eighth nerve are derived,
according to the very careful work of Adelman (2la), from the
neural crest. Another peculiarity of the octavus system is its place
in the functional scale. In its origin it is derived from the cutaneous
system, and Johnston (8) considers it under the special cutaneous
afferent system. On the other hand, Winkler (14, Vol. 7) ascribes to
it a proprioceptive function of very great importance. Tilney (13)
settles the difficulty by remarking that there need be no hesitancy in
accepting its proprioceptive function if we remember that its end-
organs are derived from the ectoderm instead of from the mesoderm,
as is the case of the other proprioceptive end-organs.
It seems probable that by an analysis of its anatomy and physiology
we may be able to place the eighth nerve in relation with the other
nerves of the brain-stem instead of in a category by itself. There are
certain similarities that persist in spite of the great differences.
To begin with, the octavus system is in reality double, the cochlear
system subserving the function of hearing, and the vestibular portion
subserving the function of equilibration. The divisions enter the
medulla oblongata separately and for the most part find different end-
stations. In this paper the terminations can only be indicated. I
follow Winkler in the following description, for he has employed
experimental methods. By strict anatomical methods the paths
cannot be definitely determined.
The vestibular division enters the medulla oblongata mesial and
slightly proximal to the cochlear division. It traverses the zone
between the corpus restiforme and the radix spinalis trigemini and
attains the nucleus triangularis or nucleus dorsalis N. acustici. The
root zone is indicated in Fig. 16. The nucleus is situated close to the
lateral angle of the fourth ventricle and extends a considerable dis-
tance both proximally and distally. Many of the fibers of the ves-
tibular nerve bend caudally and run in the tractus descendens nervi
octavi, to connect with cells in the nucleus tractus descendentis. Other
ARRANGEMENT OF PRIMARY APFERENT CENTERS 299
fibers run in the tractus ascendens nervi octavi, although Winkler
suggests that these are probably efferent fibers from Bechterew’s
nucleus.
The cochlear division enters laterally and distally with respect to
the vestibular division, and its fibers end in:
(a) The nucleus ventralis nervi acustict ;
(b) The tuberculum acusticum ;
(c) The lateral portion of the nucleus triangularis ;
(d) The nucleus corporis trapezoidis.
The last two nuclei are supposed to receive fibers from the macula
sacculi which travel with the cochlear nerve but seem to belong rather
to the vestibular system. The fibers from the organ of Corti, pro-
longations of cells in the ganglion spirale, probably end almost entirely
in the tuberculum acusticum and in the nucleus ventralis nervi acustici.
Developmental studies also show differences in the behavior of
the two divisions. The cochlea is formed considerably later in the
vertebrate series than the semicircular canals and otolith organs.
The cochlear nerve becomes myelinated at a later date than the
vestibular nerve. In my silver preparations of a three months’ human
fetus, the vestibular nerve is well stained, whereas the cochlear nerve
is discernible with difficulty and its reception nuclei are indistinguish-
able. Johnston (8) states: “ Two important things are to be noticed
in regard to the-centers for the cochlear division. The first is that
these nuclei are superficial with respect to the vestibular nuclei. In
this they offer a clear illustration of the general law that the more
highly specialized structures of the brain, and hence those which have
appeared later in the phylogeny, are placed toward the outer surface
with respect to the older structures to which they are related. ‘The
second point is that no cochlear fibers run to the cerebellum.”
The ventral nucleus of the cochlear nerve and the tuberculum
acusticum are situated ventrally with regard to the other tegmental
structures if considered in the transverse plane of section, yet taking
the floor of the fourth ventricle as the basis of judgment, these centers
are found to lie directly beneath the ependyma. ‘The great expansion
of this portion of the medulla oblongata has caused an extension of
the floor of the fourth ventricle far out into the lateral recesses, and
the floor has actually curved around the outer border of the medulla
oblongata as far as its lateral aspect. The relationship, which is clear
in the fetus (Fig. 21), is somewhat obscured in the adult nervous
system. The cerebellum comes in contact with the lateral surface of
the medulla, and much of this surface which was originally the floo1
of the fourth ventricle becomes obliterated by the fusion of the two
300 WALTER FREEMAN
masses. In the adult brain-stem only a small part of the tuberculum
acusticum can be seen in the floor of the fourth ventricle, while in the
embryo, even as late as six months, almost the whole of it, and the
Nucleus ventralis acustici as well, are found beneath the lateral part
of the floor of the fourth ventricle. Fig. 21 shows how the develop-
ment of the whole proprioceptive system at the level of entry of the
N. octavus has caused the proprioceptive centers to spread in mush-
room fashion over both the interoceptive and the exteroceptive
reception nuclei. |
The position of the acoustic nuclei in relation to the vestibular
nuclei corresponds more with the location of the nuclei of the proprio-
ceptive cognitive system. Differentiation has proceeded to a consider-
able degree, but many points of resemblance remain. For instance,
it may be called to mind that the secondary projection fibers running
from the acustic nuclei in the lateral fillet are in close approximation
with the secondary fibers of the common proprioceptive cognitive
system, namely, the lemniscus medialis.
The vestibular division was described as ending in the nucleus
triangularis and the nucleus descendens, possibly also in the nucleus
of Bechterew, although this nucleus may be the source of efferent
fibers.
In tracing the development of the vestibular system we find it
everywhere represented in vertebrates. Amphioxus apparently pos-
sesses neither labyrinth nor lateral line system, but in the cyclostome
fishes the semicircular canals are already developed and are served
by the eighth nerve. There are also lateral line organs which are
served by -branches from the, V, VII, and IX or X nérvesmaeiie
lateral line system is found in all fishes and in the aquatic amphibia,
but undergoes involution in the transition from marine to terrestrial
existence. There is very clear evidence that the lateral line system
is the forerunner and homologue of the labyrinth. The lateral lines
of fishes contain sense organs like those of the labyrinth, responding
to vibration and probably to differential pressure, and impressions
front these are relayed to the brain-stem. The reception nuclei are
located in the lobus lineae lateralis (Fig. 1), and the area acustica
(not homologous with the tuberculum acusticum of man), although
many entering root fibers run directly to the cerebellum. Some of
these original cerebellar afferent fibers still exist in the eighth nerve.
In the change from aquatic to terrestrial life the lateral line system
of organs is lost, and the function of equilibration comes to be carried .
on by the labyrinth. With this change and the suppression of the
lateral line system goes a progressive increase in the size and impor-
ARRANGEMENT OF PRIMARY AFFERENT CENTERS _ 301
tance of the labyrinth. The origin of the octavus system, however,
is probably to be found in the simple lateral lines of ancestral fishes,
subserved by the three nerves mentioned. The nerves supplying the
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FicurE 21. Semischematic diagram showing the relation of the nuclei of
the octavus system and their incorporation into the columnar architecture of
the brain-stem. The acoustic nerve is shown coming into relation with the
tuberculum acusticum and the nucleus ventralis nervi cochlearis. These nuclei
lie laterally in the floor of the fourth ventricle which is not yet obliterated by
the cerebellum. The great development of the proprioceptive system as
represented by these nuclei and by the nucleus triangularis and nucleus radicis
descendentis vestibuli has displaced the other primary afferent systems
ventrally. ‘The radicular fibers of the Nervus IX are seen penetrating the
R. spinalis trigemini and encountering the nucleus gustativus IX and the
tractus solitarius. The motor components are represented by the nucleus
ambiguus superior, and the radicular fibers of the Nervus abducens. The
section has been rotated to conform with the others.
lateral line organs follow the course of the nerves carrying general
* cutaneous sensibility and are regarded by Johnston as mere specialized
portions of these nerves.
From embryological investigations we learn that the ganglia of
302 WALTER FREEMAN
the eighth nerve are developed directly from the neural crest. In
the human embryo, according to the researches and model of Minot
(Johnston, p. 41), and the recent careful work of Adelman (21a) on
the rat, and of Bartelmez and Evans (21b) on man, the ganglia for
the seventh and eighth nerves arise from a single mass, the ganglion
acusticum-faciale.
This evidence still further suggests that the eighth nerve is not a
separate and distinct nerve from the begmning, but rather a lughly
specialized portion of the seventh nerve. This would serve to explain
their constantly close relationship, and would also fit in with the
conception of the fundamental architecture of the brain-stem.
Pursuing this idea, we find the cochlear portion behaving like the
proprioceptive cognitive division of the somatic sensory system, and
the vestibular portion behaving like the proprioceptive automatic
postural division. They are both proprioceptive in nature because
the end-organs of the octavus system are stimulated not directly by
external impressions but by the alterations of pressure, flow, etc., of
the fluid that bathes them or by the displacements of the otoliths.
The location of the nucleus triangularis acustici in the brain-stem
is between the exteroceptive and the interoceptive columns. The
radicular fibers of the N. vestibularis course caudally in the tractus
descendens nervi vestibuli lie between the nucleus funiculi cuneati and
the tractus solitarius (Fig. 17), and the peculiar assembling of the
fibers into small compact bundles separated by cellular areas renders it
possible to follow the tract down to the level of the pyramidal decus-
sation (Fig. 20). In this position the fibers lie close to the base of
the posterior horn but external to the position occupied by the caudal
extension of the tractus solitarius. In other words, the descending
root of the eighth nerve is continous and homologous with the column
of Clarke. The great expansion of the column that takes place in the
medulla oblongata is due to the large octavus component which comes
to it. The proprioceptive centers then spread mushroom-like over
the other’ primary afferent centers (Pig. 21)" The celleuinae
nucleus proprius tractus descendentis N. VIII send fibers to the
vermis cerebelli in the same way that the cells of Clarke’s column do.
The explanation of the long course distally in the medulla
oblongata 1s again to be found in the principle of usurpation. The
impulses subserving equilibration originally came to the medulla by
way of several nerves but subsequently became concentrated in one
nerve. The concentration in one nerve, however, has left unchanged
the original internal distribution of the cells of origin of the
secondary pathway.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 303
If the radix descendens octavi is considered to be the homologue
of the column of Clarke, does it show still further resemblances in
receiving fibers from more nerves than the acusticus alone? Does
it fulfill this test of being the reflex proprioceptive column for all
the mixed nerves of the brain-stem?
Up to the present time I believe that the radix descendens nervi
vestibuli has been considered to be a pure product of the eighth nerve,
but such appears to me not to be the case. In its course caudad the
radix descendens lies in close approximation with the upper portion
of the tractus solitarius, and the root entering nerves, the seventh,
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_ Ficure 22. Oblique section of the medulla oblongata of a three months’
tetus, showing the entering fibers of the N. vagus running to the tractus
solitarius. A strand of fibers at a can be traced from the root well into
the tractus descendens nervi vestibuli.
ninth and tenth, take up a position on its mesial aspect. Here, at the
dorsomesial angle of the R. descendens octavi they bend caudad in
the interoceptive column or tractus solitarius (Figs. 6, 8). There is
practically a fusion at this point between the fibers running caudad
in the tractus solitarius and those running caudad in the radix
descendens nervi octavi, and many fine fasciculi from the entering
roots seem to lose themselves in the tractus descendens (Figs. 9 and
10). This is more clearly brought out in a fortunate oblique section
of the medulla oblongata of a three months’ human fetus. ‘This
section shows the root fibers of the N. vagus penetrating in a large
bundle as far as the interoceptive column and making up the tractus
solitarius. A strand of fibers can be traced from the root however,
304 WALTER FREEMAN
well into the tractus descendens. This is seen in the accompanying
illustration (Fig. 22).
Ficure 23. Medulla oblongata of a cat whose sensory division of the facial
nerve had been avulsed. Marchi preparation. A few blackened fibers are seen
in the motor division. The tractus solitarius is completely degenerated at this
level, and two of the innermost divisions of the R. desc. N. VIII are blackened,
showing that this root receives fibers from the sensory facial root. (Fic. 2
from vanGehuchten. )
It is very definite because the black-stained fibers are not numerous
and stand out clearly in a pale field. Another piece of evidence is
based upon an estimate of the number of fibers constituting the
ARRANGEMENT OF PRIMARY AFFERENT CENTERS — 305
tractus descendens nervi vestibuli above and below the level of entry
of the tenth nerve. The count was made under oil immersion upon
the medulla oblongata of a human fetus of six months stained by
the author’s silver impregnation method. At the lower level indi-
cated, the tract appeared larger to the casual glance. An estimating
count of the fibers on the two sides gave:
Above, right 9700 left 9900
Below, right 13100 left 13700
Experimental evidence is given by Van Gehuchten (65) although
his interpretation does not concord with mine. In his study of the
central terminations of the peripheral sensory nerves by avulsing
them and examining the subsequent degeneration in the brain-stem
he found that the degeneration led to the tractus solitarius. In regard
to the facial nerve he says: “ Examined under higher power Fig. 3,
the root of the nerve of Wrisberg shows no exact limits. It is
formed of small bundles of nerve fibers which have undergone
secondary degeneration and which are placed on the one hand next
to analogous fibers of the spinal root of the fifth nerve, and on the
other next to the bundles making up the descending root of the
vestibular nerve.” From examination of the figures 2 (see Fig. 23),
3, 5 and 8 that illustrate the text, there seems to be no reasonable
doubt that the fibers lie not only next to, but within descending root
of the vestibular division. Similar conditions are found in the case
of the ninth and tenth nerves.
Summarizing what has been noted concerning the eighth nerve
we find that the octavus is a highly specialized portion of the seventh
nerve subserving :
(a) Hearing, a special proprioceptive cognitive sense;
(b) Equilibration, a special proprioceptive automatic postural
sense. Their sense organs are derived from the ectoderm.
The cochlear division engages the more newly developed lateral
part of the proprioceptive column, here represented by the tuberculum
~ acusticum and the nucleus ventralis acustici which lie in the lateral
portion of the floor of the fourth ventricle. The secondary pathways
for a certain distance, agree closely with the secondary paths of the
rest of the proprioceptive cognitive system. The vestibular division
is derived from the lateral line organs which were originally
306 WALTER FREEMAN
innervated by three or more nerves. This specialized division of
the seventh nerve, now known as the eighth nerve, has usurped the
function of the others, but the original segmental arrangement of the
primary receiving centers is still to be noted in the long intramedullary
course of the fibers in the tractus descendens and the tractus
ascendens nervi vestibuli. The tractus descendens is the homologue
and the continuation in the brain-stem of the column of Clarke in the
spinal cord, and as such receives fibers not only from the eighth
nerve, but probably also from the seventh, ninth and tenth nerves.
(To be continued)
SOCIETY PROCEEDINGS
NEW Y ORK NEUROLOGICAL SOUCIE Iny,
Tue Four HUNDRED AND THIRTY-First REGULAR MEETING, HELD
IN CONJUNCTION WITH THE ACADEMY SECTION OF
NEUROLOGY AND PsyCHIATRY, DECEMBER /, 1926.
Dr. I. ABRAHAMSON AND Dr. T. K. DAvis
PRESIDED
brie hoy Levies bol OM SelN: THE GUISk- OF
COMBINED SYSTEM DISEASE
Dr. E. D. FrrEpDMAN
We have had occasion to observe two patients with high cervical
cord lesion, in both of which the early signs pointed to combined
system disease. Later evidences suggestive of a level lesion became
manifest.
The first was a fourteen-year-old boy who complained first of
increasing weakness of the lower limbs; later the upper extremities
also showed loss of power. Shortness of breath, cardiac palpitation,
and incontinence of urine were noted at times. Priapism occurred.
Admitted to Mt. Sinai Hospital in July, 1920, he presented labored
breathing, tilting of the head with the chin directed to the left,
nystagmus in the horizontal plane, motor weakness, more marked on
the left, disturbances in joint mobility and vibratory sense in all four
extremities, astereognosis in both hands, ataxia with tabetic athetosis
in the hands, general exaggeration of the deep reflexes, diminution
of lower abdominals, bilateral Babinski, spastic-ataxic gait, a positive
Romberg sign and cerebellar phenomena, more marked on the left.
The general medical status showed no abnormalities. On one occa-
sion sugar was found in the urine. Spinal fluid revealed no abnormal
findings. Blood Wassermann proved negative. The case was con-
sidered a cross between the Friedreich and Marie forms of ataxia.
Fie leit August 20, 1920, and four months later was admitted to
Montefiore Hospital with the same complaints, now more pronounced.
The pyramidal tract signs had become more marked. He had cross-
legged progression and now presented hyperesthesia in the distribu-
tion of the upper cervical segments and tenderness over the upper
cervical spine. Below this hyperesthetic zone there were mild dis-
turbances in pain and temperature sense. He rapidly developed the
signs of a transverse lesion of the upper cervical cord and succumbed.
At autopsy the upper cervical cord was found to be compressed
by a mass springing from the odontoid process. This was composed
[307]
308 NEW YORK NEUROLOGICAL SOCIETY
of dense fibrous tissue in which was embedded a bony nodule
(osteo-fibroma ).
The second patient was a fifty-five-year-old watchman admitted
to Bellevue Hospital in July, 1924, who for seven months prior
complained of sharp pains in both shoulders which radiated down
the left arm and even into the left lower extremity. Four months
later, he noted a similar pain in the right arm. He soon was unable
to execute finer movements with either hand. Walking became
increasingly difficult and there was some hesitancy in voiding urine.
He also noticed a sharp pain in the left side of the neck radiating
upward.
Moderate emphysema and mild athero-sclerosis was present.
Weakness of the upper extremities, more pronounced on the left,
and paresis of both lower limbs was present. Superficial sensation
was intact but the joint mobility and vibratory sense were impaired
from the shoulders down. There was astereognosis in both hands.
with tabetic athetosis and ataxia. Gait was spastic-ataxic. There
was a positive Romberg sign. Abdominals were diminished. Deep
reflexes were exaggerated. A right Hoffman and bilateral Babinski
were present. The chief symptoms were those referable to the pos-
terior and lateral columns. Spinal fluid showed no abnormalities
except for a tendency to a paretic gold curve. Gastric analysis
revealed hypochlorhydria. There were no evidences of pernicious.
anemia.
It was thought that we might be dealing with a capsulo-thalamic
lesion on a degenerative basis. It was difficult, however, to reconcile
the diagnosis of a cerebellar lesion with the absence of any changes
referable to the cranial nerves. He was discharged for further
observation.
Patient was readmitted in January, 1925, with the same com-
plaints, but increasing weakness. Definite atrophy and fibrillary
twitching were now present in the muscles of the left shoulder girdle.
The sensory disturbances were the same as those previously noted,
but there was now demonstrated an area over the left shoulder, in
the form of an epaulette, in which pain, tactile and temperature sense
were impaired. Patient held his head rather stiffly. Lumbar punc-
ture now revealed manometric block and mild xanthochromia. The
sensory changes soon extended upward to Cy. Faradic responses in
the left deltoid and biceps muscles were diminished. Fibrillation was
observed in both trapezius and sterno-mastoid muscles, but more
especially on the left. Fluoroscopic examination of the diaphragm
showed limited excursions on the left side. No Bence-Jones bodies
were found in the urine.
It was now felt that we were dealing with a lesion near the
foramen magnum with antero-posterior compression of the cord at
Cy. It was advised that upper cervical laminectomy with partial
removal of the foramen magnum be performed. This was done on
May 1, 1925.
There was no evidence of bony disease. The dura appeared
whitish and dense. The arachnoid seemed thicker than normal and
NEW YORK NEUROLOGICAL SOCIETY 309
‘was definitely adherent to the cord and to the dura. Overlying the
first and second cervical segments there was a dense whitish mass
that seemed to mushroom out of the cord. It was quite thick and its
caudal extremity spread out finger-like over the cord. Attempts to
find a line of demarcation between this mass and the cord were
unsuccessful. The cord was adherent to the dura on either side for
a distance of two or three segments. The upper border of this mass
presented a very sharp line of demarcation. This adhesive process
seemed to completely obstruct the circulation of the cerebrospinal
fluid. Except for the adhesions and the mass mentioned, the cord
appeared normal. ‘The pathological condition found explained the
spinal block and the scar tissue probably accounted for the pain in
this area. It was considered that the process was inflammatory rather
than neoplastic (possibly luetic in origin). Microscopic study was
not made. The patient survived the operation only twenty-four
hours. No autopsy was performed.
Discussion: Dr. Bernard Sachs said: Dr. Friedman has pre-
sented his thesis in a splendid way. The same difficulties that he has
‘met others have also encountered, not only the difficulty of making
the differential diagnosis in such cases, but I have found the difficulty
even greater where the lesion is in the mid-dorsal region. In the
cervical region there are bound to be sooner or later symptoms which
point to involvement of the brachial plexus, such as a certain number
of cases which I have had under observation: for instance, a man
who for two years has had distinct symptoms of involvement of both
the posterior-and lateral columns, the affection, however, at present
involving only the lower extremities. There is no level lesion, and
only very slight nystagmus, which has made me suspicious that the
case might be an atypical disseminated sclerosis, but it is one of those
cases in which it is just as likely as not that we shall have to consider
the possibility of a slowly growing tumor in the mid-dorsal region.
As I review the cases which Dr. Friedman has presented, I do not
know that one could have made any different diagnosis in the earlier
stages. It was only when the sensory level symptoms appeared that
the diagnosis should have been made. Perhaps it could have been
made a little earlier than it was, but the cases are of extreme interest,
and we only encounter cases every now and then in which a diagnosis
cannot be definitely made until the post-mortem examination or some
unfortunate surgical experience proves the diagnosis.
Dr. I. Abramson said: I wish to call Dr. Friedman’s attention
to a patient who was in Mt. Sinai who presented for a long time
the syndrome of multiple sclerosis. She then developed signs and
symptoms of amyotrophic lateral sclerosis with respiratory difficulty,
like Dr. Friedman’s little boy. Later we were able to establish a
definite level in the cervical cord. The disturbance of the spinal
thalamic sensibility was at no stage very marked in this patient. The
level was established by the zone of hyperesthesias; this patient also
‘had vesical trouble, mainly incontinence. The case was operated on
310 NEW YORK NEUROLOGICAL SOCIETY
by Dr. Elsberg, and the neoplasm was found at the level indicated.
The patient survived the operation only for thirty-six or forty-eight
hours. An important point in the differential diagnosis of high
cervical tumors is the existence of early vesical trouble, not retention,
but occasional incontinence. That little boy, if I mistake not, also
showed incontinence of urine from time to time, which, combined
with respiratory embarrassment, made me consider the probability
of a high cervical tumor. In a series of cases collected by Dr.
Grossman and myself, I found incontinence of urine a not infrequent
symptom of high cervical lesions. In this little boy at the hospital
I suspected a level lesion, but we could not prove it, as sensory level
signs were absent. At the Montefiore Home, however, a very definite
diagnosis was possible that we were dealing with a high cervical
neoplasm; but the boy was not in shape to be operated on. In these
conditions it is important to look very painstakingly for level signs.
Dr. Friedman’s second case complained of much pain around the
shoulders. he moment you get level symptoms, hyperesthesias, or
root pain, you must be on the lookout for a neoplasm, and then
determine whether it 1s operable.
Dr. Friedman (closing the discussion) said: Dr. Sachs has
stressed the difficulties of diagnosis, in addition to those I mentioned,
and I want to thank him for his comments. I must apologize to Dr.
Abrahamson for having given the impression that the diagnosis .was
not made ante-mortem. I thought I had made this point clear when
I spoke of the advent of signs of a transverse lesion of the cord.
There were four diagnoses offered: intramedullary disease, atypical
Friedreich’s ataxia, central gliosis, and extramedullary compression.
One of the neurologists, a good observer, too, considered the case an
atypical Friedreich, even at the late stage, in spite of the fact that
level signs had been present. The existence of vesical symptoms 1s
important; but in some cases of combined sclerosis we may, as a
terminal event, obtain evidences of a transverse level lesion. Such
cases have been operated upon for tumor of the cord erroneously.
It is true that in viewing the cases in retrospect one can discern
elements in both cases suggestive of cord tumor. “The boy presented
the peculiar tilting of the head, with the labored breathing, sugges-
tive of high cervical lesion. He had occasional incontinence of urine
and priapism, but disturbance of spinothalamic sensation was con-
spicuous by its absence and he had no hyperalgesic zones early in
the disease.
In the second case, I believe if we had been able to get better
cooperation from the patient we might have demonstrated the hyper-
algesic zone which Dr. Abrahamson speaks of, and which we all feel
is of great diagnostic significance. All of us examined this patient
carefully for the existence of such hyperalgesia but no one could
definitely outline such sensory disturbances. It was only later, when
the pain shooting down the arm became more pronounced, the atrophy
and fibrillation in the shoulder girdle more definite, that the clinical
syndrome became manifest. ‘The stiff carriage of the head led us to
NEW VOR NEUROLOGICAL SOCIETY? - Si
probe more deeply into the disease, and then the diagnosis became
clear.
HEMILAMINECTOMY
ALFRED S. Taytor, M.D.
In the December meeting of 1909 the original paper on “ Uni-
lateral Laminectomy ” was presented. It is now called “ Hemilami-
rectomy ”’ because of the custom among most writers. Most
neurological surgeons think the method has no advantages. ‘The
usual operation, “ bilateral laminectomy,’ has been perfected and
made easy but there are conditions in which hemilaminectomy has
decided advantages. Before discussing them it should be stated that
special instruments, designed for the purpose, are essential to the
satisfactory performance of this operation. With the use of these
instruments it is possible to remove the laminae of one side so as to
give an exposure fully as wide and usable as that obtained in the
usual bilateral laminectomy.
It will be noticed that the exposure indicated in the pictures is at
an angle very favorable for the exploration of the cord with very
little manipulation necessary. The following things have been
repeatedly done without damage to the cord:
Exploration of the spine at all levels (with lumbar lordosis and
thick muscles the procedure is difficult and unsatisfactory ).
Dorsal ramisection on one or both sides.
Unilateral chordotomy can be accomplished with perfect ease, but
bilateral chordotomy cannot be done.
Exposure of spinal cord tumors with their removal. These have
frequently been done; tumors have varied from 3 to 5 cm. in length
and 1 to 2 cm. in diameter. They have been ventral; they have been
lateral; they have been dorsolateral. They have been removed so
that there has been no evidence of damage to the cord from necessary
manipulation. Intramedullary tumors have been explored, decom-
pressed by splitting the cord and leaving the dura unsutured. One
chondroma on the ventral aspect in the cervical region was removed
with rapid improvement on the part of the patient.
Exposure of adhesive arachnoiditis simulating tumors.
Exposure of “ meningo-myelitis ” simulating tumors.
Therefore, hemilaminectomy can be used with safety to the
patient; and most of the things usually done through bilateral lami-
nectomy can be accomplished through a hemilaminectomy.
The question is, whether under certain circumstances hemilami-
nectomy possesses such decided advantages over the usual procedure
that it ought to be the method of choice.
Remember that in hemilaminectomy the laminae of one side and
the spinous processes are left intact together with their muscular
and ligamentous attachments, a great stabilizing item. ‘This is par-
ticularly true in the cervical spine. When complete laminectomy
is done the ligamentum muchae is more or less destroyed and the
only supports left to the neck are the intervertebral disc and the
312 NEW YORK NEUROLOGICAL SOCIETY —
ligaments between the bodies of the vertebrae and articular processes.
Three cases are cited in which bilateral laminectomy in the cervi-
cal region was followed by dislocation of greater or less degree; in
one case leading ultimately to death; in the third case probably caus-
ing death, and in the second case causing no trouble.
In the lumbar and sacral regions, if bilateral laminectomy is
done, if there is a tendency to spondylolisthesis, then the patient has
very little support against a recurrence of this disability and there
is no bone so situated as to permit fusion of the spine or bone implant
which would give sufficient rigidity to prevent this accident. TIllus-
trations are given of these conditions.
Ventral and ventro-lateral tumors can be approached and dis-
posed of through the lateral exposure natural to hemilaminectomy
with far less manipulation of the cord than is feasible in the usual
laminectomy.
Finally, it should be stressed that if hemilaminectomy is used for
exploration and a condition is found which cannot be properly
handled, it is the simplest thing in the world to convert the exposure
into a bilateral laminectomy, involving as much of the field as is
necessary.
Various cases were cited to illustrate and prove the assertions |
made in the body of the paper. Lantern slides were also used.
Dr. Byron Stookey said: I am afraid that I am one of those
to whom Dr. Taylor has referred who did not do justice to this
operation until Dr. Taylor had demonstrated its value and its possi-
bilities. The aim of any surgical procedure should be to obtain
the maximum exposure with the least disturbance of anatomical
and physiological function. Witness, for example, the change from
the older method of the exploration of the brain as done by Sir Vic-
tor Horsley, in which the bone of the cranial vault was removed
without regard for cranial defect, to the method of osteoplastic flaps
now used by which a flap of bone is turned down and again replaced,
so that the patient is left with a minimum anatomical deformity and
yet an excellent exposure obtained. So I think with laminectomies —
a similar evolution has occurred. Until Dr. Taylor introduced this
method of hemilaminectomy a bilateral laminectomy has always been
done and no other method considered. I do not know why a great
many surgeons have been opposed to this procedure, except that it
is a great deal more difficult to do. It requires a greater amount
of skill, technique, and a longer time, and also special instruments
which Dr. Taylor has designed and without which the operation
cannot be done. If anyone has tried this operation with ordinary
rongeurs, he has undoubtedly met with considerable difficulty which
has made the procedure without proper instruments almost impos-
sible. With special rongeurs as devised by Dr. Taylor adequate
exposure of the spinal cord can be obtained. Many instances of
laminectomy are exploratory. Of the neoplasms most often missed
at exploration I think the ventral tumors, in particular the extra-
dural tumors, are those most likely to be overlooked, even in a
bilateral laminectomy. With a unilateral laminectomy the ventral
NEW YORK NEC ROLOGICAL SOCIETY 313
tumors are particularly well brought into view. The dorsal tumors
are readily seen anyway and are not likely to be overlooked, since
they are exposed as readily as the cord itself. Ventral tumors, on
the contrary, are often extremely difficult to find and not infrequently
are overlooked, even when their presence is suspected. With a hemi-
laminectomy in which the ventral part of the cord and dura are
especially well brought into view, these tumors are less likely to
be missed. I recall helping Dr. Taylor do a laminectomy on his
neurosurgical service at Bellevue for a ventral chondroma which
was small and placed in the midline, somewhat on the side of the
exploration. This tumor was taken out without difficulty through
the best exposure of the ventral surface of the spinal cord I have
Ever seen,
I have seen similar tumors which could hardly be reached by a
bilateral laminectomy. Consequently for a ventral tumor hemi-
laminectomy to my mind is the procedure of choice.
How are we going to know that a tumor is ventrally placed?
I do not believe that one can make a diagnosis a priori in some of
the patients but not infrequently after a thorough neurological study
we have enough evidence to suspect a ventral tumor. In two
instances at Bellevue’ within the last year on Dr. Kennedy and Dr.
Taylor’s service, ventral tumors were diagnosed before operation
and successfully operated. There are two regions of the cord in
which a hemilaminectomy is particularly indicated, one the cervical
region and the other the lumbar region. A patient who had a cervical
cord tumor with removal of the tumor by a bilateral laminectomy
made an uneventful recovery, but six months later he returned with
a more or less forward dislocation of the neck. I had never
encountered this deformity in any of the bilateral laminectomies
before. I reviewed the original plates, and thought I saw a slight
bony defect which was not appreciated by the roentgenologist or
myself before the operation. It is now two or three years since
the operation during which time he has had to wear a Thomas collar.
He has now begun to have some union of the two bodies of the
vertebrae, so that eventually I think he will be able to go without a
Thomas collar. In the cervical region, where the vertebrae are so
freely movable, hemilaminectomy is the procedure of choice, at least
as an exploration, and until pathology of such magnitude is uncovered
that it can not be dealt with by a hemilaminectomy. In the lumbar
region hemilaminectomy is not so simple. I have assisted Dr. Taylor
in operating many times, and he has always operated with a great
deal of ease but a hemilaminectomy in the lumbar region is difficult
and requires considerable skill and practice. However, a splendid
exposure can be obtained. For the maintenance of the body posture,
it is desirable to preserve in the lumbar region as much of the verte-
brae as is possible, and this operation, as Dr. Taylor has adequately
pointed) out, does permit one to obtain a wide exposure with a mini-
mum anatomical disturbance. I am sure that the patient who had a
liquefied disc with some bone destruction whose X-ray he showed.
and in whom he was forced to do a bilateral laminectomy, will have
314 NEW YORK NEUROLOGICAL SOCIETY
had some difficulty in maintaining proper posture. When there is
bone destruction by tumor further loss of bone substance may be
avoided by hemilaminectomy.
I think that hemilaminectomy has a very definite role in neuro-
logical surgery. Dr. Taylor gave to us some seventeen years ago
a procedure of great value which is bound to make its own place
in neurological surgery. Surgeons in many cities, Boston, Rochester,
etc., are beginning to do this procedure which Dr. Taylor gave us
some seventeen years ago, and which we have not had the good
judgment to use until it has begun to be revived.
Dr. Sachs said: As a neurologist, all I can say is that I admire
Dr. Taylor’s very conservative method and very conservative state-
ments regarding it. The method is surely in line with the best
canons of the art, and inasmuch as it is extremely conservative and
adequate, has everything in its favor. So far as the operation is
concerned, in cases of cervical tumor it seems to be unquestionably
better than bilateral laminectomy would be. In fact, the very sad
ending of one of the cases with the dislocation of the cervical bodies,
would make one hesitate to resort to bilateral laminectomy unless it
were absolutely necessary. In the case of lumbar tumors, if we can
possibly achieve what we wish to accomplish by unilateral laminec-
tomy, that would be the method of choice. In all exploratory opera-
tions, so far as my judgment would amount to anything, I should
say begin with a hemilaminectomy and then resort to the other if
it is found absolutely necessary.
Dr. Taylor has rather unconsciously drawn a line between neurolo-
gists and neurosurgeons. He said “if the patient would only
recover from his neurological symptoms.” Might I request that he
say the patient has spinal or sensory symptoms, but not necessarily
neurological symptoms, or one could go to work and say we hoped
the patient would recover from his neurosurgical condition.
I must congratulate Dr. Taylor on the discovery of a method
which seems to be admirable, and I hope that the neurosurgeons,
who have not always been ready to adopt new methods, will fall in
line towards hemilaminectomy much more generally than in the
past seventeen years during which this method has been known.
Dr. Foster Kennedy said: It has been my privilege to see Dr.
Taylor’s results and to compare them very favorably with the larger
operation of ordinary bilateral laminectomy. Sir Victor Horsley
used to say that, from his observation, it took twenty years from
the introduction of a new idea for it to become accepted by the
profession. It seems that this period of time has elapsed in a num-
ber of instances, and I) do not think that Dr. Taylor ought to be
disheartened by the time yet to go. I believe that in the next three
years this operation which Dr. Taylor has been demonstrating to
the surgical profession will be adopted largely, and that the excep-
tional operation will be bilateral laminectomy.
Dr. Taylor (closing the discussion) said: I want to apologize
to Dr. Sachs for having slipped up in English about the neurological
Niwa Chk NEUROLOGICALSSOCIELTY 315
trouble. Also I want to commend Dr. Sachs for having got the
real point of the paper. ‘The operation should be done as an explora-
tory thing, and then continued or not as the individual case demands.
It is so simple to make a bilateral laminectomy if necessary, and as
far as necessary, that the whole thing lies in knowing the situation
and finding out what you are going to deal with, and if you can
do a unilateral laminectomy, well and good. If you cannot do it,
you can do the, other thing in a few minutes’ time, and get all the
space you need without having wrecked the whole spinal column
to start with.
erie DDC bap ADE RT IN THE .COURTS+
FostER KENNEpy, M.D.
[ABSTRACT |
The fight for the recognition of individual rights from Runny-
mede to the Great War is briefly traced. The part medicine has
played in the past for the protection of the individual is cited in the
conquering of yellow fever, the plague, etc. In psychiatry a prophy-
lactic viewpoint is aimed at in examining the heredity and environ-
mental stresses of the insane, and in the effort to comprehend their
problems and aid in their adjustment.
To abolish or mitigate mental and moral ills we shall have to
do more than the priestly function of psychoanalysis. We must
control heredity, we must segregate and prohibit from increase the
proven unfit.
In the criminal courts, we, as a body, are in the main reversing
these aims. We are protecting the individual criminal from society
when society has as yet made no plans whereby in the event of
release on present charges, the criminal might be prevented from
anti-social acts in the future. A public health attitude must be
adopted in this matter, and it must be proclaimed that psychiatry
cannot properly work through the existing criminal code, that justice
is diverted by the absurdity of hypothetical questions, that 12 lay-
men cannot be expected to appraise nicely the degree of responsi-
bility of a paranoic or a high grade moron, and that the differences
of opinion between lawyers and doctors, and doctors and lawyers,
_ buttressed, if not directed by funds from opposed interests—gossiped
and wrangled out in the courts—elevate crime, debase law, and
prostitute medicine.
The real point at issue in a trial in which the defense is a plea
of insanity is not whether or not the mind was unsound, but was it
sufficiently unsound so as to be unable to determine right from wrong,
or if so, was the accused a victim of irresistible impulse to commit
the act as charged in the indictment.
The question of responsibility for crime has been moot between
lawyers and medical men from the time of Lord Erskine and the
McNaughton case in 1843, down to the present day, when calcifica-
tion of the pineal gland has been advanced as a reason why a criminal
316 NEW YORK NEUROLOGICAL SOCIETY
of eighteen should be shown preferential treatment for his murderous
peccadilloes.
The whole system wher eby a defendant employs and pays tor
medical opinion in the courts is wrong and should be abolished; a
defendant should have no more constitutional right to pick his medical
expert than he has to pick the policemen ho arrests him or the
judge who presides at the trial. Acquittal on account of mental
disease or semi-mental disease, often a feeble release of wolves to
prey on the people, should no longer be toleratd. Psychiatrists and
jurists on both sides of the Atlantic have been feeling their way
towards realization of some of these ideas in the practical working
of the courts. The American Institute of Criminal Law recom-
mended recently the following program: 1. That in all cases of
felony or misdemeanor punishable by prison sentence the question
of responsibility be not submitted to the jury, which will thus be
called upon to determine only that the offense was committed by
the defendant. 2. That the disposition and treatment (including
punishment) be based on a study of the individual offender by
properly qualified and impartial experts cooperating with the courts.
3. That no maximum term be set to any sentence. 4. That no parole
or probation be granted without suitable psychiatric examination.
5. That in considering applications for pardons and commutation,
careful attention be given to reports of qualified experts. A sixth
recommendation should be included in this program: that a panel
of qualified medical opinion be chosen if possible from university
and major hospital staffs, who would advise the consciences of the
court, who would receive adequate remuneration from no private
individual or corporation, but from the State and from the state
and from the state only. The third provision, that no maximum
term be set to any sentence of imprisonment or segregation, is of
the highest importance, for when incurable people, such as morons,
slightly feebleminded persons, constitutional inferiors, mildly psycho-
pathic individuals, etc., have proven their instability by crime, we,
as a herd, have.a right to demand their segregation probably per-
manently, but certainly prolonged, depending on the natures of their
eccentricities and of their crimes. Let us banish mawkish sugary
sentimentalism, let the law do its duty and do it quickly and let us
doctors put our knowledge at the disposal of the state and of the
courts, but not ply for hire among the unstable, the eccentrics, the
psychopaths and the dregs of the underworld.
Discussion: Dr. Joseph Collins (by invitation) said: Aristotle
said that a speech consists of two parts, one a statement of the case,
the second part was to make it good. I think Dr. Kennedy has
stated the case very well. I am not so sure that he has been so
successtul with the requirements of the second part. It is an indi-
cation of maturity, perhaps of crossing the Rubicon, that one con-
cerns himself with expert testimony. “There probably is no one in
this audience, who has suffered change of life, who has not spoken
or written upon it. I have heard the substance of what has been
spoken here ventured in varying keys many times. Dr. Kennedy
NEW YORK NEGRKOLOGICAL SOCIETY 317
opens his address with some remarks on our neglect of society as
a whole, and of our attention to the rights of individuals. Now
we do not have to look very far to see that that does not exist the
whole world over. There is an example of crass individualism going
on in the world at the present time which seems to get the sympathy
of a large number of the articulate people throughout the entire
world, namely, the experiment going on in Italy. That is indi-
vidualism with a vengeance, and not with much concern for the
group which constitutes society. JI am not so sure that the world
is not witnessing an effort.to get over the bulwark of liberty, and
that this is not a continuation of our endeavor to make individualism
the whole thing. But I do not want to discuss that. That was really
only an introduction to this entire subject. The gravamen of this
entire situation, as presented by Dr. Kennedy, is contained in two
things: first, that the hypothetical question is an abomination, and
second: that the way of eliciting and obtaining expert testimony
should be changed. ‘There is no one here mean or contemptible
enough to say a word in favor of the hypothetical question; every-
body agrees; but it is like death and taxes; it is inevitable. We
have got to put up with it. We can delay the former and ameliorate
the latter. hat is all we can do with the hypothetical question. Who
is responsiblesfor the hypothetical question? Who frames it? We
frame it. There never was a hypothetical question that we experts
were not asked either to frame or to supervise. We inject into
the hypothetical question some objective which will permit us to
answer in favor of the person or institution which employs us,
and at the -samte time eases our conscience. ‘There is a way by
which the hypothetical question can be, if not cured, enormously
improved. It has been suggested before. I even have suggested
it: there should be but one hypothetical question ; one which embraces
all the facts that have been presented by the state and by those who
represent the prisoner, and that the hypothetical question should
be asked the experts on both sides. If that were done, the hypo-
thetical question would be relieved of the enormous charge that
can be made against it, namely, that it facilitates injustice rather
than justice. If we wish to help the legal profession in a way that
will permit them to avail themselves of our expert services we can
do it by getting the Bar Association and the medicolegal associations
to agree that the hypothetical question should be prepared in that
way, and in no other way. The procedure of the hypothetical ques-
tion is exactly the same thing that we as physicians constantly face
in reaching a diagnosis. Why should lawyers be denied a procedure
that we find so useful, and essential? In the hypothetical question
we are asked to assume that so and so are the facts. When a patient
is brought to me, and I am asked to pass on his sanity, | assume that
what has been told me by those who brought the patient are facts,
and then I can use whatever capacity for interpretation, detection,
or discrimination that I have to see whether they are facts or not.
That is exactly what the expert is called upon to do with the hypo-
thetical question, and that is what the jury is called upon to do. The
318 NEW YORK NEUROLOGICAL SOCIETY
hypothetical question is exactly what the jury system is: an out-
growth of necessity ; an evolution of the process of law. We cannot
and should not get rid of it. We should better it.
Now for the second part: expert witnesses and testimony. There
are four kinds of expert witnesses: There is the expert witness who
does not know, but who does tell 1t; also the expert witness who
knows and cannot tell it. There is the expert witness who is truthful
and the expert witness who is a har. Those are the four kinds of expert
witnesses. Dr. Kennedy has suggested a method by which expert
witnesses should be called. I am not in agreement with him at all
that the individual does not have the right and should not have the
right to call upon any one that he chooses to give expert testimony.
I have witnessed in a comparatively short life too many curtailments
of the liberties of the individual promised by the Constitution. Why
should a criminal be deprived of the right of calling expert witnesses
to testify in his behalf? Until he has been proven guilty he should
have the rights conferred upon him by birth even though he was
born in sin. I heard Dr. Sachs 25 years ago, or more even, say in
this Society that experts should be called in very much the same
way as Dr. Kennedy has suggested. He has waited longer than the
twenty years of Sir Victor Horsley, and he is still a voice crying
in the wilderness. I made a suggestion a year ago last January, in
Harper’s Magazine, which was that the expert witnesses be obtained
in the following way: That the Academy of Medicine should send to
the presiding judge of the Appellate Division of the Supreme Court
a list of names of men who are qualified by study, by character, and
by experience to give such testimony. These would be retained
by the state as expert witnesses and they should have a retainer, a
yearly stipend; and whenever an expert witness was needed one
could be supplied. We-have recently been through a farcical trial
in New Jersey. Here the experts dealt with “ finger prints.’ Three
experts swore they were those of Willie Stevens, whereas three
others pointed out to the. perception and intelligence of the jury
and apparently to the satisfaction of*the whole world that those
finger prints were not the finger prints of Willie Stevens. Suppose
the testimony of the first three experts had been accepted. Willie
Stevens would now be languishing at the foot of the gallows. One
half of all expert testimony is bunk. That is the real truth about it.
One might readily gather from reading Dr. Kennedy’s paper
that prisoners who are declared insane go scot-free. They don’t.
They go, as you well know, to asylums for the criminal insane.
There is a choice between hell and Dannemora. Now that the former
has been deprived of some of its terrors a goodly number of criminals
probably choose it. I am sure that they would choose Sing Sing.
When an insane criminal recovers, and parenthetically insanity
recovers in a criminal with the same frequency that it does in priest
and reformer, then he is put on trial again. If he does not recover
he stays where he has been put and that is punishment for any
crime save bootlegging.
NEW YORK NEUROLOGICAL SOCIETY 319
I do not quite understand what Dr. Kennedy meant by preferen-
tial rights or treatment referring to the Loeb case. Those criminals
got life sentences. That ought to satisfy anyone or everyone who is
notegaited like Pekah: The. truth “et the matter 1s; Pf. think, that
criminals, despite us doctors, get what is coming to them in the
wast Inajority ot instances. ‘They do not setvit as soon as they
should, for everyone admits there is lamentable delay in bringing
them to trial, but they get it eventually. That some of them are
able to use money to their advantage goes without saying. When the
time comes that they are not, that will be the millenium.
We have got two things to do: the first one is to change the
hypothetical question; the second is to adapt some means for the
elimination of the crook as an expert. Now Dr. Kennedy has called
your attention to the fact that some of the recommendations made
by the American Institute of Criminal Law are most deserving;
but I want to call your attention to the fact that three of those
recommendations are already in effect. At the present time no
parole is granted in this state without suitable psychiatric examina-
tion, and careful attention is given to every demand for parole. I
call your attention to the fact that it is the increasing custom in this
state and throughout the country, in the courts that the history
and environment of the offender be looked into most carefully before
sentence is pronounced. I am in full sympathy with Dr. Kennedy’s
closing sentence providing that he will change only one word. He
says: “Let us abolish sugary sentimentalism; let the law do its
duty and do it quickly, and let us doctors put our knowledge at
the disposal of the state and of the courts, but not ply for hire among
Thewiistable,; the eccentric, the-psychopath, and-the dregs of the
underworld.” If he will change “not ply for hire” to read “ not
heprormhirer,, lant inetull agreement with him.
Dr. Smith Ely Jelliffe said: It is interesting to hear once again
of Runnymede and the Magna Charta and to learn from these and
later glorious achievements that it took so long for the individual
te get any rights at all.
In fact we sometimes doubt whether that safeguarding of the
liberty of personal action has been so well acquired as our learned
reader of the paper of the evening has assured us. In fact, I hope
I do not appear somewhat hypercritical if I seem to detect in the
opening sentences of this paper a blowing hot and a blowing cold—
now it is the individual who has all the rights—now the masses.
If the Great War was one for individual rights, and the bloodless
struggle (I presume Dr. Kennedy is referring to the British General
Strike) one for the masses, wherein do we find that just discrimina-
tion that I feel sure our orator would counsel. Certainly not with
us here in the United States in the Prohibition Movement—that
monumental bit of legislation which would even deprive the future
[present] President of our Academy of Medicine to prescribe for
human beings what he considers right and wise for him to prescribe
in the event the prescription should contain C2.H;OH. Think of
320 NEW YORK NEUROLOGICAL SOCIETY
it, five chief justices of the United States as opposed to four chief
justices of the United States presume to tell the doctor what he
should prescribe for sick humanity. Is this Runnymede—or Magna
Charta—or just “ Blind” Justice?
But this is possibly an aside from the issue we are called upon
to consider. No one, least of all myself, would dispute the gravity
of the situation to which Dr. Kennedy, like many another before
him, has pointed his finger in the second paragraph of this paper.
Eleven thousand homicides—nine-tenths of which I venture to sug-
gest hinge upon the very issue I have just spoken of—namely pro-
nibition. This is a terrible thing to contemplate and the comparison
from typhoid or Boer War material is not needed to make one
shudder and creep. But has Dr. Kennedy put his finger on the
real spot when he calls this “rampant individualism”? Might I
rather say that it is a direct result of .bullnecked legislation in its
muddle-headed effort to try to treat medical and evolutionary prob-
lems by law.
Dr. Kennedy assures us that Law is an instrument for the pro-
tection of society—but he forgot to say what kind of law. If he
said that good law was an instrument for the protection of society
I say—Amen. But what about bad law? Is there no such thing
as bad law? Are we all hypnotized by the belief that “LA W “is
sacrosanct and one needs be a socialist or a bolshevik because he
dares to distinguish or suggest that such a distinction is possible?
I yield to no man in my belief in the high calling of medicine
both in its individualistic as well as in its prophylactic orientation.
We did build the canal—and we have made it possible for millions
to live longer, and be happier than ever before, and we don’t need
a yellow press, or a Saturday Review of Literature to “tout” our
achievements. And may it be said that a dawn is slowly breaking
when a man’s mental equipment may be judged in a better light
than his physical one. This, I take it, is what Dr. Kennedy refers
to when he speaks of mental hygiene.
I said the dawn was breaking—but is it here? I shall never
forget a story told by one whom we all as neuropsychiaters, love,
Dr. Pearce Bailey. In his slow grim way he narrated how during
the late war thousands of individuals were rejected as soldiers
because they had “ flat feet,’’ but when it came to “ flat heads ” why
they took them in. One can readily understand how flatfootedness
almost became epidemic in 1917.
I regret to have again to lock horns with Dr. Kennedy—not this
time on his statistics, but upon his allusions to the Platonic-Aristo-
telian bipolarity. There is really no antagonism between Vitalists
and Materialists—hetween Functionalists and Structuralists. Dr.
Kennedy and I have married them repeatedly, but I would call
attention to the nature of the two marriages—with Dr. Kennedy
I fear ’tis a “ mariage de convenance,”’ with me ’tis a real love mar-
riage, and function-and structure are one—and mind is but one of
the functions of living matter. Soma and Psyche were born together,
and let us hope ever will remain so. And as to all this senseless wind-
NEWYORK NEUROLOGICAL SOCIETY 321
jamming about mind and matter, the words of an English thinker
may be recalled when he said, regarding “ mind, no matter; and as
for matter, never mind.”
But our essayist progresses by a prodigious leap when he advances
the proposition that “we as physicians must control heredity.”
Imagine the magic wand we must possess to alter a billion years
of life’s experiences on the globe; and also “we must segregate
and prohibit from increase the proven unfit.” Proven by whom?
Five supreme court justices or by some other legally appointed
authority? Who is more fit than another? and by what yard stick
are we going to measure human personality? I think Dr. Kennedy
puts it—‘‘ we must discover the seat of the vital rhythm of per-
sonality.’ Where have I heard that phrase? I confess it means
little to me—even as a follower from afar of the so-called “cuit ”
to which Dr. Kennedy attaches the title “ priestly.” I suspect our
essayist “strains at a gnat’’; let us hope that he will avoid “ swal-
lowing the camel” of mundane materialism.
Dr. Kennedy states that in our criminal courts “ we as physicians
act sometimes as brakes.” ‘‘ We would reverse the aims of the
courts.” I would like to challenge him directly. How many of the
11,000 homicides he mentions, through thew lawyers, have put in
gedeiense of insanity: do not think he can answer. In: fact, I
might even go further and state that the vast majority of the few
who are apprehended would rather put in a defense of murder of
a lower degree, than put in the defense of insanity—and why? My
own personal experience makes me state that the vast majority of
homicidal prisoners prefer to take their chances in jail rather than
in the state hospitals.
When our essayist states in the seventh paragraph of his paper
that “society as yet has made no plan whereby, in the event of
release on present charges, the criminal might be prevented from
antisocial acts in the future’ he makes, I believe, a serious misstate-
ment. . Society has made a number of plans, one of the most
significant of which is to lock the individual up in a state hospital—
Matteawan or Dannemora—in New York, and “believe you me”
in current phraseology, those are the two places in this state where
the criminal does not wish to go. This is a very poor place for us
or for him to discover the “ vital rhythm of his personality.” Every
so-called criminal with whom I have come in contact has much greater
fear of being considered a “nut” than the average man in the com-
munity. If there are any prison wardens in the audience I hope
they will correct me in this impression.
I am glad to agree most cordially with Dr. Kennedy that the
existing criminal procedure is an abomination; but I do want to
insist in the same breath that we as physicians did not make it. I
would tread a little more lightly upon the matter of the hypothetical
question. Here matters of procedure and modes of presentation of
evidence get closer to the legal frame, and I suspect, we may not
know as much as we think we do in view of the growing body of
experience in law. Because American jurisprudence does not accept
‘
322 NEW YORK NEUROLOGICAL SOCGIFG?,
our medical methods of investigation, it does not mean that the
hypothetical question is absurd, even though we, as physicians, know
it is riddled with medical absurdities. The law, however, is working
with a different frame, Einsteinally speaking, and it may not be as
foolish as we think it 1s.
And finally when Dr. Kennedy would attack the jury system—
ludicrous as it may appear in a Johnson caricature—is he not treading
rather roughly upon Runnymede and the Magna Charta? For after
all are not the twelve men good and true a symbol of the community ?
Is not our essayist a more or less peremptory Prussian when he
would attack that ancient and honorable tradition, the “jury”? I
confess that from my own point of view, I have seen many a foolish
jury, but, one may notice I say “ my own point of view.” And who
among us can claim omniscience ?
After all the twelve men good and true are not necessarily all
simpletons—such as we might think them. They are very often
astute “wise guys” that know a lot more than we do about the
“rhythm of personality.” They sell-a thousand hatsmin-aeqsy ean
7,000 stockings in a week and often are in much more intimate con-
tact with the “rhythm of personality’ than we are, as physicians,
wondering whether a little arsenic or a little pituitary will help this
or that ailment.
And now to questions of theory. I am compelled to disagree
with our learned essayist. We have, let us say, 48 states in the
Union; 23 have one series of tests; 25 have another, and: they all
vary as to the tests for responsibility for homicidal acts, testamentary
capacity, contract capacity, ability to confer with counsel, ete. Dr.
Kkennedy does not particularize, and if he is quoting New York
law on the issue of responsibility, he is misquoting. Across the river
in New Jersey one can get away with an “ uncontrollable impulse ”
but not in New York. “Lord Bramwell and McNaughton” are
all right in English jurisprudence but they really cut no ice in
America in medicolegal matters. In fact, the McNaughton situation
has practically little relevancy in American court decisions. The
1843 issues in England, dear to the medicolegal literati, have long
ceased to be of significance in the United States.
Specifically, Dr. Kennedy states that the defendant has no right
to employ expert opinion. It grieves us greatly but the Constitution
of the United States does not agree with Dr. Kennedy. We are
sorry for the Constitution, but also sorry for Dr. Kennedy that
he should not have informed himself more accurately on this minor
issue, which he compares to the right of an individual as to what
policeman should arrest him. This is one of those comic statements
that throws one off one’s guard if one is not careful.
“Acquittal on account of mental disease should no longer be
tolerated”? In other words no criminal acts are ever committed
by diseased individuals? This is certainly an absurd conclusion.
Especially since Dr. Kennedy himself tells us of the behavior changes
in encephalitis.
And finally we have the recommendation of the American Insti-
NEW YORK NEUROLOGICAL SOCIETY 323
tute of Criminal Law. Dr. Kennedy banks large upon this pro-
nouncement, concerning the evolutionary history of which one sus-
pects he is not altogether familiar—as a special pleading.
I admit that “woolly intelligentsia” receive their adequate
exploitation in the “ Daily Graphic” or the “ New York American,”
but these are only “rationalizations”’ of making silk purses from
sows’ ears; but fundamentally the twelve men good and true are
not always such apes as one might be led to infer from the discussion.
Dr. M. Allen Starr said: After this very brilliant paper, and
the very witty discussion by Dr. Collins and Dr. Jelliffe, I fear that
all I have to say will sound rather dull, but I wish to remind Dr.
Sachs and others that this matter came up very seriously before
the Academy of Medicine in the early nineties at the time of the
extraordinary interest that was taken in the medical testimony in
a certain case. At that time there was a great deal of sentiment
among the members of the Academy of Medicine that some effort
should be made by the members to remedy the state of affairs which
was practically a scandal, that large numbers -of so-called experts,
who were not experts, could be brought up into court, and establish
the capacity of the medical profession, as Dr. Collins would say,
for lying. At that time the President of the Academy, Dr. Edward
G. Janeway, appointed a committee consisting of Dr. Dana, Dr.
Janeway, and myself to take this matter up before the Bar Associa-
tion and the judges of the Appellate Division, then Judge Barnet,
Judge Ingraham, Judge Gildersleeve, and Frank Scott, who were
all very eminent members of the Bar. We met with them and tried
to devise some method by which this scandal could be avoided in
the future. The scheme that the committee evolved was this, and
the judges backed it up very decidedly, that the plaintiff should
have the power of choosing a medical expert; that the defendant
should also have the power of choosing a medical expert, and that
the judge of the court before whom the case was coming up should
himself appoint a medical expert, preferably a man who was either
a professor in a college or at the head of one of the state institutions,
like Matteawan or Dannemora, and that these three physicians should
examine the person accused of insanity and bring into the court a
report, which report necessarily would be either unanimous or two
to one on one side or the other; and the judges thought it wise to
suggest that the fees of each of these men should be settled at law
by the judge and not dependent upon the capacity of the individual
who was the defendant, perhaps, willing to pay large sums, and
that the jury should be guided in their verdict by the report which
was brought in. But there again the difficulty at once arose that
every defendant had the right to call the whole United States in
his defense if he chose to do so, and that this scheme would be an
infringement of the liberty of the individual. That was the scheme
that was adopted here in the Academy of Medicine and in the Bar
Association, and I assure you, although Dr. Kennedy and Dr. Col-
lins have thrown a certain amount of doubt on the lawyers, they
324 NEW VORK NEUROLOGICAL SOCIE EY
are just as anxious about the matter as we are; and they are anxious
at the present time, because the day before yesterday Henry Taft
told me that the Bar Association at present has a committee appointed
to study this matter, and see if they cannot work out some scheme to
set right the matter of expert testimony before the court. I do not
think the Bar Association is indifferent to this matter, and I think
that if we could come to any definite conclusion or definite recom-
mendation which we could send to them, it would meet with their
approval, or at any rate with their favorable consideration. But
up to this time neither our Academy of Medicine or the Bar Associa-
tion has found any definite method.
There is a method which is in effect and has been in effect for
25 years in Germany, which has always commended itself to me
very decidedly. An individual is arrested for a crime. The question
comes up in his defense that he 1s mentally unsound. In Germany,
when a plea of that kind is brought up, the matter is suspended at
once, and they commit the individual to a psychiatric institution
entirely unprejudiced, that is to say, not under the control of the
court, but an unofficial psychiatric institute, where the man is placed
for a matter of two to six weeks, and while there he is very care-
fully examined by individuals who are known to be expert, and those
individuals combine upon a written report. You will see such reports
all through the “ Neurologischen Centralblatt,’ quantities of such
official reports submitted by doctors qualified by the state as experts
of the court, and in a very few instances are those reports in any
way overruled. .
Now of course I am not sure that it would be wise to confine
any suspect to Matteawan or Dannemora under the present condi-
tions, but 1f we are going to have a psychiatric institute in New
York under the direction of such a capable individual as Dr. Kirby,
it seems to me that we have a solution of this problem, that we
ought to consider, and that we ought to think of the possibility of
suggesting to the court and to the Bar Association that this German
method be adopted as a measure out of our present dilemma. That
is the only thing I have to suggest in addition to this discussion.
Dr. Emil Altman said: I have nothing to add to what has been
said about criminal procedure. No one can add anything to the
schemes and to the experiences which have been expressed. here
to-night by three leaders of psychiatry. In connection with the
activities of the Chief Medical Examiner of the Board of Education
the educational authorities and the Medical Division receive testi-
mony and certificates from experts that are at such variance with
the facts as to make them a gross reflection on the integrity of both
physician and teacher.
Dr. M. Osnato said: I am wondering if this discussion is timely
or even necessary so far as the State of New York is concerned.
If you will follow the career of the criminal from the time he is
arrested until he reaches the death house at Sing Sing, you will
see that from the psychiatric side he is very well looked after.
Recently the policemen have been taught by Dr. Lahey of the Police:
NEW YORK NECRKOLOGICAL SOCIETY 325
Department, a very well trained neuropsychiatrist, and by Dr. Gre-
gory of Bellevue, in systematic courses which have been thoroughly
given. These courses are calculated to enable officers to recognize
the common symptoms of mental disease. The average detective is
now more or less familiar with the outstanding features of mental
troubles, so that the offender is observed by a partially trained ind1-
vidual as soon as he is arrested. In the station house the observa-
tion may be extended over several days. When brought before the
magistrate, if there is any suspicion of insanity, the offender is
remanded to Bellevue for observation and Dr. Gregory’s opinion
is nearly always final and determines the judges’ action. As Dr.
Collins has already mentioned, the courts are supplied by the machin-
ery of the probation system with the result of investigations which
report on the social status of the individual and his behavior over
an extended period of time. The judge who must sentence the
offender has before him, therefore, very considerable data regarding
the personality and the behavior of the individual. If anything
arouses the judge’s suspicions as to the mental fitness of the offender,
commitment to Dannemora follows, after a period of observation
at Bellevue.
During the criminal’s stay in the Tombs, he is subjected to an
examination by the Tombs physician, an individual who has con-
siderable practical experience in the detection of mental disease. If
during the man’s incarceration mental disturbances are manifested,
that fact is recorded and the judge then appoints a lunacy commis-
sion consisting of a physician, a lawyer and a layman whose duty
it is to call witnesses, including expert witnesses who are usually the
Bellevue or Kings County psychiatrists. When the case is tried,
the judge is completely cognizant of all the psychiatric features of
it. ‘The indicted insane offender must automatically be sent to Mat-
teawan if found insane.
Once convicted, if the mental situation develops after imprison-
ment, that situation is also provided for and after a commission
finds the offender insane he is sent to Dannemora. “The commission
usually consists of three of the superintendents of the State Hos-
pitals, whose duty it is to examine the offender and make recom-
mendations. ‘This commission also examines and reports on every
man in the Death House at Sing Sing.
1 think you will find, if statistics were gathered on this point,
that the difficulty is in the borderline cases occurring in offenders
who are wealthy or who have wealthy individuals interested in
them. They will often go to almost any extremity to prevent the
proper administration of justice. Then one has to deal with the
weaknesses of human nature and as to that experts are not exempt.
It is a very understandable thing why in such cases differences of
opinion are found and often do occur in experts. 1 do not believe
that the situation occurs frequently wherein a. criminal case has
ranged on opposing sides mental experts who do not agree in their
testimony regarding the mental status of the patient. So far as this
state is concerned, I feel that this discussion is not timely and it does
326 NEW YORK NEUROLOGICAL SOCIETY
not seem to me that the Society as an organization need do anything
more about it.
Dr. Kennedy (closing the discussion): I am much indebted to
Dr. Collins for his admirable discussion, and interested in his plan
for a list of experts chosen by reason of knowledge and character.
This plan does not differ very much from that which I suggested:
that they should come from university faculties and hospital staffs,
which, despite Dr. Jelliffe’s doubts, would be apt to include a few
good doctors and intelligent men.
I was also obliged to Dr. Starr for showing a plan to make experts
expert and for demonstrating the indefatigability of our effort in
this direction. It is something, I think, that we doctors keep on
trying, however little encouragement we get from our results. It
makes rather dreary reading to see that frankly dishonest reports
are coming in to the Board of Education, and while it is not exactly
germane, there is in it a certain moral analogy to our subject.
In reply to Dr. Osnato, I am glad to know that policemen used
to be Freudian and now they are Behavioristic. While he said that
New York State did not require any of these recommendations, he
spoke rather of the criminal without resources; wealth can obstruct
justice, and he admits that rich people are able to interfere with the
administration of justice; and my remarks were really directed
against our participating in that general abomination.
Judging from Dr. Jelliffe’s emotional, remarks, I would seem to
have uncovered in him a maelstrom of courtly conditioned reflexes
and pro expert complexes. To criticize the medical expertmsmii=
I assure him, to besmirch the medical nest; but rather to try to
cleanse the Aesculapian stables. I am sure that Dr. Jelliffe would
wish to lend his eloquence and erudition to this good end, rather
than to try to perpetuate a system which, while lucrative to a few,
blemishes the reputation of us all, and threatens the safety and
dignity of society as a whole.
SPECIAL REVIEW
Po teBlObkOGY ORS LH EIN TERS Exe
By Ben Karpman, M.D.
ST. ELIZABETHS HOSPITAL OF WASHINGTON, D. C.
Professor Goldschmidt has written a most fascinating book. Himself
a tireless and brilliant worker in what until but a few years ago was
a virgin soil, he shows us step by step what a rich and abundant harvest
the work has yielded. To properly evaluate and correlate the immense
material available was no mean task and in this the author has shown
himself to possess not only a keen and penetrating insight, but as well
a scientific fairness and broad familiarity with the subject which is
quite exceptional. In a remarkably clear and vivid fashion he sum-
marizes and brings up to date the results of investigation relating to
the problem of Sex Determination. The scope of the work is much
broader than the title alone would indicate. That this problem is of
immediate import to biologists and medical men, to the latter mainly
because it gives them such a large insight into the nature of many
diseases, is obvious enough, but it should also prove of immense interest
to workers in other fields both because of its purely scientific aspects,
as well as because of its ultimate usefulness to mankind; for the problem
in its practical aspects leads into the elucidation and probably actual
control of sex. In particular it brings a significant message to the
psychopathologist because it furnishes for once a thoroughly reliable
and experimentally well established conception of bisexuality as a basis
of animal organization, and also, because it presents us with an under-
standing of the biological aspects of sex abnormalities, which until now
have received but scant consideration in the hands of psychopathologists.
The significance of this study to psychopathological problems is not
immediately apparent from the book—Professor Goldschmidt hardly
touches the human aspect of it—but a proper appreciation of it may
furnish the necessary stimulus for research among human material.
The exceptionally fine and spirited translation by Professor Dakin, of
Liverpool, enhances greatly the value of the book.
I
In the introductory chapter, Professor Goldschmidt discusses the gen-
eral nature of sex and points out that permanent growth is impossible
1 Goldschmidt, Richard. The Mechanism and Physiology of Sex Determina-
tion. Translated by Dakin, Wm. J. New York: George H. Doran Company,
1924.
[327]
328 B. KARPMAN
unless the interpolation of a sexual process gives it a fresh start, thus
indicating that the roots of the problem of growth are bound up with
the problems of age, death and immortality.
Early in the evolutionary development—and this can even be seen
in some of the simplest organisms—there may be observed a division of
the body cells into two distinct groups. On the one hand we have
the somatic cells, as muscles, nerve, gland, etc., which function for
the whole body, their function necessarily leading them to death; and
on the other hand, we have the sex cells which are not being used up
physiologically during the life of the individual and, protected from
the malignant results of metabolism, remain physiologically virginal
thus surviving the rest of the body in its descendants. ‘The sex cells,
as a whole, have a different history from the somatic cells, the material
for their constitution being set aside at the commencement of develop-
ment; the separation of the germ cells is one of the earliest embryological
events.
Although the asexual mode of reproduction is of quite frequent
occurrence in the lower group of animals, especially in Protozoa, it is
not by any means exclusive or universal. Indeed, there is scarcely
an instance in the animal world of which we can say with certainty
that its only means of reproduction is asexual. Early or late, there
comes for all animal organisms a moment when a sexual act of some
kind takes place. As a rule, it is a bisexual process; in some instances
it is partherogenetic, or merely eliminative when an elimination of toxic
products with a complete reorganization of the nucleus takes place.
But the significance of bisexuality les in much more than merely
to set agoing certain alterations in the ovum by the entering spermatozoa.
Some of the evidence available suggests that bisexual reproduction
exercises, perhaps, the most fundamental influence on the structure, func-
tion and behavior of the animal life and that the phenomena of bisexuality
are intimately linked up with the nature of heredity and variation.
What establishes particularly the essentially bisexual nature of living
. organisms is the role played by chromosomes. ‘These, it appears, are
bearers of Mendelian factors and the presence of an odd number of
chromosomes in one sex and an even number of chromosomes in the
opposite sex serves to maintain the bisexuality.
It -having been established that each sex possesses the anlage of
both sexes, it is necessary now to determine: What kind of a process
is it which decides that of the two sex fundaments present in a bisexual
organism only one normally develops? The answer to this and related
problems Goldschmidt finds in the experimental and observational study
of the phenomena of sex mixtures, that is, individuals whicheare mixed
in sex (hermaphroditism, gynandromorphs, cockfeathered hens, etc.).
Goldschmidt’s own problem is concerned with the intersex, a particular
form of sex mixture. He first notes that from the point of view of
the determination of sex characters during the development of the indi-
THE BIOLOGY OF THE IN TERSEX 329
vidual two large groups are to be distinguished in the animal kingdom.
In the first group insects occupy a leading position and here, as far
as we know, all that concerns sex is fixed with the event of fertilization
so that castration or transplantation experiments are without any influence
on the development of the secondary sexual characteristics. In contrast
to insects we find that in birds, mammals and certain invertebrates, the
interpolation of hormones is essential for the completion of the deter-
mination; and here castration and transplantation experiments have
definite influence on the development or disappearance of secondary sex
characters. As an illustration of the first type, Goldschmidt takes a
species of insect known as Gypsy moth (Lymantria dispar) into which
are included a large number of races and geographical varieties. In
this moth, as in many other insects, the gonads are differentiated at
an early larval stage, long before the external sexual differences, which
are only visible in the winged adult, appear. These sexual differences
include a difference in size (the females are considerably larger than
the males), and a difference in color (the female’s wings are white
with dark, ill-defined bands, while the wings of the male are brown).
Experiments performed on these have shown that neither castration
alone nor combined with sex organ transplantation performed either
late in development or even in early embryonic stages, exerted any
influence whatever on the secondary sex characters, although the organs
thus transplanted developed normally in the artificial situation. This
shows with certainty that the sex organs and the somatic structures which
are characteristic of the sex, can be completely independent one of
the other.
Goldschmidt now summarizes the main results of his work on inter-
sexuality. An intersexual moth usually arises when the male (or female)
of one race of a certain species is crossed with a female (or male)
of another race of the same species. These hybrids show a peculiar
distribution of secondary sex characteristics in that alongside the char-
acters of its own sex they show streaks and islands of the secondary
sex characters of the opposite sex. The more distant the races are the
greater is the degree of intexsexuality, so that in very extreme cases
a stage is reached in which all the females are converted into males and
this can be demonstrated embryologically. The experiments thus demon-
strate clearly that animals are essentially bisexual and that both sexes
are capable of developing the characters of the other sex when certain
definite combinations of hereditary material which are not normal are
brought about by crossing. Goldschmidt further states that the various
organs of the body fall into a definite series as regards their develop-
ment—and this series is exactly the opposite of the order of their
embryonic differentiation. The organs which are first developed and
differentiated, as for example, the reproductive organs, are obviously
the last to be modified, while those which appear last are the first to
be changed. According to Goldschmidt then, an intersex is an in-
{
330 B. KARPMAN
dividual who has developed as a male (or female) up to a certain
point; at this turning point a switch-over reaction takes place and
the development continues in the direction of the opposite sex. ‘The
reason for the switch-over reaction is stated by Goldschmidt to
-depend on the relationship of something in the eggs (IF) to something
in the spermatozoa (M), which if disturbed leads to intersexuality ;
also that cytoplasmic influence plays a role here. Goldschmidt does not
offer any specific explanation of the nature of the reaction which
influences differentiation, but believes that enzyme-like action or hor-
monic influence is not unlikely.?
For purposes of clearer orientation it is necessary now to relate
the phenomenon of intersexuality to another type of sex mixture, namely,
gynandromorphism. We owe mainly to Morgan and his pupils a clearer
appreciation of this subject. 4° ® In its typical form the essential
feature of gynandromorphism les in the presence in an individual of one
sex of sharply marked off parts of the body which bear the characters
distinctive of the other sex. These differently sexed regions pertain
mainly to somatic and secondary sexual characters, although the genitalia
and even the gonads may be involved. Male and female characters
may be combined in many different and diverse ways.
The genetic mechanism involved in the phenomena of gynandromorph-
ism is interpreted by Morgan on a chromosomal basis and refers to
some abnormalities in the X chromosomal mechanism—for instance, to
the elimination of one of the X chromosomes, usually at some early
division of the segmentation nuclei. Morgan believes that since he
worked mainly with hybrid insects, the explanation can properly refer
only to insects, but submits that there are good biological reasons to
view human sex mixtures as mosaics, rather than hermaphroditic, in
which there is a local replacement of paris of one»sex Dy spaetae
another. Goldschmidt, on the other hand, is inclined to look upon
human sex mixtures as expressions of intersexuality, but that seems
hardly possible as these conditions (hermaphroditism and pseudo-herma-
phroditism) could not conform to his own definition of intersexuality—
starting as one sex and finishing as the other sex. Intersexuality, in
the sense of Goldschmidit, probably exists among humans but perhaps
of a different order (homosexuality ?). It is obvious that this is virtually
a virgin field which would repay the best efforts of the biologist, anthro-
pologist and psychopathologist.
* See also Goldschmidt, R. “A Further Contribution to the Theory of Sex.”
Journal of Exper. Zodlogy, Vol. 22, No. 3, 1917, pp. 597-598.
* Morgan, Th. H. et al. “Contribution to the Genetics of Drosophila
Melanogaster.” 1. The Origin of Gynandromorphs. Carnegie Inst. Pub. 278.
* Morgan, Th. H. et al. ‘The Mechanism of Mendelian Heredity.” Henry
Holt & Co., New York, 1923.
* Morgan, Th. H. “ Mosaics and Gynandromorphs in Drosophila.” Proc.
soc, Exp, Bioly and: Med.” XI.
: Sturtevant, A. E. “Experiments on Sex Recognition and the Problem of
Sexual Selection in Drosophila.’ Journal of Animal Behavior, V.
hie BIOLOGY OFT REVINTERSEX 331
Goldschmidt is at pains to make a clear cut differentiation between
intersexuality and other types of sex mixtures, more particularly gynan-
dromorphism. A gynandromorph is a sex mosaic in space in which
male and female parts lie, from the point of view of the physiology
of development, adjacent to each other; they are present simultaneously
during development. It is essentially a product of a disturbance in the
mechanism of sex distribution, due to abnormal cytological conditions
which, once established, transmit to the descendant of some cells the
chromosomes combination of one sex and to others that of the other
sex. Should the gonads develop from two such groups of cells, an
hermaphroditic condition will result. An intersex, on the other hand,
is an animal which genetically belongs to one particular sex, male or
female, but which at some stage of its development, through physiological
or genetic causes, had its course changed in the direction of the opposite
sex. In contrast to the gynandromorph which is a sex mosaic in space,
an intersex 1S a sex mosaic in time, male and female parts lying perhaps
side by side, but from the point of view of development one is younger
than the other, 1.e., at a given time during the development the whole
individual is of one sex, while at a later time it is entirely of the other
sex. It is fundamentally a product of a disturbance in the physiology
of sex determination. Hence, certain stages in an intersexual may fall
under the term hermaphroditism.
Not all workers in the field would agree entirely with Goldschmidt’s
interpretation. Morgan,’ in discussing the problem, offers rather serious
objections to Goldschmidt’s interpretation of the results. Admitting
that there is some evidence which suggests a cytoplasmic influence, he
argues that there is also evidence that there are differences in the
maternal chromosomes concerned, which with equal justice could be
called “‘ factors for femaleness.” The numerical data assigned by Gold-
schmidt to the opposing factors for maleness, and femaleness, M and F,
are arbitrary and are not yet based on any established quantitative work.
As for the results depending on male and female producing enzymes,
while admittedly many of the changes in embryonic and larval develop-
ment might be due to enzymes, there is no reason to suppose that the
relative concentration should change in the course of development as
Goldschmidt must assume that it does; and how the enzyme starting
with a lower concentration always manages to overtake the one with a
higher concentration, is not at all clear.
The above conceptions hold fairly generally for higher animals in
whom hormonic influence is at work. Here Goldschmidt summarizes
the work of other workers in the field and looks upon the various sex-
mixtures due to hormonic disturbance, as being but certain types or
manifestations of intersexuality. It is very doubtful, however, whether
it is scientifically valid to look upon hormonic sex-mixtures in the same
7 Morgan, Th. H. Op. cit., I, pp. 87-91.
332 B. KARPMAN
light as zygotic sex-mixtures; for we are obviously dealing here with
quite different phenomena, as Goldschmidt himself admits. With equal
justice Morgan could speak of all hormonic sex-mixtures as variations
of the same problem, namely gynandromorphism; yet he is rather too
careful about it. The reader is, therefore, cautioned not to be carried
away too far by Goldschmidt’s enthusiasm which, to some extent, blinds
him to other possibilities.
Castration in the Mammalia results in a cessation of the normal
development of the secondary sexual characters. The specific hormones
are, therefore, necessary for their complete development. Their absence,
however, does not as a rule, bring about the development of the secondary
sex characters of the opposite sex. If, in addition to castration, trans-
plantation of ovaries into male animals is also effected, certain other
results are obtained. The male organs which had already been differ-
entiated, cease further to develop or retrograde, whilst organs which
could continue their growth in modified form develop in the female
direction and in the end become altogether female in character—as
regards form, weight, skeleton, character of the hair, mammary glands,
secretion of milk, and even behavior. Corresponding changes are also
observed in castrated females who, with transplanted testes, take on
male development. In other words, the presence of the hormones of the
opposite sex causes the further development to follow in the direction of
that sex, and, so far as is morphogenetically possible, makes the individual
intersexual, or rather mixed in sex.
Besides experimental work we have suggestive evidence from sex-
mixture phenomena that are of wide occurrence in nature. In the
varieties of twin births in cattle, there are sometimes observed instances
when one of the twins is a normal male, and the other a sexually abnormal
calf—so-called “ free-martin.” The free-martin is usually female in its
external sex characters and more male internally. Now, all investiga-
is a female arising from a
’
tions show that, genetically, the “ free-martin ’
different egg. What, then, causes the female calf twin to become inter-
sexual? Embryological investigation gives a clear answer to the ques-
tion. Whereas, in all normal cases of twins of different sexes, there is
no connection between the two embryonic circulations, in a few cases a
common chorion is formed with anastomosis of the two blood systems
and the consequent circulation of the blood of one through the other.
If, at this early stage, the testes of the male twin produce hormones which
determine male differentiation, they can enter the female embryo by way
of the blood stream and thus induce intersexuality. But, it may be
asked: Why is it that the female and not the male becomes intersexual
since the same blood runs through each? According to F. R. Lillie,§
"Lillie, F. R. The Freemartin. Journal Exp. Zodl., 23, 1917.
Pi Ole CGy eG rie ING i SEX So
this is due to the fact that the testis differentiates histologically earlier
than the ovary and hence its hormones, working from an earlier stage,
actually repress ovarian action.
As bearing on the same problem, we have the chromosome distribution
in man. It is probable that there are at least two, if not more, types of
sperm produced. The sex-linked inheritance of certain defects, such
as hemophilia, color-blindness, etc., appear to depend on the relations
of male and female chromosomes. [Further data of constderable signifi-
cance to medicine are contributed by studies relating to disturbances
in the function of chromosomes. Some twenty years ago, Boveri work-
ing on mitosis and the development of sea-urchin larvae from double-
fertilized eggs, was impressed by the remarkable similarity between the
pathologic pictures in these cells and those observed in human cancer
tissue and suggested that in the nuclei of these cells as in those of
cancerous tissue the numerical relations of the chromosomes have been
disturbed. The suggestion has somehow never been taken up by students
of cancer, but it is a highly significant one and once more emphasizes
that every pathology is fundamentally cellular pathology.?
| es
As regards human conditions relating to the different types of sex-
mixtures, we find that they agree substantially with the results obtained
by experiments and observations on animals. The material is gathered
mainly from castrations, which have been carried out for religious, medical
and other reasons, and from the study of natural sex-mixtures, as they
spontaneously occur among humans. The most detailed investigation of
the former has been carried out by Tandler and Grosz, who investigated
the Russian castrated sect, Skoptzi. The various anatomical changes
that follow such castration is interpreted by these investigators, as mean-
ing that castration does not call forth the characters of the opposite sex,
but only a standstill at a stage of immaturity; in other words, the produc-
tion of an asexual form. With this arrested development and failure of
differentiation, growth, however, is not checked. Thus the tendency of
the castrate is to converge to a common species type, with characters
essentially similar, and the changes incident upon castration are, rightly,
regarded by them to be species character. With this interpretation,
however, Goldschmidt does not agree. He thinks that a closer analysis
of the situation reveals that we are dealing here with a moderate form
of intersexuality. He argues that intersexuality, as a result of castration,
is only possible for those organs which develop after the operation and,
therefore, still capable of differentiation; we should therefore expect that
these should be female in type. This, he thinks, is really the case. He
believes that if we exclude the regional fat deposits, which may be related
® See also Metcalf, M. M. Journal A. M. A., April 11, 1925, Vol. 84, p. 1140.
334 B. KARPMAN
to other metabolic conditions, we have here the pubic hair covering, whiclt
differentiates after castration, and is female in type; the beard developing
is also of the female type. Here again one feels that Goldschmidt is
overstressing his point, for, as already stated, castration in mammals
without transplantation (and this is the case with human castrates)
results in cessation of the normal development of secondary sex-char-
acters, but does not, however, lead to the development of those of the
opposite sex.
As for natural human sex-mixtures, Goldschmidt would regard them
all as expressions of intersexuality. These sex-mixtures are generally
spoken of as pseudo-hermaphroditism, of which the anatomists distinguish
two types, viz.: femininus and masculinus. These include a great variety
of conditions in which, as regards inner and outer genitalia, every possible
intermediate stage between the two sexes is found; from individuals
externally male and internally containing ovaries, Mullerian and Wolffan
ducts, to the other extreme of individuals, externally female, with
internally fully developed testes, etc. The other type of sex-mixture,
which Goldschmidt only mentions in passing, is that of homosexuality,
and this, too, he regards as a stage of intersexuality. Here he is
obviously not on very sure grounds, and vigorous objection might well
be raised against it; for there is, as yet, no experimental proof of it, and,
in the nature of things, such proof would be very difficult, if not impos-
sible to obtain.
Elsewhere Goldschmidt 19 indulges in a little speculation on the
possibilities of the problem, stating, with Moll, that homosexuality must
be looked upon not as a disease but as an anomaly—a biologic variation
that, perhaps, resulted through incomplete sexual differentiation. He
argues that, if it is permissible to regard homosexuality as a genetic
condition (since the general laws of heredity are the same for plants
and animals, lower and higher) it would be justifiable then-to look upon
homosexuality as but a biological expression of intersexuality and
analogous to butterfly experiments; bearing in mind, of course, the
action of hormones in man, and, further, that in the buterflies, the female
is heterozygous, while in humans, it is the male that is heterozygous. But,
if homosexuality is biologically conditioned, the question arises: What
are the abnormal factors that are responsible for its manifestations?
It the Gypsy moth can have such marked differences between its many
races, so marked, in fact, that their crossings produce various types of
abnormalities such as intersexuality and sterility—may not the humans,
also, present among themselves a variety of organic types which are only
compatible within certain limits? We do not, of course, refer to the
races in the sense generally accepted—white, yellow, negro, etc., for
human races are greatly mixed, and it is not stated or proven anywhere,
” Goldschmidt, R. Die Biologische Grundlagen der Intersexualitat und des
Hermaphroditismus beim Menschen. Arch. Rass ; i
See rc assen u. Gesellsch. Biol. Vol.
LEESBIOLOGYCOP PAE INT ERSEX 335
that various human racial crossings produce a progeny that is abnormal
in the sense of intersexuality, homosexuality, or sterility; but we refer
here to the existence of certain anatomical types, perhaps, in some such
sense as that of Kretschmer, Draper, Tandler, and others. Admittedly,
there may exist various organic and functional incompatibilities between
the mates, or inherited mutations within the folds of the family. Then, we
also have the possibility of hormonic disturbance, which may be conceived
as having several aspects; some hormonic disturbances may be essentially
functional in nature and, not unlikely, also due to psychogenic influences.
It is obvious that we are dealing here with a multiplicity of factors to
disentangle which is no small task. Psychopathology is yet to find its
answer for the biology of human homosexuality. These, and similar
problems, are of importance to medicine, and still await their final
solution.
To sum up, we have in this work of Goldschmidt a vivid illustration
of the fundamental service which ‘biological research contributes to the
solution of many human problems. Through its experiments and observa-
tions on animals, it throws into a suggestive relief the problem of human
sex-mixtures, including homosexuality; an understanding of the disturb-
ances in the relations of chromosomes, as observed in lower animals,
sheds a new light on the nature of a cancer, while a proper appreciation
of the distribution of male and female chromosomes and their relation to
each other, puts the problem of heredity in an altogether different light.
And it also gives us a significant clue as to the possibilities for voluntary
control of sex. But biology contributes more than that. In the light of
biology, the entire problem of sex acquires a new meaning: for, whereas,
we ordinarily think of sex as only referring to sexual appetite and mating,
the biologist emphasizes the multiform processes that precede mating—
the distribution and relation of the chromosomes in heredity and variation,
the meaning of bisexual constitution, etc. It further emphasizes the
tremendous, one would say, exceptional rdle that sex plays in all biological
processes. Here is material that would bring joy to the home of the
Freudian. For it appears that sex not only plays an important role in
all life processes, but, indeed, plays the role par excellence; it pervades
and permeates all life reactions; even, perhaps, that animals eat in order
to reproduce, and the mortal soma exists for the sake of the immortal
germ-plasm. Parasite-like, the sex cells take no active part in other
functions of the body beyond their own metabolism, but live on the work
and labor of the soma, that eventually dies from exhaustion. But with
- the death of the soma, the germ cells continue to live—forming a material
bridge between the generations, links in a continuity which is theoretically
unlimited, and, in this sense, they are immortal. There thus seems to be
something of an antithesis between personal and racial existence, death
and life, between what we please to call the ego and sex drives. Again,
such antithesis may well be only apparent, for as Weismann said:
“There is nothing in the results of biology which would indicate that
336 B. KARPMAN
physical death is a necessity; it is rather an adaptation. When at length,
the body becomes unfit, it acquires through reproduction a new body;
it is, therefore, in the best interests of the race that there should be
death. . . . Life and death are concomitant phenomena and not
antithetic but mutually complementary to the logical sequence of things.”
So Der Totentanz bekommt Ein Lebentanz. Here is a field with a
message of its own, pregnant with tremendous possibilities for the
psychopathologist, as yet barely touched, and still awaiting many hands
and many heads to help its solution.
BooK REVIEWS
Schaffer, Karl. UEBER DAS MORPHOLOGISCHE WESEN UND DIE
HISTOPATHOLOGIE DER HEREDITAER SYSTEMATISCHEN NERVEN-
KRANKHEITEN. Julius Springer, Berlin. 18 marks.
Prof. Karl Schaffer, OO. Professor of Psychiatry and Neurology
of the Budapest University, has occupied himself more or less
intensely with the heredodegenerations of the nervous system for the
past twenty-five years. It is about that time—1902—that his con-
tribution to amaurotic family idiocy was made, and since then a score
or more studies have shown sincere, painstaking, and thorough grasp
of the problems, with particular emphasis laid upon structural
correlations.
Not only have the heredodegenerations clinical-biological relation-
ships, but Schaffer maintains that histopathologically there is warrant
in grouping them as a unity. At the Innsbruck meeting of the Ger-
man neurologists (1924), Schaffer presented his material as a general
pceterat. wh lLiniswhesnas revised and brought. to. date .and),in’ this
No. 46 of the Springer Monograph Series presented his present day
summary of his ideas with the evidence.
Schaffer adheres to the Jendrassik generalization that the heredo-
degenerations may be considered globally as a group, and the present
monograph attempts to make an anatomical classification of the entire
material. Thus he divides it into three subgroups: (1) Those in
which Motor Phenomena prevail, dependent upon (a) Pyramidal
Heredodegenerations, (b) Extrapyramidal Heredogenerations, (c)
Amyotrophic Heredodegenerations; (2) those of Sensory Signifi-
cance, (4) spinal Tléeredoataxias, (b) Cerebellar Heredoataxias;;
and (3) Associated Forms, (a) Early Type of Familial Idiocy and
(b) Late Types of Familial Idiocy.
In general, Schaffer is sympathetic to the Mendelian conceptions.
Whereas in many instances the complete criteria are lacking, still
the general situation is such as to permit the use of the generalizations.
Can the histopathological picture be utilized in furthering a more
workable systematization of the whole group? This question Schaf-
fer answers in the affirmative and devotes the 250 pages of this most
valuable monograph to its elucidation. His early work upon the
amaurotic family idiocies gave him the impulse towards this system-
atization and.he has followed it up throughout the group as far as
it was possible with the clinico-pathological material at his disposal.
As early as 1914 his attention was focussed upon embryonal factors,
and in an elective ectodermal involvement he has sought to work his
way through to a general outlining of the heredodegenerative proc-
esses. He outlines very clearly the histopathological trends that
[337]
338 BOOK REVIEWS
result from such involvements and traces his own modifications of
views, as outlined in some papers published in 1918 and 1922, in
which the work of Sachs, showing cortical arrested development,
was of importance. From these considerations sprang his study of
macro-micro degeneration stigmata, influenced by the work of Retzius,
Brodmann, Elliot Smith, and others, which were carried into the
cytological field with fine discriminate capacity.
Thus he develops the broad conception that the heredodegenera-
tions are evidences of developmentally determined diseases of the
nervous system, not only clinically and hereditarily, but macro-
scopically and microscopically set apart from other affections of the
human organism. .
These factors, as well as those of exogenic moment, 1ntoxications,
intercurrent disease, etc., are elaborated at great length in this well
worth production, which no review could adequately summarize,
much less find fault with. It should be read by all interested in the
field, and where 1s the clinician who does not find abundant material |
in his consulting room?
Platt, Charles. THeE Ripple oF Society. [E. P. Dutton & Com-
pany, New York. |
This author has already given us studies upon the Psychology
of Thought and Feeling and the Psychology of Social Life, and here
enters into what is wrong with the social scheme of things in that
there are malefactors a plenty, why and what is to be done about it.
Certainly with every newspaper spattered over with robbery and
murder and no one going about without a bunch of keys—a sure
index of a dishonest crowd—something is wrong—trite as this is
said either of Denmark and everywhere else.
The author enters into all this. He says that all we need are a
few fundamental concepts—he purposes to demonstrate them. We
have not been able to find them. Instead, we find a very readable,
rather light mousse of pleasing essays which, as an introduction to
the problems involved, will be found quite acceptable.
Levine, Israel. Das Unpewtsste. Authorized Translation by
Anna Freud. [Internationaler Psychoanalytischer Verlag, Leip-
zig, Wien, Zurich. |
It is a rare compliment for a psychoanalytic work to be translated
into the language of its originators, but this work of Levine’s upon
the “unconscious ” merits this attention. We have already spoken
of it, as it appeared from the Macmillan press. It is a very sound
and valuable book.
Maier, Hans W. Der Koxarnismus. [Georg Thieme, Leipzig.
Loumarks:|
A 269-page monograph, the most complete with which we are
acquainted, dealing with acute and chronic cocaine taking. The
BOOK REVIEWS 339
whole is seen chiefly through the eyes of a psychiatrist, Dr. Maier
being first assistant in Bleuler’s Clinic at Burgholzli, Zurich.
The various pathological phases of delusional formation, hallu-
cinations, and antisocial conduct are excellently portrayed from a
foundation that is analytic in the best sense as well as more formally
psychiatric.
As has been known for years, withdrawal is a comparatively
innocuous procedure, but to prevent relapses is not so easy. Com-
bined morphinism and cocainism is a particularly severe situation.
The mental deterioration here observed is of rapid development.
Social efforts at control are suggested through governmental
supervision. How inadequate and even farcical such efforts are, and
will be for centuries to come in the United States, can be easily read
in the light of the Prohibition farce—not to mention the widespread
use of cocaine in the United States.
The monograph is most excellent.
Train, Arthur. THE Brtnp Goppess. [Charles Scribner’s Sons,
New York. $2.00.|
As one looks at the mural decorations of the Criminal Court
building, not in New York City but in many another, the blind-
folded, white robed figure of Justice stands out in bold relief among
innumerable other symbolic representations. Our New York goddess
cannot be permitted to be blindfolded. As the layman listens to the
legal procedure from time to time and notes its practical efficiency,
no doubt the query often arises as to the significance of this blind-
folding mechanism. Ideally representing “no favorites,” practically
it seems to foreshadow, and that not infrequently, stupidity.
Thus, when a well known criminal lawyer would deal with the
situation of the “ Blind Goddess,” we cannot help but pause and read
what he has to say, especially as it is fashioned in a fascinating form
and gets to grips with real situations.
We cannot tell what this delightful novel has to say, but we can
say—by all means read it. It is worth much more than many a
ponderous medico-legal tome even though it may be a trifle Arrow-
smithian.
Bassoe, Peter. Nervous AND MENTAL Disease. Vol. VIII.
Series 1925. Chicago Year Book.
The summary of the neuropsychiatric literature of 1925 appears
this year as creditable as those of former years, and the English
speaking public are fortunate in having this well digested series of
abstracts. The editor’s well seasoned comments add not a little to
the value of the volume.
Thomson, J. Arthur. CoNcERNING EvoLuTIon. [Yale University
Press, New Haven. $2.50.]
This interesting volume, neither too large in scope as to require
a summer’s vacation to read, nor yet so condensed as to falsify the
340 BOOK REVIEWS
essential features of a highly intricate subject, comes to us as a series
of lectures of the Dwight Harrison Terry Foundation, the object of
which is to aid in the building up of a broadened and purified religion
through all of the agencies of science and philosophy.
The deliverer of the lectures, Professor of Natural History in
the University of Aberdeen, has acquitted himself well in the prin-
ciples of the foundation, and written a most fascinating book upon
evolution, not for the expert but for everybody.
Steiner, Max. DIE PSYCHISCHEN STORUNGEN DER MANNLICHEN
Potenz. Dritte Auflage. [Franz Deuticke, Leipzig u. Wien. |
To this small monograph of sixty pages Freud contributes an
Introduction. In it he states that the author was one of the first
specialists working in another field to recognize the significance of
psychoanalysis in his specialty and after serious work has maintained
throughout his original attitude, and he adds a paragraph or: two
about the advisability of the specialist, no matter what his field,
knowing something about the “nervous” functioning of his organ.
When Dejerine, after forty years of close observation in all fields,
came to the conclusion that nearly 80 per cent of the polyclinic
patients had “false cardiopathies,’ “false gastropathies,’ “ false
enteropathies,” etc., meaning that a neurosis was hidden behind what
the various special workers had called organic disease of the respec-
tive viscera, the Paris physicians pronounged him “ anathema.”
But subsequent experience has shown the general truth of his point
of view—even if for different mileux the percentages may vary
somewhat.
This makes the present work of interest, for here are numerous
neurotic patients in whom “impotency”’ is the organ manifestation.
Experience is showing that most impotency is psychogenic in origin.
It exists in both sexes. It manifests itself by frigidity, as well as by
nymphomania in the female, and loss of erection, premature ejacula-
tion, and inability to ejaculate in the male, with a host of intermediary
phenomena. As we know, not only from Stekel’s works but from
many another, the celebrated lovers, the Don Juans of the world, are
usually impotent.
It is of service, this little book, not to the genitourinary specialist
alone, but for all physicians ; for the principles here expounded apply
in many other fields.
Kleist, K. EpisopiscH—E DAMMERZUSTANDE. [Georg Thieme,
Verlag, Leipzig. 3.60 marks. |
Professor Kleist of Frankfort presents here, in a short mono-
graph of about eighty octavo pages, a very intense and clear descrip-
tive study of episodic dreamy states. He points out that when
Kraepelin finally rounded out his conceptions of the two types of
constitutionally founded psychotic manifestations, namely dementia
precox and manic-depressive psychoses, clinical psychiatry was left,
as it were, in the stocks, and exhausted itself in unfruitful efforts at
determining the clinical boundaries, on the one hand to limit the
BOOK REVIEWS ; 341
extensions of the conception, and on the other to widen them.
Naturally criticisms came from many sides, those of Hoche being
prominent. No progress could be made until new data could be
assembled and new viewpoints constructed. These followed when
Sieffert, Bonhoffer, and Rudin worked with the reactive psychogenic
disorders of psychopaths. Then Bonhoffer cleared up a niche in the
precox area in his delineation of the symptomatic psychoses; Kleist
in his involution paranoia, and others separated some of the presenile
states from the precox-manic magma and thus the process goes on.
Kleist calls attention to his separation of an autochthonous con-
stitutional psychosis, along Wernickean lines, from the same heap,
and in the present monograph would try to clear up the symptomatic
expression, heretofore generalized as the dammerzustande—dreamy
states, twilight states, etc.
From the standpoint of a series of structural system degeneration
possibilities, too broadly classed as ‘“ degenerative psychoses” by
Schroeder, Kleist believed some advance may be made, there were
treasures here to be unearthed. Thus his migraine psychoses, some
narcolepsies, episodic depressions, and instinct compulsions in psycho-
paths. To these he would here add a series of episodic twilight states
not related to any so-called epileptic etiology, yet clinically often
closely resembling.
The present pamphlet describes nine cases, arranged as Simple,
Hallucinatory, Expansive, Irresponsible, and Psychomotor twilight
psychotic states. The general features are then discussed. The
general mold is purely descriptive: Constitution with a capital C
provides all the etiological requirements, with Heredity crouching in
the background. Motivation or Purpose, as understood by the
Freudians, and which threatens the old descriptive rubrics, is not
mentioned.
The monograph is excellent, since it shows how little we still know
about the dammerzustande and of value as an effort to sort out
possible structural mechanisms, a point upon which it is frequently
forgotten Freud has always insisted. For Freud such mechanisms
are conceived of as functionally synthesized for carrying out definite
purposes; for the bulk of psychiatrists the mechanisms are of purely
anatomical import. The latter want to see the blueprint of the New
York Central Railway—and thus locate any trouble; Freud was
more interested in the purpose that led the passenger to take this or
that railway and not the picture of the tracks—both visions of course
being desirable—ultimately to be synthesized, as Schilder in his recent
Entwurf is attempting.
Jaspers, Karl. .PsycHOLOGIE DER WELTANSCHAUUNGEN. Dritte
Auflage. [Julius Springer, Berlin. |
A third edition, unmodified since the second. It is a large work
‘of nearly 500 pages, each page itself being .full-size octavo. The
work is divided into three sections, with an Introduction of fifty
pages and an Appendix of about the same. The first section deals
‘with the Situation—Einstellung—where-are-we-at sort of material.
342 BOOK REVIEWS
Active, contemplative and mystical attitudes are distinguished. The
formal descriptive and the relative and moving systems are discussed.
The ideas of Plato, Eckhart, Spinoza, Kant, Schopenhauer, and Hegel
are all entered into as contemplative aspects of the Einstellung.
These with the mystic forms constitute an environmental reactivity.
Then the introspective attitudes are dealt with, and finally the author
has an enthusiastic attitude or Einstellung of which the symbol is
love. In the second chapter the “ World Picture” is looked over.
Here also we have an introduction, a sensory space world, a psychical
cultural world, and a metaphysical world. Section III deals with
the “ Life of the Spirit ’—with introductory remarks, then Scepti-
cism and Nihilism, the Limits of the Confined; The Gehatse, the
Limits of the Eternal: The spirit is eternal and free. This chapter
ends with a section upon the Mystic.
This offers the barest of ideas of the scaffolding of this extremely
complicated work. By the psychology of the “ Weltanschauung ”’ the
author means something different from a prophetic philosophy, the
which is his term for philosophies in general, since they would be
sufficiently generalized to explain everything and hence are prophetic
in function. In Hegel’s Phenomenology of the Spirit the author
finds the first indication of this particular field, and in Kant’s con-
ceptions of the “Idea” the complete ground plan upon which he
would build.
It is an interesting structure that he has reared. One looks it
over with puckered brows, at times wondering what may be the
applications for daily life, since we had the preconception that a
psychology of the principles of a universal word grasp should have
practical application, for any or every situation in life, even though
it were some one situation abstracted from the whole.
On the whole a work to be read and enjoyed, as it offers much
material. We find it a trifle dogmatic here and there; relativity is
not overlooked but is soon glossed over. The so-so-ness from an
absolutistic point of view shows through as a skeleton upon which
a distinctly attractive series of garments is draped.
OBITUARY
seth Gaeta te deh ving
DR CIPARE ES HERMAN CLARK
Dr. Charles Herman Clark died at his home at the Lima State
Hospital, Lima, Ohio, on November 15, 1926. Dr. Clark had not
been in good health for some time having been a sufferer from
arterial hypertension and renal complications, including albuminuric
retinitis, but his passing came rather unexpectedly.
Dr. Clark was born on a farm near Mechanicsburg, Ohio, in
1866. His education was obtained in the schools of his native county
and the Starling Medical College of Columbus, Ohio, where he
Praquaved iil S75..eiitet an interneship in St. Francis Hospital,
Columbus, he became Assistant Physician at the newly opened Ohio
Hospital for Epileptics at Gallipolis, Ohio, under the Superintendency
of Dr. H. C. Rutter. In 1895 he was transferred to the Columbus
State Hospital where he served under the late Dr. A. B. Richardson.
In 1898 Dr. Richardson was sent to open the recently constructed
Massillon State Hospital and Dr. Clark was transferred with him
to Massillon. In 1899 Dr. Richardson became Superintendent of
St. Plizabeths Hospital, Washington, D, C., and Dr. Clark again
accompanied him to his new field. Following Dr. Richardson’s
death, Dr. Clark continued on the resident staff of St. Elizabeths
Hospital under the Superintendency of Dr. William A. White until
1907, when he was recalled to Ohio to become Superintendent of
the Cleveland State Hospital. As the Medical Director of this
institution, he displayed marked executive ability. In 1914 he was
called upon to assume the Superintendency of the newly constructed
Lima State Hospital for the criminal insane, which position he filled
with recognized success until his death.
Dr. Clark was a member of the American Psychiatric Associa-
tion and of his County Medical Society, the Ohio State Medical
Association and the American Medical Association. For many years
he had been active in American Psychiatric Association affairs and
since 1924 had been a councillor of this organization. While not
a voluminous writer he was the author of many excellent papers
upon psychiatric subjects. As a preceptor and developer of young
[343]
344 OBITUARY
men he was preéminent. Three of his former assistants are now
superintendents of State Hospitals in Ohio.
For thirty-three years Dr..Clark served continuously in the State
Hospitals of Ohio and the Government Hospital at Washington. He
was a psychiatrist of outstanding reputation in Ohio, esteemed not
only for his skill in mental and nervous disorders, but for his fine
personality, his high ideals and sterling character and his useful
citizenship. He is survived by his wife and daughter who make
their home in Lima.
Wo. H. PritcHarp, M.D.
N. B.—AlIl business communications should be made to Journal of
Nervous and Mental Disease, 64 West 56th St., New York.
All editorial communications should be made to Dr. Smith Ely Jelliffe,
Managing Editor, 64 West 56th St.. New York.
Vo. 65 APR e19Z/ No. 4
The Journal
OF
Nervous and Mental Disease
An American Journal of Neuropsychiatry, Founded in 1874
ORIGINAL ARTICLES
Poe oy NOLOME OR MENTAI AUTOMATISM AND ITS
io ieee ee OR i PION TO DHE CHRONIC
po oe la Oe Sy COS ao REVIEW *
BY PeecivaAL.BAILeyY, M.Do PHD:
ANCIEN ASSISTANT ETRANGER DE LA FACULTE DE MEDECINE DE LEAGUES, &
CLINIQUE DES MALADIES MENTALES
1. Introduction
2. Syndrome of Mental Automatism
a. Sensory Automatism
b. Motor Automatism
c. Psychic (ideoverbal): Automatism
3. Etiology of the Syndrome
4. The Chronic Systematized Psychoses
A. Constitutional Psychoses
a. Passional Psychoses
-1. Querulance
2. Erotomania
3. Jealousy
4. Fanatic Idealism
b. Interpretative Psychosis
c. Imaginative Psychosis
B. Chronic Hallucinosis
C. Chronic Hallucinatory Psychoses
5. Role of the Syndrome of Mental Automatism in the Formation of a
Chronic Hallucinatory Psychosis
INTRODUCTION
This review has for its object to attempt a systematic exposition
of the phenomena grouped by G. G. de Clérambault under the title
of syndrome of mental automatism (syndrome of passivity, syndrome
of interposition), together with his views of the role which they play
in the development of the chronic systematized psychoses (para-
phrenia and paranoia). de Clérambault is one of the most original
and picturesque figures in the modern psychiatric world in France,
* Read before the Boston Society of Psychiatry and Neurology, Dec. 16,
1926.
[345]
346 PERCIVAL BAILEY
but his views on this and other subjects have not been systematically
exposed but are to be found widely scattered in obscure French
publications not likely to circulate in this country. They have never-
theless attracted considerable attention and seem to me to be of
sufficient originality to merit this study. The phenomena in question
have been known of long date. The interest in de Clérambault’s
conception of them lies in his insistence that they have a common
origin, that they are due to an organic lesion of the central nervous
system and that they constitute the basal factor in the provocation
of many systematized psychoses.
The author has studied all of M. de Clérambault’s publications
on this subject; has regularly followed his conferences at the Infirm-
erie Spéciale de la Préfecture de Police de Paris, and will attempt
to set down faithfully his conceptions, but it is of course understood
that M. de Clérambault is in no wise responsible for any lack of
understanding on the part of his auditor since this manuscript has not
been submitted to him for correction although he knows and approves
of its publication.
SYNDROME OF MENTAL AUTOMATISM
M. de Clerambault is not satisfied with the term “ mental automa-
tism ”’ and has from time to time employed others, such as syndrome
of interposition, syndrome of irradiation, syndrome of passivity,
syndrome of interference, syndrome of parasitism, etc., without mak-
ing a final choice. At any rate the automatism is a triple one, com-
prising phenomena of three sorts (a) sensory, (b) motor, and (c)
ideoverbal. It includes all of the processes described under the name
of hallucinations but is more comprehensive than this term and
includes many illusions and other phenomena which will be described
in detail, many of a negative character. It is moreover difficult to
establish sharp distinctions between these different symptoms; for
many an illusion is a hallucination whose point of departure is obvious
and_a hallucination is an illusion whose point of departure is
latent (Séglas).
a. Sensory automatism.—It is unnecessary here to attempt a
complete exposition of sensory hallucinations and illusions. It will
suffice to note their characteristics as they occur in the chronic
systematized psychoses.
First and foremost are the auditory hallucinations which are
rarely absent. It used to be considered that they were a fundamental
and predominant feature of the chronic hallucinatory psychoses but
the work of later years has shown that the predominant feature is
THE SYNDROME OF MENTAL AUTOMATISM 347
the ideoverbal automatism to be described later. This fact was
remarked by Lugaro long ago. Auditory hallucinations are frequent,
nevertheless, and vary from the most imprecise, resembling a simple
memory, to the most complete objectivation. Although they are
usually in the later stages verbal (phonemes) in the beginning they
are often non-verbal (akoasmes) and vary through the whole range
of auditory complication from brute noises, and differentiated
sounds—cries of animals, sputtering of electricity—to syllabic hash
(jeux syllabiques), salads of words (kyrielles de mots), nonsensical
expressions (non-sens), even to the most complete words, phrases
and conversations.
The content of the verbal auditory hallucinations is most variable
and by no means always hostile. It may in the beginning be entirely
neutral and greatly surprise, astonish and even amuse the patient,
because it is so absurd and alien to his personality. The content may
be even flattering and quite agreeable. Any stimulus may increase
these hallucinations and they multiply especially under the influence
of emotion.
Hallucinations or illusions of the general or visceral sensibility
(coenesthésie) are also frequent. The patients complain that their
head is held in a vise, that their uterus is displaced, that their bladder
is ingeniously distended, etc. A special type of hallucination of the
general sensibility is found in the genital hallucinations. It is not
meant here those tactile and coenesthetic hallucinations in the genital
region which the patients express by saying “ They compress my
organs”? or “ They withdraw my sperm through the meatus,” but
actual voluptuous impressions with excitation and ejaculation. Such
hallucinations seem to be especially common in old maids.
Hallucinations of taste and odor are not rare and are usually of
a disagreeable character described as that of sulphur, of burning
rubber, etc. The patients usually refer to them by an interpretation
saying “ They put phosphorus in my soup.” ‘“ They send foul gases
into my bedroom,” etc. Occasionally the odor is agreeable, like that
of incense or perfumes and the taste “like that of the manna
from heaven.”
Cutaneous hallucinations are rare and may give an impression
of heat, of cold, more often of touch and usually of pain. ‘“ They
pinch my legs,” “They stick needles into me through the bed clothes,”
are expressions employed. Although the patients often complain
bitterly, it is rare that these impressions give rise to any motor
response similar to the listening attitude adopted by the subject of
auditory hallucinations, but Chaslin describes a girl who several times
348 PRRCIVAL Baga a
during the examination jumped, cried “ Outch”’ and claimed it was
“because someone had pricked her with a needle. The cutaneous
impressions may also be agreeable, resembling caresses, especially
iri female subjects and are often associated with genital hallucinations.
Visual hallucinations are not so common as auditory and
coenesthetic ones but are more common than usually supposed and
vary from the most elementary kaleidoscopic color play to the most
ccmplete visual pictures, even verbal. They have no relation to the
course of thought of the patient ; have often no relation among them-
selves; carry no affective charge and are independent of the auditory
hallucinations. One patient described them as “ free images.” ‘They
are usually flat, airy and transparent. They are seen as pictures
and not as realities. The patients say ““ They make me see pictures,”
“They show me a cinema.”
b. Motor automatism.— Here are collected the phenomena
described by Séglas in 1888 under the name of motor hallu-
cinations. They are hallucinations of the kinesthetic sensibility, espe-
cially of the vocal musculature. They may be either partial and
indeterminate as in the case of the young girl who complained that
her arm was continually moving, or partial and differentiated when
the patients complain that they have a sensation of walking, jumping,
taking hold of an object, bending the leg. More generalized halluci-
nations of this kind result in complaints that they are shaken in bed,
forced to fly through the air, feel that they are pushed and directed.
Much more common are the verbal motor hallucinations. The
patients insist that they do not hear speaking, but that they feel it.
‘They move my tongue ”’; “ They force me to speak”; “ They speak
with my voice’’; “ My tongue falls into step with the thoughts of
others ”’; ““ There is something which speaks when it wishes.”
These phenomena may or may not be accompanied by visible
movement of the speech musculature, and may even extend to the
actual ejaculation of words, the so-called verbal impulsions. The
patients complain that they are forced to say words they do not wish
to say and that are contrary to their thoughts (logokinésie of Kramer,
onomatomanie, coprolalie, écholalie).
When the motor hallucinations are mild the patients can stop
them by talking or by reading aloud, but when they are more intense
the patient is unable to speak during these motor verbal hallucina-
tions, the final motor pathway being unable to transmit at once two
contradictory impulses (Sticker). Some patients complain that they
cannot think without having the sensation of speaking. Others
THE SYNDROME OF MENTAL AUTOMATISM 349
accuse internal voices—movements that take place inside them, they
say. At a more advanced stage they say “the words are formed
in my mouth.” |
Verbal motor hallucinations may be combined with auditory hal-
lucinations in variable degree or may be entirely independent.
Closely allied are certain impressions which may be described
as emotional hallucinations. The patients experience as phenomena
imposed upon them gaiety, sadness, anxiety, astonishment, anger.
“Why do they cause me to be angry?” said one patient. “I am
suddenly gay without cause” said another.
c. Psychic (ideoverbal) automatism.—These phenomena allied
to the psychic hallucinations of Baillarger or the pseudohallucinations
of Kandinsky are considered by M. de Clérambault of the utmost
importance and often precede and predominate over even the auditory
hallucinations, properly speaking. They are either positive or nega-
tive. The positive phenomena include:
1. Psychic hallucination. Thought 1s emancipated either undif-
ferentiated or entirely mute. There is no exteriority. It is a sort
of abstract intuition. The patients express what they experience
by saying: “It is as if one were speaking to himself but without
moving his lips’; “ They make me understand mentally—by inspira-
tomepyvathewspiri. 50me-call it “san, interior voice; the voice
Gite conscience, |e Lhey speak to/me inside: my head,” “I, do
not hear their voices.”
2. Ideorrhea (idéorrhee). A succession of thoughts passes
through the patient’s head which he cannot control and to which he
does not wish to pay attention. ‘‘ They make me think without rest.”
3. Mute procession of the past (dévidage des souvenirs). This
phenomenon may be appreciated from the statements of the patients.
Solucyesnuw «me all of myaimemories:) Vhey make me, seé “my
past.” “ They present for my consideration historical images.”
4. Substitution of thought. Perpetually a foreign idea is substi-
tuted in the course of thought. The subject can only begin to think.
“Always something comes contrary to my idea.” “They give me
that habitude of always thinking to the side of what I should think.”
“T suffer from a double thought.”
5. Pressure of thought (aprosexie). The typical formula applied
by the patients is “I know not where to find my thought in all that
is wafted to me.” They say also “ My thought is always dispersed ”’ ;
“T can only think of too many things”; “ My ideas come too fast.”
Every effort of attention only makes things worse; there is then a
ver table swarm of ideas.
oS ASS
350 PERCIVAL BAILEY
6. False recognition, false resemblance and sentiment of strange-
ness. ‘‘ They make me recognize people.” “ People have a strange
unreal appearance.” ‘These phenomena are well known, but are not
usually associated with the syndrome of mental automatism.
7. Passage of an invisible thought. The subject believes that a
thought is imminent which he recognizes without being able to define
and the idea recognized disappears without being defined. It is in
some sort as if the patient had perceived the shadow of an
object passing.
8. Echo of thought. Whenever the patient thinks, there is a
running commentary as though someone in the neighborhood were
reading aloud his thoughts. This phenomenon is a common and
early symptom. ;
9, Enunciation of acts. The patient thinks he hears someone
announce aloud every act he performs. “ They repeat everything
I do.” “They say, ‘ Well, she is making her bed.’ ‘She is taking
off her chemise.’ ” |
10. Anticipation of thought. “They find before me the names
of things.” “‘ They know before I do what I am going to say.”
11. Flight of thought (Pierracini). The patients complain that
their thoughts escape them before they have time to formulate them.
“I am not master of my own tongue.” “I have no more secrets.”
‘“ My own ideas escape me.”
The negative phenomena are no less interesting and have a great
theoretical importance as will be explained. They consist of arrest
of thought, seizure of thought, absence of thought, disappearance of
thought, sudden forgetting, etc. The patients express these processes
111 various ways. “ My thought disappears suddenly.” “ They cause »
me to forget.” ‘They stop my thinking.” ‘I wait for ideas which
do not come.” “ They steal my thoughts.”
To these various phenomena Heuyer and Lamache have added
another which consists in this—that the patient believes he can read
the thoughts of others (devination de la pensée).
All of these various phenomena may exist, or any combination
of them, but the more abstract ones included under the name of
psychic automatism appear first when the onset of the psychosis is
insidious, to be followed by the more elementary sensory and motor
automatisms (noises, play of colors, syllabic hash, nonsensical
expressions) and finally by complete verbal hallucinations, internal
conversations, etc.
THE SYNDROME OF MENTAL AUTOMATISM 351
De Clérambault sometimes isolates the more elementary and non-
ideational processes (echoes, nonsenses, paresthesias, psychomotor
phenomena and inhibitions of all sorts) under the name of minor
automatism (petit automatisme) for reasons which will appear later.
ETIOLOGY OF THE SYNDROME
Taking as a point of departure the ability of intoxications and
infections to provoke hallucinations and illusions of all kinds and
after an elaborate and exceedingly minute investigation of the manner
in which they install themselves in the mentality of the patient
de Clérambault postulates that all of the phenomena described above
under the title of mental automatism have a mechanical origin in
a physico-chemical alteration of the cells of the central nervous
system, more particularly of the cerebral cortex.
The role which infections and intoxications play in the produc-
tion of sensory and motor automatism is well known. Even such
a gross lesion of the brain as a tumor may provoke visual, gustatory
or olfactory hallucinations (Jackson, Horrax, etc.), and a localized
syphilitic lesion motor hallucinations (Sérieux). But that the more
abstract phenomena of the minor or ideoverbal automatisms are
produced in the same way is not so readily admitted, and yet cases
have been reported in which they were clearly caused by syphilis
(Heuyer), mania (Logre), hypertension of the cerebrospinal fluid
(Claude and Lamache), chronic alcoholism (de Clérambault), arti-
ficial menopauses (de Clérambault), epidemic encephalitis (Schar-
fetter), etc. In most cases;/however, the cause is not evident and
this is due to the fact that these phenomena are a late sequel, the
result of insidious and systematic electivity. The cells are subject
to a subtle but persistent attack at an age when their resistance
is greatest.
The effects of intoxications and infections upon the central
nervous system follow several laws.
iene eeflects on weach toxin isecditterent, cl he® electivitye of
response of the nervous system to various toxins is too well known
to demand discussion. Even in the case of cocaine and chloral which
both produce simultaneously tactile and visual hallucinations or
illusions, there are differences in the effects of each toxin.
2. In general the cells are more susceptible the higher their posi-
tion in the hierarchy of function. -A good example is seen in the
different stages of ether narcosis. Even among centers of the same
level there are differences of susceptibility, if one is to judge from
the hallucinatory psychoses. The cortical regions which give rise
6 ay'4 PERCIVAL BAILEY.
to sensory, motor and psychic automatism are usually affected
together, as for example in subacute alcoholism, but it is not always
so, the motor zone being incomparably more resistant than the other
two except in its verbo-motor portion. ‘There seems also to be a
sexual variation, the sensory zone being much more vulnerable in
the female, especially the genital zone which is almost invariably
attacked in the female and rarely in the male.
3. The cells defend themselves more easily the slower the attack.
The effects of brutality of attack are well shown by alcohol. In
acute episodes of chronic alcoholism visual hallucinations break out
suddenly and are accompanied by even more gross evidence of
derangement of the nervous system (tremor, perspiration, etc.),
while in the more chronic manifestations auditory hallucinations are
the rule and visual hallucinations are rarer. Moreover in the more
insidious cases a stage preceding the complete auditory hallucinations
may be observed including all the phenomena of the minor automatism
(echo of thought, anticipation of thought, systematic contradiction,
syllabic hash, etc.).
4. The period of latence between an infection, for example puer-
peral fever, and the onset of a psychosis is also an important. factor.
If the mentality is immediately affected, the subject in case of
chronicity will have more massive troubles—confusion, affective
dementia, and gross hallucinations; if the onset is retarded, the
dementia will be less profound and the sensory phenomena more
discrete.
5. The nervous cells defend themselves better as the patient gets
older, at least until the onset of senility. There are numerous exam-
ples of this law, which is of great theoretical importance. The scale
of ages shows us different effects of nervous lesion for each period
of existence. In the fetal period gross medullary and cerebral defects
result in paralysis and idiocy. In infancy the same insult results in
more circumscribed motor defect and less pronounced psychic defects
(imbecility, mental retardation). Later on perversions and disturb-
ances of character are the principal effects; at puberty chronic con-
fusion and dementia precox with dementia predominating; from
twenty to thirty years, paranoid precox; from forty years onward,
hallucinatory psychoses with total or subtotal conservation of intellect
and affection.
Epidemic encephalitis has recently furnished a striking example
of this rule. This extraordinary malady in early infancy produces
defect of intellect (imbecility or even idiocy); in later infancy dis-
turbance of sleep and hyperactivity without actual mental defect; at
THE SYNDROME OF MENTAL AUTOMATISM 353
the approach of adolescence perversions of character; around twenty
years of age syndromes resembling paranoid dementia precox, and
at more advanced ages only asthenia.
We might expect therefore that at an advanced age a subtle ana
long continued intoxication would attain only the highest neurones ;
that not all of these would be affected but only a variable number,
depending on the subject and the toxin, and finally that they would
not be destroyed but their function perverted.
Other arguments for a mechanical origin derived from the mode
of onset of the hallucinatory phenomena will be outlined in the last
section of this article on the role which mental automatism plays in
the origin and development of the chronic systematized psychoses.
But first it is necessary to present a brief outline of these psychoses
as they are conceived by de Clérambault.
THE CHRONIC SYSTEMATIZED PSYCHOSES
(Paranoia, Paraphrenia, Hallucinosis )
A good description of these psychoses is given by Sérieux and
Capgras. For de Clérambault the most of the chronic systematized
psychoses are mixed affections of divers origins. The pure psychoses
he would limit somewhat as follows:
A. Constitutional psychoses.
a. Passional psychoses (délires passionels de Clérambault).
1. Erotomania.
2. Querulousness (délire de quérulance).
3. Jealousy (délire de jalousie).
4. Fanatic idealism (idéalisme passioné de Dide).
b. Interpretative psychoses (délire d’interprétation de
merieux et Caperas ).
c. Imaginative psychoses (mythomanie de Dupré).
B. Degenerative psychoses.
Chronic hallucinosis without delirium.
In class A hallucinations are absent, and in class B systematized
delirium is absent. Such pure psychoses are rare. The vast major-
ity of chronic psychoses are made up of varying combinations of
these primary elements forming a third class (C), the chronic hal-
lucinatory psychoses, which are therefore a sort of symbiosis.
A. Constitutional psychoses——They are, one might say, a sort of
hypertrophy of some constitutional trait, either passionate, interpreta-
tive, or imaginative. They evolve without any terminal defect of
354 PERCIVAL BAILEY
intelligence. Three main types are recognized by Sérieux and
Capegras.
a. Passional psychoses.—In a series of keen psychological analyses
de Clérambault has shown that at the basis of this group lies a pro-
longed emotion in the form of desire or rage. Every conviction, he
says, to which an emotion is attached, may serve as the nucleus of a
passional delirium; sense of proprietorship, theoretical sense of
justice, maternal love, religiosity in all its forms, etc. The emotion
which is prolonged was in the beginning associated with a definite
idea and this ideo-affective association remains an indissoluble unit,
predominantly affective, which is impervious to the general ideation.
The two essential signs are therefore (1) the obsession and (2) the
morbid passionate exaltation. Their delirium evolves on a hyper-
sthenic constitution. ‘“‘ Their thoughts and their sentiments are
pushed by a maniacal force” (Schtle). The delirium starts explo-
sively and spreads like a fan, the subject’s passion inducing errors of
judgment only m the realm of his obsession and its implications.
The affective state may die out in the long run but the course of the
malady is never terminated by a dementia.
1. Querulousness—The querulant starts with the idea of an
injustice suffered. The passional reaction is abnormal in intensity, in:
tenacity, in the reactions which it provokes, and disproportionate to
the cause. If his injustice is legal he may start an endless series of
processes against the judges and lawyers, who have decided against
him. If he is a hypochondriac he may go so far as to kill the physi-
cian whom he accuses of aggravating his malady. |
2. Erotomania.—The erotomaniac is characterized essentially by
a passional- obsessive state which pushes him to seek tirelessly the
object loved. De Clérambault has shown that the erotomaniac is
in no way a-platonic lover and not at all averse to sexual voluptuous-
ness. The patient starts from the conviction that he is loved and
exclusively loved by a person of higher social rank who has first made
advances. He only reacts to these advances. This conviction is
maintained by the affective state in spite of every appearance to the
contrary. The delirium tends to develop in three stages: stage of
hope, stage of disdain, stage of rancor, but does not always reach
the final stage, and especially hope is never entirely absent.
3. Jealousy—The jealous delirium starts from a conviction of
conjugal infidelity. It is distinguished from the simple emotion by
the obsession, the morbid excitation, and the gross errors of judgment.
4. Passionate ideaksm.—Under this term Dide has described cer-
tain reformers, mystics, and inventors who, starting from a sudden
THE SYNDROME OF MENTAL AUTOMATISM 355
conviction concerning science, politics, religion, etc., hold passionately
to their conviction, defending it with the most incredible errors of
judgment, utterly impervious to reason, and ready to lay down their
own lives or those of others in its propagation.
b. Interpretative psychosis——This psychosis has been described in
masterly fashion by Sérieux and Capgras. Its distinguishing features
are (1) multiplicity of false interpretations serving to elaborate sys-
tematized deliria of various kinds; (2) absence of hallucinations ;
(3) conservation of psychic lucidity and activity; and (4) chronicity
of the delirium with absence of terminal dementia. The subject of
this psychosis rarely alters reality but explains it in his own way,
adapting it to his own hopes and fears; in other words, giving it
always a personal significance. The nature of the system of delirium
which he builds upon these egocentric interpretations depends upon
his circumstances, education, etc. One can distinguish many types—
the persecuted, the megalomaniac, the jealous, the amorous, the
‘mystic, the hypochondriac, etc.—and various combinations of them.
This psychosis is distinguished from the passional psychoses
largely on the lesser intensity of the emotional state and the tendency
of the delirious interpretations to spread instead of remaining fixed
to one obsession. ‘The patients are also largely hyposthenic and timid
in contrast to the hypersthenic and aggressive individual who is the
subject of a passional psychosis.
c. Imaginative psychosis——Described by Dupré and Logre, this
rare psychosis is distinguished by pure fabulation, gratuitous affirma-
tions of fictional circumstances, recital of romanesque adventures, etc.,
instead of errors of deduction from real facts as occurs in the inter-
pretative psychosis. All the other features of the two psychoses are
identical. The false idea is given out without hesitation and is from
that time on maintained as the absolute truth without variation. The
delirium develops by progressive extension and is only feebly system-
atized because of its imaginative character.
B. Chronic. hallucinosis—This term includes all the phenomena
described above under the name of mental automatism, more particu-
larly of “ petit automatisme mental” when they are not accompan‘ed
by a delirious interpretation on the part of the subject. It invariably
leads to dementia of greater or less degree. Pure cases are rare.
Usually the patient uses his mental automatism as a basis on which
to build a chronic systematized delirium so that a chronic hallucinatory
psychosis results.
356 PERGIV AD DALLES.
ROLE OF THE SYNDROME OF MENTAL AUTOMATISM IN THE
FoRMATION OF THE CHRONIC HALLUCINATORY PSYCHOSES
For M. de Clérambault the syndrome of mental automatism and
more particularly the psychic or ideomotor automatism (petit auto-
matisme mental) is the basal factor on which a hallucinatory psy-
chosis is built. The systematized delirium is the reaction of the sub-
ject’s personality to the phenomena which take place within him, and
which he feels are independent of and often contradictory to his
habitual course of thought. The idea of persecution, the idea of
jealousy, or any other idea is incapable of giving rise to any hallucina-
tory process.
De Clérambault insists that the initial phenomena which assail the
patient are of neutral affective tone and nonideational (anidéic).
They consist of echo of thought, enunciation of acts, paresthesias,
noises, play of syllables, salad of words, arrest of thought, etc. The
patients must be observed at the onset of their troubles, and for this
purpose de Clérambault is ideally situated at the Infirmerie Spéciale.
Later on the patients have either forgotten the initial phenomena,
retrospectively misinterpret them, or become reticent and will not
speak of them, being either defiant or entirely absorbed by their
delirious ideas. Especially is it impossible later to determine the
initial affective tone of the patient. The automatisme, surprising the
patient in a neutral affective state, may never modify his character
nor cause the construction of a delirium. In this case a chronic
hallucinosis results. The subject, usually slightly euphoric, tolerates
the phenomena without searching an explanation. He is somewhat
astonished by them; doubts of their reality do not trouble him;
sometimes he believes it an innocent practical joke. Usually, how-
ever, the patient reacts by the formation of a systematized delirium,
the nature of which depends upon many factors: (1) the strangeness
of the phenomena; (2) the intellectual make-up of the patient (cul-
ture, imaginative tendency, etc.) ; (3) the nature of the hallucinatory
process and its concordance with the character of the patient; (4) his
affective tone (pessimism, optimism, hostility, etc.). The delirious
idea is the reaction of an intellect and affectivity which remain rela-
tively intact to the automatic troubles which appear spontaneously and
surprise the patient in a period of neutral affectivity and intellectual
quietude.
1. Strangeness of the phenomena.—The strangeness, as well as
the intensity, unexpectedness, and persistence of the impressions
which assail the patient, who feels that they are alien to his habitual
course of thought, and the habit which they have of breaking into the
THE SYNDROME OF MENTAL AUTOMATISM 357
middle of a train of thought or speech without having any connection
with it, naturally lead the patient to the conviction that they are
imposed upon him by some outside influence.
The phenomena are not always objectivated, even the purely sen-
sory ones, and this again is due to their strangeness. One can no
longer admit the total identity of the hallucination with a real percep-
tion. Hallucinatory sensations are less acute, less precise, less pain-
ful. The hypochondriac with coenesthetic hallucinations complains
bitterly of tortures he endures but he does not have the motor contor-
tions which accompany a person actually tortured in the way he
claims. The auditory hallucinations seem to come nearest to repro-
ducing an actual perception, but all the hallucinatory sensations of
these patients have this incomplete character.
2. Intellectual tendency and level—The imaginative capacity of
the patient and his cultural level evidently play a role in the extent
and elaboration of his delirious romance. An imbecile or senile per-
son will offer but a paltry explanation for his many woes, while an
intelligent person versed in the sciences or even in the so-called occult
sciences (magic) will offer the most ingenious explanations of the
means by which he is made to suffer.
The rational explanation that the phenomena may have been due
to toxic localized stimulation of some of the higher neural connec-
tions in the cerebral cortex, however, is entirely beyond the capacity
of even an intellectual patient. He usually seizes upon a witch, a
demon, mental telepathy, or wireless telegraphy as the source of his
troubles. It should not cause surprise to find even the most cultured
patient allege the most incredible and childish origin. Recent work
has shown how easily we all fall back into prelogical, perhaps pre-
historical methods of thought. It takes but little to overturn the
most healthy scepticism.
3. Nature of hallucinatory phenomena—The nature of the hal-
lucinatory phenomena have a great influence in fashioning the deliri-
ous superstructure, especially if they are of a kind to reinforce the
preexisting personality. For example,’ an individual already hypo-
chondriac and excessively preoccupied with the state of his internal
organs is assailed by painful coenesthetic hallucinations. Huis delirium
is preéstablished. He may conclude simply that he has an incredible
and inexistent malady or that his inner organs are inhabited by vari-
ous animals. If he is a little less fearful and more imaginative he
may believe his is possessed by a devil. If the hallucinatory sensa-
tions are agreeable the patient may give to them a mystic significance.
Kinesthetic hallucinations also give rise to ideas of possession, usually
358 PERCIVALBAILEX,
of external possession, the so-called delirium of influence (délire
d’influence ). |
Visual hallucinations are rare and still more rarely exist alone.
They are usually definitely perceived as irreal. They are essentially
neutral; anxiety dissipates them; euphoria favors them and so they
prosper usually in mystic deliriums. Olfactory hallucinations seem
always to give rise not only to an exogenous explanation but also to
ideas of persecution.
4. Affective tone.—Although it is certain that the phenomena of
mental automatism often tend by their very character to give rise to
ideas of persecution, they often do not do so even where an exogenous
explanation is given. The worms or serpents may have been swal-
lowed by accident; the patient believes himself poisoned, but by
accident ; he gets short-circuited in a wireless conversation ; it is annoy-
ing, but accidental, etc. A patient-hears.a cry of Stop theta
looks around to see to whom such a cry may be addressed. He may
hear such remarks for some time before it occurs to him that they
really are addressed to him personally. |
Other patients are only falsely called persecuted. They allege that
the phenomena of which they are the subject are due to the malevo-
lence of persons in their environment and may even name them.
But their convictions are not very firmly established. They use such
expressions as “One must believe it,” ‘One is obliged to think so,”
“Tt is difficult to escape the conclusion that,” etc. They are expan-
sive and confident before the physician.
In order for a complete persecutory psychosis to develop upon a
basis of mental automatism, it is necessary for the patient to have a
paranoid personality of long date. The mental automatism is then
iceally adapted to add fuel to the flames of his vindictive character.
The influence of preéxisting character may also be seen in the
frequence with which old maids, timid, retiring, and usually altruistic,
develop an automatism consisting essentially of friendly voices, and
flattering themes without a systematized delirium.
A mythomaniac, perverse, jealous, erotic, or imaginative char-
acter will influence the nature of the delirious ideas in a similar way.
The idea of persecution results from an attempt at explanation by a
hostile personality. The same attempt at explanation by an imagina-
tive and optimistic personality might give rise to a megalomaniac or
mystic delirium.
THE SYNDROME OF MENTAL AUTOMATISM 309
CONCLUSION
The syndrome of mental automatism—sensory, motor, and ideo-
verbal—is due to physico-chemical alteration of cortical neurones, or
their connections, by a subtle and systematic insult at an age when
their resistance is greatest. This alteration may be due to infection,
intoxication, degeneration, traumatism, etc. The syndrome usually
begins with nonideational (anidéic) phenomena—echo of thought,
paresthesias, salad of words, etc. The subject, who is surprised by
these phenomena in a neutral affective state, usually gives to them an
exogenous explanation because of their strangeness and their lack of
connection with his habitual psychism, and may react to them by
erecting a system of delirious ideas determined largely by his previous
personality, the result being a chronic hallucinatory psychosis.
BIBLIOGRAPHY
1. de Clérambault. Automatisme mental. Bull. de la Soc. clinique de méd.
mentale, April, 1920, Dec., 1923, and Jan., 1924; Annales médico-psycho-
logiques, Nov., 1923, Jan. 1924, and Feb., 1924; La Pratique médicale
francaise, May, 1925, and June, 1926.
2. de Clérambault. Erotomanie. Bull. de la Soc. einidue de med. mentale,
Dec., 1920, Feb., 1921, June, 1921, July, 1921, June, 1923.
3. Sérieux and Capgras. Délires systematisés chroniques. Chapter X of
Vol. I on psychiatry, 2nd Edition. Traité de Path. méd. et de Thérap.
appliquée. (Sergent, Ribadeau-Dumas et Babonneix). Maloine, Ed.,
Paris, 1925. [Summarized by White. Outlines of Psychiatry. Ed.]
4. Heuyer and Lamache. Le symptome de “devination de la~ pensée.”
one des médecins aliénistes et neurologistes. Paris, May 28—-June 1,
19
INTRAVENTRICULAR HEMORRHAGE *
A CLINICAL AND PATHOLOGICAL STUDY OF THREESG@2iaias
By Irvine J. Sanps, M.D.
ASSOCIATE IN NEUROLOGY, COLUMBIA UNIVERSITY ; ATTENDING NEUROLOGIST,
BROOKLYN JEWISH, AND BROWNVILLE HOSPITALS ; ASSOCIATE
NEUROLOGIST, MENTEFIORE HOSPITAL
AND
Max Leperer, M.D.
PATHOLOGIST TO THE BROOKLYN JEWISH HOSPITAL
From time immemorial, hemorrhage into the ventricles has
attracted the attention of physicians. Because of etiological consider-
ations the clinical course and anatomical picture, the internist, the
neurologist, and the pathologist have found much of interest in this
morbid condition.
Sanders in 1881,(1) studied 94 cases from the literature, and
made some valuable deductions. He stated that the most common
and direct cause of primary intraventricular hemorrhage was rupture
of some vessel on or near the ventricular walls. He mentioned seven
sources from which the blood might come, 7.e.: (1) the vessels of the
choroid plexus; (2) vessels of the tela choroidea; (3) arteries rami-
fying on the ventricular walls, viz., the choroids, branches of the
arteries of the corpus callosum, etc.; (4) veins, 7.e., vena corpora
striata, those of the thalamus the vene galeni, etc.; (5) large aneur-
isms encroaching upon or existing within the ventricles; (6) tumors
involving neighboring parts and pressing into the ventricles, or those
actually found within these cavities themselves; (7) inflammatory
conditions or ulcerations of the ventricular walls.
According to Gowers (2) “the blood usually comes from the
vessels of the choroid plexus, as of the velum interpositum, rarely
from a vein in the wall of the ventricle. Probably the hemorrhage is
due in most cases to the rupture of miliary aneurisms, which have
been found in the choroid plexus. But it occasionally results from
severe mechanical congestion, as in attempted hanging, from convul-
sions, or after a severe concussion, sometimes at an interval of a
few days or one or two weeks. In rare cases it proceeds from a
large aneurism that has perforated the ventricle, or from a vascular
* From the Pathological Department of the Brooklyn Jewish Hospital.
[360]
INTRAVENTRICULAR HEMORRHAGE 361
growth, or occurs in hemorrhagic diathesis,, as purpura or
leucocythaemia.”
Gordon (3) reports 12 cases of extra- and intraventricular hemor-
rhage, 5 being primary ventricular hemorrhage and 7 being secondary
effusions into the ventricles from an original extraventricular area
situated close in the vicinity of the cavity. In two of his cases the
sources of bleeding could be distinctly seen in the choroid plexus.
He added that “the most interesting manifestation in primary ven-
tricular hemorrhage of my 5 cases were: sudden onset; the most
profound coma from the very beginning; convulsions more marked
on the side opposite to the lesion than on the same side in the uni-
lateral cases, and on the side opposite to the seat of the largest hemor-
rhage of the bilateral cases; finally the absence of marked paralysis.
In the cases of primary variety, life persisted in from 6 to 24 days.”
According to Oppenheim,(4) primary ventricular hemorrhage
occurs only rarely. Usually there is a neighboring hemorrhage which
has broken through the ventricular wall and has filled all the cavities.
When that occurs, the result is increased disturbance of conscious-
ness, increased paralysis of all extremities, convulsions, and rigidity.
Usually there is slowing of the pulse, increased respiration, and
bloody spinal fluid. According to this authority death is inevitable,
and usually follows within 24 hours after the original onset.
That a small number of cases of intraventricular hemorrhage
recover, is acknowledged by most authorities. Lannin (5) reported
a case of intraventricular hemorrhage in a child of ten years who
had collided with a playmate, both children’s heads striking and
both falling to the ground. Two hours later, unconsciousness, tonic
and clonic convulsions of both arms and legs, more on the left side,
ensued. The pupils were widely dilated, eyeballs were turned to the
right, and there was a right facial paralysis. A right decompression
was done and there was no blood in the subarachnoid space, but there
was blood in the right lateral ventricle. Recovery followed in this
case.
That the diagnosis of ventricular hemorrhage is often very diff-
cult, even by an expert under the most ideal conditions, is illustrated
by Elsberg’s (6) report of a case of a ruptured aneurism of the
right middle cerebral artery into the ventricles. The patient, a man
of twenty-one years of age, of negative family history and a good
personal history, fell and struck his head. Twelve days later he
stooped to open the furnace door and he experienced sharp pain in
his head, felt dizzy and faint, and became unconscious. Stupor
persisted for 24 hours. He then complained of headache and of
362 Io J. SANDS AND M,LEDERER
diplopia. Bloody spinal fluid was obtained. The Wassermann reaction
on this fluid was negative. Thirteen days after the beginning of his
illness he had a generalized convulsion, and was unconscious for an
hour. A second spinal fluid was again bloody. Three days later he
was admitted to the Neurological Institute where he complained of
headache, faintness, dizziness, and general prostration. At that
time he showed beginning bilateral papilledema, sluggish knee jerks,
loss of ankle jerks, rigidity of neck and bloody spinal fluid. Three
weeks after the beginning of symptoms, he began to complain of
blurred vision in the right eye. The temperature rose to 101°. The
right pupil became larger than the left and did not respond to light,
and there was papilledema of two diopters of the right eye. The left
knee jerk was livelier than the right. There was diminution of the
right abdominal reflexes. He then had a convulsion involving the
left arm and left leg and both sides of the face, and he became stupor-
ous. The diagnosis lay between a tumor near the lateral ventricle on
the right side with hemorrhage, and a ruptured aneurism in the
anterior or middle cranial fossa on the right side. Bilateral decom-
pression was done, but the patient did not improve, and died about
8 hours after operation. Post-mortem examination revealed a
small aneurism connected with the right middle cerebral artery near
its origin, which had ruptured into the frontal lobe. The mass
of blood then ruptured into the ventricles.
Tilney and Casamajor (7) had a patient under close and con-
tinuous observation from one hour after the onset of the illness
until death which ensued 12 hours later. They correlated the clini-
cal and the pathological data. They divided the symptoms into two
groups, those resulting from hemorrhage into the cisterns, and,
secondly, those resulting from extent of the hemorrhage into the
ventricles. According to these observers, the symptoms of hemor-
rhage into cisterns are:
1. Sudden, intense pain in the head, having a wave-like character
rapidly increasing in severity and accompanied by severe pain ex-
tending from the neck to the shoulders, hips and rectum. This pain
lasts for several moments when the patient suddenly becomes
comatose.
2. Propulsive vomiting followed by forceful, spasmodic defeca-
tion and urination. This occurs shortly after the establishment of
coma and may recur at intervals for several hours.
3. Tonic, sustained cephalogyric and oculogyric spasms.
4. Tonic contraction in the arms and legs accompanied by muscu-
lar spasms producing rhythmical abduction and adduction of the
INTRAVENTRICULAR HEMORRHAGE 363
upper and lower extremities. These convulsive movements are
synchronous with repiration and persist for several hours.
5. Rapid, irregular cardiac activity with high, fluctuating blood
pressure. Cheyne-Stokes respiration. In the course of several
hours these cardiac and repiratory symptoms cease.
6. No initial change in the reflexes but later a loss of the super-
ficial reflexes, an increase of the deep reflexes and the appearance of
a bilateral Babinski.
7. Moderate degree of bilateral choked disc,
diopters.
8. Slight rise of temperature, 1.e., 100°-101°.
The symptoms indicating extension of the hemorrhage to the
ventricles are:
1. Repeated tonic spasm of the entire somatic musculature, hold-
ing the trunk and neck in orthotonos, the extremities extended with
exception of the fingers, which are flexed.
2. These spasms last for one to two minutes and are followed by
an interval of complete relaxation.
3. Marked elevation of the blood pressure iusltorad by a rapid |
decline.
1.€., one to two
4. Irregularity of cardiac and respiratory action.
Their report was so thorough and so instructive, that it enabled
us to correctly diagnose our cases.
With the above data in mind we wish to report the following
three cases that have recently come to our observation:
Case I. T. W. W., male, fifty-seven, white, married, U. S., admitted
November 25, 1925, at 4:40 p.m. and died November 26, 1925, at
4:15 A.M. .
The man was. native born, with negative family history. He was
married for thirty-five years. His wife had given birth to two children
who died immediately after birth. She had never miscarried. According
to the information given by the patient’s wife, he was being treated
for high blood pressure for the past six months, the highest being 185
systolic. He never had any paralytic strokes. In the morning of
November 25th he complained of headache. He left his home, however,
for his work as a janitor in a high school. At 11:30 a.m. while at work,
he suddenly cried out with pain, screaming that his head hurt. He
gripped the wall to protect himself from falling. He was carried
into the school office, his right leg being paralyzed. He was then taken
home in a taxi. On arriving home he muttered a few syllables, vomited
and became unconscious. An ambulance was called and he was admitted
to the hospital at 4:40 p.m.
364 IIc SANDS AND MO LEDERER
An examination at that time revealed the patient to be comatose,
the respiration was Cheyne-Stokes in character, and later changed to
noisy irregular breathing, with periods of apnea. Pulse was 100, small,
thready, and of poor quality. There was no evidence of external injury
to head or to body. Pupils were contracted and did not react to light
or to accommodation. The eyes were turned to the right; right corneals
were absent. There was flaccid paralysis of the left-upper extremity,
and spastic paralysis of both lower extremities. There was no rigidity
of the neck, no Brudjinski, no Kernig. The left knee jerk was some-
what increased; the right knee jerk was sluggish. Left biceps was
Fic. 1. Case I. Note all ventricles filled with blood.
greater than the right. There was an indefinite Babinski on the left side.
There was no bleeding from the ears, nose or mouth. The heart was
moderately enlarged to the left; the left border reached almost to the
anterior axillary line. The sounds were of poor quality and barely
audible. Lungs were negative.
A catheterized specimen of urine showed a trace of albumin and
hyaline and granular casts. Blood pressure was 110-90, pulse 101. At
5:45 pulse was 60, blood pressure 120-86. At 6:30 p.m. the pupils did
not react to light and the corneals were absent. Both upper extremities
were flaccid with diminution in deep reflex response on the right side;
both lower extremities were hypertonic and there were bilateral increased
knee jerks, but no ankle clonus. There was a suggestive Babinski on the
right side. The respirations were irregular in rate and rhythm and
they were 30 per minute—pulse was 79—temperature 100.6. Spinal
fluid was bloody, under increased pressure, and was reported negative
INTRAVENTRICULAR HEMORRHAGE . 365
for Wassermann reaction. Blood was also negative for Wassermann
reaction.
At 9:45 p.m. patient was still comatose, face was flushed, Cheyne
Stokes breathing, and pupils were irregular. Abdominals, knee jerks,
ankle jerks, and cremasterics were absent. There was no Babinski.
Bilateral Kernig was marked—no cervical rigidity—spasticity in lower
extremities was present. Discs showed slight definite papilledema. Blood
pressure at this time was 230-110.
From the very beginning when the patient was observed in the
hospital, there were peculiar adduction and abduction of the upper
extremities and to a lesser degree of the lower extremities, which lasted
six hours and which were of the type described by Tilney and Casamajor
in their case. This was a very striking symptom, which aided in
establishing the correct diagnosis of intraventricular hemorrhage. Patient
died 4:15 a.m. November 26, 1925.
Post-mortem.—Calvarium removed with ease. Dura was somewhat
congested. On incision of the dura there escaped blood tinged spinal
fluid. On removal of the brain there was a small blood clot in the
intrapeduncular space more on the left side. The basilar artery showed
numerous atheromatous areas as did both middle cerebral vessels.
On section of the brain there was a hemorrhage which filled the
entire ventricular system. Efforts to find the bleeding vessel proved
unsuccessful, as the brain had been hardened in situ. Microscopic
examination showed moderate arteriosclerosis of all the large and small
vessels and general edema. No evidence of any inflammatory reaction
was found. The other findings are epitomized as follows:
Both lungs show evidence of old healed tuberculosis, emphysema,
bronchitis and pulmonary edema. The heart is the seat of a general
enlargement which is mostly right sided. The coronary vessels are
normal. The aorta contains a few atheromatous plaques. The kidney
showed slight changes incidental to a mild arteriosclerosis. About the
gall bladder region there were numerous adhesions. The liver edge
was scarred and gall bladder wall thickened.
Case II. J. R., aged sixty, was admitted to the hospital on February
2, 1925, at 7:15 p.m. and died at 8:15 p.m. of the same day. He was
an Italian, baker by occupation, married and had four children. He was
a hard worker all his life, drank moderately, and there was no history
of any previous serious illness.
For six months previous to his illness, the patient had been complain-
ing of headache, especially on arising, of dizzy spells, and of spots
before his eyes. Two months before his illness, he discontinued his
work because of these symptoms. At 6 p.m. while at dinner with his
family, he suddenly collapsed, fell to the floor, foamed at the mouth,
vomited, and immediately became unconscious. The ambulance was called
366 I. J. SANDS AND M. LEDERER
and he was admitted to the hospital 7:15 p.m. He was comatose, cyanotic,
had definite Cheyne-Stokes respiration, and foaming at the mouth. There
were audible pulmonary rales. The pulse was 184, regular. Heart sounds
Fic..2.0) Casenl Te Note marked arteriosclerosis of all vessels, and hemorrhage
in the cerebello-medullary cistern.
were feeble and distinct—there were no murmurs audible. Abdomen
was distended. Blood pressure was 236-140. The pupils were dilated
and fixed. There was right facial weakness. Right biceps and triceps.
INTRAVENTRICULAR HEMORRHAGE 367
were 4 plus, while those on the left were 2 plus. Left knee jerk was
2 plus. Abdominals were absent. The lower extremities were flaccid,
and the upper extremities showed some hypertonicity. There was no
Kernig, and no pathological reflexes were elicited. Ten cubic centi-
meters of bloody spinal fluid was removed under increased pressure.
-* Second blood pressure reading was 204-100. Patient died at 8:15 p.m.
Post-mortem.—Skull was very thick. _Dura was clear and glistening.
No subdural hemorrhage was seen anywhere. The brain showed marked
arteriosclerotic changes. The left vertebral, the basilar arteries, and
-the three cerebral vessels were markedly sclerosed. There was a sub-
arachnoid hemorrhage filling the cerebello-medullary cistern. The sagittal
section revealed hemorrhage which filled the entire fourth ventricle which
‘apparently came from a large pontine hemorrhage. The other ventricles
were free from fluid.
Microscopically, there was considerable fibroplastic thickening of the
pia with thickening of the vessel wall. There’ was moderate satellitosis.
There was no evidence of any inflammatory reaction.
Findings of the other organs are as follows: Lungs—pulmonary
artery is the seat of a marked atheromatosis. The bronchi are con-
gested and there is pulmonary edema. The heart is greatly enlarged
due to an extreme hypertrophy of the left ventricular wall. There were
a number of areas of fibrosis. The musculature showed some tigering.
The aortic cusps were somewhat sclerotic. Right heart was dilated
and slightly hypertrophied. Foramen ovale was patent. Aorta showed
some atheromatosis which was specially marked in the descending portion.
Coronary vessels were patent, but showed some sclerosis. The liver was
markedly enlarged and fatty. Pancreas is atrophied. Kidney—right
kidney weighed 320 gms. Capsule stripped with difficulty. Surface
showed many depressed areas. On section, striations of cortex not
clear. Vessels throughout were prominent, and showed lesions of arterio
and arteriolar sclerosis. Left kidney weighed 720 gms. and was the
seat of myriads of cysts varying in size and containing clear fluid.
Islands of apparently normal renal tissue free from cysts were scattered
throughout.
Case III. R. C., thirty-one, white, U. S., widower, admitted February
21, 1926, died March 21, 1926.
Family history was negative. Patient was an only child. He had
a common school education. He worked as a clerk for a steamship
company. He married in 1918 and has one child. His wife died from
postpartum infection. The child is living and well. Patient led a
moderate life, smoked and drank in moderation, and never had any
serious illness.
On January 23, 1926, while at work patient fainted; he was not
unconscious very long, and was able to go home. That night he vomited
368 IJ. SANDS AND Mie LEDERER
five times. Since then apparently he had been quite drowsy after
working hours, sitting down and resting most of the time. He had
headaches which were not localized, but which were worse on the top
of the head. On February 17th he suddenly became unconscious in his
place of business. He was removed to the Kings County Hospital. There
he was stuporous, drowsy and did not recognize anybody. Within 12
Fic. 3. Case II. Note hemorrhage into pons, fourth ventricle and
= cerebello-medullary cistern.
hours he regained consciousness. Four days later he was transferred to
this hospital.
On admission, he showed marked cervical rigidity with marked
Kernig. Pupils were equal, regular and reacted well. Eye grounds
showed moderate blurring of discs. There were apparently no cranial
nerve lesions. There was diminution in all deep reflexes. Abdominals
were very sluggish. No Babinski or modifications. He complained
of intense headache which seemed to come from the back of his head
INTRAVENTRICULAR HEMORRHAGE 369
and would shoot towards the top. Spinal fluid puncture revealed bloody
fluid under moderately increased pressure. The blood count showed
hemoglobin of 65 per cent, erythrocytes 4,000,000, leucocytes 24,000,
polymorphonuclears 85 per cent, mononuclears 4 per cent, lymphocytes
11 per cent. The specific gravity of the urine was 1,029 and contained
no albumin, no sugar or casts, but positive acetone reaction. X-ray
of the skull was negative. The Wassermann reaction done on the blood
and spinal fluid was negative. Spinal fluid gave a colloidal curve
of 555543210, which was typical of a bloody fluid.
The patient’s condition continued to improve while in the hospital,
his chief complaint being persistent headaches. His temperature at first
was 100 and later went up to 101 and finally came down to normal.
His pulse varied from 100 to 90. Respiration varied from 25 to 20.
A note made by one of us (I. J. S.) on February 27, 1926, stated that
the patient at that time showed slight but definite cervical rigidity with
diminished deep reflexes, no cranial nerve lesions, no cerebellar signs.
Our impression was that we were “dealing with a subarachnoid hemor-
rhage, most likely from a leaking intracranial aneurism.” A second spinal
fluid showed the following: Fehling’s solution was reduced, albumin
2 mm. ring, globulin positive one plus, the Wassermann reaction was
negative. The second blood count showed leucocytes 14,000, polymor-
phonuclears 74 per cent, mononuclears 4 per cent and lymphocytes 22
percent:
At 11 p.m. on February 28, 1926, the patient began to froth at the
mouth, and there were twitchings of the left side of the face. There
were clonic movements on the left upper extremity. He was comatose,
respiration was irregular, slow; pulse was of good quality. The twitchings
and convulsive seizure lasted about 10 minutes and then there was a
free interval of five minutes, when the convulsions again returned. This
occurred six times. Finally the patient ceased to breathe.
Post-mortem.—Skull was removed with ease. Dura appeared clear
and glistening. On incision of dura no blood was seen. Brain weighed
1,450 gms. There was considerable congestion of the brain. A subpial
hemorrhage was present over right precentral area. There was a
subarachnoid hemorrhage in the interspace between two cerebellar hemi-
spheres. In the region of the left anterior interpeduncular space there
was a blood clot which was adherent to the left posterior communicating
vessel of the circle of Willis. The brain was fixed in formalin and
sectioned. The entire ventricular system was filled with blood clot. On
study of the circle of Willis there were two aneurisms, each the size
of a small pea which arose from the left posterior communicating artery
near its origin from the left internal carotid artery: Both had ruptured,
the upper one into the left inferior horn of the lateral ventricle and the
lower one into the subarachnoid space. The inferior horn of the left
lateral ventricle was three times the size of the corresponding horn on
370 I. J. SANDS AN DYMY LEDERER
the right side. Microscopic examination failed to reveal any evidence
of inflammatory reaction. The pia was thin and glistening. The brain
showed some edema and congestion.
The thoracic and abdominal organs showed no noteworthy changes.
SUMMARY
It is quite evident that premonitary symptoms of intraventricular
hemorrhage are absent. The headache, dizziness, fainting spells, etc.,
which are present in two of our cases pointed to the concomitant cere-
bral arteriosclerosis. The last case, in which the aneurisms were
found, presented a chain of symptoms that are frequently seen in
cases of ruptured intracranial aneurisms (8). The acute onset of
cranial symptoms in a man of known cerebral arteriosclerosis, or
suspected intracranial aneurism, with the early appearance of coma,
the persistent bloody spinal fluid, the presence of repeated tonic
spasms of the entire somatic musculature, with the absence of
classical signs of paralysis, should lead to the diagnosis of intra-
ventricular hemorrhage.
The presence of a multilocular unilateral cystic kidney in the
second case, makes it of additional interest from a pathological view-
point. The leukocytosis in the last case is illustrative of the general
leucocytosis that occurs after extreme hemorrhages, and which has
been ably discussed by Musser.(9) The sustained elevation of
temperature is explained by the toxic effects of the liberated blood, and
by pressure and irritation of the blood on the area of the tuber ciner-
eum which is said to contain thermotactic centers (7). Of academic
interest is the problem of which ruptured aneurism has killed the
patient. The large size of the left inferior horn of the lateral
ventricle would point to the probability of a long period of time
during which the blood had collected and distended it. On the
other hand, the earlier clinical course of the disease would lead to the
conclusion that there was at first a rupture of the lower aneurism into
the subarachnoid space, and from which apparently the patient was
recovering. The appearance of the clots in the two aneurisms did not
shed any light on the subject. The failure to find the bleeding points
in the first two cases is attributed to the otherwise sound policy of
immediate fixation of the brain in formalin.
BIBLIOGRAPHY
1. Sanders, Edward. A Study of Primary, Intermediate, or Direct Hemor-
rhage into the Ventricles of the Brain. Am. Jr. Med. Sc., 82:85,
(July) 1881.
NOT WOOD Ny ONS Crit CESS eS
INTRAVENTRICULAR HEMORRHAGE 371
The Symptomatology of Primary, Intermediate, or Direct Hemmorhage
into the Ventricles of the Brain. Idem, 82:337, (Oct.) 1881.
Gowers, W. R. A Manual of Diseases of the Nervous System. Vol. II,
p. 391. P. Blakiston’s Son & Co., Phil., 1903.
. Gordon, Alfred. Ventricular Hemorrhage, A Symptom Group. Arch.
Int. Med. 17:343, (March) 1916.
. Oppenheim’s Lehrbuch der Nervenkrankheiten. S. Karger, Berlin,
1923 ay Ob aliens 23).
Lannin, G. E. J. Hemorrhage into the Lateral Ventricle, Recovery.
Canad cla Miwon ood Lo COC LOLS:
. Elsberg, C. A. ° Ruptured Aneurism of the Right Middle Cerebral
Artery. Neurological Bulletin, 1:210, (May) 1918.
. Tilney, F., and Casamajor, L. Hemorrhage into the Basal Cisterns and
Ventricles of the Brain. Neurological Bulletin, 1:161, (April) 1918.
. Sands, I. J. Intracranial Aneurisms. Jour. Nerv. & Ment. Dis., 64:12,
(July) 1926.
. Musser, J. H., Jr. The Leucocytes After Hemorrhages. Am. Jr. Med.
5c.162:407, (July )71921-
INTRAVENOUS .TREATMENT OF SOME EPILEPTICS
WITH CALCIUM CHLORIDE AND GLUCO-CALGI i
By ELMER K tein, M.D.
ST. ELIZABETHS HOSPITAL, WASHINGTON, D. C.
AND
EUGENE Forcione, M.D.
WASHINGTON, D. C.
This work was prompted by an article in the Revue Neurologique
in which Petzetakis (1) reported some favorable results from the use
of calcium chloride injected intravenously. He varied the dosage
during the four months of the treatment from .5 gram every other
day during the first month to .8 gram on alternate days the second
month, then back to .5 gram the third month, and again .8 gram
twice weekly during the fourth month. Hs series consisted of only
two cases of essential epilepsy, and in both cases he reported the
disappearance of the seizures and the clearing up of other associated
symptoms. It is not stated just how long the cases were followed
up. It is also interesting that an injection of calc1um chloride was
given during a seizure which curtailed it to one minute from the
usual five-to-ten-minute period.
Disregarding the work of Rossello (2) and Lovero (3), this
worker was the only one to have given calcium intravenously to
patients suffering from epilepsy. The work of these other two can-
not be used in any critical evaluation of the substance in this disorder,
for, while their patients had epileptic manifestations, the calcium was
administered primarily for the tuberculosis from which they were
suffering.
The administration of calcium in the treatment of epilepsies is
not new, albeit its use rests chiefly on empirical grounds, for the
pharmacological action of the substance 1s complex and little known.
‘Thus Cushny (4) says in summing up its actions: “ Calcium appears
to depress the neuromuscular connections in striated muscle like
curare and later to weaken the muscle itself. The removal of lime
is said to increase the irritability of the terminations of the autonomic
nerve in mammals.” On the other hand, its action on the vagus is
* Read before the Washington Society for Nervous and Mental Diseases,
January 20, 1927.
[372]
INTRAVENOGS ERE AT MENTO OF EPILEPTICS pois
just the opposite. Sabbatani (5) was probably the first one to under-
take a critical examination of the action of calcium salts on the body
both in normal and epileptic individuals. He showed that the dis-
tribution of calcium in the cells is ina state of equilibrium. When
he experimentally reduced the calcium in animals there occurred
excitation, convulsive seizures, and an increased local irritability of
the cerebral cortex. On the other hand, an increase in the calcium
content gave rise to depression. From these phenomena he concluded
that epileptic seizures are induced by a reduction of calcium, and that
by increasing the calcium content of the body the convulsive seizures
would be reduced or stopped.
In a later and more accurate study Frisch and Weinberger (6)
conclude that preparoxysmally and during the height of the seizure
the chloride ion of the calcium chloride is retained in the tissues while
the calcium ions are discharged into the blood, which determines an
increased irritability of the central nervous system. After an attack
there is restoration of the chemical equilibrium. These workers seem
to regard the chemical interchange in the tissues as being causative
rather than associative factors. On the basis of the assumption which
underlies such work as quoted above by the last named three workers,
namely, that it is calcium deficiency in the nervous tissue which deter-
mines the hyperirritability and seizures, many therapeutic attempts
have been made in the handling of epilepsy. Audenino and Bonelli(7)
treated ten cases with calcium salts and reported favorable results in
all but one. To six of the patients the salts were administered per
os, to four hypodermatically. Linguerri (8), repeating the experi-
ments of Sabbatini, confirmed his results. Silvestri (9) had similar
experiences with three patients to whom he gave one to three grams
of calcium hypophosphate daily by mouth. Ciccarelli (10) reported
improvement in all the twenty-nine cases to whom he orally admin-
istered calcium salts. Bryant (11) obtained beneficial results from
the administration of calcium lactophosphate in patients with petit
mal attacks. However, Donath (12), who had done much work with
epileptics, obtained almost negative results with nine patients to whom
he gave three to nine grams of calcium chloride by mouth. Lallement
and Dupony (13) treated fourteen epileptics with calcium lactate with
negative results. Indeed, they observed an increase in the number of
attacks during the period of the treatment. An interesting undertak-
ing was that of Obregia and Urechio,(14) who injected .1 to .2
grams of calcium chloride intraspinally. They treated eighty-six
cases, and their work was carefully checked. Uniformly negative
374 E. KLEIN AND E. FORCIONE
results were obtained save in those cases in which, in addition to the
calcium, bromides were also given.
In all the therapeutic attempts with calcium that have come to the
writer’s attention the drug was given by mouth. Exception to this
are the intraspinal work just mentioned (Rossello (2) and Lovero (3)
really gave it for tuberculosis), the work of Audenino and Bonelli (7),
who treated some of their patients hypodermatically, and that of
Petzetakis.(1) It was generally accepted that calcium was absorbed
from the intestinal tract into the blood stream with difficulty, and it
was in order to overcome this obstacle that these workers seemed to
have resorted to the para-oral route. The assumption concerning the
absorption of calcium from the alimentary tract was first shown to
be incorrect by Hjort,(15) who, by allowing dogs to ingest various
calcium salts and by determining the calcium concentration of the
blood serum at hourly intervals, showed that calcium is rapidly
absorbed and relatively rapidly eliminated. While our work was
under progress, Roe and Kahn (16) published their findings of sim-
ilar experiments in human subjects and showed that the curve of
calcium absorption and elimination from the alimentary tract is
roughly analogous to the sugar curve. They obtained an 81 per cent
increase of calcium in the blood serum from the oral administration
of large doses of calcium lactate. Had this fact been known earlier
it would have made the undertaking of this work unnecessary. While
the supposed difficulty of calcium absorption from the walls of the
intestine made the intravenous route the one of choice in the present
work, no defense is offered for the pharmacologic rationale for the
use of calcium itself. Opinions of pharmacologists and therapeutists
are too conflicting for that, and it was undertaken largely on empirical
grounds. Drugs can and do alter the condition of the organism,
make it vary in its susceptibility to stimuli, and modify its responses.
The logic of empiricism would permit its usage whether one’s concep-
tion of the convulsive disorders was one which rested on a basis of
neuropathology or whether it rested on a broader basis in which
convulsive seizures are looked upon as a mode of reaction of the total
organism in response to effective stimuli, whether biologic, psycho-
logic, or both. Thus it may well be that it is some chemical or
biologic deficiency which conditions the convulsions in some cases,
while in others the calcium deficiency may merely be a part of the
total organismic change much in the manner of the changes which
occur in the secretion of adrenalin in emotional alterations. In sup-
port of this view is the work of Glazer,(17) who was able to parallel
INTRAVENOUS TREATMENT OF EPILEPTICS 375
the curve of the calcium content of the blood serum with the curve of
excitement and sedation which he verbally induced in patients.
Whether the convulsions are an expression of a general person-
ality disorder or of a biologic defect, it was hoped in the light of the
recent favorable empirical results cited that the intravenous calcium
might exert some favorable influence in the course of the disease.
Since the decrease or increase in the number of seizures was to be
the criterion of improvement—though it is recognized that an im-
provement in the seizures may not tpso facto be an improvement in
the disease—cases were selected with the highest number of monthly
seizures. No discrimination was used as to the type of epilepsy, as
it was felt that by taking a promiscuous group deductions from the
results would be facilitated and indications for the drug, if any, more
readily affirmed. ‘It is entirely possible that the conflicting results
obtained by different workers was largely due to the preponderance
of one type of epileptics in some groups over others.
There were twenty-seven cases selected. Of this group one
refused the treatment after six weeks, one after eight weeks, and two
after three months; one eloped six weeks after his treatment was
begun. Only twenty-four cases will, therefore, be considered, since
those who received but brief treatment do not allow their being
included in this study. Of these, fifteen were patients with essential
epilepsy; in five trauma was given as the precipitating factor; in one
arteriosclerosis, and three had seizures as a result of some infantile
encephalopathy. One of the patients had a history of lues with a
paretic serological curve, and another is probably a case of catatonic
dementia precox with episodic seizures. Incidentally, this is the only
case in which there was diminution of the attacks.. In all the other
cases there was a consistent increase from one a month to five times
the original number of seizures. In one or two cases the initial
increase of seizures was probably due to the withdrawal of the
luminal which they had been taking until then. Again, in some of
the cases the seizures were on the increase before the treatment was
begun. The injections were started at the swell of the tide without
mitigating its rise. The conclusion, however, is inescapable, that
there was a general tendency towards an increase in the number of
seizures in most of the cases treated. In no case was there diminu-
tion of the seizures at the beginning of the treatment, as is so often
noted in epileptics with the initiation of almost any therapeutic
measure.
The patients were divided into two groups without reference to
their type or condition; 14 of these received calcium chloride and
376 E) KLEIN AND’ EY FORCGIONE
13 received gluco-calcium. Calcium chloride was injected in aes
per cent solution at the following rate and dosage:
.5 gram twice weekly during the first and second months
.75 gram twice weekly during the third month
1.0 gram twice weekly during the fourth month
Gluco-calcium is stated to be a degradation product of glucose and
calcium and was designed for use in pulmonary tuberculosis, its
supposed advantage being its low toxicity. The higher concentration
of calcium in this compound (15 c.c. of the solution being equiva-
lent to 1 gram calcium chloride) permitted the introduction into the
blood stream of more than twice the amount of calcium than is
present in the same quantity of 5 per cent calcium chloride solution.
But the disagreeable burning sensation precluded its injection in
much larger doses. It was injected for a period of five months as
follows:
gram twice weekly during the first and second months
3 gram twice weekly during the third month
1
ls
1.66 gram twice weekly during the fourth month
2.0 gram twice weekly during the fifth month
Before these injections were begun the calcium concentration in
the blood serum of each patient was determined by three tests at
48-hour intervals. At the end of each month the calcium concentra-
tion of the blood serum was again determined, forty-eight hours
subsequent to the last injection. Determinations were made on the
whole blood according to the Kramer-Tisdall method, blood coagula-
tion being prevented by the addition of sodium-citrate. As might
be expected, in accordance with the findings of Roe and Kahn, the
initial excess of calcium was eliminated so that at the end of forty-
eight hours there was no conspicuous increase sustained. In all cases
the increase was within the limits of physiological variation. Nor
did the larger doses of gluco-calcium result in a higher blood calcium
concentration. Both calcium chloride and gluco-calcium were injected
during the course of some seizures without shortening the seizure
or producing any perceptible change in their character. The sero-
logical and clinical results were equally negative.
Conclusion
1. There was no benefit derived from the use of calcium over
four- and five-month periods in various types of epilepsy. Not only
was there no diminution in the number of seizures but there was a
tendency toward an increase.
INTRAVENOUS TREATMENT OF EPILEPTICS 377
2. No advantage was seen in the use of gluco-calcium over
calcium chloride.
3. There was no sustained increase in the calcium concentration
of the blood serum after the injection of one-half to two grams of
calcium salts.
BIBLIOGRAPHY
. Petzetakis, M. .Arrét d’une crise épileptique aprés injection intra-
veineuse de chlorure de calcium. Revue Neurologique, 32:174, 1925.
. Rossello, H. J. Calcio en epilepsia. An. fac. de med., Montevideo,
5:487-505, 1920.
. Lovero, N. Cloruro di calcio per via endovenosa nella cura dell’
epilessia. Gazz. med. napolet., 6:387, 1923.
. Cushny, A. R. A Textbook of Pharmacology and Therapeutics. Lea
and Febiger, Philadelphia and New York, 1918.
. sabbatani, L. Calcio negli epileptici. Arch. di psychiat. (etc.), Torino,
23:66, 1902.
. Frisch, F., and Weinberger, W. Untersuchungen bei period. Epilep-
sien) Zeitscnr. 1. cd. ses. Neurol. us Psych.,°79:576, 1922.
. Audenino, E., and Bonelli, A. Azione del calcio negli epilettici.
Riforma med., Roma, 18:674—477, pt. 3, 1902.
Linguerri, D. Sali di calcio nell’ epilessia. Bull. d. sc. med. di Boligna,
6:656-664, 1906.
. Silvestri, T. Epilessia e sali di calcio. Gazz. d. osp., Milano, 28:22-24,
1907
: Ciccarelli, A. Policlinico Roma de Prat, 16:133-165, 1909.
. Bryant, J. Use of calcium in treatment of epilepsy. Boston M. and
Babi lo3to47 OLS,
. Donath, J. Der Wert des Chlorcalciums in Behandling der Epilepsie.
Epilepsia, Amst., 7:141-155, 1909.
. Lallemant, E., and Dupony, R. Traitement des épileptiques par le
lactate de calcium. Gaz. de hop., Par., 53:712—714, 1910.
. Obregia, A., and Urechio, C. J. Essais de therapie intrarachidienne
par les sels de calcium dans l’épilepsie. Compt. rend. Soc. de biol.,
Par., 76 :674-676, 1914.
. Hjort, A. M. Influence of orally administered calcium salts on serum
Calciiniaue) = biol” Chem, -05°783,. Octs1925:
. Roe, J. H., and Kahn, B. S. Calcium absorptions from the intestinal
tract in human subjects. J. A. M. A., 80:1761, June, 1926.
. Glazer, F. Psychische Untersuchungen des Blutserums Kalkspiegel.
Klin. Wochenschr, 3:1492, 1924.
THE COLUMNAR ARRANGEMENT OF THE PRIMARY
AFFERENT CENTERS IN THE BRAIN-STEM OF MAN
By WALTER FREEMAN, M.D.
SENIOR MEDICAL OFFICER, ST. ELIZABETHS HOSPITAL, WASHINGTON, Dae
(Concluded from page 306)
J
2. The “ Radix Mesencephalica Trigemini’
Surrounding the lateral angle of the upper part of the fourth
ventricle and the aqueduct of Sylvius is a fasciculus of coarse fibers
arranged in crescentic fashion, which is termed the radix mesen-
cephalica trigemini. On its inner side, sometimes intermingled with
the fibers themselves are some large globoid cells with one or two
processes, rarely more. These were first described by Deiters (72),
who likened them immediately to the cells in the spinal ganglia. Their
connection with the trigeminal nerve has been abundantly proven,
and not only that, but the great majority of these cells are in relation
with the third division and undergo chromatolysis and atrophy after
section of the mandibular nerve. A few undergo atrophy after section
of the maxillary nerve and, at least in animals, none are injured by
division of the ophthalmic ramus. Van Valkenburg (75) has reported
a case in which the first division was involved in a tumor mass in-
tracranially, and in this case he found atrophy of a large number of
the cells, especially from the level of the trochlear nucleus upwards.
We shall have occasion to return to his finding. He considered that
it proved that fibers in the ramus ophthalmicus came from these cells.
It has been shown by Johnston (73, 1909) that the peripheral
processes of these cells of the mesencephalic root run with the sensory
division of the N. trigeminus. Some of the cells may be seen lying
between the motor and sensory nucleus of the nerve in the tegmentum
of the pons. There has been much discussion as to the nature of these
cells, but the problem has apparently been solved by Johnston, who
showed that these cells were really homologous with the sensory cells
of the spinal ganglia, and that they had remained in their primitive
position, intracerebrally. In Amphioxus for example, there are no
spinal ganglia, and all the sensory ganglion cells lie within the sub-
stance of the cord, situated dorsolaterally from the central canal. In
cyclostomes the root has not been identified. Kappers suggests that
[378]
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 379
it may be due to the lack of any masticatory organs, but the motor
V nucleus is well developed. In all higher forms these cells are
found. In reptiles they lie in the roof of the mesencephalon close
to the midline. These intramedullary sensory ganglion cells probably
transmit proprioceptive impulses from the muscles. Examining the
root from the point of view of the column, we find it situated in the
lateral and dorsolateral sector of the neural tube, more or less in the
location where the proprioceptive column is found in the spinal cord.
Its most caudal portion at the level of entry of the trigeminal nerve
occupies a different position than usual with respect to the intero-
ceptive column. There seem to be-two reasons for this. In the first
place the fibers running to these cells are found on the inner or
ventral side of the sensory root, apparently a primitive relationship.
In the second place, referring back (p. 86) to what Johnston (8)
said in regard to the lateral situation of the more recently developed
centers, it will be remembered that the interoceptive system of the
N. trigeminus is:supposed to be a secondary rather than a primary
characteristic of the nerve, owing to the development of the mouth.
It would be more likely, therefore, that this system would be found
to the outer side. These two bits of evidence may explain the loca-
tion of the proprioceptive column to the inner side of the intero-
ceptive. In any event the interoceptive column terminates at this
level as far as I have been able to determine, while the proprioceptive
column continues much farther proximal.
The processes of these cells lying in the mesencephalic root are
shown to enter by the sensory V root. Many collaterals are given to
the motor nucleus however, according to Cajal, and it is probable
that other collaterals end in relation with other cells in the neighbor-
hood. The sensory ganglion cells that are found in the radix mesen-
cephalica are not the actual homologues of the cells in the main
proprioceptive column of Clarke, because the former are true sensory
ganglion cells, primary neurones, whereas the cells in the column of
Clarke constitute the beginning of the secondary pathway. It seems
more probable that the homologue of the column of Clarke is to be
found in the cells that accompany the radix mesencephalica, forming
a triangle in cross section to its outer side. Johnston has opened a
very promising field for study by showing that the radix mesen-
cephalica trigemini is made up of intracerebral sensory ganglion cells.
The condition of the root and of the accompanying smaller ganglion
cells must be investigated in cases of thalamic and of cerebellar
lesions.
380 WALTER FREEMAN
From the level of entry of the fifth nerve the radix mesencephalica
trigemini extends forward to the anterior corpora quadrigemina. It
is very early in development, being, with the fasciculus longitudinalis
medialis and the roots of the third nerve the only structure which is
well impregnated in the mesencephalon of the fetus of three months.
Here it can be seen penetrating far into the anterior colliculus. The
reason for this extensive prolongation forward has been obscure. In
its forward extension the cells lie in a different neuromere, in the
ophthalamic neuromere instead of in the trigeminal. Yet experi-
mental work has failed to show that these cells are injured by division
of the ophthalmic ramus of the fifth nerve to any appreciable degree.
The reason for this extension to higher levels has puzzled Kappers.
The old discussion that was waged between Golgi and Cajal must
be brought up again. In 1893 Golgi (78) published his observations
on the “ Origin of the Fourth Cerebral Nerve.” The ganglion cells
of the radix mesencephalica are difficult to impregnate, but in success-
ful preparations the large cells stand out clearly as unipolar cells
(some are bipolar). Golgi saw processes of some of these cells
running into the velum medullare anterius and joining the root fibers
of the N. trochlearis. Some of the cells were disposed along the
course of the nerve, and some of the fibers of the mesencephalic
root joined those of the N. trochlearis.
These statements of Golgi were criticized with more energy than
tact by Cajal (2) who said that the cells were entirely devoted to the
fifth nerve. Golgi admitted willingly that many of the fibers from
the mesencephalic root left the pons in the fifth nerve, but suggested
that the cells of the radix mesencephalica might supply both nerves.
He also stated his belief that the cells of the mesencephalic root,
although supplying the superior oblique muscle were not the only
cells concerned in the innervation of this muscle. Cajal’s opinion
was takeri as final however, and the question was allowed to rest.
The question of function of the radix mesencephalica trigemini
was later investigated by numerous authors, especially May and
Horsley, Van Valkenburg, and more recently, Kosaka (74). The
last named showed that in the rabbit, section of the mandibular nerve
resulted in degeneration of about 1200 nerve cells in the radix
mesencephalica, whereas one hundred cells remained unaltered. Sec-
tion of the ophthalmic and maxillary branches had practically no
effect. In the dog, section of the mandibular division which was
followed by complete degeneration of the masticatory nucleus on the
same side, was accompanied by the degeneration of 546 cells out of
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 381
1010 below the level of the IV nucleus, and 205 out of 871 above
this level. He found that in the monkey a few of the cells degen-
erated after section of the maxillary nerve in the orbit, only 71 out
of 2744 cells. Section of the infraorbital nerve alone caused de-
generation of only 14 cells. The opposite root in each case remained
entirely intact. Therefore it seems that not all of the cells can bé
accounted for by a consideration of the N. trigeminus alone. It is
said that enucleation of the eyeball has no effect upon the cells in the
mesencephalic root, but as far as I know, no investigation of the
condition of the root has hitherto been undertaken after operations
upon the extraocular muscles. It has been shown by Sherrington (12)
and others that the third, fourth and sixth nerves contain many
afferent fibers subserving presumably muscle sensibility. These fibers
run in the motor roots since there are no separate sensory roots and
no sensory ganglia have been described. Golgi saw fibers running
from some of the cells in the radix mesencephalica trigemini into
the trochlear nerve.
The number of cells in the mesencephalic root is notably increased
at the level of the trochlear nucleus and again at the level of the
nucleus oculomotorius, moreover some of the large globoid cells have
been found scattered in the oculomotor nucleus. Winkler states that
some of the fibers from these cells join the third and fourth and
possibly the sixth nerves. He suggests (14, vol. 2, p. 34): “It is
therefore natural to ask if the N. trochlearis and the N. oculomotorius
do not convey fibers to the radix mesencephalica trigemini, of which
some return to the N. trigeminus by sympathetic connections.” This
explanation seems to be rather far-fetched. A much simpler explana-
tion would be that these cells are the ganglion cells whose afferent
fibers are found in the oculomotor and trochlear nerves, and that
these nerves resemble still more the spinal nerves of Amphioxus that
have no extraspinal sensory ganglia.
I have recently performed a series of animal experiments in order
to test this hypothesis. In four cats under ether anesthesia the orbit
on one side was exenterated, not only the eyeball but also the muscles,
nerves and glands being removed. In a control animal the eyeball
was simply. enucleated. After a lapse of time the animals were
sacrificed and their brain-stems cut in serial sections. One series
was treated by the Marchi method, and the others studied in cell
preparations. The preparations by the Marchi method showed slight
degeneration in the radix mesencephalica trigemini on the side of
operation at the level of the oculomotor nucleus, and on the opposite
382 WALTER FREEMAN
side at the level of the trochlear nucleus. The corresponding nerves
showed slight retrograde degeneration.
In the brain-stem stained with azure-erythrosin it was found
that in the upper portion of the radix mesencephalica trigemini many
of the large globoid cells were missing upon the side of the lesion,
or were represented by shrunken, hyperchromatic structures quite
apparently degenerated. This difference between the tract on the
two sides of the brain was quite notable from level of the oculomotor
nucleus as far as the rostral limit of the tract (Fig. 24). There was
some degeneration in the tract upon the side opposite the lesion at
the level of the trochlear nerve, but none below this level. The
oculomotor nucleus upon the side of operation had undergone marked
degeneration with chromatolysis of a large proportion of the cells.
A small number of cells of the opposite nucleus had also undergone
shrinkage and chromatolysis. The trochlear nucleus upon the side
opposite operation had undergone practically complete degeneration,
leaving intact its fellow on the side of operation. In the brain-stem
of the animal whose eyeball had simply been enucleated there was
no difference appreciable between the two sides in either the radix
mesencephalica or in the motor nuclei. Counting the large normal-
appearing cells above the trochlear nucleus revealed the following
differences :
III nucleus IV nucleus
Animal Side of Side of
Number’ operation Opposite side operation Opposite
1 482 787 230 145
Ve 189 412 126 91
Control 665 710 187 208
There were several difficulties encountered in the investigation.
In the first place the orbit of Animal 1 was incompletely exenterated.
Muscle fibers were later found in the mass of scar tissue filling the
orbit, and even in the second animal there were numerous motor
cells intact in the oculomotor nucleus on the side of operation.
Secondly the large globoid cells were liable to undergo shrinkage
during technical procedures even though the precaution of double
embedding was observed. In animal 3 in which this was not done,
the preparations were almost useless for study. Thirdly, the large
cells often appeared in two or even three successive sections. The
lower total number of cells in Animal 2 was probably due to thicker
sections. In spite of these objections however, it seems to me that
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 383
on account of the well marked differences between the two sides,
the results are significant. When the extraocular muscles were re-
moved there was degeneration of a large proportion of large globoid
cells in the radix mesencephalica trigemini in the rostral portion of
the tract.
Ficure 24. Mesencephalon of a cat whose left orbit had been exenterated,
the muscles and nerves as well as the eyeball having been removed. There is
severe degeneration of the oculomotor nucleus on the same side, and the large
globoid cells have disappeared from the mesencephalic root. Those cells were
probably concerned in the sensory innervation of the extraocular muscles.
In studying the relationship of the radix mesencephalica trigemini
to the extraocular muscles the case reported by Van Valkenburg (75)
may be considered. In this case a tumor of slow growth involved the
first branch of the N. trigeminus while sparing the second and third
384 WALTER FREEMAN
rami. At the same time however it caused complete ophthalmoplegia.
In his investigation of the radix mesencephalica trigemini Van
Valkenburg found that above the level of the trochlear nucleus there
were 144 cells on the normal side as compared with 64 on the diseased
side, and that at the upper end of the series, sections 877 to 904,
there were 21 cells on the healthy side, and none at all on the other
side. Since it has been shown in experimental work on animals that
no cells degenerate after section of the ophthalmic division of the
N. trigeminus, the degeneration of these cells was probably due to
the involvement of the nerves to the extraocular muscles.
Assuming that the upper part of the radix mesencephalica con-
tains the ganglion cells which supply the extraocular muscles with
proprioceptive sensibility, we have a satisfactory explanation for the
forward extension of the mesencephalic root into the ophthalmic
neuromere. Moreover its prolongation.into the anterior corpus
quadrigeminum would place it in very appropriate surroundings from
the standpoint of function.
In summary then, the radix mesencephalica trigemini is composed
of intracerebral ganglion cells homologous with the intraspinal gang-
lion cells of Amphioxus. The peripheral afferent fibers run in the
ramus sensibilis of the N. trigeminus but are not interrupted in the
Gasserian ganglion. Most of them come from the ramus mandibu-
laris but a few probably from the ramus maxillaris. There are many
collaterals running to the nucleus motorius trigemini. The radix
mesencephalica trigemini is the forward continuation of the proprio-
ceptive column, and supplies muscle sensibility to the muscles of
mastication. The ophthalmic and maxillary divisions are scarcely
represented in the mesencephalic root.
Some of the fibers from the cells of the radix mesencephalica
trigemini enter the trochlear nerve, the number of the cells in the
root is increased at the level of the nucleus trochlearis and again at
the nucleus oculomotorius, and some of the globoid cells lie within
the oculomotor nucleus. Many of the cells in the radix mesen-
cephalica remain unaltered after section of the N. trigeminus which
causes complete degeneration of the motor nucleus; moreover, many
of the cells were found degenerated in a case of ophthalmoplegia and
after experimental exenteration of the orbit. Therefore it is believed
that the radix mesencephalica trigemini supplies proprioceptive
muscle sensibility not only to the muscles of mastication, but also to
the extraocular muscles.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 385
IV. GENERAL SUMMARY AND CONCLUSIONS.
The study of the spinal cord has been made from the standpoint
of the segment and of the column, for the individual segments
resemble one another so much that there is no point in considering
them separately. The study of the brain-stem on the other hand
began with the study of the individual nerves. These showed so
many obvious dissimilarities that although certain resemblances were
recognized, the nerves were described as entities. It is only com-~-
paratively recently that the division of the brain-stem into segments
has been undertaken, and although there still exist many uncertain-
ties in regard to the actual number of segments entering into the
formation of the bulb yet this method of analysis has given interesting
results and has facilitated an understanding of the general mechanism
or fundamental architecture of the brain-stem. Still more recently
there has been a tendency developed, especially by the American
school of anatomists, to consider the brain-stem from the aspect of
the column, thus likening it to the spinal cord. The division inta
somatic and visceral efferent and somatic and visceral afferent colums,
separated by a sulcus limitans, has assisted greatly in the study of
the primary systems. This work was begun on the lower vertebrates,
but it application to the higher vertebrates, and especially to man,
should yield further helpful and interesting results.
In this paper an attempt is made to apply the laws laid down for
the columnar structure in the lower animals to man. There are many
gaps in the defense of the thesis that will have to be stopped by
further investigations, but it is believed that some of the gaps are
here pointed out, and that continuing the search with a knowledge
of what we are seeking, new ground will be conquered and new
fields for investigation will be opened.
In the first chapter I have indicated that the fifth, seventh, ninth
and tenth cranial nerves are similar in construction to the spinal
nerves; each one innervates a certain cutaneous area with general
exteroceptive cutaneous sensation. Each one innervates a certain
area of mucous membrane with general interoceptive sensation.
Each one supplies motor fibers to certain muscles which spring from
the visceral motor system originally surrounding the alimentary canal.
Each one carries proprioceptive fibers from the muscles it innervates.
Each one contains segmental reflex fibers. The lower nerves carry
gustatory fibers. The afferent divisions upon entering the brain-stem
divide into two main portions, a ventral division carrying extero-
ceptive fibers and segmental reflex fibers and a dorsal carrying intero-
386 WALTER FREEMAN
ceptive and proprioceptive fibers. The several systems of fibers
run as follows:
1. To an interrupted column of large cells that is found at the
inner tip of the restiform body. It is represented at one end by the
nucleus cuneatus, and at the other by the nucleus sensibilis trigemini.
Between these two levels we find the nucleus ventralis tractus solitarii,
and two collections of cells that are called the nucleus sensibilis
glossopharyngei and the nucleus sensibilis facialis. These cells receive
impressions of light touch with discriminative qualities, and proprio-
ceptive impulses underlying spatial perception. Their axones make
up the lemniscus medialis.
2. To the nucleus tractus spinalis trigemini. The majority of
the fibers in the spinal root of the trigeminus come from the fifth
nerve, but a considerable percentage in the lower parts come from
the ninth and tenth nerves, and probably also from the seventh. In
its hypertrophy with respect to the other nerves, the N. trigeminus has
usurped the cutaneous fields formerly supplied by the other nerves.
The intracerebral course of these fibers of the N. trigeminus, convey-
ing pain and temperature sensations, has been increased because of the
necessity for coming into relation with the fixed origins of the sec-
ondary fibers. The spinal root is homologous and directly continuous
with Lissauer’s tract in the spinal cord. It seems probable that the
pain and temperature fibers find different nuclei, for dissociation of
these sensations is found not infrequently in lesions of the radix
spinalis trigemini. The segmentation about the buccal orifice is shown
by the progressive advance of the sensory dissociation in syringo-
bulbia, to be as definite as that existing about the anal orifice.
3. To the nuclei of the tractus solitarius, which is merely the
most prominent part of the interoceptive column. This column lies
in a definite position and can be traced from the level of the nucleus
sensibilis trigemini as far caudal as the closure of the fourth ventricle,
and even beyond this to the pars intermedia of the spinal cord with
which this tract is homologous. Two special nuclei are described in
this interoceptive column, at the levels of entry of the seventh and
ninth nerves. These are probably gustatory nuclei. No similar
nucleus could be determined in the case of N. vagus. It is shown
fairly conclusively by comparative evidence that the tractus solitarius
carries fibers for general visceral sensibility rather than for taste.
4. (a) To the radix descendens nervi vestibuli. The eighth nerve
is shown to be a derivation by specialization of the seventh nerve.
Its acoustic division corresponds more closely to the proprioceptive
ARRANGEMENT OF PRIMARY AFFERENT CENTERS _— 387
cognitive system, finding its nuclei situated laterally in the floor
of the fourth ventricle, and its secondary tract in close relation with
the secondary tract of the common proprioceptive cognitive and
exteroceptive discriminative system. Its vestibular division exerts
a special proprioceptive function and finds its reception nuclei in the
Nucleus triangularis and the Nucleus tractus descendentis N. ves-
tibuli, a column of cells which is practically continuous with the
column of Clarke in the spinal cord. The secondary tract in both
instances runs to the vermis cerebelli. The other bulbar nerves
probably contribute fibers to this descending tract. The explanation
for the long caudal extension of the tract is again to be found in
the principle of usurpation.
4. (b) The afferent fibers running from the muscles of masti-
cation and from the extraocular muscles, are not interrupted in a
ganglion of the dorsal spinal type, and find their cells in the radix
mesencephalica trigemini. This root is made up of sensory ganglion
cells supplying muscle sensibility to the muscles of mastication and
to the extraocular muscles. The cells lie in the same column as do
those of the radix descendens vestibuli, that is, in the proprioceptive
column.
When the location of the columns is compared at various levels
it is seen that a constant relationship is maintained and that the
relationship is practically identical with that observed in the spinal
cord. In other words the findings in the spinal cord can be applied
directly to the brain-stem, making allowances for the overgrowth
of certain components of some nerves, and others of other nerves.
In doing so, many of the structures that are encountered cease to
have an obscure and unusual significance, and when the disguise is
stripped off, become much more like the same structures in the spinal
cord with whose appearance we are more or less familiar.
This study also shows that although the bulk of some intramedul-
lary tract is made up of the fibers belonging to a particular nerve,
this nerve has no exclusive rights to the use of the pathway. There ©
are no viae privatae among the primary afferent systems.
In summary I append a table showing the origin, components,
function, course and termination of the various mixed cranial nerves
as they are believed at the present time to be represented.
I desire to express my appreciation for the willing assistance
and cooperation I have received in both the clinic and the laboratory
from Professor Giovanni Mingazzini and Professor Giuseppe Ayala.
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ARRANGEMENT OF PRIMARY AFFERENT CENTERS 391
AB REN DT AY
THe Nervus Facratis AND Its NucLer In ELepuas INpDICcUuS.
The extraordinary development of the facial musculature that
forms the elephant’s trunk, renders the brain of this animal especially
interesting for comparative study. Through the courtesy of Pro-
fessor Marburg at the Neurological Institute in Vienna, I am able
to report the results of my examination of slides in that remarkable
collection.
The Nucleus motorius VII has a longitudinal extent from the
level of entry of the N. glossopharyngeus to that of the N. trigeminus.
It is also of marked breadth and thickness, forming a prominent
swelling on the ventral surface of the medulla oblongata immediately
caudal to the pons. The nucleus is lobulated and contains a very large
number of cells. From it the proximal motor radiculi run straight
dorsally and proximally to form the genu N. facialis. This lies
somewhat more laterally in the floor of the fourth ventricle than is
the case in man, and two distinct eminences are formed; by the Fasc
longitudinalis medialis medially and by the genu N. facialis laterally.
Between them, in a few sections, lies the small Nucleus abducens.
The cross-section of the genu N. facialis appears larger than the
motor root at its exit. The R. sens. N. facialis enters the medulla
oblongata at its junction with the pons, lying between the R. motoria
N. VII and the N. octavus. This root is extraordinarily large, being
more than half the diameter of the motor root itself. The entering
fibers of the R. sens. N. VII break up almost immediately upon their
entrance into the brain-stem. Many strands lying centrally placed
in the root penetrate the R. spinalis trigemini, and some apparently
do not emerge. The subst. gel. Rolandi is enlarged at the level
of entry of the R. sens. N. VII and contains an unusually large
number of large cells causing it to resemble the same structure as
it appears just below the entry of the R. sens. N. V. A fasciculus
situated mesially (the most ventral division of the entering sensory
root), is quite the most prominent part of the sensory root. It
penetrates the R. spin. V, runs dorsad, and then curves proximad
and mesiad, coming close to the R. motor. N. VII in its distal course.
This bundle of fibers can be traced directly into the genu N. facialis.
The inference is that these are the segmental reflex fibers that have
already been discussed in connection with the facial nerve of man
Gities: Grand: 29.) %
The N. octavus is smaller than the R. motor. N. VII. Its larger
cochlear division enters to the outer side of the corpus restiforme.
The small vestibular portion penetrates the medulla oblongata between
392 WALTER FREEMAN
the R. spin. V and the corpus restiforme, reaching the N. triangularis
and turning caudad in the R. desc) N. VILI> This Ri desc Nea
appears larger than the N. vestibularis itself, and some of the fibers
from the dorsal division of the R. sens. N. VII, seemed to join this
root. No opinion could be formed as to the entrance into the root
of fibers from other nerves. The Radix spinalis trigemini and the
corpus restiforme lie relatively close to one another. Situated close
to the mesial border of the corpus restiforme, more ventral than the
R.vescVil.
7 S=< /i CORPUS RESTIFORME,
——e 7 NuUC.SENSUD
SS / (LOWER SECTIONS)
~ Nuc.TR. Sov.
f/
ff
|) - Rav.sens.-Vil
. \ }
if Rav.arr VI.
SL by YY
Up 19a
a
= ee Rap.spin.V.
. — 4 ey ! F
= “ S cev.Roc.
Rad.c oT.
Nuc.Mor. Vi
F.LONG. POST.
—
Figure 25. Semidiagrammatic sketch of the pons of Elephas indicus.
(Weigert preparation from the collection of the Neurologic Institute in
Vienna. Courtesy of Professor Marburg.) The nucleus motorius N. facialis,
the genu N. facialis and the radix motoria N. facialis are all shown. The genu
is larger than the outgoing fibers. More dorsally than the radix motoria is a
large band of fibers that entered the pons with the sensory division and diverged
mediad, running directly into the genu N. facialis. Other strands of the
entering R. sens. VII are seen penetrating the R. spinalis trigemini, and some
running to the gustatory nucleus. In lower sections, at the inner edge of the
corpus restiforme a considerable group of cells is to be found, with some
strands of entering fibers running directly to them.
Nucleus proporius tractus desc. N. VIII and distal to the main body
of vestibular fibers, is a fairly large collection of cells corresponding
in type to those of the nucleus sens. trigemini. Some strands of
fibers entering with the R. sens. N. VII can be traced directly to this
nucleus, thus establishing the probability of its being the Nucleus
sensibilis N. facialis, and the homologue of the larger sensory nucleus
of the N. trigeminus.
Fibers from the dorsal division of the R. sens. N. VII penetrate
the R. spin. V and run to the viscerosensory column. There is
apparently only one nucleus in connection with this tract. It lies
ARRANGEMENT OF PRIMARY AFFERENT CENTERS 393
at the tip of the R. spin. V and immediately internal to the R. desc.
N. vestibuli, and consists of small cells embedded in a somewhat
gelatinous matrix. Since the tractus solitarius is much smaller above
and below this level, this nucleus is probably the Nuc. gustativus
Nev tigen thesconponents, of the R. sens. N. Vil are thus
accounted for with particular facility in the case of the elephant,
because of the peculiar development of the parts supplied by
this nerve.
Pub Be INDI.
Professor Mingazzini, in whose laboratory most of this work was
done and whose constructive criticism has been so helpful, has sug-
gested that I append a description of the method for the silver
impregnation of serial sections which has been used in many of the
preparations from which drawings were made. Previous descrip-
tions have appeared elsewhere, but as at present applied the method
is as follows:
The material is fixed in alcohol. The entire brain of a full term
fetus should be allowed to harden for six months. The method
is applicable after fixation in 10 per cent formaldehyde, but there
is more liability of precipitation. ‘The pieces are embedded in paraffin,
sections are cut at 10 to 20 micra, and these sections are attached to
slides or cover-slips with a minimum of albumen-glycerin fixative.
An excess gives rise to precipitation. After drying, the paraffin is
removed by xylol, and the slides are carried through graded alcohols
in the ordinary manner to distilled water. They are then laid sepa-
rately, section side up, in small dishes the bottoms of which are
covered by a layer 3 to 5 mm. thick, of a fresh warm 10 per cent
solution of gelatin in distilled water. The gelatin is allowed to harden
and upon the surface is poured a fresh solution of silver nitrate of
2 per cent strength, forming a layer that is equal in thickness to the
layer of gelatin. The gelatin acts as a tissue of uniform thickness
and consistency through which the silver ions can diffuse to the
underlying nervous tissue. The dishes are covered and are kept
in the dark for from 4 to 8 days. A longer time is not harmful and
is sometimes necessary to increase the impregnation of the cellular
elements.
When the impregnation is complete the silver nitrate solution
is poured off and the gelatin is melted by partly immersing the dish
in hot water. Upon inverting the dish the gelatin slides away, leav-
ing the section in the bottom of the dish. The slide with the section
394 WALTER FREEMAN
upon it is immediately immersed, without washing, in a mixture
with the following proportions:
Silver nitrate, freshly prepared 10 per cent 3.0 cc.
Glycerin, warm 5 Oca:
Gelatin, fresh, warm, 10 per cent 5 Osan
Agar-agar, warm, 1.5 per cent a0 sce
Hydroquinone, 5 per cent 0.7— 2.0 cc.
The glycerin, gelatin and agar-agar solutions should be kept in
the oven or on a water-bath at 40 degrees or above. The agar-agar
keeps fairly well but should be filtered through cotton whenever
a cloud of sediment forms. The solution of geltain must be made
fresh on the day of using. The hydroquinone seems to improve in
its reducing power with age. The mixture blackens in two minutes
and solidifies in about ten minutes so that it must be made freshly
for each pair of sections. (With a little practice, a pair of forceps
in each hand, two sections can be developed at the same time.) The
sections are moved about constantly in the developer until they
assume a reddish brown tint that passes to grayish brown. The
development is best carried out behind a screen, for direct daylight
hastens the reaction to too great an extent. Too much hydroquinone
results in rapid reduction with insufficient contrast, while too little
results in slow development with the likelihood of precipitation. A
small amount of precipitate does not interfere with histologic picture.
When the desired color is reached, the coverslip is washed in warm
water to remove the reducing mixture and is immersed for a minute
or two in a 5 per cent solution of sodium hyposulphite. Too long
immersion causes the cells to become indistinct although the fibers
become somewhat more brilliantly outlined. This is followed by
thorough washing in tap water, dehydration, and mounting in balsam.
The use of paraffin sections makes the control of serial sections
much more easy, and it also allows the use of other stains than silver.
For instance three adjacent sections may be stained by silver, toluidin
blue and hematoxylin-eosin, thus giving a varied picture of practically
the identical area. The silver impregnation method is especially
useful in the immature nervous system because it stains black only
those fiber systems that have reached a certain degree of development,
leaving the others brownish or practically unstained. The varying
shades of brown to black also serve to differentiate different systems
of fibers where they run in close proximity to one another, as for
instance in the inferior cerebellar peduncle.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS — 395
BIBLIOGRAPHY
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0. Ranson. Anatomy of the Nervous System. Philadelphia, Saunders, 1920.
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A. The Nervus Trigeminus
17. Cushing, Harvey. The Sensory Field of the Cranial V Nerve. Johns
Hopkins Hosp. Bull., 15:213, 1904.
18. Dana, Charles. The Question of Protopathic and Epicritic Sensibility and
the Distribution of the Trigeminus Nerve. J. Nerv. AND Ment. Drs.,
Vol. 33, 1906.
19. Davies. The Functions of the Trigeminal Nerve. Brain, 1907. _
20. Hartmann, Edouard. La Neurotomie retrogassérienne. Paris, Doin, 1924.
B. The Nervus Facialis
21. Agosta. Innervation sensitive du facial. Medicina ital., 4, 1921. (Ref. in
Rev. neur., 1:282, 1924.)
21a. Adelman. The Development of the Neural Folds and Cranial Ganglia
of the Rat. J. Comp. Neurol., 39:19, 1925. ;
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the Period of Somite Formation. (Unpublished: referred to by Adel-
tat hl 925:
22. Amabilino. Sui rapport del ganglio genicolato con la corda del timpano e
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23. Baudouin. Le systéme sensitif du nerf facial. Gaz. des Hop., 32:501, 1921.
(Ref. in Rev. neur., 1:282, 1924.)
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Van Gehuchten. Le nerf intermédiaire de Wrisberg. Le Névraxe, 1:5,
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Hunt, J. Ramsay. On Herpetic Inflammations of the Geniculate Ganglion.
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Hunt, J. Ramsay. The Sensory. System of the Facial Nerve and Its
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Hunt, J. Ramsay. The Sensory Field of the Facial Nerve, etc. Brain,
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Nageotte.. The Pars Intermedia or Nervus Intermedius of Wrisberg and
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Psychiat., 1906.
Rinehart, D. A. The Nervus Facialis of the Albino Mouse. J. Comp.
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Roger and Reboul-Lachaud. Le syndrome zostérien du ganglion géniculé.
Paris méd., 11:364, 1921.
Souques. Syndrome du ganglion geniculé. Bull. et mém. soc. méd. Hop.,
Paris, 36:146, 1921.
Souques and Hartmann. Les fibers de la sensibilité profonde passent-elles
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Weigner. Uber den Verlauf des Nervus intermedius. Bull. internat. de
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C. The NN. Glossopharyngeus and Vagus
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Hunt, J.. Ramsay. Herpetic Inflammations of the Geniculate, Auditory,
Glossopharyngeal and Vagus Ganglia. Arch. Int. Med., 5:631, 1910.
Van Gehuchten. Anatomie du systéme nerveux de l’homme. Louvain,
1906, pp. 553 ff. _
Vernet. Syndrome du trou déchiré posterieur. Rev. neur., 1:422, 1918.
D. The Nerves Carrying Gustatory Impressions
Ariéns-Kappers. Vergleichende Anatomie. Vol. II, Part 1. (A section
is devoted to this question.)
Ariens-Kappers. Der Geschmack, peripher und zentral. Psych. en Neur. |
Bladen, Amsterdam, 1914.
Cushing, Harvey. The Taste Fibers and Their Independence of the
N. Trigeminus. Johns Hopkins Hosp. Bull., Vol. 14, 1903.
E. The N. Hypoglossus
Froriep. Uber ein Ganglion des Hypoglossus, etc. Arch. f. Anat. uw.
Entwickelungs, 1882.
hee Pork as d’anatomie humaine. Paris, Doin, 1911. 6th Edition.
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i III. THe Primary RECEIVING CENTERS
A. The Radix Spinalis Trigemini
Cajal, S. Ramon y. Beitrag zum Studium der Medulla oblongata. 1896.
Breuer and Marburg. Zur Klinik und Pathologie der apoplektiformen
Bulbarparalyse. Obersteiner’s Arb., 9:181, 1902.
Gerard, Margaret W. Afferent Impulses of the Trigeminal Nerve. Arch.
of Neurol. and Psychiat., 9:306, 1923.
Head and Holmes. Sensory Disturbances from Cerebral Lesions. Brain,
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Head and Thompson. The Grouping of Afferent Impulses Within the
Spinal Cord. Brain, 29:536, 1906.
Kijatschin, Experimentelle Untersuchungen iiber den Ursprung des N.
Trigeminus. Neur. Centralbl., 16 :204, 1897.
72.
ARRANGEMENT OF PRIMARY AFFERENT CENTERS — 397
. Kutner and Kramer. Sensibilitatsst6rungen bei akuten und chronischen
Bulbarerkrankungen. Arch. f. Psych., 42:1002, 1907.
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Pons und der Oblongata. Deut. Zeitschr. f. Nervenheilk., 41:41, 1911.
. Ranson. An Experimental Study of Lissauer’s Tract and the Dorsal
Roots. J. Comp. Neurol., 24:531, 1914.
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Cerebellar Artery. J. Nerv. AND MENT. Dis., 35 :365, 1908.
. Spiller, Wm. G. Remarks on the Central Representation of Sensation.
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Monatsschr. f. Psych. u. Neurol., 29 :407, 1911.
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Kopfe insbesondere in Fallen von Syringomyelie. Jahrb. f. Psych.,
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und der Oblongata. Deut. Zeitschr. f. Nervenheilk., 41:8, 1911.
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Proc. k. Akad. v. Wissensch., Amst., 17:914, 1915.
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. Van Gehuchten. Le Faisceau solitaire. Le Névraxe, 1:73, 1900.
. Van Gehuchten. Recherches sur l’origine réele des nerfs craniens. Jour.
de neurol., 1898.
. Van Gehuchten. (Pages 593 ff. in his Anatomie.)
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des N. Vagus, etc. Okayama Igakkwai, 1905, No. 188.
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DOtjo ato bo
. Tumbelaka. Konsekutive Veranderungen eines kleines Herdes in dem
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Winkler. Opera Omnia. Vol. 7, p. 39.
“
SOCIETY PROCEEDINGS
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY
REGULAR MEETING, THURSDAY, OCTOBER 21, 1926. DONALD GREGG,
M.D., PRESIDENT, IN THE CHAIR
DEMONSTRATION: OF DECORTIGATED GATS
Drs. GEORG SCHALTENBRAND AND STANLEY COBB
For the purpose of physiological and pharmacological studies of
mobility we intended to repeat the old experiments of Goltz, Roth-
mann, Dusser de Barenne, and others, who successfully removed the
forebrain in higher mammals. We are especially interested in the
eventual share of the striatum in mobility, and of a more exact
localization of the bulbocapnine in catalepsy.
The technique of the operations is of interest because we have
found it much better to operate under local anesthesia than under
ether. We first give the animals a dose of bulbocapnine hydro- ~
chloride—0.02-0.03 of a gram to a kilogram of the animal’s weight.
After about fifteen minutes the cat becomes cataleptic; she is then
placed on the operating table and shaved. The neck is first opened
and small bulldog clips are placed on the carotid arteries (this part
of the operation is done under ether anesthesia, for it was found that
handling the vagus nerve when the animals were not thoroughly
anesthetized caused death in some cases). When the carotid arteries
have thus been temporarily closed the animal is turned over and the
head is prepared. Novocaine, 1 per cent solution, is then injected
into the scalp and epicranium, and the operation proceeds under
strictly aseptic precautions. Through an enlarged trephine in the
skull the dura is opened and the hemisphere laid bare. If the animal
is to be made a “thalamus cat” the procedure is as follows: The
gyrus-fornicatus is split until the lateral ventricle is widely open, then
the incision is carried down to the anterior edge of the cornu ammonis,
along the outside edge of the lobus pyriformis and along the rest of the
basal rhinencephalon, meeting the beginning of the incision approx-
imately at right angles, so that only a thin layer of rhinencephalon
remains anterior to the thalamus. With a blunt dissector the hemis-
phere is then raised and carefully removed. There remains then only
thalamus and the basal portions of the rhinencephalon.
If a “striatum preparation” is to be made the lateral ventricle
is opened as above and the knife circles round the outer edge of the
caudate nucleus. The incised cortex is lifted carefully and the cortex
of the island of Reil is removed afterwards. We have then remain-
[398]
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 399
ing only cortex in the pyriform lobe, and the striatum remains intact.
After all bleeding has been stopped, by placing pieces of muscle in
the brain cavity, the muscles are sewed over the wound, the skin
closed with a Michel clips. About a half an hour afterwards the
clamps are removed from the carotid arteries. After the operation
the animal remains on the operating table restrained with head-holder
and straps for from four to six hours. This is because of the
marked motor restlessness which follows such operations. We
remove only the cortex of one hemisphere at the time and wait for a
few months before we make the second operation. At present we
have one cat alive which has been operated bilaterally, and three
which have been operated only on one side.
The results of these unilateral decortications are as follows:
Immediately after the operation there is the hyperkinesis mentioned
above. Next morning, if all has gone well, the animals are able to
walk, and it is then found that they circle towards the normal side;
that is to say, if the right hemisphere has been removed, the animal
circles towards the left. This, however, only lasts for about one or
two days, and usually by the third day the animals begin circling
towards the operated side. This phenomenon persists, or at least
lasts, for two or three months (this being as long as we have observed
any hemidecortications). When, however, the animals are blind-
folded they immediately begin circling towards the opposite side;
that is, they revert to the condition that they had immediately after
the operation. An animal with the right hemisphere removed, when
blindfolded will circle towards the left.
Besides the above-noted locomotor phenomena it is seen that there
are changes in tone. Immediately after operations, and lasting for
one or two days, there is a spastic paresis of the contralateral legs;
these extremities are held in strong extension. Later on this weak-
ness and extensor rigidity diminishes, so that from three to four days
after operation there is observable only a slight increase of tone in
the contralateral legs and a moderate exaggeration of the extensor
posture, visible when the animal is lying on its back. This, however,
can be demonstrated even two to three months after operation. In
the sensory realm there is found to be impairment of the sense of
position on the contralateral side. This is best shown by placing the
limbs in some abnormal position; the animal then is apparently
unconscious of this uneasy posture and does not move. There is also
impaired localization for pain stimuli. When the animals are able to
run and can stand being taken outdoors where there is plenty of
room, it is easily shown that they have a homonomous hemianopsia
in the field opposite to the lesion (an animal with the right hemis-
phere removed would have a left homonomous hemianopsia). This
can be demonstrated by calling the animal until it begins to follow
you; then by walking in and out of the field of vision it is found.
that the animal loses track of you; she is lost while you are in the
hemianopic field, whereas she immediately runs towards you when
you get into her intact field of vision. A curious symptom, shown
by some of the animals, was a great shaking of the contralateral legs
400 BOSTON SOCIETY OF PSYCHIATRY AND NECROLOGS
during the first few days after operation. This was begun whenever
the animal started walking, and was especially noticeable if it in any
way got moisture or dirt on its feet. It is apparently an exaggeration
of normal shaking.
We will demonstrate three animals: The first is a maltese cat,
operated on August 8, 1926. There was removal of the right hemis-
phere in front of and above the thalamus. The animal could then be
referred to as a “right-sided thalamus cat.” Immediately after
operation her body arched to the left, the convex side being to the
right. A few days later, when convalescent and walking about, she
circled to the right and has done so ever since. When blindfolded,
however, she reverses the direction of circling. She still has marked
extensor tone of the left legs when lying on her back.
The next cat was operated on October 1, 1926; the right neo-
palium was extirpated, leaving the right striatum intact. Since the
operation she has shown changes of posture of the head. In locomo-
tion she circles to the right, but when blindfolded circles to the left.
There is hyperextension of the left legs when she is laid upon her
back.
The third cat had her first operation on August 4, 1926, when
we removed the left neopalium without injuring the striatum. Imme-
diately after the operation the cat circled to the right, but a few days
later began circling to the left. There was contralateral hyperexten-
sion and marked shaking movements of the right legs whenever the
cat began to walk. Early in September the examination showed that
there was still a certain amount of right-sided hyperextension and
the cat still circled to the left whenever she walked. About Septem-
ber 20 she began to look ill, and it was decided to operate and remove
the other hemisphere before she should die. Operation revealed great
hydrocephalus and some meningitis of the right hemisphere. The
neopalium on the right was removed, leaving the animal a “ bilateral
striatum cat.” She made a good recovery and shows the following
important symptoms: She is able to recognize smells and eats spon-
taneously, but in a reflex way which causes her to eat too much; her
gait is somewhat shaky and occasionally she has exaggerated shaking
-movements of all four legs, as if trying to shake off moisture or some
obnoxious object attached to the paw; she walks about easily, often
bumping into objects as if blind, and she is hyperkinetic. Her pupils
react well to light, and she shuts her eyes when a bright light falls
suddenly into them. It is now three weeks since the operation, and
she appears to be getting along perfectly well. When given bulbo-
capnine she reacts with cataleptoid reaction like a normal cat.
Some other cats that we have operated on unfortunately died.
Two of them were “thalamus ” cats and survived the second opera-
tion; they appeared much like the one I presented this evening, but
contracted pneumonia and died. Altogether, we have observed seven
unilateral cats. We intend to go on and make the remaining uni-
lateral cats into bilateral thalamus or striatum animals.
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 401
Discussion: Dr.H.C. Solomon: If the vision cortex is removed
on one side without other cortical disturbance, will the animal tend
to move in a circle as do the animals with removal of half the cortex ?
Dr. Stanley Cobb: I believe so; I am not sure. We ought to
do that as a check.
Dr. Solomon: Has any other work been done on hemidecortica-
tion?
Dr. Cobb: There have been, in the history of medicine, various
decorticated animals that were kept alive after operation for a con-
siderable period and really showed the chronic symptomatology. I
have listed these in chronological order, as follows:
CHRONIC DECORTICATED ANIMALS
Magendie 1825 goat
Goltz dog |
Rothmann rl Striatum
Pavlov dog
Dresel dog—Thal.
Dusser de Barenne 2 cats (1 with Rhinenceph.)
Karpus and Kreidel monkeys
Morita rabbits
Magnus rabbits
Rademaker rabbits
The first, an experiment by Magendie, was not a true chronic
experiment. I merely mention it to show at what an early date the
physiologists began to speculate about these things. Monkeys always
had shock after the operation, and did not come out of it, even
though they survived as long as six weeks. Rabbits and other
rodents have frequently been used but are not of as much interest
as the carnivora and higher mammals. Therefore, this animal is
about the eighth higher mammal and perhaps the third cat to survive
this operation.
Dr. Solomon: If you just remove the motor cortex, you get a
paralysis ?
Dr. Cobb; A short one, yes.
Dr. Solomon: Is there paralysis after the removal of the hemt-
cortex immediately on recovery ?
Dr. Cobb: They have some weakness for about forty-eight
hours; after that there is nothing...
Dr. Solomon: Is that less than if they had the motor cortex
removed °
Dr. Cobb: About the same.
402 BOSTON SOCIETY OF PSYCHIATRY AND NEURCLeG
VACCINE THERAPY IN MULTIPLE (SCUCEROS Is
PRELIMINARY RE ROR
Dr. HENRY VIETS
In July of this year we started, at the Massachusetts General
Hospital, treatment of cases of multiple sclerosis with typhoid vac-
cine. ‘This type of treatment has been used at other clinics since
1918 with fair results.
In 1922, Karl Crosy reported on the treatment of fifty-nine cases
(Jahrb. f. Psychiat. u. Neurol., 1922, XLII, 19). He found improve-
ment in about 30 per cent. In 1924, MacBride and Carmichael
treated seventy cases with some improvement (MacBride, Henry J.,
and Carmichael, E. Arnold, Lancet, 1924, II, 958).
We have treated six cases with at least one course of vaccine
therapy. The courses have been eight treatments, once a week, and
the dose has averaged from 0.1 c.c. to 3.2 c.c. when given subcu-
taneously, and from 0.025 c.c. to 0.75 c.c. when given intravenously.
The vaccine used was the triple typhoid vaccine from the Massachu-
setts State Board of Health, 1 c.c. being equal to 2,500,000,000
bacteria. The average age of our patients was twenty-five years,
and the average age of onset 20.6 years. All cases suffered from
spastic paraplegia and all but one had lost their abdominal reflexes.
Tremor was present in all. One had speech defect, one spincter
weakness, one visual defect, and three had nystagmus. Three had
progressed steadily, and three showed irregular progress of the
disease. Chills and fever accompanied nearly all the injections,
especially those given intravenously. The fever rose in four to six
hours to 101 or 102, subsiding rapidly. No patient had any definite
ill effects from the treatment. Four were thought to have improved;
one to have markedly improved; two others had less numbness but
otherwise showed no change.
Discussion: Dr. H. C: Solomon: I have seen’ severalmoietie
cases in the out-patient department that have been given this course
of treatment. Of those, three have reported marked improvement
of the sensory symptoms. In my experience most cases of multiple
sclerosis have sensory symptoms, and that is the first thing the patient
complains of. In these three cases the patients have said they have
had complete remission of the sensory phenomena. One patient said
he~had been cured three times previously by his family physician by
some drug which worked within twenty-four hours and completely
cured his sensory symptoms. The other two patients seemed to be
enthusiastic about what had occurred. This treatment has been used
elsewhere for a considerable length of time. In New York many
types of nervous diseases have been treated with typhoid vaccine. As
to the frequency of treatments with typhoid vaccine, it can be given
every other day. We have given typhoid vaccine to patients who
have had malaria treatment every day for several days to produce a
chill. The chill lasts a short time and leaves no ill effects, and that
is the end of the whole situation as far as typhoid is concerned.
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 403
THE NEUROPSYCHIATRIC PROBLEM OF THE U. S.
VETERANS BUREAU
In considering the neuropsychiatric problem of the Veterans’
Bureau, let us cite some historical and statistical facts.
From the experience of the allies, we knew that a large proportion
of our casualties would be from neuropsychiatric disease. Therefore,
upon our entering the war, the army of the United States developed
a Neuropsychiatric Corps which sought to eliminate, before entrance
into military service, such men as were unfit from a psychiatric point
of view, and to adequately care for cases developing during service.
As anticipated, psychiatric cases developed rapidly, and the Federal
Government was forced to throw this tremendous burden upon the
U. S. Public Health Service, which was better prepared than any
other department to attempt to cope with the situation. However,
its facilities were wholly inadequate, and dependent as it was upon
legislation by Congress to provide suitable hospitals and expert care,
it could not meet the emergency as it should be met. The utilization
of all available government hospitals and the leasing of civil or pri-
vate institutions had to be resorted to pending the erection of special
hospitals. The personnel problem was met by putting into the
Public Health Service a large number of reserve officers, principally
from the emergency medical officers of the U. S. Army.
With the continual increase of ex-service men requiring medical
care, it was decided in 1921 to amalgamate with this work the Bureau
of War Risk Insurance and the Vocational Rehabilitation Service.
Accordingly, a separate bureau called the U. S..Veterans’ Bureau
was formed, with a director appointed by the President of the United
States and directly responsible to him.
The following figures give some idea of the magnitude of- Vet-
erans’ Bureau activities:
1o75=— otal eaispursements ol .e.5..5 5. over $393,000,000
1976——Total. disbursements ......50... over 400,000,000
Of above figures, $40,000,000 was for maintenance of hospitals.
Hg Gtr Dellea ted CASES lk), ce bee 64 eee wes 211,644
1925—Monthly disbursements of above........ $8,000,000
1925-—Personnel in Veterans’ Bureaw...+....:. 27,622
Compensated cases:
Neuropsychiatric disabilities ...... 21% (44,800 plus)
Wuberculosig .cisabilities 04% ies 21% (45,000 plus)
In 1925, 44 per cent of all hospitalized cases were neuropsychiatric
in type, there being 12,139 at the end of the year in this group.
RO oer PUG ETE RCLAY Sho fies beet Oak shies ord eatin 5,787,170
PAGeCEACer Der CapitacCOSts.. 3.6 tu de socio $4.04
Examinations of ex-service men........ 1,144,330
Men listed in Vocational Rehabilitation. . 330,000
404 BOSTON SOCIETY OF PSYCHRLALRY iv ave OG ROp a
On June 30, 1925, insurance records were maintained for 552,340
veterans carrying $2 865, 028,729 of insurance.
Now, as to the character and the cause of these neuropsychiatric
disabilities :
At first, the preponderance was in the psychoneurotic group and
later in the psychotic group. Gradual elimination from hospitals of
the psychoneurotics by means of out-patient departments and the
agency of the Social Service has been largely accomplished. Con-
gressional acts which practically placed a premium on a man’s remain-
ing in the hospital have been changed or amended. When a man’s
compensation is continued while he is hospitalized, and ceases or is
cut down upon dehospitalization, it is difficult to effectually get him
onto his feet again. ‘The psychotic group in which the preponderance
now is comprised practically all variations of mental diseases but
to-day in the main consists of the deteriorating psychoses, the chizo-
phrenic group.
With regard to the origin of these cases, a certain small number
relatively speaking had a traumatic neurosis (so-called shell-shock
cases). The much larger proportion consisted of cases where the
strain of military life, either in combat or at the rear, was poorly
borne. My own personal belief is that the chief cause for these
nervous and mental breakdowns was the strain of adaptation. It is
probably true that many of our insane veterans would have become
so if they had never entered the army, but it probably would have
been under some stress or strain which they were mentally unable to
handle. I give mental stress as the chief cause, but this does not
preclude other causes of perhaps minor importance. I have not
touched upon the question of a physical basis for mental disease
because, in the absence of such evidence, one seeks the cause in the
psychic realm.
We come to the important point: What can be done for these
men, and what is the Veterans’ Bureau accomplishing ?
What can be done, under present limitations of medical knowl-
edge, may be summarized under the following headings:
Conduct control
Physical examination and treatment
Physiotherapy (broadly speaking )
Drugs (when indicated )
Occupational therapy
Mental treatment
Occupational therapy
Recreation
Psychoanalysis (broadly speaking )
What the bureau is accomplishing: By means of its hospitals
and out-patient departments, and by financial assistance, it is assisting
its psychoneurotics on their feet. Vocational training has been of
considerable help in the work, although the psychoneurotic patient is
not a particularly encouraging subject.
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 405
Its chief problem in the hospitals treating neuropsychiatric cases
is the care of its psychotics. Bureau hospitals of this type are sixteen
in number, twelve of which are of practically new construction. Six
have been finished and opened within the last two and one-half years.
These hospitals are caring for 7,744 patients at present, and have a
total medical personnel of 236, with a total personnel of 4,216.
The hospital at Northampton is a fair example of these newer
hospitals. The following statistics apply to it:
Physicians, including administrative officers........ 9
CES RSET NCOTAGESE |, (200 8 apa LNA a a 6
RCC ia LemI (ise caren Ent Te cl ah Ugo hlacta eee 25
ec anicamoeraonticu el ob. le X-ray, etc.).< «ios 3 14
(CORN EIEN GEYCTR SO) EIT Eo JE Geli Jal RS err 186
241
HPAIETIUEDODUIAUION. cir sian pace sss 433
Gradiiatemnurses i... le bis wy eae 20
Py titest tl AR TeITOATI ES fo lele seis 's oa o4 eve 76
The hospital reservation comprises 282 acres, and is situated on
a hill at an elevation of 425 feet, and 100 feet above the highway.
The buildings are twenty-three in number, with two more to be added
during the present year. Nearly all are of brick and concrete and
are fireproof. The main group of buildings is at the top of the hill
enclosed by a wire fence, and briefly consist of the administration
building, with the administration offices in the center of the building,
and admitting wards, infirmary ward, continued treatment ward, and
physiotherapy department in its wings. In the clinical corridor of
this building is a laboratory, large general operating room, sterilizing
room, and etherization and recovery rooms. There is also a large
dental clinic, ear, nose and throat room, and X-ray department. All
departments are splendidly equipped with every modern means of
caring for the bureau beneficiaries. In the basement of the adminis-
tration building is an issue room, various store rooms, and occupa-
tional therapy rooms. mv
To the rear of the administration or main building are grouped
six other ward buildings, the kitchen and mess halls, as well as the
attendants’ quarters and the new recreation building. These build-
ings are arranged about an oval, in the center of which is a fine ball
field. The recreation building contains an auditorium seating 500,
large stage, four dressing rooms, social room, smoking room, library
and pool room. In its basement are bowling alleys, gymnasium, and
swimming pool with shower baths.
Comparatively few ward windows are grilled.
All buildings are heated from a central heating plant, and steam
is supplied to the larger kitchens. All other cooking is done by elec-
tricity. All the buildings in the main group are connected by covered
walks. Water supply is from the Northampton city main, and sew-
age disposal is into the city system. The total cost of the plant is at
present about $3,000,000.
The hospital is licensed by the State Commission of Mental Dis-
406° BOSTON SOCIETY OF PSViCRI AT RIGA NEUROLOGY
eases by authority of an act of the Great and General Court passed
in 1924, so that we must comply with both the regulations of the
Veterans’ Bureau and the requirements of the state laws concerning
the insane.
Because of certain technicalities we can receive only patients who
are insane and who are receiving compensation. Most of our patients
are transfers from various state hospitals in New England, which
means that 75 per cent of our load is of deteriorated cases—cases
which had been in state hospitals as a rule for years, and in which
recovery can hardly be expected. Of the remaining 25 per cent fully
half are suffering from mental disease in which deterioration is to be
looked for. No patient is charged for his hospital care, but each
must supply his own clothing if he is financially able. Almost all are
able because, in addition to their care they receive $20 a month for
clothing and luxuries. This is called an institutional award and
represents $20 of the $80 or more which each totally disabled man
would receive. If the patient had dependents, the balance of $60 is
paid to his guardian. If the patient recovers, the balance is payable
to him.
As to treatment and results. So far as numbers are concerned,
the chief medical problem is the care and treatment of chronic cases;
but there is also the treatment of cases which might be considered as
recoverable. In the treatment of this latter group, particular stress
has been laid on hydrotherapy, occupation, detailed personal attention,
and medication where indicated.
In the treatment of the first and large group, we have been com-
pelled to depend upon physical and mental hygiene which includes a
reasonable institutional system of living, occupational therapy, physio-
therapy, and recreation. Fortunately, treatment directed to the
physical and mental condition runs fairly parallel, as every physical
handicap must be overcome if the maximum mental benefit is to be
received. On the physical side, there’ must be painstaking investiga-
tion, with suitable, energetic, and adequate treatment if physical dis-
ease is discovered. The most conscientious work on the part of the
clinical service is necessary here, and the equipment of the hospital is
practically complete for the application of every recognized means of
treating physical illness.
On the mental side the treatment falls into four divisions:
Occupational therapy :
Recreation (not to interfere with occupation )
Entertainments
_ Drives
Bowling
Swimming
Music
Baseball
Dancing
Psychoanalysis
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 407
Psychotherapy is very limited because the ward surgeon, burdened
as he is with administrative details, etc., cannot give the time desirable.
Certain results have been secured which statistical tables cannot
reflect. Obviously, the number of “recoveries”? we can record is
very limited, but the large majority of our patients show marked
improvement in such particulars as better living habits, interest in
their personal appearance, improved table manners, willingness to
assist on the wards, better conduct at entertainments and church
service, keener appreciation of enjoyable affairs, and less discontent,
and more enjoyment of life with happier adaptation to their surround-
ings as a whole. Of the total number of 600 patients thus far
received, 84 have made a sufficient improvement to remain at home,
presumably making a reasonably satisfactory social adjustment, and
in several instances an economic one. The remaining patients are
improved as outlined above, and many are approaching a point where
‘they can go out on visit.
Patient activities about the hospital, under the direction of the
occupational therapy department, not only serve to further their
physical and mental improvement, but are the means of substantial
saving to the government. The condition of the grounds is rapidly
improving, made possible mainly through patient labor under the
direction of our landscape architect employed part time. A nursery
has been established; lawns built or completed; a sunken garden at
the main gate has been constructed with plants and cement pool and
fountain. All these activities are carried on directly or indirectly as
occupational therapy projects, and though progress with patient labor
is not so rapid, it nevertheless serves a two-fold purpose, as stated
above. Other activities in which patients have been engaged success-
fully are as follows:
Construction of tennis courts
Construction of garages
Construction of poultry houses
Construction of piggery
Construction of ornamental fountains
Brush making
Shoe repairing
Cleaning and pressing clothes
Repairing furniture
Carpentry about hospital
Craft work
Certain features of our service might be mentioned. ;
The present status of our medical officers is as Civil Service
employees. The administration of the hospital is directly under the
medical division of the central office of the U. S. Veterans’ Bureau.
Admissions of patients, except in emergency, are made under author-
ity of the various regional offices of the bureau. New patients are
held under temporary commitment papers until they are examined
and committed in the local district court. Examinations for this
purpose are conducted by expert psychiatrists having no direct con-
nection with the bureau. Codrdination of the various bureau activ-
408 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY
ities in the New England section, as well as inspections and investi-
gations, are under the control of a chief coordinator whose office is
in New York. ‘The financing of the hospital is under a very rigid
budget system.
During the past two years great advance has been made in the
organization of the Medical Department of the bureau. An advisory
board, the so-called medical council, has been appointed, consisting
of physicians of the highest standing in the United States. Research
work has been undertaken and an organization built up to carry it on.
The bureau has its own magazine, the Medical Bulletin, which is
contributed to by the medical officers of the service. Every medical
officer is required to contribute a paper at least yearly, and from this
number are selected those articles of greatest value or of most timely
interest.
In conclusion, the neuropsychiatric problem of the Veterans’
Bureau is precisely the same problem which every state has to meet
and has been meeting for generations. In meeting this problem the
Veterans’ Bureau has a great advantage, in that it is not as limited in
expenditure of funds as has usually been the case with the state. I
believe its real problem now is to so develop its medical personnel as
to secure a maximum professional and scientific interest in its work.
Congress has been and is doing its share. It remains for the repre-
sentatives of the medical profession in the bureau to spare no labor
or pains: First, in giving the highest type of medical and nursing
care for its mentally ill patients; and second, to advance the scientific
knowledge of psychiatry to its utmost.
Discussion: Dr. E. Q. Crossman: When I attempt to visualize
the problems of the Veterans’ Bureau, particularly with reference to
neuropsychiatric disabilities, I realize that in Congress there are
fifty-seven different committees, and the Veterans’ Bureau, in the
psychiatric department, has fifty-seven different problems. Dr.
Pierce has presented the summary of the origin, progress, and func-
tions of the Veterans’ Bureau in an admirable manner. Perhaps I
ought to elaborate on the work a bit. It is divided into three depart-
ments—neuropsychiatric, general medicine and surgical, and tuber-
cular or respiratory diseases. There are fifty-two different hospitals
in the country run by the Veterans’ Bureau; there are more than
100 clinics, and between 27,000 and 30,000 cases in the hospitals all
the time. ‘The aim in Washington has been to develop in every way
possible scientific medicine and many things have been done that I
know have tended and are tending to make the Veterans’ Bureau
hospitals as good hospitals as there are in the country. The American
College of Surgeons surveyed all of the hospitals about two years ago
and all but four were accepted. I think all but one are now accepted
by the American College of Surgeons. Dr. Pierce has spoken of
various forms of treatment: the department of research, medical
department, medical bulletins, etc. Our thought was that every man
should be urged to write a scientific paper every year that would
result in great good. It certainly has. The Veterans’ Bureau has
something like 1,500 full-time medical officers, between 1,600 and
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY ~° 409
1,700 nurses, and a personnel in all of about 25,000. So you can see
that it is no small affair. It is a gigantic proposition and chiefly a
medical proposition. ‘There is not a problem anywhere in the Vet-
erans’ Bureau that does not have a medical slant, and our aim has
been to administer with as much sense as we could develop in the
care of the men entrusted to us.
Before I left Washington, a committee of three, consisting of
Di ely oichtist, colonelanithe W'S. Army; Dr. Philip’ B? Metz,
mietnee Department of hesearch in’the U.S. Veterans’ Bureau at
Washington, and Dr. A. K. Krause, of the Johns Hopkins University
at Baltimore, Md., was appointed to study and investigate the residual
effects of war gases upon the human body. This investigation will
prove, I believe, to be one of the most valuable contributions to
medicine that has been developed by the Veterans’ Bureau, and is
being done thoroughly. We have heard so much about men being
gassed with a great lack of scientific knowledge to date, but the time
and material now available seems suitable for definite and dependable
report to the profession.
There were cases of men without number floating around with
half a dozen different diagnoses. There must be a definite diagnosis
because it has to do largely with the very vital question of compensa-
tion. The director authorized a diagnostic clinic in Washington,
accommodating about 250 patients, and that hospital is manned by
part of the staff of Johns Hopkins University and the remainder from
Washington, and men are sent there from every area in the Fast.
That has been of vast importance because when a man goes there he
has every facility known to science for study and diagnosis, and when
a conclusion is reached, it is final, so far as the diagnosis is concerned.
We also started a small diagnostic clinic in Cincinnati with twenty-
eight beds in conjunction with the Cincinnati General Hospital, and
that is running along the same lines. Before I left we had practically
decided to recommend another diagnostic clinic at Palo Alto, Cali-
fornia, in connection with the hospital there. Those are some of the
things that are being done along the line of settling these various cases.
You might ask how many of all these men that were in the service
have really applied to the Veterans’ Bureau. I have not the figures
available on that proposition, but there were treated not very long
ago in one month at the out-pateint clinics something like 105,000
different people; that is in addition to the work that is being done in
the hospitals. So far as this country is concerned, the Veterans’ -
Bureau is certainly our biggest medical organization.
Dr. Pierce has spoken about the expense. You, of course, all
know that there are three hospitals in Massachusetts: one at North-
ampton, the West Roxbury Hospital, and the hospital for tuberculosis
at Rutland, the latter accommodating 400. The last time I checked
up there were 266 patients at Rutland, 277 at West Roxbury, and
433 at Northampton. All the Veterans’ Bureau hospitals in New
England are in Massachusetts. There were about 200,000 men
inducted into the service from Massachusetts and, you will recall, at
first the only hospital here was the one at West Roxbury. Northamp-
410 BOSTON SOCIETY OF PSYCHIATRY AND NEVUROLCG.
ton was built, and Rutland was remodelled, so that makes the three
hospitals in New England.
The district office in Boston had supervision over all New England
except Connecticut. Decentralization. took place, and now each state
has a regional office and clinic. New York has two: one in Buffalo
and one in New York City. Pennsylvania has one in Philadelphia
and one in Pittsburgh; but for the most part the men are cared for
by their own people in their own states.
Dr. Pierce has stated that the Veterans’ Bureau offers the greatest
medical opportunity for research and investigation and scientific work
that has ever been offered to the medical profession, and certainly if
there is a better understanding of the work that is being attempted
by the government throughout the country, I am sure it will be of
great benefit to the profession and to the men who are unfortunate
enough to be turned over to our care.
Dr. George Clymer: Dr. Pierce and Dr. Crossman have given
you a very good outline of the work of the Veterans’ Bureau, and I
simply want to say one word in testimonial of the tremendous im-
provement in the work that is being done in the Veterans’ Bureau
hospitals. I have been fortunate in having had an opportunity to
see the development of this work, as I started, in 1919, as a visiting
consultant at the East Norfolk Hospital, to which ex-service men
who had epilepsy and various sorts of convulsive and hysterical
attacks were sent. Soon after the hospital at West Roxbury was
opened I added that to my route, and since the Northampton hospital
opened I have been going there also.
In the early days the work that was done in the first two hospitals
was pretty rudimentary. The records were poor; patients were
diagnosed, and not a great deal was done to try to help them. There
were a great many psychoneurotics at that time, but very little attempt
was made at constructive therapy. Now I think that anyone who
cares to go either to West Roxbury or Northampton will find extraor-
dinarily good records of the patients and excellent conditions.
There are still a great many problems in regard to the diagnosis
and the treatment of these cases. There is one group that is still
giving much trouble that has not been mentioned. This is the group
of constitutional inferiors—the men who do not fall into the group
of psychotics, or psychoneurotics. They do not make a good adjust-
ment in the community, either socially or occupationally. They are
sent to the hospitals because of various symptoms and maladjustment
in their communities. After a while they are discharged because the
hospitals do not feel they can do anything more for them. They do
not fall into any of the groups that ordinarily can be taken care of,
and in the course of time they come back again. It seems to me that
this is one of the problems which the Veterans’ Bureau still has
ahead of it.
In this community there is another problem which may not be as
great as it seems to me, but about which I feel rather strongly, and
that is the problem which was emphasized only a short time ago in
the case of a man who had been a patient at the West Roxbury hos-
a
—
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY All
pital where he was diagnosed as a paranoid precox. The West Rox-
bury hospital is not licensed to accept committed patients. He could
not be committed there, and in the course of time his guardian and his
family insisted that he be taken from the hospital. He was discharged
from the hospital against the advice of the officials, who were power:
less to hold him legally, and recently he ran amuck, seriously wound-
ing one person and killing himself. It seems to me that this is a
definite problem which is not being satisfactorily met by the Veterans’
Bureau in this community.
Dr. H. C. solomon: While our Veterans’ Bureau hospitals are
good, and they have improved tremendously in the last several years,
the fact still remains that they are compared, I think, with the state
hospitals, and that is a wrong comparison. ‘The state hospitals are
doing the best work that it is possible to do with so little money.
Government hospitals are run on a more liberal allowance, but they
do not get enough money to take care of the patients as well as they
might be taken care of. Every time you talk about adding a man to
the medical staff it is looked upon as though that meant fifty men
because there are fifty hospitals. If you ask for $1,000 for a medical
library, the government thinks of $50,000. The state hospital is
based on a little better than $10 per capita as the ideal; in the gov-
ernment hospitals the-ideal is about $20, but that is not sufficient to
get good personnel. You cannot do a great deal of personal work
with patients when you have eighty or more patients under your
charge, when three hours a day are devoted to conferences and five
hours a day to paper work.
Dr. Donald Gregg: Why was it that the peak of the load was
understood to be ten years after the war? Am I correct in thinking
that the peak of the load would fall at that time? |
Dr. Pierce: I cannot tell you exactly about that. According to
the acts of Congress any man who developed a neuro psychiatric dis-
ease previous to January 1, 1925, was considered to be a service
connected case. The policy of the government from the start was
to take care of men who were suffering as a result of war service. I
cannot tell you exactly how it was computed, but it was fairly obvious
that there would be a great many cases.
Dr. Gregg: Is the load decreasing now?
Dr. Pierce: It is still increasing. I do not know when it will
stop increasing. For instance, we have among our 433 patients only
15 or 16 paretics and 4 or 5 cases of neurosyphilis. Dr. Solomon
speaks of ideals. I think we have certain definite ideals, and as
emphasizing what he said it strikes me that the amount of money
which can be spent in ordinary medical and surgical work in hospitals
is almost limited. Why should we discriminate against those men-
tally ill? Perhaps because in the first two instances you see definite,
concrete results, but in our type of cases they are more difficult to see.
CRITICAL REVIEW
ProF. SIGMUND FREUD
“DIE FRAGE “DER LAIENANATAY Si.
By A. A. Britt, M.D.
OF NEW YORK
In the introduction to this book, “ The Question of Lay-analysis,”
the question is raised whether a layman, that is, one not a physician,
should be allowed to practice psychoanalysis. The author thinks
that this question is of both timely and local significance. It is timely,
for hitherto, ‘“ The consensus of the wish was that no one should
practice it.” The demand that only physicians should analyze is
seemingly a friendlier attitude to analysis which the author views
somewhat suspiciously. It 1s of local significance because, in some
countries, all healing by laymen is forbidden by law, while in others,
like Germany and America, every patient can be treated in any
manner and by whomsoever he chooses, and anyone may “as a
quack ”’ treat any patient, provided he assumes responsibility for his
act.t But, in the author’s native land, Austria, as well as in France,
the law is preventative, insofar as it forbids anyone but physicians
taking any sick people for treatment, and as neurotics are sick people
and the lay-analyst is not a physician, the law seems very clear and
specific. Nevertheless, the author finds some complications with which
the law does not reckon, and which need some elucidation. Thus
he questions whether neurotics are to be looked upon exactly like
ordinary sick people, whether the lay-analyst is nothing but a layman
and whether the physician in the case actually offers what one usually
expects from ordinary physicians. If the doubts raised here are
valid, the law should not be applied without some modifications.
But, as any changes in the law will depend on persons who need not
necessarily be familiar with the special features of psychoanalysis,
the author proceeds to present his arguments before them or rather
before a suppositious, intelligent layman. This person (a creation of
his imagination), is not just a mere listener, but an alert judge, who,
* Internationaler Psychoanalytischer Verlag, Leipzig and Wien, 1926.
1 The author is misinformed about America by which he undoubtedly means
the United States.
[412]
“DIEPPE RAGE DER LAIENANALYSE” 413
throughout the book follows critically whatever the author presents,
and does not hesitate to pick flaws and hurl argumentative questions.
The mode of presentation is very interesting and ingenious and
follows the Socratic method. The author begins by describing a
number of neurotics suffering from the various disturbances well
known as neurasthenias, hysterias, compulsions, and phobias, and
proceeds to tell how the average physician manages such cases with
temporary or no success at all, and finally brings the patient to the
analyst.
The “impartial” one was somewhat impatient while he listened to
the description of these patients, but soon became attentive and re-
marked, “ Now we shall see what the analyst will do with these
patients whom the doctor could not help.” And then follows an
exposition of psychoanalysis which is not only of interest to an im-
partial layman, but extremely instructive even to the experienced
analyst. Indeed, the reviewer doubts whether any layman but this
particular one could have followed the author, who leads him through
all the intricate steps of the development of his discoveries.
As the subject is unfolded, the impartial one becomes more and
more interested and fascinated by the author’s masterly elucidations,
but by no means remains a passive listener. He thrusts at the author
all the arguments that were hurled at psychoanalysis from the be-
ginning of its existence, but the latter knows well how to dispose of
them. ‘Thus, in talking over the cathartic method, the impartial one
remarks that in all probability, the effort made by the psychoanalyst
brings about a hypnotic attachment, or a suggestive binding of the
patient to himself, which explains the miraculous results of psycho-
analytic therapy as the effects of hypnotic suggestion, except that
hypnotism works much faster. The author’s answer to this is very
significant: ‘‘ What you said about the special personal influence of
the analyst is surely very noteworthy. Such influence exists and
plays a great role in the analysis. But not the same as in hypnotism.
We should surely succeed in demonstrating to you that the situations
here and there are quite different. It may be sufficient to remark
that this personal influence—this “ suggestive ” factor—is not utilized
to suppress the painful symptoms as is the case in hypnotic sugges-
tion. Moreover, it would be a mistake to believe that this factor is
altogether the carrier and promoter of the treatment. In the be-
ginning yes, but later it rebels against our analytic intentions and
forces us to the most prolific counter measures. I would also like to
show you by an example how little the analytic therapy has to do with
414 A; AP BRIE
“ diversion and talking it out.” If one of our patients suffers from
a feeling of guilt, as if he had committed a serious crime, we do not
advise him to dismiss it on the ground of his definite feeling of
innocence; this he already attempted himself unsuccessfully. But we
remind him that such a strong and persistent feeling must surely be
based on something which may perhaps be discovered.” (Page 17.)
To which the impartial one retorts, “ [ wonder whether you could
calm the patient’s feeling of guilt in this way. But what are your
analytic aims and what do you do with the patient?” (Page 18.)
The author then runs through the whole history of psychoanalysis.
He starts by telling his listener that psychoanalysis did not originate
as a philosophic system; that it has developed slowly; that every
fragment of it has been subjected to heated disputes; that it was
continuously modified as it was brought in constant contact with
observation, and that only a few years before different expressions
were used to discuss this theory. Nor could one guarantee that the
present day expréssions will remain as definitive. The science is
still very young and there will undoubtedly be many changes and
modifications. To the question why the author talks of a new psy-
chology, when psychology and psychologists have existed for a
long time, the author states that he does not dispute this but that
deeper investigation will show that these great accomplishments must
be ranked with the physiology of the senses, that the old psychology
did not occupy itself much with the theories of the psychic life.
The impartial one then asks why the author wishes to explain the
foundation of the psychic life, overlooked by all psychologists,
through observation of sick people. To which the author replies
that embryology would deserve no confidence if it did not readily
explain the congenital malformations, and then cites the case of an
obsessive patient who constantly reasons about problems which
seem foolish or indifferent, and asks whether the school psychology
could ever offer the slightest explanation of such case. Moreover,
our nocturnal thoughts, our dreams, follow their own paths and pro-
duce phenomena which we do not understand, which look strange
to us and resemble morbid products. The academic psychology does
not give us any interpretation of dreams. When an interpretation is
attempted at all it is put on the basis of sensory stimuli, or explained
by the unequal depths of sleep of different parts of the brain. Buta
psychology that cannot explain the meaning of dreams cannot be of
any use in the understanding of normal psychic life, and cannot claim
the name of science. |
4
3
Ae
’
wHifer RAGE DER LAIENANALYSE? 415
A schematic description of the psychic apparatus following the
author’s recent formulation of the Ego, Super-ego, and the It, is
given in the clearest possible manner, and then follows a very in-
teresting discussion on the dynamics of the Ego and the It as mani-
fested in the pleasure principle, and the principle of reality, the
development of the psychosexual life as seen in the child, the castra-
tion anxiety, the penis envy as seen in the boy and the girl,—all of
which is related to the history of civilization, mythology, etc.
The listener starts the fifth chapter, by saying, “I believe that
I can follow your aim. You wish to show me what knowledge is
necessary for the practice of analysis in order that I should be able
to judge whether only a physician should be justified in doing it.
But so far, very little medical was brought forward. There was
much psychology, and a fragment of biology, or sexual science, but
perhaps we have not come to the end?” (Page 65.)
To which the author assents by saying, “ Certainly not. Many
gaps must still be filled.’ And then asks his listener how he would
imagine an analytic treatment. The latter, after putting the re-
sponsibility of his forthcoming statements. on the author, gives the
following: “I will assume that a patient comes to me and com-
plains of some symptoms. I promise him a cure if he will follow my
suggestions. | ask him to tell me everything with absolute frank-
ness. Whatever he knows or what comes. to his mind, and that he
should not deviate from this rule, even if some of it is disagreeable
to tell.” (Page 65.)
To which the author adds, “ Even if he thinks that that which
occurs to his mind is unimportant and senseless.”’
The layman continues with his description of the whole treatment,
and when he finishes, the author cries, ‘Bravo! Bravo! I see I
am again exposing myself to the reproach that I have educated a
person who is not a physician to do analysis.” (Page 66.) And
then proceeds to give the finer points of the analytic technique, in-
terpretation of dreams and its complicated mechanisms, and showed
how much practice and learning is necessary to fit oneself for the
work. It would be impossible to give in a short review a detailed
description of this very fascinating work.
An excellent discussion on transference is presented at the end
of the chapter, in which the author shows the manner, as well as the
difficulties of these mechanisms, and ends by saying, “ On the part
of the analyst it demands much skill, patience, calm and self-denial.”
The listener begins the sixth chapter by stating that listening to
416 AMA BIC
the description of psychoanalysis and all the knowledge that one
needs to use it successfully, does not demonstrate to him how it can
influence his judgment about treatment by laymen. For, states he,
(page 85), “ The neuroses are a special form of malady ; analysis is
a special form of treatment; it is a medical specialty. or, it is the
accepted rule, that when a physician wishes to specialize in a particu-
lar field of medicine, he must have a good education in that particular
specialty. He, who wants to become a surgeon, serves a number of
years in a surgical clinic, as does the eye specialist, the throat
specialist, etc. . . . In the same way, I would imagine the psy-
choanalyst would proceed. He would get the necessary education
etc., but I cannot see where the lay-analyst comes in.”
To which the author replies, “the physician who does what you
promised for him will be welcome to us. Four-fifths of those who
claim to be my pupils are physicians.” (Page 86.) And then goes
on to blame the physicians for not having taken the proper attitude
toward analysis in the past. On the contrary, they scoffed at it and
tried to hurt it. (The author forgets that proportionately the same
attitude was and is still taken by laymen, and psychologists, and that,
as he states, his first pupils were preponderatingly, if not altogether
physicians. )
A discussion about treatment in general with special reference to
the treatment of neurosis then follows, in which the author claims
that not only do the medical schools not give the proper interpreta-
tion of the neuroses, but that they take a false and harmful attitude
toward the subject. ‘“ The physicians, whose interest for the psychic
factors of life have not been awakened, are only too ready to under-
estimate and to mock them as unscientific.” (Page 90.)
The reviewer may be permitted to say that this state of affairs is
no longer as widespread as the author thinks. Most of the teachers
of psychiatry no longer take this attitude, and this is particularly
true in the United States where psychoanalysis has obtained a good
hearing and is constantly gaining more ground in medical and
academic circles.
The unprejudiced layman then becomes more or less impatient
and tells the author that he seems to avoid a direct statement con-
cerning the question of lay analysts, and adds, “ It seems to me that
you propose that inasmuch as physicians who wish to do analysis
cannot be controlled, one should punish them, in a way out, of re-
venge, by taking away from them the monopoly of analysis and open
this medical activity to lay people.”
“DIE FRAGE DER LAIENANALYSE” 417
To which the author replies that he is not sure that his listener
correctly understood his motives. That he puts the accent on the
demands, that no one should practice analysis who is not en-
titled to it through a specific education. And to the question what
his definite proposals are, there follows a long discussion on dif-
ferential diagnosis, which the author admits is not always easy and
cannot always be made, and states, “ The responsibility for such a
decision can naturally be undertaken by the physician only.” In a
later passage the author again states, “I demand that in every case
that comes for analysis the diagnosis should be first made by a
physician.” (Page-110.)
On page 111 we read the following significant passage: ‘‘ There
is still another case in which the analyst must call in the doctor to
assist him. In the course of analytic treatment symptoms preponder-
atingly physical may appear, in which one is doubtful whether they
should be considered in connection with the neurosis, or independent
of it as a disturbance of a new organic disease. This decision must
again be left to the physician.” To which the listener remarks: “In
other words, the lay-analyst cannot dispense with the physician even
during the analysis. A new argument against his usefulness.” (Page
111.) This is truly an impartial way of presenting the subject.
Indeed, one feels as if the author is a bit overzealous in presenting the
arguments against.
The following remarks of the impartial listener are of particular
significance: “‘ Your attitude towards lay analysts now becomes
clear to me. You insist upon the fact that there should be lay-
analysts, but, as you cannot get around the fact of their inadequacy
for their task, you bring every argument to excuse and to facilitate
their existence. But for the life of me, I cannot see why there
should be lay-analysts, who, at best can only be second class thera-
pists For my part, I would be willing to disregard the few lay
people who are already educated into analysts, but new ones should
not be made, and the institutes should be pledged not to accept lay
people for instruction.” (Page 112.)
The reviewer may be permitted to deduce from these remarks that
we have just heard the expression of Freud’s own struggles with this
moot question,—the impartial one expresses the author’s own conflicts
with the problem.
The author would agree, he states, with his critcial listener if it
could be shown that this restriction would serve the interests of all
1 Emphasized by the reviewer.
418 AAW BRILE
parties concerned, and proceeds to demonstrate that it would not.
He states that these interests are of three kinds, the patient’s, the
physician’s, and last, but not least, of science, and then goes on to
examine every one of them. To the patient it is a matter of in-
difference whether the analyst is a physician or not, provided he has
the necessary qualifications (?). The lay-analysts of to-day are noi
composed of the riff raff, on the contrary, they are persons of
academic education. It would not be to the interest of the physician
to incorporate psychoanalysis into medicine, as the study of medicine
is a long procedure as it is, that the medical. student is more and more
burdened with new subjects, and that modern conditions are such
that the material existence of the type of persons who study medicine
should be satisfied at the earliest possible period. The studies re-
quired for the average physician do not necessarily prepare him for
the treatment of the mind and he could well omit a number of
subjects if he wishes to specialize in psychoanalysis, for which he
needs in addition to the deeper psychology, a good education in
biology, especially in the sexual life, a good acquaintance with the
morbid pictures of psychiatry. Moreover, the study of analysis
includes subjects which are quite remote from the general physician,
such as mythology, psychology of religion, and a knowledge of litera-
ture. He could dispense with anatomy and with the knowledge of
the course of the cerebral nerve fibers as well as with all germ dis-
eases, etc., which are not of any direct help in the understanding of
the neuroses.
When the author comes to the scientific interest he does not think
it desirable for psychoanalysis to be swallowed up by medicine, and
find its place in psychiatry in the chapter on therapy next to hypnotic
suggestion, autosuggestion and persuasion. Psychoanalysis deserves
a better fate; it has already done much for the sciences dealing with
civilization and its institutions, such as art, religion and sociology.
The use of analysis as a therapy of the neuroses is only one of its
applications, and the future will perhaps show that it is not the most
important one.
The author’s arguments would be as plausible when applied to
other science such as engineering or law. There may have been good
jurists and good engineers who have not passed through all the pre-
liminaries prescribed for these sciences, nevertheless it is hardly
probable that the average student could become a good engineer, a
lawyer or doctor without knowing something about all the phases of
this particular science. The reviewer has never seen a medical
student who loved all the subjects which were obligatory for the at-
“DIE FRAGE DER LAIENANALYSE” 419
tainment of his medical diploma. The beginner in any field of science
usually dislikes the preliminaries, the medical student may chafe
under the studies of anatomy, physiology, bacteriology or chemistry,
but his strong desire to realize his cherished wish to become a medico
impels him to accept these subjects as a part of his course.
Indeed, it is these very fundamentals of medicine which force
the student to face the reality of his undertaking. For all those who
wish to become medical or lay healers are imbued with an infantile
omnipotence of thought which must be toned down considerably.
Many cannot stand the stress of reality, and drop out, the others
soon realize that medicine is a difficult study, and by the time they
reach the “ interesting ” part of it they have acquired not only knowl-
edge but an effective discipline and a deep sense of responsibility
absolutely necessary in the study and treatment of diseases—attri-
butes which few, if any, so-called “ lay-analysts”’ possess. I have
no doubt that abroad there are some lay-analysts, women and men
of excellent character and great learning, but as far as my knowledge
goes most of those who returned here from abroad as lay-analysts,
after having spent there some time and considerable money, are either
unfit to judge disease or have degenerated into quacks. I cannot
see how any lay-analyst could submit to the author’s requirements of
deferring to the physician whenever in doubt and maintain himself
psychologically. At best they would be considered “second raters ”’
in the words of the impartial listener, which is surely not conducive
to proper psychoanalytic esprit.
Long, long ago I learned to accept what Freud offered even
before I became convinced of it from my own knowledge, for ex-
perience has taught me that whenever I thought a statement was
far fetched or incorrect I soon found that I was wrong. It was a
lack of experience on my part that caused the doubt. However, for
many years I have tried very hard to agree with the author on the
question of lay-analysts but I could not accept his views. The more I
observe it in operation the less I become convinced of its usefulness
and practical application. His brilliant expositions of the problem
have no more convinced me than seemingly his ‘‘ impartial listener ”’
to whom he offers as a last argument the fact that “our civilization
exerts an almost unbearable pressure upon us and needs a corrective,”
and asks whether it is phantastic to expect that psychoanalysis was
destined to offer this corrective. He looks for an American who may
perhaps get it in his mind to spend a sum of money to educate the
social workers of his country psychoanalytically, and make out of
them a salvation troupe to combat the cultural neuroses,—remarks
420 A, A. BRILL
which elicits from the listener the exclamation: ‘Aha! a new sort
of salvation army.” To which the author rejoins, “ Why not, for
our phantasies always work in accordance with models.” (Page
123.) <A flood of students will then flock to Europe and pass by
Vienna, the author thinks, because Austria has a law against laymen
treating diseases. Evidently the listener takes this rather jocosely,
for the author says: “ You smile? I do not say this to influence
your judgment, not at all. For I know that you do not believe me,
nor can I guarantee that it will happen. But this I know, it can only
be of local significance, laws and prohibitions will not affect the
possibilities of the inner developments of psychoanalysis.” (Page
123")
In other words, with all the brilliant and ingenious arguments
added to a masterful exposition of his subject, the author feels that
he has not convinced his hearer.
I fully agree with the author that psychoanalysis will continue
to develop despite all rules and regulations to the contrary, but as
far as I can see there are no restrictions against psychoanalysis as
a science. This is certainly true of this country. Proof: the author’s
hope lies here, many of his former and present pupils seem to be
pleased to come to our shores. Nevertheless, I fell with many, many
others that psychoanalysis as a therapy should be restricted to those
who, like the author, were trained to know the whole man physically
and mentally, to physicians who had a good training in neurology,
psychiatry and psychoanalysis.
CURRENT LITERATURE
I. VEGETATIVE NEUROLOGY.
1. VEGETATIVE NERVOUS SYSTEM.
Dart, R. A. THe Misuse or THE TERM “VISCEREAL.” [J. Anat.,
LIV, 177. Med. Sc.]
The author summarizes the history of the use of the term “ visceral ”
and concludes that the term “visceral” (afferent or efferent) can have no
morphological significance in neurology apart from its limitation to the
vegetative innervation of the endodermal lining of the archenteric tube
and its derivatives. As such it may include presumably. “ afferent ”
elements, by means of which the viscera are brought into more or less
intimate connection with the central nervous system. But as soon as the
“visceral”? (endodermal) elements become entangled in description with
the “ectodermal” portion of the vegetative nervous system in supposed
contradistinction to the so-called “somatic” nervous system, confusion
is bound to result, and particularly in considering the “afferent” or
sensory side. Most productive. of harmful results is the extension of the
“visceral afferent” conception to the study of the special sense organs,
which arise in the ectoderm. It is evident, prima facie, that to call any
such ectodermal mechanism “ visceral ” is to indulge in a loose terminology
which neglects all embryological considerations. Even in the case of
taste, which appears to have endodermally arising receptors and ganglion
_ cells in all higher forms, it is definitely known that portion of the
mechanism is ectodermal—and not “ visceral’—in certain fishes. Not
even this reservation can be made in the case of smell, which is purely
somatic. It would be possible to make out as good a case for the
“visceral ’ character of the musculature and innervation of the diaphragm,
because it happens to be related to the function of respiration. Finally,
Dart contends that there is no justification in morphological considerations
either for the conception of a “visceral cortex,’ or for regarding the
‘
striatum as a “ sympathetic organ.”
Pottenger, F. M. Importance oF KNOWLEDGE OF REFLEXES IN DIAGNOSIS
oF Putmonary Tusercu.osis. [Med. Jl. and Rec., Feb. 20, Vol.
Cx | ALM A. |
Pottenger discusses the innervation of the lungs, the principles of
reflex action, some common reflexes in disease, sensory and trophic
phenomena of diagnostic value, sensory reflex from the lung, sensory
[421]
422 CURKEN TD Lit ERATURE
reflex from the pleura and trophic reflexes from the lung. He says, after
one has once grasped the neurology which underlies these changes and
attained skill at detecting them, he has at a glance very important
suggestions as to the presence or absence of past or present chronic
inflammation in the lung. The trophic reflexes combined with the motor
reflexes of the lung present accurate signs of the past and present history
of disease in the organ.
Riccitelli, E., and Franchini, Y. Nasat Neurosis. [Sem. Med., Oct. 4,
1923. ]
Spastic vasomotor rhinitis, hay fever, nasal hydrorrhea and other
forms of nasal, laryngeal and bronchial neuroses, according to these
authors, are a single syndrome. ‘The reflex sneezing, etc., is merely the
casual stimulus for the vagotonic or other reflex. The vagotonia, they
claim, is due to some infection or intoxication. In the overwhelming
majority of cases, latent tuberculosis or inherited syphilis is responsible.
In their fifty cases treated on this basis, usually with minute doses of
tuberculin or mercury or both, not only was the nasal neurosis cured in
80 per cent, but the general health improved notably. [Here again
psychogenic factors are blindly overlooked. ]
Harner, Clyde EH. THE ENDOCRINOLOGY OF THE Ear, NOSE, AND THROAT.
[Coll Med, *V olrax Xie Aue. |
Harner states that the moral and mental makeup of both individuals
and races is determined by the endocrines. The thymus plays a part in
our prenatal development and then the pituitary comes to the fore and the
period of growth and physical development is gone through. It is at this
time when the thyroid and sexual endocrines lie dormant that we find
most of the tonsil-adenoid disturbances. Also the acute inflammations
and catarrhal conditions of the ear, nose and throat, including pertussis,
laryngismus stridulus.
When the ovaries and testicles function we find laryngeal changes in
the boy, hypertrophic turbinates, especially at the menstrual period, in
therein!
In the hyperhypophyseal state the larynx may become acromegalic.
Migraine may be caused by an engorged hypophysis.
~The hyperactive thyroid gives rise to few local symptoms but the
hypothyroid state causes many symptoms in the respiratory tract. Condi-
tions are found such as asthma, hay fever, large tonsils and adenoids,
thickening and infiltration of the mucosa of the turbinates, larynx, bronchi
and bronchioles, and sometimes chronic catarrhal otitis media. These
hypothyroid individuals are unsatisfactory patients and as a rule poor
surgical risks, bleeding after well performed tonsillectomies, etc. In the
exudative diathesis type of child, nonbeneficial operating for removal of
tonsils and adenoids has the endocrine factor for a basis.
VEGETATIVE NEUROLOGY 423
Adrenalin may be used as treatment for atrophic rhinitis and oto-
sclerosis. Combination of thyroid and ovarian substance may be bene-
ficially used in treating annoying tinnitus in women at the menstrual
periods or at menopause. Thyroid extract and adrenalin in acute rhinitis
and the “grippy” infections makes the patient more comfortable and
hastens recovery. Thyroid extract also helps chronic eczema of the ear
in certain cases.
Where possible, fresh single gland substances should be used and
good results reported. Then endocrine factor should be borne in mind in
treating this type of cases. [Author’s abstract. ]
Emile-Weil, Levy-Frankel and Juster. NasoracrAL REFLEX IN LUNG
AND Nervous Diseases. - [ Bull. d. 1. Soc. Méd. d. Hop., Vol. XVII,
neal ee AN |
Emile-Weil, Lévy-Frankel and Juster say that excitation of the
mucous membrane of the nose causes changes in the cardiac rhythm and
congestion of the face. The superior meatus of the nose is stimulated
with cotton and this is followed normally by congestion of the homo-
lateral eyelid and conjunctiva, with secretion of tears and slight mydriasis.
In acute and subacute pulmonary affections, the reflex is intense on the
side affected. In unilateral chronic pulmonary disease, the congestive
reflex is variable but the pupillary mydriasis on the affected side is con-
stant. In neuralgia, the conjunctival and lacrimal reaction is exaggerated,
and in liver affections the congestive reflex is very rapid and intense.
In tabes with Argyll-Robertson pupils, the pupil reflex does not occur,
but it is present when these ocular signs are absent.
Pottenger, F. M. A Discussion oF THE ETIOLOGY OF ASTHMA IN ITS
RELATIONSHIP TO THE VARIOUS SYSTEMS COMPOSING THE PULMONARY
NEUROCELLULAR MECHANISM WITH THE PuHySIOLoGic BASIS FOR THE
EMPLOYMENT OF CALCIUM IN ITs TREATMENT. [Am. Jl. of Med.
SC ook Vib e203 2
In determining the etiology of asthma, one must consider the suscepti-
bility of the individual patient to causative agents, because of (1) hyper-
irritability of the bronchial division of the vagus nerve and general
vagotonia as a rule, (2) a relative increase in the potassium as com-
pared with the calcium-ions of the cells of the bronchi, (3) changes in
the incretions which disturb the equilibrium of the nervous mechanism
or of the ion content of the cell, and probably of its colloidal phases,
especially the thyroid, pituitary and parathyroid glands. It is also neces-
sary to consider the possibility or specific sensitization to pollen, animal
emanations or foods. Inflammations and other forms of irritation which
cause reflex vagus activity, such as those involving the nose, sinuses,
gastrointestinal tract, genital system and the lung may lead to asthma.
Physical, chemical and climatic irritants must also be considered.
424 CURRENT LITERATURE
The paroxysms of asthma may be relieved by atropin, which inhibits
the vagus mechanism or by stimulation of the antagonistic sympathetic
system. Adrenin is also successful in the treatment of the paroxysms,
inasmuch as it restores the sympathetic parasympathetic equilibrium.
The attacks have been observed to regress during the toxic stage of acute
toxemias accompanying tonsillitis, influenza, pneumonia, typhoid fever and
tuberculous exacerbations. This effect was probably due to the toxins
stimulating the sympathetic mechanism and thus counteracting the vagus
effect.
It is known that nerve stimulation results in cellular changes resulting
in the elaboration of certain substances which enter the blood stream.
The effect may be due to colloid changes. In asthma, the parasympathetic
activity prevails, which presupposes a relative increase in potassium as
compared with calcium-ions in the cells. The hypersensitive cells which
are responsible for the reaction of anaphylaxis present changes in colloid
arrangement, which result in a shifting of the ion equilibrium. © This is
manifested by a decrease in the sympathetic action, associated with a
relative deficit in calcium-ions, increased permeability of the cell mem-
brane and associated hyperactivity on the part of the parasympathetic
nerves. Many asthmatic individuals suffer from other manifestations of
protein hypersensitization, such a hay fever, urticaria and eczema and
present evidence of parasympathetic hyperactivity, in the form of an
increase in oculocardiac reflex, bradycardia, hyperchlorhydria and spastic
constipation. In many cases there is a familial history of similar con-
ditions. Hyperirritability of the neurocellular mechanism of the bronchi
probably underlies the asthma, whatever the precipitating factor may be.
Treatment should be directed toward relaxing the bronchial spasm
and relieving the bronchial secretion by changing the electrolytic content
of the cells. Pottenger administered calcium in order to restore the neuro-
cellular equilibrium. The dose was empirically determined; small doses
were first given (5 c.c. of a 5 per cent solution) intravenously. The
dose was increased to 10 c.c. if necessary; the treatment was repeated
as indicated. The patients were kept in bed. When the drug was
injected slowly, untoward effects were noted. A slight facial flush was
noted and the patient reported a sensation of warmth over the abdomen.
The blood pressure increased from 5 to 10 points following the injection.
but usually returned to normal within thirty minutes. The pulse rate
decreased from 10 to 20 points per minute and later returned to normal.
When the injections were made rapidly, the patients complained of intense
heat, profuse perspiration, constriction of the throat and nausea for about
thirty minutes. A burning sensation in the rectum was also noted. One
patient developed aphonia.
The action of calcium resembles that of adrenin or of stimulation of
the sympathetic system. The result of adrenin in asthma is satisfactory
VEGETATIVE NEUROLOGY 425
but transitory. It is hoped that calcium will prove of more permanent
value. The dosage must be determined in each individual case.
Pottenger employed calcium in cases of bronchial asthma precipitated
by bacterial infection. Both the spasm and the bronchial secretion were
relieved. The results were prompt and satisfactory. The relief of heart
strain was marked; it was manifested by a decrease in the pulse rate.
Calcium therapy is also indicated in other conditions accompanied
by hyperirritability of the parasympathetic system, such as asthma, hay
fever, urticaria, serum disease, spastic colon and diarrhea.
Hekman, J. TREATMENT oF AstHMA. [Ned. Tijd. v. Gen., Dec. 15,
Noh lel Xe el VL A. |
Hekman calls attention to the invariable presence of streptococci in
large numbers—with other bacteria variable—in the sputum from 300
cases of bronchial asthma in different parts of the Netherlands. In nearly
every instance the asthma had developed in direct connection with some
infectious disease, generally in childhood. Hence he ascribes the asthma
in these cases to some inflammatory process in the smaller air passages,
and treats with a vaccine made from the sputum. He reports encouraging
results even in the patient’s usual environment. Intractable cases some-
times yielded to change of scene, tuberculin treatment, protein therapy or
turpentine fixation abscess. Asthma from anaphylaxis is rare in com-
parison to this form.
Veitch, J. TREATMENT oF ASTHMA WITH COMBINED PEPTONE AND VAC-
Pee bite Meda iin lan, 5.1924. J. A.M. A.]
The solution used by Veitch was in three strengths: A—5 c.c. of 6 per
cent solution = 0.25 gm. peptone + 235 million organisms mixed catarrhal
vaccine. B—5 c.c. of 10 per cent solution = 0.5 gm. peptone + 940 million
organisms mixed catarrhal vaccine. C—10 c.c. of 10 per cent solu-
tion=1 gm. peptone + 1,880 million organisms mixed catarrhal vaccine.
The injections were given every seven days: for the first four weeks
half a tube of A solution per week, for the second four weeks half a tube
of B solution per week, and so on, increasing in strength of dosage. The
injections were given intramuscularly in the so-called painless area just
below the anterior superior spine of the ilium. Generally the results
were good.
Ramirez, M. A., and St. George, A. V. Errotocy or AstuMa. [Med.
Ji and Record, Jan. 16, Vol: CXX.]
These observers claim that all persons react to histamin when injected.
The reaction is two or three times more intense—speed; extent; wheals
(from 15 to 30 mm. in diameter), intensity of the reaction—in persons
who manifest symptoms of endogenous asthma. The treatment of asthma
with histamin is therefore a corollary and is here reported as of value.
426 CURRENT LITERATURE
Beretervide, H. A., and Pozzo, F. AstHMA IN CHILDREN. [Sem. Meéd.,
Feb. 14, 1924. ]
Signs of inherited syphilis in all but one of the nineteen examined for
it were found in the 22 cases reported of bronchitis of the asthmatic type
in children. Under treatment for syphilis all were benefited. The
tracheobronchial adenopathy was accompanied by an abnormal width of
the aorta hence probably luetic.
Duke, W. W. TREATMENT OF HaAyY-FEVER ASTHMA AND OTHER MANI-
FESTATIONS OF ALLERGY. [Am. Jl. Med. Sc., Nov., Vol. CLXVI.]
Here “ allergy ” is the “nigger in the wood pile.”’ Asthma, hay fever,
the dermatoses, the gastrointestinal, urologic and neurologic symptoms,
urticaria, angioneurotic edema, hypotension, are all manifestations. Five
different lines of treatment are suggested: (1) avoidance or removal of
the specific cause of illness, (2) or of contributory causes, (3) specific
protein treatment, (4) nonspecific protein treatment and (5) symptomatic
treatment.
Storm van Leeuwen, W., Varekamp, H., and Bien, L. BroncHIAL
ASTHMA AND CLIMATE. [Klin. Woch., Vol. III, March 25. B. M. J.]
W. Storm van Leeuwen, H. Varekamp and L. Bien refer to the well
known fact that bronchial asthma occurs in certain cases when the patient
has inhaled substances which are harmless to normal individuals—for
example, pollens, ipecacuanha, castor oil, or effluvia from horses or other
animals. They believe that there are other unknown colloid substances
which may produce asthma in “ sensitized” patients, and they find that
the removal of such patients to a mountainous country has an immediately
beneficial result in many cases. Other factors beside altitude have to
be considered, including air pressure, humidity, temperature, and amount
of sunlight. In Holland there are three principal zones: (1) the dunes
and sea coast; (2) the banks of the larger rivers; (3) the driemesandy
areas. If patients from the coast are sent to the third zone they improve,
while those from the second zone do not. The authors determined to
send three patients to various Swiss mountain stations, and observations
were made at Basle (100 meters) and at various mountain stations, the
highest being St. Moritz (1,800 meters). The three patients were natives
of the different climatic zones. Each was carefully examined daily
(auscultation and blood pressure). ‘The third patient (from Groningen)
did not improve as rapidly as the others, but eventually, when at St.
Moritz, all were free from symptoms of asthma and of bronchitis. The
authors conclude that (1) the majority of cases are due to inhalation
of certain “ asthmogenous” substances of usually unknown nature; (2)
these unknown substances are seldom found in mountain stations, so that
at 1,200 to 1,800 meters the majority of patients are free from symptoms;
(3) sojourn in mountainous country does not cure asthma.
VEGETATIVE NEUROLOGY 427
Galup, J. ASTHMA AND Loss or Vacus SyMPATHETIC BALANCE.
[Presse Méd., Vol. XXXI, June 16.]
In this chase after the causes of asthma the author found the oculo-
cardiac reflex exaggerated in 35.52 per cent of 152 asthma patients,
and inverted or abolished in 34.88 per cent. Thus in 70 per cent the
balance between the vagus and the sympathetic was upset, one or the other
being predominant at the moment. The oculocardiac reflex can thus serve
as a guide for symptomatic treatment.
Calderon, L. F. Essentrar Astuma. [Rep. d. Med. y. Cir., March,
Loose hers. M Ay]
Calderon has encountered three cases of intermittent and periodical
dyspnea during expiration, in young women, with a slightly febrile tem-
perature at first. The only physical signs were slight cyanosis of the
lips and variable sibilant rales scattered through both sides of the chest.
There was little or no dulness on percussion. Each paroxysm of the
asthma exhausts the patient, but in the intervals she attends to her
usual duties, although weak. The differential diagnosis is still obscure.
and no treatment has been effective.
Lumsden, T. Respiratory CENTERS. [Jl. of Phys., Vol. LVIII, Aug.
ame WA |
Rhythmical respiration in the cat and probably in all mammals, Lums-
den asserts, is managed by an inspiratory mechanism, the apneic center at
the level of the striae acousticae; by an expiratory center just below
this level; and both these centers are controlled by a higher center,
pneumotaxic center, in the upper half of the pons. The gasping center
near the apex of the calamus scriptorius is probably a relic of some pre-
vious respiratory mechanism and does not appear to influence true rhyth-
mical breathing of normal type, although it may or may not be a relay
in. the tract of apneic impulses to the inspiratory muscles.
Pottenger, F. M. Carcrtum anp AstHMa. ([Cal. St. Jl. of Med., July,
VoloXXI1.|
Pottenger claims now that the patient’s reaction is an expression of a
hyperactivity of the vagus potassium. Whether this is actually a hyperir-
ritability of the sympathetics and a lessening of the cellular content in cal-
cium or a hyperirritability on the part of the vagus and an increase in the
potassium content of the cell is not yet certain, but that there is a relative
hyperacidity of the parasympathetics and of the potassium content of the
cells is evident, not only from the symptomatology, but from the measures
that are used to combat the paroxysms. Calcium is definitely identified
with sympathetic, and potassium with parasympathetic action. Reasoning
from this concept of the neurochemical control of activity in the bronchial
tissues, Pottenger tried to relieve the paroxysmis in a severe case of asthma
by producing a relative increase in the calcium content of the body cells.
428 CURRENT LITERALORE
The remedy was given in the form of calcium chlorid, in doses of 5 c.c.
of a 5 per cent solution, intravenously. After the second dose, which
was given two days after the first, improvement was noted, and after
three doses she was entirely relieved of paroxysms. In each of three other
cases the paroxysms have been completely relieved.
Trabaud and Charpentier. TREATMENT oF AstHMA. [Bull. d. 1. Soc.
Méd. d. Hép., Vol. XLVII, March 23. J. A. M. A.]
Trabaud and Charpentier report a case of asthma recurring at infre-
quent intervals from the age of six. Native of a sheep country, the
young man one day was employed at a wool carding machine, and in
fifteen minutes he was seized with an attack of unprecedentedly severe
suffocation. Other attacks followed, and he had to stop this work. During
the war he was forced to work for the Germans. He remembered this
wool carding machine experience, and he ripped his mattress and buried
his head in the wool filling. A few minutes later he was seized with
such a violent attack of asthma that he was sent to the hospital. Six
months later, having improved, he again resorted to the means that had
served him so well before, with the same results, so he was permanently
exempted from forced labor for the enemy. Since that time he has been
subject to asthmatic attacks of varying severity and at irregular intervals,
until given the cutaneous reaction treatment with wool applied to a
scarified place on each deltoid region. At the first application, urticaria
developed instantly around the area, but soon disappeared. The dyspneic
shock followed some hours later. The local and respiratory reactions
grew less pronounced, and in two months the asthma seemed to have
been entirely cured. He can now handle and sleep on wool without harm.
II. SENSORI-MOTOR NEUROLOGY.
3. SPINAL CORD.
Woltman, Henry W. NevroLtocic ASPECTS OF THE EARLY DIAGNOSIS
OF PERNIcIOUS ANEMIA. [Annals of Clinical Medicine, Vol. I.]
A tentative diagnosis of pernicious anemia can often be made on
neurologic evidence alone. About 12.7 per cent of the patients come to
be relieved of symptoms primarily due to involvement of the nervous
system; 1.4 per cent have these symptoms before anemia is present.
Ordinarily they do not appear until an average of about ten and a half
months after the appearance of anemia. While both position of joint and
vibratory sensibilities are conducted up the posterior column of the cord,
the former is not so often lost as the latter. Sometimes pain, tactile and
temperature sensibilities are also lost; however, these forms of superficial
sensation are usually preserved almost intact. Hamilton and Nixon
have shown that if the terminal ramifications of the peripheral nerves
are examined, multiple neuritis can be demonstrated. This was manifest
SENSORI-MOTOR NEUROLOGY 429
clinically in 4 per cent of our cases and explains the paresthesias these
patients so often complain of much better than does the cord involvement.
In about 80.6 per cent of patients with pernicious anemia the nervous
system is affected. The characteristic findings are loss of vibration and
joint sensibility. Mental changes are striking, and some observers assert
that they can diagnose pernicious anemia on the mental changes alone.
The psychosis is usually of the so-called symptomatic or infection-
exhaustion type. Although about 25 or 30 conditions are said to give
rise to combined sclerosis, only a few of practical importance are observed
in this part of the country. Pernicious anemia and arteriosclerosis of the
nervous system are often found in the same patient. In arteriosclerosis,
as in pernicious anemia, we often find combined sclerosis and sometimes
multiple neuritis, but not so frequently. Certain findings, however, should
put us on guard, and we must make allowance for these in examining
the nervous system for evidence of pernicious anemia. Small, irregular,
poorly reacting pupils are often found in arteriosclerosis and are not
common in pernicious anemia. Arteriosclerosis of the fundus usually
means arteriosclerosis of the central nervous system; the reverse is not
always true. There is a characteristic mental change in arteriosclerosis
that is evident on examination and often helps to differentiate the two
conditions. A presumptive diagnosis of pernicious anemia can often be
made on the neurologic picture alone before anemia has put in its ap-
pearance. Finally, the examination of the nervous system often helps in a
very practical way in deciding whether the patient has a primary idiopathic
type of pernicious anemia or some other type of severe anemia.
[Author’s abstract. ]
Dufour, H., and Duchon. MuLTIPLe ScLEeRosIs AND SypuiLis. [Bul.
daleooceMed. da liop... VoL ALVII, June 22.|
In this patient with a clinical multiple sclerosis syndrome the Wasser-
mann reaction of the c.s.f. was positive and improvement followed
bismuth treatment. There was no history of syphilis and no other positive
evidences.
Brown, Earle G. Potiomyetitis Eprpemic IN Topeka. [Jl. Kan. Med.
Soc., Vol. XXIII, Nov. ]
Thirty-six cases of acute poliomyelitis were reported in Topeka over
a period of 57 days, from July 30 to September 25, 1923. Thirty-four
of the 36 cases were of the white race. But one case resulted fatally.
Eleven of the patients were under six years of age. Eight were twenty
years of age or over. Four of the 8 were male and 4 females. By
occupation, 12 were students. Sore throat was a prominent onset symp-
tom in 20 cases. Nine patients had paralysis of the leit leg; 5 of both
legs; 4 of the right leg; 3 of the left arm; 2 of both legs and arms;
2 of the right arm; 2 of the left leg and left arm. Contact could be
430 CURRENT LITERATURE
established in but one instance. No two patients secured milk from the
same dairyman. [Author’s abstract. ]
Bouttier and Bogaert, Van. SPINAL Corp IN INFANTILE POLIOMYELITIS.
[Ann. d. Méd., Vol. XIV, Aug.]
A careful clinical anatomical study by the late deceased neurologist
Bouttier and colleague of seven normal cords with comparative material
from the cord in a case of infantile poliomyelitis in a boy, aged 15. The
acute phase began at the age of 10, and for two years the boy was
unable to move arms or legs or to sit up. Then he began to improve
somewhat, notwithstanding the uniformly distributed destruction of the
motor cells in the anterior horns. The lateral column of sympathetic
cells was intact throughout, and the muscles of the trunk were com-
paratively normal. Bouttier queries whether the spinal sympathetic system
might not have been responsible for the partial resumption of motor
function.
Krabbe, Knud H. Acute ANTERIOR PoLioMyYE itis. [Review of Neu-
rology and Psychiatry, 1919.]
Author describes two cases of acute poliomyelitis, in that he draws
the attention to that fact that this disease can begin earlier and later
in the life than ordinarily accepted and, therefore, can make some diff-
culties in diagnosis. The first case was a little girl in whom the disease
began as she was two months old. During the disease there appeared
gangrena of some of the fingers. The other case was a man, aged 54
years. There was some diagnostic difficulties against the diagnosis of
thrombosis of the anterior spinal artery. In both cases the patients died
and microscopical examination of the spinal cord confirmed the diagnosis:
acute anterior poliomyelitis. [Author's abstract. ]
Berardinelli, W. AcuTE ANTERIOR POLIOMYELITIS IN ADULT. [Braz.
Med.) June oO) 1923,
This patient, a young adult, had a flaccid paralysis of both hands
and one leg, and a severe cephaloplegia.
Adams, D., Blacklock, J., Riddell et al. DissemiNATED ScLerRosis. [B.
Mi -J., Nov. 10, 1923.]
The Royal Medico-Chirurgical Society of Glasgow held a discussion
on the pathology, symptomatology, and treatment of disseminated sclerosis.
Dr. Douglas Adams in an opening paper briefly reviewed the literature
of disseminated sclerosis, and referred more particularly to recent results
obtained in an investigation which was being carried out in the Patho-
logical Department of the University and Western Infirmary of Glasgow
in collaboration with Drs. E. M. Dunlop, J. W. S. Blacklock, and J. A. W.
McCluskie. In a considerable number of cases paralysis had been trans-
mitted to rabbits by the injection of blood or spinal fluid from patients
SENSORI-MOTOR NEUROLOGY 431
suffering from the disease, and had been passed from rabbit to rabbit,
both by direct inoculation and by passage through culture. Spirochaetes
were found in the organs of seven of the inoculated animals both by dark
ground examination and by staining, though examination of the cultures
employed yielded negative results. These results were regarded as con-
firming the view that the diease was infective in origin. Emphasis was
laid on the necessity for early diagnosis, and in this connection the value
of the colloidal gold reaction was urged. The results of intensive anti-
specific treatment of 50 cases were referred to. In many cases consider-
able clinical improvement had been noted and this had coincided with a
modification of the colloidal gold curve in a negative direction. In the
majority of cases the subsequent absolute or relative freedom from relapses
during a period of three years was striking. The investigation was being
continued under a grant from the Medical Research Council.
Dr. J. W. S. Blacklock described in more detail the various experi-
ments performed, and said that when blood or spinal fluid from cases
of disseminated sclerosis had been inoculated directly into rabbits about
one-third of the animals developed nervous symptoms. Emulsion of the
central nervous system of these paralyzed animals produced nervous
symptoms in a proportion of cases on inoculation into other animals either
directly or after passage through Noguchi’s medium. No nervous symp-
toms had been noted in over 200 normal control animals kept under
observation for periods varying from four months to over a year, nor
had paralyses developed in animals inoculated with various protein
substances. He considered it probable that a virus was present in the
blood and cerebrospinal fluid of these patients which was capable of
existing in the central nervous system and of producing paralysis in a
proportion of the animals inoculated. The pathological lesions that had
been noted in the central nervous system of the inoculated animals were:
(1) Cellular infiltration, chiefly under the ependyma of the ventricles.
(2)Degeneration of nerve tracts—this had been observed only in one
animal which had lived for over a year after the onset of paralysis; the
other animals which had shown nervous symptoms had lived for too
short a time after the onset of such symptoms to allow definite patho-
logical changes to occur. (3) Petechial hemorrhages. (4) Multiple
lesions of the nature of softening.
Dr. Brownlow Riddell referred to the frequent occurrence of slight
and transient eye symptoms in the early stages of the disease, and urged
the importance of a critical interpretation of such symptoms in a case
presenting no other apparent clinical feature. The surprisingly slight
attention paid by the average patient to transient eye symptoms, with
the speedy recovery therefrom, and the absence of any other sign or
symptom, combined to present a clinical picture often underestimated or
attributed to a functional, hysterical, or digestive origin. Dr. Riddell
then discussed in detail the various symptoms, including diplopia, acute
432 CURRENT LITERATURE
retrobulbar neuritis, nystagmus, and optic atrophy, and described a number
of illustrative cases.
Professor C. H. Browning, in commenting on the results of the ex-
perimental work, said that the small proportion of successful transmissions
was not surprising in view of the insusceptibility of both man and animals
to the disease. He emphasized the fact that the virus persisted in the
culture media which had been inoculated with blood from cases and
kept over long periods in the incubator, and was inclined to the opinion
that the pathogenic agent was a living organism or the product thereof.
He then referred to the value of the colloidal gold reaction as a means
of early diagnosis and of controlling the results of treatment.
Professor Robert Muir, in referring to the pathological and histological
changes in the disease, said that while they were very definite they yet
presented certain peculiar characteristics. The essential features at an
early stage were (a) a disappearance of the myelin sheaths, (b)a persist-
ence of the axis cylinders, and (c) an absence of Wallerian degeneration.
These changes occurred in patches which were often sharply cut off, as
though by a knife, from the surrounding healthy tissues. The process
was peculiar and quite unlike a true sclerosis. The colloidal gold reaction
in the cerebrospinal fluid he considered would mark a real advance, if
completely established, and would prove of great assistance in controlling
treatment. Referring to the etiology, he was of the opinion that, while
a great many facts supported the infective theory, the state of the experi-
mental work was as yet too uncertain for complete proof. While hopeful,
it was not conclusive.
5. CEREBELLUM; PONS; PEDUNCLES; MID-BRAIN.
Van Bogaert, L. INFERIOR SYNDROME OF THE RED Nucteus. PsycuHo-
SENSORIAL DISTURBANCES OF MESENCEPHALIC ORIGIN. [Revue Neuro-
logique; Anv 31) T.. ly Now, p. 417)
The patient, fifty-nine years old, suffered a sudden shock without loss
of consciousness after which she had a staggering gait and diplopia.
That night she had visual hallucinations, chiefly animals. The examina-
tion showed increased tendon reflexes on the left side and a positive
Babinski reflex on the left. There was a ptosis on the right eye with a
complete third nerve palsy. The motor trigeminus was normal but the
sensory part was slightly affected. There was some dysmetria on the
left. [Camp, Ann Arbor. ]
Potzl, O., and Schloffer, H. Cyst or Caupate Nucreus. [Med. Klinik,
Jan. 4, Vol. XXI.]
An interesting clinico-pathological report from the Prague clinic of
a patient with a cyst of the left caudate nucleus. This patient with choked
disks and much deterioration also showed pressure on the frontal parts
*
4
D
SENSORI-MOTOR NEUROLOGY 433
of the cortex, near the frontopontine radiation, and motor disturbances.
An affection of the striate body was assumed. A cyst was found which
contained 86 c.c. of fluid. A communication between the lateral ventricle
and the cyst was established by introduction of a tenotome along the
needle.
Herman, E. SYMPTOMATOLOGY OF SYDENHAM’S CHOREA: CHOREA WITH
BILATERAL PAPILLARY EDEMA: RiGHT SipED HEMICHOREA WITH
RicHt HEMIPLEGIA AND INTERMITTENT ApHasiA. [Revue Neuro-
logique, An. 31, T. 1, No. 4, p. 425.]
The first patient, eighteen years old, had a right-sided chorea lasting
about three months. It improved but the movements recurred about a
month later. This time the ocular fundi showed blurring of the disc
margins, venous congestion and hemorrhages. These findings persisted for
about two weeks. ‘The second patient was seventeen years old. There was
a history of chorea at the age of six but the present attack was attributed
to grief from the loss of her mother. The choreic movements occurred
in attacks lasting an hour or so. The right side would become weak and
she would also have spells of short duration in which she would become
mute, without loss of consciousness. (Camp, Ann Arbor.)
Marque, A. M., and Camauer, A. F. Wiutson’s Disease. [Prensa Méd.,
Fane 2), 1925-4
An early report from the Argentine of this syndrome illustrated with
six photomicrograms. In spite of the fact that the Wassermann had been
positive syphilis was not thought to be the direct origin of the striatal
lesions. The liver was small and abnormally hard, but did not show any
acute inflammatory lesions.
Walshe, F. M. R. DecereprateE Ricipiry 1N Man. [Encéphale, Feb.,
Pon J ALM A. |
Walshe reports a case resembling Sherrington’s decerebrate rigidity
in a woman, aged twenty-four, with a double hemiplegia. Necropsy
revealed a typical suprapituitary tumor filling the third ventricle. The
compression exerted by the tumor as well as by a secondary hydrocephalus
were probably responsible for the symptoms of the decerebrate type. He
concludes that the physiologic signs of experimental decerebrate rigidity
are similar to those in pyramidal spastic conditions.
Papadato, L. MricroscoprcaL Finpincs 1N Witson’s Disease. [L’En-
eephale, Vol. XX, Jan.]
Clinicopathological report of a case of Wilson’s disease, in a young
man, showed diffuse lesions predominantly localized in the lenticular
nucleus, and affecting the whole neuroglia. The changes in the liver were
interpreted as resulting from the lesions in the lenticular region. These
were ascribed to a probable antecedent encephalitis.
434 CURRENT LITERATURE
Wimmer, A. THE StriATE SYNDROME IN CONGENITAL ENCEPHALOPA-
tues. [Revue Neurologique, An. 31, Vol. II, No. 4, p. 316.]
In one case the symptoms were bilateral and the striate lesions were
attributed to asphyxia at birth. The upper extremities were little affected.
In the lower extremities the tendon reflexes were exaggerated but there
was no Babinski reflex. The patient was an imbecile. In a second case,
a girl aged fifteen years, also an imbecile, the symptoms were confined to
the right side except for some tremor of the left thumb. In this case the
lesion was regarded as dysplastic and due to some hereditary defect.
[Camp, Ann Arbor. ]
Foix, Chk On Tonus AND Contractures. [Revue Neurologique, An. 31,
TAZ NG ate :
Foix defines tonus as “a state of active tension of the muscles, per-
manent and involuntary, and variable in its intensity according to the
various associated or reflex activities that may reinforce or inhibit it.”
Electromyographic studies of muscles in voluntary contraction and in
static contraction were made with the Einthoven galvanometer and showed
distinct differences. In the static contraction the oscillations were small
and rhythmical. The author describes two distinct types of contractures:
pyramidal and the extrapyramidal. The latter are further divided into
the decerebrate rigidity, Parkinson rigidity, and pallidal rigidity. From
the study of the reflexes contractures are classified as tendon reflex,
pryamidal, cutaneo-reflex, spinal automatic, and postural reflex: extra-
pyramidal. [Camp, Ann Arbor. ]
‘
Herman, E. EXPERIMENTAL STUDY OF CHOREA. [C. R. Soc. Biologie,
Vol, XCEaOcte a1.)
Experimental study upon rabbits inoculated with cerebrospinal fluid
from patients with Sydenham’s chorea. The presence of a filtrable virus
was claimed to have been discovered. Corresponding anatomic and clinical
was claimed to have been discovered which has a marked affinity for
organs derived from the ectoderm. Corresponding anatomic and clinical
changes are inferred.
~De Giacomo, U. CLINICAL AND EXPERIMENTAL StTupy oF ATHETOSIS.
[Rivista di patologia nervosa e mentale, Vol. XXIX, p. 791.]
The author describes in detail five clinically observed cases of general-
ized athetosis, submitting them also to microscopic and experimental
study, in order to make clear the inner nature of this unusual syndrome.
It was established that the fundamental and constant symptom is present
in a special form of hypertonia, the characteristic movements of which
are only the more evident clinical expression. The author demonstrates
the existence of a pure form of this disorder in which the frequent but
not necessary association of other symptoms is absent, such as infantile
SENSORI-MOTOR NEUROLOGY 435
Spastic paralyses, epileptoid convulsions, profound disturbances of the
somatic and psychic development. He attributes to the pure form an
exclusively extrapyramidal origin and considers that the association,
variable and inconstant, of the other symptoms is due to the extension of
the causal morbid process (agenesia, inflammation, etc.), which is opera-
tive in intrauterine life or in the first months of extrauterine existence
upon the cerebral cortex and the pyramidal myomotor system. The
physiopathological mechanism of athetosis would consist in a_ special
ataxia of the pallidum produced by destruction of the corpus striatum or,
more rarely, a disturbance of the striate function through lesion of the
thalamus, peduncles, etc., 1.e., in an alteration of the function which
inhibits and regulates the tonus of the antagonists in all the static and
kinetic mechanisms of the muscular system. [Author’s abstract. ]
Nayrac, Paul, PATHOGENESIS oF HEPATO-LENTICULAR DEGENERATION.
PRevuesNeuroiogique, in. ol) 1.2; No, 2, ps 15). ]
Report on the histopathologic findings in a case reported clinically in
the Revue Neurologique, December, 1923, p. 504. There were severe
degenerative changes in the globus pallidus and the nucleus of the tuber
cinereum. There were less marked changes in the putamen, the optic
thalamus, and the cerebral cortex. ‘There was an intense congestion of the
liver with islets of parenchymatous degeneration and beginning fibrosis.
[Camp, Ann Arbor. ]
Urechia, C. I., and Nitescu, I. ROLE or TusBer CINEREUM. [Bull.
Acad. Méd., Feb. 17, 1925.]
Experimental research on pancreatectomized dogs in which a degen-
erated periventricular nucleus of the tuber cinereum was found. This
finding may confirm the connection of the pancreas with the vegetative
centers of the tuber; also the significance of the periventricular nucleus
in sugar metabolism, as claimed by Lewy and Dresel and others. A dia-
betic hypothermia and a pronounced alteration of the periventricular
nucleus also found in a case of frostbite suggest that this region may
contain important pathways related to the integration of heat production.
They use the faulty conception of “ centers.”
Camus, J., et al. D1apetes From Lestons IN TUBER CENEREUM. [Presse
Dicd we Vol. x Nie Hel: 255) J. A. M.A.)
Camus, Gournay, and Le Grand induced experimental lesions in the
region of the tuber cinereum in rabbits by introducing fine capillary glass
tubes filled with a fatty acid. Glycosuria occurred in nine rabbits out of
twenty-three, and persisted from one to several weeks. The maximal
amount of sugar in the urine was 6.4 gm. per cent. Macroscopic exam-
ination showed injury of the tuber cinereum in the nine positive cases,
while in the fourteen negative cases the lesion was located elsewhere.
436 CURRENT LITERATORE
The microscopic findings in eight positive cases demonstrated injury of
the paraventricular nucleus in all. In most instances the nucleus of the
tuber had also been damaged. Both nuclei proved to be intact in all the
negative cases. In one case the pituitary had been completely destroyed
by the capillary tube, but diabetes did not appear. Meningitis, compres-
sion, or some lesion at the base of the brain may affect the nucleus of the
tuber, causing polyuria. A lesion in the walls of the third ventricle, or
ependymitis, hemorrhage, or a tumor in the third ventricle may affect the
paraventricular nucleus, producing glycosuria.
III. SYMBOLIC NEUROLOGY.
1. PSYCHONEUROSES; PSYCHOLOGY.
Romer, ©. TREATMENT OF PsyCHONEUROSES. [Klin. Woch., Vol. 3,
354. |
The first patient was a woman twenty-nine years of age of the
asthenic, frail type, with schizoid tendencies. She suffered from an
exaggerated timidity and hypersensibility, and had, from childhood been
torn between fear and a latent sexuality, the nature of which was entirely
unknown to her. She had an abnormal sense of shame during menstrua-
tion and was afraid of any contact with men, with the exception of her
father, whom she loved. There was a possibility of the Edipus complex
in this relationship, although her love for her father may be explained
by the fact that the neurotic and frightened girl instinctively turned to a
reliable individual for protection against her sexual conflicts. She had
violent aversions to foods due to accidental unpleasant associations. Dis-
agreeable experiences of minor importance assumed for her an intense
emotional coloring, and became associated with irrelevant acts. She had
suffered for years from headache, following an accidental blow on the
head. By means of questioning under hypnosis (psychocathartic method),
it was possible to elicit many significant childhood and early adult
memories, and to explain away the food phobias and other factors of the
anxiety neurosis. Following her father’s death, the first explosive out-
burst of grief was followed by a cool composure. This combination of
hypersensibility and coolness is characteristic of schizoid individuals.
The fear of martiage was finally overcome by further treatment, and the
patient later married and became to all appearances adapted in her rela-
tions to her surroundings. |
Another patient, a woman of twenty-seven years of age, with a nervous
constitution, had suffered since her fifteenth year from headache. There
appeared to be a connection between this symptom and a jealousy of an
older sister whom she considered her intellectual superior. At the age of
nineteen years her fiancé was killed. She concealed her grief, repressed
her libido, and endeavored to sublimate, by an interest in the troubles of
her friends, and by strenuous professional intellectual work. Her close
SYMBOLIC NEUROLOGY 437
attachment to her mother was probably a regression to a childhood type
of libido. The repression of the normal impulses was further manifested
by an abnormal fear of witnessing “ugly” or “immoral” plays. The
schizoid tendency was marked. Her physical health was excellent, and
she was athletic and active. The hypnotic treatment relieved the headache
and neurotic symptoms. A recurrence followed a proposal of marriage
which suggested her lost fiancé and aroused the underlying emotional con-
flict. Hypnosis removed the tension, and restored the confidence and
control of the patient, who now appears to be completely recovered.
The third patient, a girl of seventeen years of age, had experienced a
psychic trauma (sexual) during childhood. Her mother’s severe dis-
approbation and reproach formed the basis of a sense of guilt which
rendered her relations with her companions uncertain. Her gratification
in her mother’s affection when she was ill led to a subconscious impulse to
gain this gratification frequently. Her father and grandfather had a
familial tendency to headache, and this symptom therefore suggested
itself to her. The physiologic pain accompanying the first menses, for
which she was unprepared, and which constituted a shock, became fixed as
a psychogenic habit, and was perpetuated as an almost constant abdominal
pain, which simulated appendicitis and glandular tuberculosis. The phys-
ical structure was dysplastic. Scoliosis and kyphosis were present, and
were accompanied by severe and constant backache, which was aggravated
by the fear that she might be accused of simulation. Acute articular
rheumatism occurred, and was relieved by tonsillectomy. Psychotherapy
restored the confidence and equilibrium of the patient to such a degree
that she became engaged, and even survived the loss of her betrothed
without a recurrence of the symptoms.
A case of urticaria, based upon a psychic factor was relieved equally
by suprarenin or by distilled water. A case of pruritus was based upon
fear of infection by a servant suffering from venereal disease. Both
these cases were completely relieved. In another case, severe bronchial
asthma and pulmonary distention were traced to a disappointment in love
combined with a moral struggle against masturbation. The patient was
of a schizoid asthenic habitus. His mother had died of pulmonary
tuberculosis, and this fact would explain the localization and fixation of
the symptoms. In another case, the mother of the patient had asthma,
and the fear of inheriting the condition led to a psychogenic simulation
of the symptoms. Hypnosis led to temporary relief. Analysis of the
patient’s life, and explanation of the psychologic causes of the symptoms
led to their disappearance and to objective improvement in the patient’s
condition. In the latter case a conflict developed, in the form of a certain
hostility toward the physician. This transference of the emotional com-
plex to the physician increased the difficulty of the psychoanalysis.
Psychoanalysis must be carried out with the greatest caution. Sexual
complexes must be especially carefully approached. The analyst must
frequently combat the hostility and lack of codperation on the part of the
438 CURRENT LITERATUKE
patient, who is averse to acknowledging the psychic origin of his symp-
toms, or is rather attached to them as a useful excuse for his shortcomings.
In such cases psychoanalysis is difficult, but especially valuable. Symp-
tomatic relief does not constitute cure. The prognosis depends upon the
degree to which the patient is able to understand the cause of his symp-
toms and to adjust himself to realities.
Patini, E. CRIMINALITY AND Hystero-Epitepsy. [Il Policlinico, Feb.
18, Vol. XXXI, Br. Med. Jl.]
In discussing at some length the question whether the crimino-hystero-
epilepsy syndrome of Bratz, the psychasthenic epilepsy of Oppenheim.
and the narcolepsy of Gélineaud-Friedmann should not be grouped to-
gether under the single term “ psycholepsy,’ as suggested by Morselli,
rather than considered as separate nosological entities, E. Patini (Il Poli-
clinico, XX XI, February 18, p. 211) gives in detail the case of a barber
aged thirty-four. The family history included alcoholism, syphilis, insan-
ity, and infantile convulsions. The patient suffered from the latter during
his first year; he was late in learning to walk. He did fairly well at the
elementary school, but his career at the technical college was cut short by
imprisonment for wounding a comrade with a stone. After this he gave
himself over to a life of vagabondage and petty. crime, with occasional
intervals of barbering. While on active service with the army for two
years his record was good, except for some lack of discipline, until one
night he stumbled over the dead body of an Arab, when he passed into a
state of stupor, like narcolepsy, until dawn. There followed nervous
disturbances, with ten to twelve convulsions at various intervals. These
usually occurred when he mounted guard, and occasionally after wine,
and culminated in an attack on a non-commissioned officer during what
Patini regards as a state of pre-epileptic automatism immediately followed
by a fit, on recovery from which he was found to be mentally deranged and
kept under restraint. After discharge he was twice imprisoned for theft,
once with violence. Various stigmata of degeneration, many cutaneous
scars, and symbolical tattoo marks were present, and zones of dulling of
tactile, painful, and thermic sensibility, some astereognosis, and lack of
precision in joint, muscle, and coordination tests. The visual fields were
generally contracted, more so on passing from center to periphery than
vice versa; taste, smell, and hearing were diminished. The tongue showed —
fibrillary tremor and dextro-protrusion, and there was asymmetry of the
lower part of the face on the right side. Muscle power was normal, but
there was marked fibrillation of the pectorals and tremor of the hands.
Romberg’s test brought out some temporary swaying; the reflexes were
normal. Vasomotor skin reflexes were very easily provoked by emotional
or mechanical stimuli (dermographia). The fits were ushered in by a
feeling of weakness and by sweating; he became pale and fell without
initial cry; he had on occasions injured his head, bitten his tongue, and
passed urine and feces involuntarily. After violent general convulsions
SYMBOLIC NEUROLOGY 439
lasting twenty to thirty minutes the attack ceased and he regained his
senses with a feeling of malaise, general weakness, dazedness, and no
recollection of what had happened during or just before the fit. Super-
ficially he appeared psychically normal, but special tests showed poorly
sustained, easily distractable attention, deficient intellectual capacity, and
a good memory except for the period of and immediately before the fits.
Morally he was surprisingly normal, showing affection for his family,
inclination for friendship, sensibility to kindness, and no pride in his
crimes nor penitence. He did not try to excuse them, but adduced many
extenuating circumstances, such as his being orphaned at a tender age
and his lack of upbringing; he bore a deep grudge against society, which
instead of helping him to reform had sent his to gaol. There was no
evidence of malingering. Patini dissects the case and the differential
diagnosis minutely. He points out that this case combines some of the
characteristics of all the above-mentioned types of epilepsy, a pleomorphic
disease in which variations, symptoms, and syndromes may easily multiply
without forming a nosological entity. He concludes that cerebral vaso-
motor disturbance in an individual of such a potentially morbid type may
cause impulsive acts and further convulsive disturbances, and that the
underlying psychical degeneracy forms the foundation for the three
factors which constitute the grand triad of the Bratz type.
Courtney, J. W. PsycHoNneEuRoTic BACKACHE. [Bost. Med. & Surg. JL,
- Dec. 20, Vol. 189.]
Backaches or rachialgias of the nervously adynamic, in Courtney’s
one-sided opinion, spring not from ideas, but from pathogenic factors of
a physical order. These pathogenic factors have a definite place in the
category of disease mechanisms in general. The most scientific and
logical method of combating the pernicious effects of these factors is
through agents which tend to better the physical structure and stabilize
the functional activities of the neuroglandular mechanism of organic life.
Stopford, John S. B. A New ConceEpTion OF THE ELEMENTS OF SENSA-
TION. [Brain, Parts III and IV, Vol. 45.]
John S. B. Stopford thinks that no nerve of clinical importance is
distributed exclusively to skin. Consequently after section, there is bound
to be some disturbance of so-called deep sensibility and it seems quite
impracticable to divide sensation into superficial and deep varieties which
accompany muscular branches, since the sensory supply of the finger joints
undoubtedly arises from the digital nerves. There is also probability that
other forms of deep sensibility are in part, at least, transmitted by
branches arising independently from the main nerve. The various forms
of sensation included under deep sensibility may be dissociated. In
recovery reappearance of the recognition of contact and appreciation of
pain on excessive pressure occur early, as a rule during the stage of
protopathic recovery. Definite improvement in localization and signs of
440 CURRENT LITERATURE
recognition of passive movement of joints occurs very late and not until
there is evidence of epicritic recovery. Deep sensibility ought to be
divided like cutaneous sensation, into epicritic and protopathic varieties.
The sense of pressure is crude in comparison with appreciation of. the
direction, localization and range of passive movement in a joint. The
former may have thalamic, the latter cortical representation.
Gurewitsch, M. CHarAcTER ALTERATION AND ORGANIC BRAIN DiIs-
EASES. [Zschr. f. d. ges. Neur. u. Psych., Vol. 86.] °
Gurewitsch shows that alteration of character may take place in
childhood from encephalitis epidemica or other pathological processes.
The changes may take a variety of forms which may resemble schizo-
phrenic diseases, constitutional psychopathies, moral insanity especially,
and manic-depressive diseases. He cites cases in which the changes
followed syphilis or typhus.
Starcke, A. Tur CastraTION CoMPLEX. [Int. JI. Psa., 2, No. 2.]|
Defined by the author as the “network of unconscious thoughts and
strivings, in the center of which is the idea of having been deprived, or
the expectation of becoming deprived of the external (male) genitals.”
It is a general, possibly a universal complex, but varying greatly in its
dynamic potential. Other authors have combined the idea of “ punishment
for a sexual offense” as a part of the complex, but Starcke does not
believe this is necessary. The castration wishes, and its ambivalent
fears he groups under four classes: (1) I am castrated (sexually deprived,
slighted), I shall be castrated; (2) I will (wish to) receive a penis;
(3) another person is castrated, has to (will) be castrated; (4) another
person will receive a penis (has a penis). The first three types he says
are manifest as wishes, thoughts or fears. The fourth corresponds to the
infantile theory of the ‘woman with a penis.”
The complex is usually traced to a “threat.”’ Freud’s “ Kleine Hans ”
affords an interesting analysis and opens up for the author four general
problems: (1) “Any” threat is usually in phantasy referred to a “ sin-
ful” place. Genital manifestations being frequent the localization of the
“sin” becomes evident. (2) Cleanliness of the genitals are early sources
of idea ‘linkage; conflict between attendant and child early focuses on
this ceremony and transgressions here early lead to fixation. (3) Local-
ized inflammatory disturbances occasionally determine the punishment
anxiety, and (4) Actual and universal situations. It is to the latter the
paper is limited.
The complex Starcke holds has a positive side. The penis is put upon
the body in places where it does not exist and the first universal identifi-
cation is the nipple. ‘The withdrawal of the nipple” as the first “un-—
lust” symbol is here regarded as of importance in the development of the
content of the castration thought. He gives several dream fragments
indicating the mechanism; one of his own being extensively utilized in
SYMBOLIC NEUROLOGY 441
which the oral-eroticism and the castration complex have a common
meeting ground: ‘Thus the incest phantasy—my penis disappears in my
mother—is another way of saying—my nipple (mother’s nipple in my
mouth) is again “lost” in the ‘“ mamma.”
In order to arrange the material the author has recourse to Semon’s
mnemic hypotheses. The memory of having possessed a nipple like
organ, is an early deposit. Starcke develops two interesting later evolu-
tions out of the oral eroticism as exemplified in the smoker, who wants
the “form.” and the candy eater, who wishes the gustatory repetition.
Weaning as a necessary activity would make the castration complex
universal. The breast feeder and the bottle feeder must have different
and important conditionings. The author illustrates the participation of
the castration complex in a compulsion neurotic with irregular weaning
as an important constituent. Similar situations come out—are ecphoriert
—under any loss stimulus and in the depressed manic the castration com-
plex appears in the oral-erotic stage. Thus the whole nursing formulae
become of transcendant importance.
The infantile theory of the ‘““ woman with a penis”’ originates from the
nursing infant situation. The mother-complex also has an important
source in the breast situations. The author also believes that sadism and
the breast situation may be intimately related. Thus in certain cases in
which nursing is attended with considerable pain to the mother by reason
of cracked nipples or other difficulty. The perception of this on the
part of the infant is sufficient to overdetermine the sadistic association.
Biting of the nipple is another variant; striking the breasts another. By
reason of the early predominance of the sucking activity, this oral-erotic
domination makes the nipple-penis connotation of transcendent value.
As the author puts it, “the nipple, in the form of its later double, the
penis, is perceived as the center of one’s own personality, and an injury
to it is felt as a severe injury to the ego itself. The withdrawal of the
nipple is the primitive castration activity.”
Chelmonski, A. PuHysicat NEEpS OF THE SicK IN Hospirtats. [ Pols.
ipazreek., 19). On 19275 | Ay MA. |
In this article Chelmonski is touching an interesting subject, the
importance of the individual care of the sick not only physically but also
psychically. To support his view of the importance of this, he cites
various physiologic phenomena excited directly by the mind, such as the
secretion of saliva and gastric juice from the imagination of savory food.
Chelmonski reiterates the necessity for consideration of psychic influences
on sick persons, especially in hospitals.
Fleury, Maurice de. NErEURASTHENIA AND STATES OF DEPRESSION. [La
Presse Médicale, Vol. 30, July. |
This author goes back to the dialectic psychology of Dubois, holding
that there is nothing more than an artificial dividing line between hysteria,
442 CURRENT LITERATURE
neurasthenia, melancholia, the anxiety neurosis and certain states of
mental degeneration. Neurasthenia is an accidental condition, it suggests
toxi-infection and is not constitutional. Its dominant character is fatigue,
not imaginary, hypochondriacal fatigue, but a real physical depression,
made obvious by loss of tone in the muscles not only of locomotion but
of the vegetative system and by a lowering of function in the endocrine
system. It is a curable disorder and the most appropriate treatment is
to attack the physical side in the first stage and the mental side later.
Unlike melancholia onset is slow, so is recovery and there is little ten-
dency to relapse (a very superficial view of psychogenic dynamics).
Freud, Anna. Bratinc PHANTASIES AND DAy Dreams. [Int. Jl. Psa.,
Voll VeeNos teen
Freud’s well-known paper on a widespread phantasy—a child is being
beaten—is here taken as a foundation for further investigation and
exemplification. The following paragraph is chosen as a starting point.
“In two of my four female cases an artistic superstructure of day-dreams,
which was of great significance for the life of the person concerned, had
grown up over the masochistic phantasy of beating. The function of
this superstructure was to make possible the feeling of gratified excite-
ment, even though the onanistic act was abstained from.” From a variety
of day dreams the present authoress selects one which illustrates this
paragraph. This occurred in a girl of fifteen whose abundant phantasy
life had not brought her into conflict with reality. Her beating phantasy
began at about five years. Its early content was—“A boy is being beaten
by a grown-up person’’—later, ‘“‘Many boys are being beaten by many
grown-up persons. The objects and the misdeeds were indeterminate.
The phantasy was accompanied by excitement and usually terminated in
onanism. The usual sense of guilt found present here also, as Freud
has shown, indicates an earlier unconscious form of the phantasy, of
which the new statement is a modified substitute. In the unconscious
form the “beater” is the father, the beaten, the subject herself. Even
this form is not primary—the beater is the same, the father, but the
beaten one is some one else, a brother or sister, but a rival for the father’s
affection. Thus the phantasy gave to the individual all of the father
and turned on the rival his wrath. When the later repression takes place,
guilt_arises, and the object of the punishment is the child herself. The
pregenital anal-sadistic phase makes the beating a symbol of being loved.
The third phase has the libidinous excitement, the sense of guilt and the
latent content ‘“ My father loves only me.” In the present case the sense
of guilt was chiefly directed against the masturbatory activity. For years
the little girl sought to separate the two components and tried to over-
come the “habit.” Now began a phase of elaboration of the phantasy
to prolong the permitted aspects and to delay the tabooed climax. Insti-
tutions, schools, reformatories, complicated rules were elaborated. The
beaters were usually teachers. Much embroidery of the situations was
SYMBOLIC NEUROLOGY 443
constructed with the gradual growth of increasing moral standards the
whole phantasy was subjected to greater suppression. Self-reproach,
pangs of conscience and a short period of depression followed each
“climax,” which had begun to be preceded by and followed by a sensation
of “pain.” At about the age of eight to ten a new type of phantasy
arose—“ nice stories” she called them. They contained pleasurable ele-
ments and kind considerate behavior. The figures now were determinate
—they were no longer concealed as in the previous “bad” phantasies.
These new phantasies became most strikingly complete and elaborate.
The climax of each situation was accompanied by a strong feeling of
pleasure, but there was no autoerotic act and no sense of guilt. We
now had an artistic superstructure which had grown up over the maso-
chistic phantasies of beating. The patient had no idea of the relationship
and separated the “nice” from the “ugly” phantasies very definitely.
Whereas all individualities were hidden in the “ugly” phantasies, the
analysis of the people of the “nice” phantasies brought out a number of
significant details. These she would discuss—she narrated these “ con-
tinuous ”’ stories with different plots and different figures with gusto. One
of these was the prototype as it were. This plot apparently was borrowed
along about fourteen from a medieval romance found in a boy’s story book.
She took up the thread, elaborated it and dealt with it as if it were her
own. It was later found impossible to dismember the original from her
own creation, which in the main was: A medieval knight has for years
been at feud with a number of nobles who have leagued together against
him. In course of battle a noble youth of fifteen (the then age of patient)
is captured by the knight’s henchmen. He is taken to the knight’s castle
and there kept prisoner some time, until at last he regains his freedom.”
This is used as an outer framework for her day dream, which may be
altered at will in its different integers. Two figures remain fairly con-
stant. The noble youth and the harsh and brutal knight. The two char-
acters are worked out in great detail.
The prisoner’s fear and fortitude while undergoing all sorts of violent
threats are felt with great excitement and at the climax, when the anger
and rage of the torturer are changed into kindness and pity, this excite-
ment resolves itself into a feeling of pleasure. These phantasies might
occupy a few days or a few weeks in their coming to the denouement.
This knight and prisoner day dream on close inspection was a very
monotonous type of affair. Strong and weak: misdeed of the weak which
puts him at the mercy of the other—the latter’s menace, apprehension—
with much prolonged elaboration and final solution by pardon and har-
mony. This is all there was in all the many elaborate situations in her
nice stories and their relation to the beating stories is quite obvious. The
solution was altered, reconciliation took the place of beating, otherwise
they remained much the same in principle as closer study revealed. Oc-
casionally the two types of stories would be intermingled, the beating
scene serving as a vehicle to lead up to the onanism which occasionally
444 CURRENT LITERATURE
‘
broke through. The function of the “nice” story as a sublimation of
its predecessor is made quite clear.
In a third section the evolution of a continued story is traced. The
patient finally wrote down a version of the day dream in which the pre-
vious repetition of the single events was abandoned to a longer and more
elaborate recital of the event, the climax being achieved gradually.
Writing the story was held to be a defense to the overindulgence of the
day dream, which as a fact did actually fade away. But this is not quite
explanatory and the writer concludes that the author gradually acquiesced
the point of view of the reader. She began to renounce her private
pleasure in favor of the impression she could create in others and she
turned from an artistic to a social activity, and thus found her way back
from the life of imagination to life in reality.
Tendeloo, N. P. LocarizaTIon oF CoNnsciousNEss. [Deutsche med.
Woch., Vol. 49, Sept. 21.]
(a9
Tendeloo says that “a completely uninjured constellation of all the
psychic factors is indispensable for clear consciousness.” It presup-
poses a connection between all the psychic centers. A severe disturbance
occurs only with extensive lesions.
BOOK REVIEWS
Dorsey, George A. Wuy WE Benave Like Human BEINGS.
| Harper and Brothers, New York and London. |
The author of this most delightful book was once a professor of
anthropology and a curator of anthropology in the Field Museum of
Natural History. The museum habit has been raised to a high
degree of service, for here is a veritable “museum of life” with a
most amiable, informed, and amusing guide. He opens showcase
after showcase, all nicely arranged and in order. He even starts
with the nebular hypothesis and traces the whole developmental his-
tory of what has been built into man in the course of a billion years.
Although the showcases are packed and the labels almost confusing
in their profusion—they must be pretty thick for the uninformed
reader—yet there is a piquancy in the short descriptions and a whim-
sicality as one is prodded along the shelves that holds the attention
and makes this book what it is, the most attractive and fascinating
account of human origins, structures, and behaviors that has appeared
in many a year. Here and there an evident distortion appears, but
the narrative possibly runs all the smoother for the bit of romance.
Then again the author glosses over the surface. ‘This again is in
the interest of his readers possibly—for they are mainly nonspecial-
ists. And specialists are usually so stodgy. This superficiality
expresses itself in a too strict patterning after certain poster brands
of behaviorism in the psychological showcases. We are personally
intrigued in his neo-Lamarckian attitude—for we have put it to our-
selves for a score or two of years, Where did the evolution come
from if not from inner push, environmental variety, and the making
of new structures? His cracks at Weissmann are, we believe, all
deserved, as if the germ plasm were any holier than any other plasm
and not connected with the nerve net. He clears up a lot of bunk
about biology, using the word itself, we are glad to see. A trace of
sloppy sentimentality shows in the endocrine section; here a bit of
romancing dresses up these mystics in bizarre costumes. If the
collection had been arranged in a different plan we are disposed to
believe we could see cheek by jowl these conceptions along with the
Galenic humors and the Egyptians’ use of the liver in divination.
The endocrines don’t crack the whip—the cravings for freedom, for
creativeness crack the whip, and the endocrines offer certain early
bits of transforming machinery to respond. In the worms the
adrenals (chromaffine cells) were all over the, place, as Gaskell, Jr.,
has shown. What neurobiotaxic principles caused aggregates of
endocrine cells to form would make a study in extensions of Kap-
per’s work upon certain nerve cell combinations of transcendant
[445]
‘
446 BOOK REVIEWS
interest. Going through any carefully arranged museum starts a lot
of inquiries—this charming book is no exception.
Freud, Sigm. PSyCHOANALYTISCHE STUDIEN AN WERKEN DER
DicHTUNG UND Kunst. [Internationaler Psychoanalytischer
Verlag, Wien, Leipzig, Zurich.| |
The modus of those inner constructions which lead to the pro-
duction of literature or art, such as poetry or as painting or sculpture
has always been a matter of curiosity to the outsider, as well as to the
producer himself. Practically all poets and painters of distinction
have formulated their ideas as to how these promptings have arisen,
and the onlookers, technical biographers, or curious savants have
spilled oceans of ink in formulating their conceptions as to how it is
done.
Correspondence courses can tell us “ how to be a ‘ poet’ in twenty
weeks,” but of such is not the kingdom of Apollo.
Freud has taken some side excursions into the domain of the
unconscious relative to this general situation. They have been scat-
tered throughout his writings during nearly twenty years. Hence
this volume, which aims to bring these together, unaltered, thus pre-
senting his method of study in a clearer light and giving a better
outline to the results obtained.
The general thesis that such activities arise from the unconscious
is as old as the hills. This Freud knows perhaps better than anyone
else, but he was interested to know where the energy came from and
why in this or that individual it created poems, painted pictures, or
cut marble images, and what of the particular form taken by these
energy carrying vehicles. Why in this case joyous, or sad, and all
of the possible variations crowded upon book shelves or hanging
tpon walls or collected in open or closed spaces?
To correctly appraise these studies they should be read. No
review can even do more than mutilate the essence of their subtlety
or the measured ease’ of their presentation. These studies are doubly
welcome in this collected volume.
Masson-Oursel, Paul. ComMparATIVE PuHiILosopHy. With an
introduction by F. G. Crookshank. [Harcourt, Brace & Company,
New York. |
Dedicated to Lévy Bruhl as his “ master” the present work, one
of the stimulating volumes issued under Ogden’s editorship as the
“International Library of Psychology,” is unique. The present
reader does not pretend to review it. One would have to be a poly-
histor, a universal linguist and deeply versed in all of the philosophies
of the world to pass judgment upon it.
Some few points arrest our attention. The much despised “ rea-
soning by analogy” is rightfully put into its positive frame in spite
of stuffy pseudologicians. It is surprising how much valuable devel-
opmental material the author gets out of the many philosophical
systems through its use. Even more fascinating are the chapters
BOOK REVIEWS 447
upon comparative logic, comparative metaphysics, and comparative
psychology.
This is avowedly an introduction only, as the author terms it,
an interlocutory examination into the content of the philosophical
evolution in the civilizations of Europe, India and China by the use
of the comparative method.
The author shows us that the use of analogy such as he has
defined it, is neither arbitrary nor fallacious; and that without mini-
mizing the specificity of facts it is permissible to formulate judg-
ments of the following order: “ Confucius played in China a role
comparable with that which Socrates filled in Greek thought; Bud-
dhaghosa rendered to Buddhism the same service that St. Thomas
did to Christian faith. Facts which we had supposed belonged only
to Europe have been recognized to be endowed with a certain gen-
erality; by comparison we are able to sort out that which the dif-
ferent sophisms and scholasticisms have in common from that which
is particular to each: our interpretation of these facts, even in so
far as concerns Europe, is thereby modified.
On the other hand, this renewal we call the Renaissance stands
out as an event proper to our western civilization alone. The com-
parative method would appear to be valid, since it extends, defines,
transforms and revises our knowledge.”
Brugsch, Th., and rene F. H. Di BIoLoGiz DER PERSON.
Marana ae Lieferung. 2 , pp. 323-748, 125 illustrations, 1 table.
Urban & Schwarzenberg, Berlin and Vienna. |
In this the second section of Vol. 1 of this important Handbook
of a General and Special Study of the Human Constitution, a sec-
HoneOrmoUU0u pages uthere sare (but four chapters. Dr. G: Just of
Greifswald writes upon Special Human Heredity; Dr. W. Lubosch
of Wurzburg discusses individual anatomy, separating it from
Racial Anatomy and Variation Factors, inquiring into its nature,
the nature of twins and developmental factors within the individual.
Dr. G. Mittasch of Dresden contributes a stimulating chapter upon
Individual Pathology and Disease in General, while the last chapter
by Dr. F. Schiff of Berlin takes up the relationships of the Personal
Constitution and the capacity or disposition to infection in general
and in particular.
Since the overwrought enthusiasms of medicine since the rapid
rise of chemical and bacteriological analysis in the past 50 years
had swung too far into an exclusive consideration of exogenous or
environmental factors in the causation of disease, it is a healthy
sign to see this swing back to a knowledge of the balanced relation-
ships of outside and inside factors. For this work, although thus
the effort is intent upon the setting forth of inside or constitutional
agencies, the program is larger and will include interactionism as the
last two chapters indicate.
Here we can only point out the intellectual feast that is being
set before us. We hope to give an extended series of comments
as the volume comes to a close. Certainly, in recent times, no fuller
448 BOOK REVIEWS
table has been offered, and served by special workers well qualified
in their respective capacities. Our enthusiasm for this work mounts
with each new chapter studied. Here are solid gnostic acquirements
with an open outlook towards future possibilities. This is no closed
system but a going concern.
Pruette, Lorine. G. STANLEY Hatt. A BioGRAPHY oF A MIND.
[D. Appleton and Company, New York and London. |
Carl Van Doren in his charming introduction says, “ Perhaps
we Americans, with our republican partiality for simple characters,
are specially in need of the study of more complex types, such as
President Hall belonged to. As a nation we are very unfamiliar
with them, our history lacks them, our literature lacks them, or has
lacked them until lately.” There is some truth in this although
perhaps we prefer to say that there are plenty of opportunities for
Americans to exhibit a greater richness of complex reaction types
if we were not hedged about with so much puritanical prudery with
its resultant hypocrisy. “ Simple characters ’—this is the bunk. Most
of us are afraid and hence conform to a monotonous mode which -
is called “simple.” Those that do explode are often so” Bizarre
that perhaps the model of Little Men and Little Women were pref-
erable. Beer in his “ Mauve Decade” has pilloried this “ simplicity ”
and this “ hypocrisy.”
Stanley Hall was one of those men of strength who dared defy
the current traditions. ‘The titanic struggle he made with intellectual
bossism is a revelation of his character and is enough to make one
go Bolshevik at certain tendencies in educational circles.
But of the man himself, his early struggles,—the playboy of west-
ern scholarship our author aptly terms him,—no one can fail to love
him after reading this delightful portrayal of his activities and insight
into his life. Here is a biography that is worthwhile, of a man, who
stands out in the history of education of this country as a giant, and
a human being.
Dide, Maurice. INTRODUCTION A L’ETUDE DE LA PSYCHOGENESE.
[Masson et Cie, Paris. ]
Subtitled an Essay upon Psychobiological Evolution one turns
to this work with anticipations of pleasure and profit. In the intro-
duction we are told that psychology becomes more and more depend-
ent upon experimental science and clinical methods and opposing
schools are merging since they are beginning to draw their materials
from the same source. He believes that a psychiatrist can construct a
philosophical hypothesis from the material with which he works.
Psychology is becoming more and more a neuropsychiatry. Psycho-
logical synthesis can no longer be expressed without the aid of the
vegetative system, including therein the endocrine activators. The
feeling life of mankind incorporates the syntheses of the sympathetic,
the medullary, mesencephalic, cerebellar and cortical activities. No
real “ normal” psychology is possible without the aid of psychiatry.
BOOK REVIEWS 449
On last analysis psychology has to go back to energic sources for
a complete statement. Hence the author begins his book with a
chapter on physicochemical researches. Biological Researches fol-
low upon this foundation. Radiant and convergent energy are the
terms the author uses in the upbuilding of his thesis. ‘ Instinct”
affinities are a later arriving stage. To the elaboration of this idea a
chapter is devoted. There are some interesting generalizations—
old, but in a new phraseology, reminiscent of the bipolar energy
potpourri of Crile, but simpler and more Heraclitian.
Chapter III deals with the “ Elan Psychogenetique ’—otherwise
inner feelings or affectivity. Here Eppinger and Hess do service
and the organic substratum of the emotional life is stressed. Neuro-
vegetative anomalies are brought into the clinical picture as protein
shocks, etc., thus epilepsies and other periodic and cyclic phenomena.
This is but a brief glance at this interesting little book of specu-
lations, fruitful and intriguing. There are but 200 pages and we
will certainly gain some striking appositions of thought in its reading.
Roheim, Géza. SocrAL ANTHROPOLOGY. A PSYCHOANALYTIC
STUDY IN ANTHROPOLOGY AND A HIstTory oF AUSTRALIAN
TotEemMism. [Boni and Liveright, New York. |
On the surface of things it might seem that a work of this kind
could be left only for those students of the history of mankind
whose special field has been termed anthropology. While this may
be true for certain anthropological treatises it is not true for this
one. It can no more be neglected by the neurologist and psychiatrist
than could Frazer’s great classic, the Golden Bough. In fact for
such it is even more important, for while Frazer’s work will remain
one of the most enlightening and stimulating works upon the his-
torical development of man’s customs and behavior the present work
goes beyond the purely historical methods of research and through
the labors of an interpretative psychology enters more deeply into
the origins of these same customs and social activities. Thus by the
comparative method of study of the unconscious of present day
mankind as revealed successively from top to bottom in his artistic
creations, his day-dreams and those of the night, the dissolutions of
psychotic behavior, the history of ceremonial, of custom, the utiliza-
tion of symbols as magic instruments to carry out his inner cravings,
all of this meets in some inner nucleus of biological activity. From
this spring of the unconscious flow all of the activities that we
speak of as social.
It is to the investigation of these underlying strata of man’s evolu-
tionary development that the author turns our rapt attention.
Australia has well been called the home of fossils. A fauna and
a flora that is extinct for the rest of the world exist in this isolated
region. Just so the earlier rudiments of many of man’s customs,
now semidissolved in complex considerations in later developing
stages of societal behavior, here in Australia the dissociated rudi-
ments exist in pure culture. They thus offer particularly enticing
450 BOOK REVIEWS
material for the understanding of later changing forms. Here is
an open ontological chapter in the book of human life and Roheim
has made it a profitable field for research. Here the intimate rela-
tionship between the observances, the ritual of primitive man and
our own mental mechanisms are carefully laid bare, whilst the man-
ner in which primitive customs and modes of thought stray into our
own civilized life in the form of folk-lore and fairy story are
richly portrayed.
No one, as Dr. Eder says in his delightful introduction, “can
deny the skill with which Dr. Roheim has presented his vast wealth
of material; the patience and persistence with which he has sought
to substantiate every statement; no detail 1s regarded as too trivial
or too obscure to escape adequate notice; every statement receives
corroboration from all available sources. Every theory advanced
is based upon an exhaustive and unprejudiced exposition of the
facts, and of all the facts. Dr. Roheim is always careful to point
out gaps in our knowledge and weaknesses in the structure that
require strengthening or even replacement.
Dr. Roheim brings zeal, a rich store of knowledge, a trained
scientific imagination to bear upon the solution of the seemingly
baffling problems found in this strange story of man. He follows
up every clue with a penetrating insight that, without losing any
detail, never gets out of touch with the main issues.”’
Watson, John B. BenHAviorism. |The People’s Institute Pub-
lishing Company, New York. | |
In this series of popular lectures the author reiterates his well
known position in relation to psychology. As a protesting student
of things scholastic one is reminded a bit of the Soviet cleaning out
of the old régime. One wonders whether a surreptitious use of
the older ideas under camouflaged names will not be the result. This
we believe will occur with the author’s rejection of the concept of
instinct. Action patterns, types of structure, etc., in what sense
these newer terms really differ from the older despised teleologies
and entelechies, or the midway tropisms, instincts, etc., all reside
in the intelligence of an individual taught that etymologies are after
all different from actions and that all definitions are but provisional
tools for cutting into the realities of life. Watson gives us no
better conceptions to work with after he has dumped overboard
the admittedly inadequate definitions—for as F. C. S. Schiller has
reminded us that a “true definition must contain all that is knowable
of a thing, and who among us can flatter ourselves to know every-
thing about anything.” We would have liked to see a better series
of portrayals of “instincts” rather than their replacement by the
grossly mechanistic theses here portrayed. Even a Watsonian Be-
haviorist I think will agree with the thesis that it is no armchair
deduction to say that seeking mates and food constitute the chief.
activities of the entire living phylum. It “seems to me,” as Mr.
Heyward Broun would put it, that to generalize these activities
BOOK REVIEWS 451
behind the terms of the instinct of race continuance and the instinct of
of self-preservation is as good a form of mental tool with which to
summarize and thus intellectually handle the phenomena as any other
as yet devised. Only a moron would imagine that by the term
‘instinct "’ thus used we are making another anthropomorphic God.
Naturally such an atrocious anthropomorphism is no longer needed
in psychology, but I suspect it is the Behaviorist who would create
such a straw image and through this maneuver bring it into dis-
credit and thus seek to dethrone it from psychology.
The lectures are very discursive, a hodge podge in places, not
carefully evolved in others, but always readable and to be judged
with one’s tongue in one’s cheek—a bit.
Helson, Harry. Tue Psycnorocy or GrestaLtt. [American Jour-
nal of Psychology, Ithaca, N. Y.|
The author, an instructor in psychology in the University of
Illinois has contributed to the American Journal of Psychology an
interesting and thoroughly comprehensive series of critical papers
upon the new Configurational om Gestaltersychology. These. are
here available in reprint form and offer one of the most succinct
and valuable résumés of this movement in contemporary psychology.
Homburger, August. VoRLESUNGEN UEBER PsyCHOPATHOLOGIE
DES KINDESALTERS. [-Julius Springer, Berlin. |
A whopping big book is the realistic phrasing that comes to
consciousness, as one cuts through, later thumbs, and then reads here
and there in this 49 lecture, 850- page work devoted to the psycho-
pathology of childhood. Although there pops into the reviewer’s mind
a remark once made by Cattell at a meeting of the American Psycho-
logical Association to the effect that a child playing for five minutes
in the sand—the meeting was at some seaside resort—would afford
material enough for the work of their association almost for per-
petuity. Fortunately this ideal of minute description of childhood’s
behavior has not obsessed the writer, although the 850-pages make
one wonder if it could not have been said less bulkily.
The work opens up with chapters upon development, practice,
habit, association, action and mental order. Methodologically the
author allies his thoughts here with such thinkers as Husserl, Jas-
pers, and includes some of the conceptions of the newer configura-
tionists such as Koffka and Koehler. Three lectures develop the
themes just mentioned. Then follow eight lectures upon feeble-
mindedness, including the methods of testing intelligence, one lecture
upon etiology, one on Mongolism and Cretinism and two well planned
lectures upon the training of the feeblemindedt Six chapters now
follow upon the feeling life of children and the development of their
relations to the environment. This naturally leads up to the child’s
conflicts, to which two lectures are devoted. The so-called psycho-
pathic character, or constitution is a direct derivation and then the
author deals with nervous children, anxious, fearful children, weak
452 BOOK REVIEVES
and careless children, those poor in their feeling life, those that are
irritable. Then lectures follow upon hysteria, compulsion neuroses,
the sensitive child, the only child, infantilism and the psychopathic
peculiarities of encephalitis epidemica. Chapter 30 deals with manic-
depressive and cyclothymic children, children’s lies, pathological lying
and phantasy formation, those that run away, tics, enuresis, suicide,
criminality—these have special chapters. Freud’s conceptions are
dealt with in two lectures. Puberty, the epilepsies, five lectures,
schizophrenia in childhood and juvenile paresis. This about com-
pletes this extremely interesting and genuinely valuable book.
Krutch, Joseph Wood. Epcar ALLAN Por. A StTuDy IN GENIUS.
[Alfred A. Knopf, New York.]
The Poe tradition still affords enough substance to make new
books of which the present is by no means to be neglected.
In the first place it gives an excellent picture of Poe, one that is
sympathetic and yet not sentimental nor maudlin; nor in the harsher
tones of criticism, not by any means absent, is the author senten-
tious or overbearing.
Finally as to the psychological interest the author has partly
entered into the spirit of an understanding of the unconscious
processes but touches upon them ever so lightly. Perhaps this is
wiser since a true analytic research might be too stodgy and this
after all is a work for the lay audience. It is not without interest
to the psychiatrist—and to such Poe has always been an alluring
figure.
Hillyer, Jane. Retuctantty Torp. [The Macmillan Company,
New York. ]
It so happens that we have been struggling with a huge scientific
German tome, “ Selbstschilderung der Verwirtheit,” by an assistant
in the psychiatric clinic of Heidelberg and turn to this work to find
much the same kind of material in quite a different form. It is
an autobiographical sketch of the sensations, ideas of a woman
passing through a psychotic attack. It can be arranged with Maupas-
sant’s H’Ourla, or James’ Turning of the Screw, or Stetson’s The
Yellow Wall Paper, in literature. Dr. Collins who writes an intro-
duction compares it with Gerard de Nerval’s Le Réve et la Vie,
and makes some medieval comments about “ insanity,” an abstraction
now relegated to legal usage. |
Under quite appropriate subtitles the authoress gives an impres-
sion of her mental travail: A. Locked Door, The House of Dis-
tortion, The Tight Rope and the Ring. Here one can follow the
tension, the dissociation, the tenuous hanging on to some semblance
of ego function and a final compulsive defense mechanism which
would wall up the spiritual abscess and prevent self-destruction.
None of this is discussed in the introduction. It might have rendered
this spiritual autobiography as illuminating from the scientific side
as it is interesting from the human aspect.
BOOK REVIEWS 453
Sachs, B., and Hausman, L. Nervous ANp MENTAL DISORDERS
FROM BirtH THROUGH ADOLESCENCE. [Paul B. Hoeber, New
York. |
This work, which the senior author would have it clearly under-
stood, is not a new edition of his older work of similar title but is
an entirely new book. It may conveniently be divided for the
reviewer's purposes into three sections. An admirable section upon
the anatomy of the nervous system. Admirable in its succinct com-
pression but quite unnecessary in view of many excellent works more
adequate for the purposes even of such a work. ‘There are about
eum@dreepacesworetiisem ine bulk of the book, for it is*bulky,
860 pages, is made up of what the authors call organic diseases of
the nervous system, functional and toxic diseases, endocrine dis-
orders and vasomotor and trophoneuroses. ‘This takes us to page
715. The remainder of the book, about 100 pages, deals with mental
conditions.
In general our idea about the book is that the opening chapters
are adequate—but superfluous—especially since the anatomical
foundations or classifications have been almost entirely abandoned
in favor of a purely clinical grouping. The second section is ortho-
dox and excellent. The descriptions are clear and definite, at times
a little too definite possibly. This gives them pedagogic advantages
but hardly indicates the movement of thought and research. To
our minds the conception of “diseases” is a trifle scholastic and
structural, instead of being moulded upon more functional and
dynamic lines. The retention of the older notions of the antithesis
of “functional” and “organic” exemplifies this, and the general
grouping, admittedly a difficult matter, does not keep the student to
a larger unitarian view of the organism as a whole with its modifica-
tions of function.
The chapters upon mental conditions are far from satisfying.
Here lack of functional thinking gives a dogmatic presentation which
is much to be deplored. This dogmatism centers about the scholastic
notion of “normal.” We read of the “normal child” and “ normal
youth ” and find a marked weaving of autobiography with the pres-
entation of what would better be objective evidence. The chapter is
well done and for the most part restrained but the blurb upon
psychoanalysis, with which it terminates, is so autobiographical of
the senior author that it makes one wonder if he really understands
sympathetically any other type of personality than his own. Apart
from this smudge we see this work as a very sincere and valuable
contribution. Apart from the overemphasis upon gross structural
disorders and the underemphasis upon the tenfold more frequent type
of behavior problems which confront the physician in touch with
infants and adolescents the work is to be highly commended.
OBITUARY
fxn to hie Seneca Ne
ROBERT HENRY COLE, M.D., F.R.C.P. Lonp.
The death of Dr. Cole, which occurred August 10, 1926, removes
a much respected authority on mental disease from the ranks of
London consulting physicians.
Robert Henry Cole was the eldest son of the late Mr. R. C. Cole
of Ealing, and was born in 1866. He was destined for the Civil
Service, and for a short time worked as a clerk in the India Office
He qualified in medicine, nevertheless, at the age of 23, and after
holding a house appointment at St. Mary’s Hospital, took up the
special study of psychiatry to which the rest of his life was devoted.
Thirty-six years of association with Moorcroft House began with
his appointment as resident physician soon after leaving St. Mary’s,
and in the years during which he held this post he won a high repu-
tation for clinical skill and for the helpful care which he bestowed
on his patients. He always made remarkably good use of his time;
he read a great deal and he was keenly interested in his specialty.
In 1907 he began to engage exclusively in consulting practice, and
soon afterwards was appointed physician for mental diseases to
St. Mary’s Hospital and lecturer in the medical school. He later
became an examiner in mental diseases and psychology in the Uni-
versity of London, and held several other appointments, including
those of Home Office Visitor to the State Inebriate Reformatory at
Aylesbury, visitor to the approved institutions for the mentally de-
fective in Middlesex, and lecturer in mental diseases at Bethlehem
Royal Hospital. His considerable experience is embodied in the
well-known textbook on mental diseases which he wrote—now in its
third edition—whilst his knowledge of, and sympathy with, modern
views on psychology and treatment were shown in his presidential
address to the Section of Psychiatry of the Royal Society of Medicine
recently published in our columns. This thoughtful comment on
the progress of the last thirty or forty years is evidence of a wide
outlook, and is written in his characteristic style.
For the Royal Medico-Psychological Association Dr. Cole did a
great deal of painstaking work. At the time of his death he was
[454]
OBITUARY 455
chairman of the Parliamentary Committee of the Association, in
which office his acquaintance with the legal relations of insanity were
very valuable. Intimate knowledge of the history of lunacy legisla-
tion enabled him to offer wise counsel, and the Association owes
Rosert Henry Core, M.D., F.R.C.P.
a great deal to him. “ His place,” writes one of his colleagues, “ will
be hard to fill. Those who knew him will miss his genial and kindly
presence. Unchanging loyalty was the most striking feature of his
friendship. He always gave unsparingly of his best, and was ac-
456 OBITUAKN
customed to take immense pains with his patients, on whose behalf
he labored without counting the cost in time and trouble. And his
younger colleagues would seek his advice constantly, knowing that
he would appreciate their problems and help them in every possible
way.
Dr. Cole leaves a widow, a son, and a daughter. [L. Lancet. ]
Professor Leonardo Bianchi of Naples died February 13, 1927.
Also Professor d’Abundo who succeeded the chair of Professor
Bianchi. Obituary notices will appear ina later issue of the JOURNAL.
N. B.—All business communications should be made to Journal of
Nervous and Mental Disease, 64 West 56th St., New York.
All editorial communications should be made to Dr. Smith Ely Jelliffe,
Managing Editor, 64 West 56th St.. New York.
Vor. 65 MAY No. 5
The Journal
OF
Nervous and Mental Disease
An American Journal of Neuropsychiatry, Founded in 1874
ORIGINAL ARTICLES
REFLEXES IN APES
By G. D. AronovitcH, M.D.
NEUROLOGIST AT THE METCHNIKOW HOSPITAL, LENINGRAD, RUSSIA
The biogenetic trend in neuropathology has led us to consider the
data of comparative anatomy and physiology. The evidence obtained
in this field enables one to explain a series of clinical facts from the
evolutional viewpoint and thus makes it possible to trace the phylo-
genetic development of some of the reflexes in man. We believe that
many of the symptoms found in nervous syndromes are none other
but manifestations of evolutional regression, that is of a lowering
of the nervous system to a lower level of functioning. Thus, for
instance, the symptomatology of lesion of the central motor neuron or
the so-called “ pyramidal” symptoms characterize just this lowered
stage in the functional development of the central nervous system,
when there appear a series of reactions peculiar to a lower animal
organism.
In order to determine the biological nature of both normal and
pathological manifestations of the nervous system in man compara-
tive physiological data are indispensable. My present work 1s a
result of this attempt and in it I selected as material for my neuro-
logical investigations apes, since they stand nearest to man in the
evolutional scale of the animal world. I do not expect my investiga-
tions to be considered as final. We have accumulated but the facts
which were of neurological interest to us from the clinical viewpoint.
I started my investigations on apes in our Zoological Gardens in
Leningrad (3 Maccacus rhesus, 1 mongoby and 1 female orang-
outang of four years old), and then proceeded with the most 1m-
portant part of my work in the “ Affenhouse”’ of the Hagenbeck
Zoological Park in Hamburg. The total number of apes subjected
to investigation was 23 (14 Maccacus rhesus, 2 baboons, Cino-
[457]
458 GD AKRONOVITCH
pithecini, 4 mongoby, I orang-outang, 2 lemurs, Cat), their age
varying between two to four years. The methods applied to the
apes were those methods of neurological examination accepted in the
clinic. Here I once more wish to emphasize that this work is nothing
but an experiment in comparative neurology.
Now let us give our attention to the cranial nerves and their
reflexes in apes.
Pupillary reaction to light, direct and indirect: A stimulation
of the pupils by means of any source of light (personally I used
for the purpose an electric pocket lantern) always produces a reflex
contraction of the pupil in apes. This direct reaction 1s always ac-
companied by an indirect one, that is by a simultaneous contraction
of the other pupil.
Pupillary reaction to convergence: This reaction may be ob-
served in apes when one has succeeded in fixing its gaze by showing
it at a distance some shining object, say a percussion hammer, and by
rapidly approaching this object to the ape’s nose. Then a distinct con-
traction of both pupils is observed with a simultaneous convergency
of both ocular axes towards the middle line.
We succeeded to produce in the apes (subjected to our investiga-
tions) the following mucous reflexes.
The corneal reflex: A slight touch on the cornea by means of a
piece of paper or cotton produces a reflex closing of the eyelids. A
similar motor reaction that is a rapid closing of the eye is produced
in apes by touching the conjunctiva of the sclera with a piece of
paper. This is the so-called conjunctival reflex. The nasal reflex,
which is produced by a mechanical irritation of the mucosa of the
nose with a piece of twisted paper or a feather and manifests itself
in a puckering of the nose and motions similar to sneezing also be-
longs to the group of mucous reflexes. Further I succeeded in ob-
serving in apes a reflex caused by an irritation of the external ear
passage. By irritating the walls of the external ear passage with a
piece Of paper, a match or a feather—a contraction of the face
muscles is produced—a closing of the eyelids, a motion of the cheeks
and even a drawing away of the head. This protective reflex is very
brisk and constant in apes.
I also verified McCarthy’s supraorbital reflex, Bechterew’s Augen-
reflex and the nasopalpebral reflex (Guillain) as being among the
periosteal facial reflexes present in apes. The supraorbital reflex is
always produced in apes by a percussion in the regio supraorbitalis
but outside the region of m. orbicularis orbite. The percussion not
only results in the contraction of this muscle on the side stimulated,
REPLEXES IN. APES 459
but also produces a cross-wise muscular reaction, 7.e., a contraction
of M. orbicularis oculi on the other side and is followed by a slight
closing of both eyes. The nasopalpebral reflex, which in its periosteal
nature, its reflexogenic zone and in its motor effect is identical with
the supraorbital reflex is of the same constancy in apes. The naso-
palpebral reflex is produced in apes by a percussion with a hammer
on the nose at its base. This produces a reflex reaction which mani-
fests itself in a rapid closing of the eyelids, 7.e., a symmetrical and
bilateral contraction of m. orbicularis orbite. From the anatomo-
topographical point of view these muscles in no way differ from the
same muscles in man. Thus for instance this reflex is one of the
motor components of a more generalized periosteal reflex as
Simchowicz’s Nasenaugenreflex or Astwazaturow’s nasolabial reflex.
While obtaining these reflexes in order to avoid any protective
reflex movements of the animal, which also manifest themselves in
a closing of the eyelids when some object is rapidly and suddenly
approaching toward its eyes—réflexe de défense, opticofacial or
opticopalpebral reflex, Bedrohungs reflex,—I usually asked my as-
sistant to cover the animal’s eyes with his hand at a right angle
towards its forehead and besides I gave it a light hit with the percu-
tory hammer from above, on the side of the forehead.
The study, or more correctly speaking, the verification of the
abdominal reflexes in apes was of particular chnical interest to us.
I applied for this purpose the usual technique, consisting of stroking
the skin of the abdominal wall, which corresponded to the upper,
middle and lower abdominal reflex areas. During the experiment
the animal was either laid flat on its back with bent hind (lower)
extremities or was seated in a semi-reclining posture, being supported
by my assistant. Thus a complete relaxation of the belly muscles
was attained. In none of the examined apes could I produce the
abdominal reflex, 7.e., a contraction of the belly muscles in reply to a
skin irritation such as are observed in man. Nevertheless the
morphological structure of the abdominal wall muscles does not
differ materially from the same structure in man. We find in apes
the m.m. recti abdomin., obliquus, extern., intern., transversalis ab-
domin, with analogical fixations and functions. Besides these surface
abdominal reflexes (or skin reflexes) other deep abdominal reflexes
have been lately noted in man. These are—the periosteal reflex or
réflexe médio-pubien (Guillain, 3) and the téndo-abdominal reflexes
(Astwazaturow,4; Triumphow,5). Both these reflexes are almost
identical and have been suggested by the different authors quite
independently from one another and almost simultaneously. Reflexre
460 GD. ARONOVITCH
médio-pubien or the periosteal reflex results from a percussion on
symphysis pubis and causes contraction of the abdominal wall muscles
and an adduction of both thighs in man. According to Guillain this
reflex consists of two effective parts: the upper and the lower. The
first consists in the contraction of the belly wall muscles (m.m. recti
abdom. and obliq.) the second in a symmetrical contraction of the
adductor muscles (m.m. adductores, pectinei) of both thighs caused
by a percussion on the symphysis ossis pubis. In apes a percussion
of the symphysis pubis produces only a reflex motor reaction on the
part of the hind extremities—an adduction of the thighs, but the
abdominal muscles do not contract. Thus in apes the réflexe médio-
pubien consists only in its lower component, that is the motor
reaction produced by a percussion on the symphysis pubis manifests
itself only in an adduction of both thighs which are also somewhat
rotated inward, whereas the upper component of this compound
reflex—the contraction of the belly wall muscles—is absent. In
order to excite the réflexe médio-pubien it is best to place the ape
lying on its back or in a semi-reclining posture, with the hind extremi-
ties slightly bent in the hip and knee joints with a slight rotation
outwards, the assistant holding the animal by the upper (front)
extremities. Then the reflex may be observed most distinctly and
one is able to see the contraction of m.m. pectinei, adductores. As
regards the tendo-abdominal reflex (Astwazaturow, Triumphov)
which is identical with the réflexe médio-pubien it is elicited by a
percussion on the tendons of the abdominal muscles in the region of
lig. Pouparti and Tuberculum pubicum and consists in man of a
contraction of the abdominal muscles (chiefly m. rectus abdomin. and
the oblique muscles) on the side of the body subjected to the
stimulus. This deep tendo-abdominal reflex (Astwazaturow) cannot
be obtained in apes. My repeated and numerous observations enable
me to affirm that the abdominal reflexes—hboth the superficial skin
reflexes and the deep periosteal and tendinous reflexes—are absent
in apes of breeds which were subjected to my investigations.
This fact seems to us to be of great interest from the evolutional
viewpoint and may serve to confirm the correctness of our point of
view with regard to the nature of the abdominal reflexes in man,
which is described in detail in Professor Astwazaturow’s,(6) Arono-
vitch’s (7) and Triumphov’s articles. The phylogenetic data ob-
tained—leaving aside the ontogenetic data—also makes us believe
that the appearance of the abdominal reflexes in man stands in rela-
tion to the acquisition by the human body of the erect posture, with
its forming the action of standing and walking on two legs. A mighty
RECLE ARS IN APES 461
reflex mechanism for the abdominal muscles which is capable of
prompt excitation is certainly quite indispensable for these acts as
the abdomen lacks a bony support in front. It is interesting to note
in passing that when our orang-outang attempted to move about in a
vertical posture on its hind extremities and holding on to the bars of
his cage with outstretched upper extremities our attention was drawn
to the fact that its abdomen was distinctly propendant.
The abdominal reflexes (both the deep and the superficial ones )
in man are a manifestation of that particular tone of the abdominal
muscles which had formed during the process of evolution when the
human organism acquired and finally fixed its erect posture, whereas
apes, even the anthropoids, are not yet orthograde creatures and as is
well known chiefly move about as quadramanus animals. Thus it
follows that the abdominal reflexes are phylogenetically new reflexes.
In many of the apes I succeeded to produce the so-called
Bechterewrs costal reflex (9) which is supposed to be a bone reflex
and which is caused by tapping with a hammer or passing the handle
of the hammer along the cartilages of the lower costal arches roughly.
The reflex manifests itself in a contraction of the muscles in the
region of the epigastrii together with a contraction of the intracostal
muscles. This contraction of the intracostal muscles and the notches
of the oblique abdominal muscles, reminding one of the keys of a
piano, when caused by passing with the handle of a percussion
hammer along the costal arches are particularly pronounced and
distinct in lean apes in a condition of inanition. Repeated tests do
not produce a weakening of this contraction which does not seem to
become gradually exhausted as is usually the case with a reflex
action. Personally I am inclined to consider this phenomenon as a
condition of increased mechanical muscular excitation but not a
retlex.
In male apes subjected to my investigations (Maccacus rhesus,
mongoby—the other being females) the skin folds on the anterior
abdominal wall in the inguinal region formed a kind of pocket, con-
taining small testes of the size of a pea or a coffee-bean. The scrotum
was not fully developed and possessed no muscular fibers (1m. cre-
master). Therefore we were not able to produce the cremaster and
scrotum reflexes which may be attributed to an insufficient morpho-
logical development of the scrotum in these apes. Unfortunately
I had not the opportunity to examine representatives of the higher
Simiidae which are said to possess a fully developed scrotum
(Sonntag, 8).
462 G. DOAKONOV IEG
Deep reflexes—the tendinous and periosteal reflexes—of the hind
(lower) extremities are very constant in apes.
The knee reflex. A percussion on the lig, patellae at the lower
edge of the patellae produces in apes a contraction of m. quadriceps
femoris and consequently a pronounced extension of the lower
extremity in the knee-joint. In order to obtain this reflex my assist-
ant seated the ape on his lap with its hind extremities drooping down-
wards, or the animal was placed in a semi-reclining posture with the
extremities bent in the knees and somewhat abducted. In these
conditions, if the ape’s attention is directed elsewhere, a hit with the
percussion hammer on the lg. patellae always produces a vivid
knee-reflex—a straightening of the corresponding extremity. In
some apes a similar test produced simultaneously a crossed knee-jerk.
We also succeeded in producing in apes subjected to our investiga-
tions in a similar posture a crossed knee-adductor reflex—a reflexive
contraction of the adductor muscles of the thigh (m.m. pectin. ad-
ductores( by an irritation (percussion on lig. patellae) of the oppo-
site side of the body, that is by eliciting the usual knee-reflex.
It is not difficult to produce in an ape the Achilles reflex. The
ape is placed lying on its back with the extremities bent in the knee
joint. The foot is subjected to a slight: passive dorsal flexion and
is sustained in this position with the hand. A hit with the percutory
hammer on the tendon of m.m. gastrocnemii thus causes a contraction
of the gastrocnemius muscles and a plantar flexion of the foot. In
apes a mechanical irritation of the skin of the sole produces a typical
seizing action of the foot (extension and opposition of the hallux
with a subsequent flexion of the hallux and the other four toes and
a rotation of the entire foot medially)—but we do not observe in
apes the usual plantar reflex normal in man and consisting in a simul-
taneous flexion of all five toes. In apes the functional activity of the
foot differs but little from the functional ability of the hand. It
possesses the seizing function in an equal degree and therefore an ape
easily clasps any object (for instance a tree) with its foot by abduct-
ing, extending and opposing the hallux to the toes in just the same
way as it does with the front (upper) extremity. The human foot
almost entirely lacks the seizing function. Owing to the anatomical
peculiarities in the structure of the human foot it performs this func-
tion only in a rudimentary manner and this only in early childhood
or in pathological cases of lesions of the pyramidal tract. Babinski’s
symptom which is observed in such cases in reply to a skin irritation
of the foot is a rudiment of this seizing function of the human foot.
REPLEXES IN APES 463
Here the action of the hallux is limited as it produces only the initial
motion (dorsal extension) not being capable of performing the essen-
tial movement of the seizing action (opposition of the hallux) owing
to the absence of a corresponding muscle (m. opponeiis).
I shall not deny that my neurological investigations of apes were
accompanied by many difficulties owing to their peculiarities. The
apes which are excitable and irritable in most cases resisted our in-
vestigations either by always being in motion or by spontaneously
checking the reflex movement. It needed much time and patience
in order to test this or the other reflex having profited by the moment
when the ape’s attention was directed elsewhere by my assistant.
These difficulties were particularly pronounced during the examina-
tion of the upper extremities as my assistant usually held the ape
by its front extremities having placed them behind its back. It was
often rather difficult to decide whether the flexion of the forearm
(reflex of m. biceps) was a result of an irritation of the tendon of
m. biceps or the result of a mechanical irritation of the flexors of the
forearm owing to the insufficient development in apes of the tendon
lacertus fibrosus (Sonntag).
I did not succeed in causing the carporadial reflex in apes and a
percussion on the distal section of the radial bone did not produce
any reflex effect.
With regard to the above described reflexes it must be added that
the degree of their manifestation or in other words their intensity
varied fairly considerably. In some of the excitable and fearful apes
(maccacus rhesus, mongoby) who according to the evidence of the
personnel showed signs of nervousness, we actually observed a
general increase in the reflex excitation. An examination, a touch
with the percussion hammer or a feather were enough to cause a
general shuddering of the animal and besides the reflexes were also
noticeably increased—as for instance the corneal, the nasal, the naso-
palpebral or the knee-reflex, whereas in other specimens the reflexes
showed no particular deviation and were of equal intensity.
REFERENCES
1. Guillain, George. Le réflexe naso-palpébral. Comptes réndus des séances
de la Société de Biologie, 1920, p. 1394. ;
2. Simchowicz. Nasenaugenreflex—Deutsche Zeitschr. v. Nervenheilkunde,
1922
3. Guillain. Le réflexe médio-pubien, Etudes Neurologiques, 1925.
4. Astwazaturow. Eine biologische Deutung des Verhaltens der Reflexe bei
Pyramidenbahnerkrankung—Zeitschr. f. d. ges. Neurologie u. Psych.,
1926.
a ? 7% ie. ens Mi eg ee as fk
ear. . aS ee
ght Ao As gen 4
> é, a ies py
E a
464 ; -GaDAKARON OVA LOH, +g
5. Triumphow. On the tendo-abdominal reflex (Russian) Report in’ the —
Society of neuropathologists. Leningrad, 1925, Februar. | ron
6. Astwazaturow, U. On the Nature of Abdominal reflexes. The Journal of —
Nervous and Mental Disease. June, 1925. ;
7. Aronovitch, G. On the Nature of Cremasteric Reflex. Ibidem, 1926. 7
8. porta, Charles. The Morphology and Evolution of the Ape. London, —
9, Bechterew. Nervous Diseases. Petrograd, 1915 (Russian).
is
oy
J ]
ENDOCRIN AND BIOCHEMICAL STUDIES IN
SCHIZOPHRENIA
By Kart M. Bowman, M.D.
ASSISTANT PROFESSOR IN PSYCHIATRY, HARVARD MEDICAL SCHOOL; CHIEF MEDICAL
OFFICER OF THE BOSTON PSYCHOPATHIC HOSPITAL, BOSTON, MASSACHUSETTS
The following studies were undertaken in an endeavor to see
whether a number of special tests would yield any useful information
concerning the nature of the schizophrenic process. In view of the
fact that Kraepelin (1) has emphasized the possible endocrin origin
of dementia praecox it seemed advisable to study a series of cases
using tests which would, in general, have some relationship to the
activity of the endocrin glands. Twenty-four cases of schizophrenia,
18 females and 6 males, were studied with this purpose in mind. The
following studies were made:
X-RAY STUDIES
These studies were made to learn if any abnormal findings would
be revealed which might throw any light on the nature of the schizo-
phrenic process. X-rays of the skull were taken to show particularly
the sella turcica and the sinuses. X-rays of the teeth were taken.
An X-ray was made of the terminal phalanges, partly to note if
there was any evidence of tufting. X-rays of the chest were made
in order to determine the size and shape of the heart, the condition
of the lungs and whether or not there was a thymus shadow. An
X-ray of the gall bladder was made. An X-ray series of the gastro-
intestinal tract was made, using the usual barium meal. All X-rays
were taken by the X-ray technician, Mr. William Pollino, and the
interpretations were all made by the hospital roentgenologist, Dr.
Whitman K. Coffin.
BasAL METABOLISM
A basal metabolism was done, using the Roth-Benedict outfit and
the standard technique. The standards for body surface as deter-
mined by DuBois (2) were used. In some cases repeated studies
were made but in many cases the lack of cooperation of the patient
* Read before the Association for Research in Nervous and Mental Disease,
December 27, 1925.
[465]
466 K. M. BOWMAN
prevented a completely satisfactory determination. It would seem
that in some cases our findings are undoubtedly too high and that
further tests with complete cooperation would have given lower
readings.
BLoop SUGAR CURVE
The blood sugar curve was calculated, using the standard method
prescribed by Janney.(3) The sugar determinations were made,
using the method of Folin and Wu.
GALACTOSE TOLERANCE TEST
The galactose tolerance test was done, following the technique
prescribed by Rowe.(4) (Forty grams of galactose were fed to
women and thirty grams to men.)
BLoop CHEMISTRY
A study of the blood chemistry was made. Examinations for
the non-protein nitrogen, urea, creatinin, amino acid nitrogen and
sugar were made, following the method prescribed in Folin’s Manual
of Biological Chemistry. The uric acid was determined by Bene-
dict’s (5) method, using a tungstic acid filtrate. The calcium deter-
mination was done according to the method of Kramer and Tis-
dall.(6) The phosphorus was done by the method of Bell and
Doisy (7) and the chlorides were done by the method of Austin and
Van Slyke. (8)
BiLoop CouNT
A complete blood count was done, using the standard technique.
One hundred cells were counted for the differential. The hemo-
globin was determined by either the Tallquist or Sahli method as
shown by the letter T or the letter S in the findings.
KoTTMAN TEST
The Kottman (9) test was performed under the following tech-
nique which is given in detail since most writers on the subject are
extremely vague with regard to the exact details and methods used.
(1) Fasting blood obtained at 9 a.m. and poured into a centrifuge
tube; (2) Then tubes with the blood immediately transferred to
an ice box, corked and allowed to stand there for five hours and then
centrifuged ; (3) 1 c.c. of the clear serum (with no hemolyzed blood)
transferred into a standard Wassermann tube (1.20 cm. & 8.5 cm.) ;
—— = ——-
BIOCHEMICAL STUIIES IN SCHIZOPHRENIA 467
(4) 0.25 c.c. of 0.5 per cent solution of potassium iodid added and
the iodid allowed to diffuse through the serum by gentle agitation
of the tube, for 60 sec.; (5) 0.3 c.c. of a 0.5 per cent solution of
silver nitraté added to the tube gently agitated, for 60 sec. (6)-After
satisfactory mixture had been obtained the test tubes were exposed to
a 500 watt lamp for five minutes at a distance of 25 cm.; (7) fol-
lowing exposure 0.5 c.c. of 25 per cent sol. of hydroquinone was
added; (8) color change noted at 2%, 5, 7%, 10, 20, and 30 minutes.
The following precautions were taken to insure a standard and
uniform technique.
The patient received no iodides or bromides for at least a week
before that test. The breakfast was omitted on the day of the test so
that at least 12 hours expired before the blood was drawn.
The serum must be absolutely clear with no traces of hemolysis
or else the delicate color changes are easily obscured. ‘Lhe serum
must not be in contact with air more than six hours because oxidation
of the serum accelerates the test. Before the completion of the test,
the serum must be in an ice box because temperature changes alter
the velocity of the reactions. |
In order to eliminate the individual variations the same individual
reads the color changes. The following terms are for the various
color changes.
Light color change; light brown, brown, deep brown.
The solutions are freshly prepared and kept in dark bottles.
SPINAL FLUID
The spinal fluid was examined as follows: All examinations were
made in the morning after the patient had been fasting for at least
twelve hours. A fasting blood was taken at the same time in order
that the blood sugar might be compared with the spinal fluid sugar.
In Case No. 7 the patient was fed sugar for a blood sugar curve
shortly before the lumbar puncture was made. The spinal fluid sugar
was determined, using the Folin-Wu method as described in Folin’s
Laboratory Manual, 1922. The spinal fluid was diluted with water
I-10 and the remaining technique was the same as that for blood
sugar. ‘The total protein was determined by the method of Denis
and Ayer.(10) Pandy’s method was used in testing the globulin.
The cell count was made using a Fuchs-Rosenthal counting chamber,
and an ordinary pipette for white blood cell counts. Polychrome
methylene blue is drawn to 0.5, then spinal fluid to 11. The colloidal
gold test was made according to the usual standard conditions. The
Wassermann test was made at the Massachusetts State Wassermann
468 K. M. BOWMAN
Laboratory at the Harvard Medical School. It may be stated here
that the blood Wassermann was negative in every case.
GASTRIC ANALYSIS
The gastric analysis was done under the usual standard conditions.
The fasting contents were obtained and after the feeding of an Ewald
test meal the Rehfuss tube was allowed to remain for one hour at
which time the gastric contents were again examined. The micro-
scopic study of the fasting contents was made and both the fasting
and one-hour contents were examined for free hydrochloric acid, total
acidity and for blood by the benzidene test.
RENAL FUNCTION
The renal function test was done under the standard conditions
of injecting 1 c.c. of phenolsulphonephthalein and examining the
urine secreted for 2 hours 10 minutes following the injection.
OCULOCARDIAC KEFLEX
The technique employed in this series was to have the patient
flat on his back on the table. After he had arranged himself com-
fortably the radial pulse was counted for one minute. The blood
pressure was then taken with a Baum-anometer apparatus and the —
pulse was counted through this minute to determine whether the
taking of the blood pressure influenced the rate. In the appended
tables these two minutes are designated as 1 and 2. During the next
two minutes pressure was made on the eyeballs of the patient with
the thumbs. The endeavor is made to make this pressure just short
of the pain threshold. The pulse is counted during these two minutes
and through consecutive following minutes until it returns to the rate
of the first minute. The blood pressure readings are resumed at the
time the pressure is released and consecutive readings are made until
the pressure returns to level of first reading if possible.
X-RAY STUDIES
Case 1: X-rays of the skull were entirely negative. The sella was
of normal size and shape with no evidence of erosion. The sinuses were
clear and showed no evidence of infection. The terminal phalanges and
hands were negative and there was no evidence of tufting.
Case 2: X-rays of the skull showed that the sella was small and
nearly bridged. The sinuses were clear. X-rays of the teeth showed
that there was pericementitis of the upper left second molar. There was
BIOCHEMICAL SLODIES- IN “SCHIZOPHRENTA 469
a large area of decalcification involving all the lower incisors due presum-
ably to infection and atrophic changes in the bone. The terminal phal-
anges were negative. The heart was long and narrow, markedly ptotic
type. The lungs showed numerous partly calcified glands with peri-
bronchial thickening but no evidence of parenchymal involvement. The
findings were consistent with healed or inactive tuberculosis. The thymus
was not enlarged. Gall bladder was negative. The gastro-intestinal
study was negative except for ptosis and moderate stasis in the caecum
and ascending colon 24 hours.
Case 3: X-rays of the skull showed that the sella was small and
nearly bridged. The frontal sinuses were absent but rather large supra-
orbital ethmoidal cells were present covering a considerable area, but
being very shallow. X-rays of the teeth showed an apical abscess of the
lower right first molar, and pericementitis of the lower left second bicus-
pid. All the last molars were unerupted. The terminal phalanges were
negative except for a slight tendency to small size and round, smooth ends.
The heart and lungs were negative and the thymus was not enlarged.
The gall bladder was negative. The first gastro-intestinal series showed
that the stomach was in normal position, that the duodenal cap did not
fill properly, probably due to nervousness and dislike of buttermilk with
resulting duodenal spasm. There was a possibility of intrinsic duodenal
lesion (ulcer). There was no definite filling defect noted in a very
poorly filling cap. There was no six hour residue and the barium was
in the ascending colon and hepatic flexure. At the end of 24 hours there
was no barium in the bowels. A second gastro-intestinal series was
entirely negative.
Case 4: X-rays of the skull showed two areas of bone thinning in
the right frontal region high up (probably parasinoidal sinus) connected
by enlarged vessels with a similar area over the right orbit, probably due
to old trauma or inflammatory or neoplastic disease with resulting
engorgement of vessels. A second X-ray revealed similar findings. The
sella was negative. The sinuses were clear. X-rays of the teeth showed
that there was a probable old healed apical abscess of the upper right
second bicuspid. The upper third molars were absent. The terminal
phalanges were negative. The heart and lungs were negative. The
thymus was not enlarged. There was a possible subdeltoid bursitis present
on the right side and a small calcified mass three inches below the head
of the humerus on the right side was present. The gastro-intestinal
series Showed no evidence of abnormality except a small, irregular, poorly
filling duodenal cap which in certain positions showed probable evidence
of gall bladder pressure. The films of the gall bladder, however, showed
nothing abnormal.
470 Kk. M. BOWMAN
Case 5: X-rays of the skull showed a rather large sella which was
nearly bridged. The sinuses were negative. Teeth showed apical
abscess of the upper right lateral incisor. The terminal phalanges
showed a slight tendency to tufting which was not at all marked. The
heart and lungs were negative. The thymus was not enlarged. The
gall bladder was negative. The gastro-intestinal series was negative.
Case 6: X-rays of the skull showed that the sella and sinuses were
negative. The teeth showed no evidences of infection. The terminal
phalanges were negative. The heart and lungs were negative and the
thymus was not enlarged. The gall bladder showed a very doubtful
shadow present but reéxamination was entirely negative. The gastro-
intestinal series was essentially negative but showed slight colonic stasis.
There was slight ptosis of the colon. At the end of 24 hours the bulk of
the barium was in the hepatic flexure and ascending colon and sigmoid.
Case 7: X-rays of skull showed a normal sella and sinuses. There
were no teeth present. The terminal phalanges were negative. The
heart was long and narrow and the lungs were negative and the thymus
was not enlarged. The gall bladder was negative. The gastro-intestinal
series showed a long, dropped stomach with a small six hour residue.
There were no filling defects. The duodenum was negative. There was
a moderate amount of barium meal in the ascending colon at the end of
24 hours but there was not much stasis.
Case $: X-rays of the skull showed that the sella was rather large
but not eroded. The sinuses were clear. The teeth were negative.
The terminal phalanges showed a question of slight tufting. The heart
and lungs were negative and the thymus was not enlarged. The gall
bladder was negative. The gastro-intestinal series showed that the
stomach was atonic and that there was slight ptosis. There was a small
six hour residue. There was a moderate 24 hour colonic stasis in the
ascending colon.
Case 9: X-rays of the skull showed that the sella and sinuses were
negative. The teeth showed an apical infection of the upper right
first bicuspid, an apical pericementitis of the upper left cuspid, a pocket
between the lower left second bicuspid and molars. The lower third
molars were absent. The terminal phalanges were negative. The heart
was negative but the pulmonary artery was prominent. The lungs were
negative except for a moderate generalized peribronchial thickening
which was not considered tuberculous. The thymus was not enlarged.
The gall bladder was negative. The gastro-intestinal series showed
that there was a concavity of the antrum of the stomach, possibly due
to a gas distension of the hepatic flexure. No other filling defects were
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 471
noted. Peristalsis was very inactive. The duodenal cap filled poorly
and showed spasms. There was a fairly large six hour gastric residue,
presumably due to the inactive peristalsis and the spastic duodenal cap.
There was a moderate 24-hour stasis. No ptosis was present. No definite
organic lesion was noted.
Case 10: X-rays of the skull showed that the sella was normal.
There was slight crowding of the right ethmoid. There were several
rather large Pacchionian depressions. ‘The teeth were negative. The
terminal phalanges were negative. There was a “drop heart.’ The
lungs showed a questionable bronchiectatic focus in the right base.
There was moderate peribronchial thickening. The thymus was not
enlarged. The gall bladder was negative. The gastro-intestinal series
showed that the stomach was rather dilated, somewhat atonic and ptosed.
There was no six-hour residue and no filling defect. Small bowel was
negative. The colon was ptosed and there was moderate 24-hour residue.
Case 11: X-rays of the skull showed normal sella and sinuses. The
teeth were negative. There was some recession between the left first
molar and bicuspid. The terminal phalanges were negative. The heart:
was somewhat narrow and long. The lungs showed very slight increase
of linear markings in both upper lobes, particularly the right, possibly
due to very early tuberculosis but not at all definite. The thymus was
not enlarged. The gall bladder was negative. The gastro-intestinal series
showed that the stomach was slightly atonic. There were no filling defects
or six-hour residue. Occasional pressure defect of the antrum was noted.
Small bowel was negative. There was slight colonic ptosis and con-
siderable colonic and sigmoidal 24-hour residue.
Case 12: X-rays of the skull showed sella of normal size with no
erosion. The right antrum was densely clouded due to pus or a much
thickened membrane. X-rays of the teeth showed foreign bodies in the
upper right second bicuspid region plus a minute root fragment. Foreign
bodies in the upper right incisor area. The heart and lungs were nega-
tive. The thymus was not enlarged. X-ray of the abdomen showed
numerous metallic objects in the gastro-intestinal tract such as nails,
screws, etc., and a hot water bottle stopper in the rectum (the patient
had put foreign bodies into his mouth and rectum). A barium series
could not be taken.
~ Case 13: X-rays of the skull showed the sella and sinuses to be
normal. There was a definite thickening of the tables of the frontal
bone extending to the region of the coronal suture from a point 1%
inches above the floor of the anterior fossa, probably a very slight
exostosis. An X-ray of the teeth showed an impacted lower right third
molar, an impacted rudimentary upper right central incisor, recession
of both the right and left upper second and third molars. The terminal
phalanges showed erosion of the third right terminal phalanx (traumatic).
‘The heart and lungs were normal and the thymus was not enlarged.
472 Kk. M. BOWMAN
The gastro-intestinal series showed a pressure defect of the duodenal cap
and the antrum, probably due to kidney but possibly to gall bladder
pressure. Stomach was otherwise negative. There was no stasis. There
was considerable ascending and transverse colon stasis at 24 hours.
Case 14: X-rays of the skull showed the sella and sinuses to be
normal. Teeth showed apical abscesses of the upper left lateral incisor,
lower left second bicuspid and the upper right first bicuspid. The
terminal phalanges were normal but rather small and rounded. The heart
and lungs were negative and the thymus was not enlarged. The gall
bladder was negative. The gastro-intestinal series showed the stomach
to be negative except for a moderate amount of six-hour residue.
There was slight dilation of the second position of the duodenum, possibly
due to a low-grade obstruction which might have come from the gastric
stasis. There was considerable colonic stasis at 24 hours, the barium
being chiefly in the ascending colon and the hepatic flexure.
Case 15: X-rays of the skull showed that the sella was rather large
but within normal limits and not eroded. The sinuses were large but
normal. X-rays of the teeth showed unerupted third molars and con-
siderable unfilled caries. Otherwise negative. The terminal phalanges
were negative. The heart and lungs were negative and the thymus
was not enlarged. The gall bladder was negative. The stomach was
negative. There was moderate stasis in the terminal ilium. The appendix
was long and much coiled. The colon was negative and fairly well
emptied at 24 hours.
Case 16: X-rays of the skull showed the sella and sinuses to be
normal. The teeth showed apical abscesses of the lower left first molar
and upper left first bicuspid and pericementitis of the lower right first
molar. The terminal phalanges were long and slender but otherwise
negative. The heart was narrow, dropped type. The lungs were nega-
tive. Thymus was not enlarged. The gall bladder was negative. The
stomach showed active peristalsis. The antrum filled poorly but without
definite filling defect. There was no six-hour residue. The duodenal
cap also filled rather poorly but apparently was negative. The small
bowel was negative. There was considerable 24-hour colonic residue.
There was moderate ptosis of the stomach and bowels.
Case~17; X-ray of the skull showed the sella and sinuses to be
normal. There was a questionable bony plaque two inches long near the
upper angle of the occiput, apparently lying in the cranial cavity. X-rays
of the teeth showed that both upper cuspids were unerupted and malposed.
Otherwise it was negative. The terminal phalanges were negative.
The heart and lungs were negative and the thymus was not enlarged.
The gall bladder was negative. The gastro-intestinal series showed
that the stomach was long, dilated, ptosed and there was a small six-hour
residue, about 1% of the total amount. There was no filling defect. The
duodenal cap and the small bowel were negative. There was considerable
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 473
colonic ptosis and stasis. The barium colon was half way to the splenic
flexure in 24 hours.
Case 18: X-rays of the skull showed that the sella and sinuses were
negative. The teeth were negative except for a questionable pericemen-
titis of the lower left first molar. The terminal phalanges were negative.
The heart was dropped type. The lungs were negative except for fairly
distinct peribronchial thickening at the right base. The thymus was
not enlarged. The gall bladder was negative. There was a broad linear
shadow extending across the upper left on the right side. This might
be due to a thickened pleura at the anterior side of the diaphragm. The
gastro-intestinal series showed that stomach was negative except for a
small six-hour residue, probably due to broken fast. The duodenal
cap and the small bowel were negative. There was considerable 24-hour
colonic residue. There was a bulbous appendix in the six-hour film.
Case 19: X-rays of the skull showed that the sella and sinuses were
normal. The teeth showed a doubtful pericemental infection of the
upper left cuspid and first bicuspid and upper right cuspid. The terminal
phalanges were negative. The bones were rather long and slender. The
heart was small, not markedly ptotic. The lungs were negative. The
thymus was not enlarged. The gall bladder was negative. The gastro-
intestinal series showed no filling defect, six-hour residue or ptosis of
the stomach. The duodenal cap was extremely small and spastic, possibly
due to ulcer or possible spasm due to extrinsic causes. No definite
ulcer lesion but considerable irregularity on the right side of the base.
There was moderate ilial stasis and apparent displacement of the terminal
ilium by what appeared to be a pelvic mass. The colon was negative.
Case 20: X-rays of the skull showed the sella and sinuses to be
normal. The teeth showed impacted lower left third molar and lower
left second bicuspid. The upper right and left third molars were un-
erupted. The terminal phalanges were rather small and rounded. The
heart and lungs were negative. The thymus was not enlarged. The
gall bladder was negative. The gastro-intestinal series showed that the
stomach was slightly ptosed and rather large. The duodenal cap filled
poorly but showed no characteristic defect and was probably spastic.
The small bowel was negative. The colon was slightly ptosed and
contained a fairly large 24-hour residue in the tranverse position.
Case 21: X-rays of the skull showed the sella to be normal in size
and shape but nearly bridged. The sinuses were negative. The teeth
showed apical recession (pericementitis) of the upper left first bicuspid
and cuspid. There was a questionable apical abscess of the upper left
lateral incisor. There was recession anterior to the lower left first
molar. The terminal phalanges showed rather flaring tips with a question
of slight tufting. The heart was negative. The lungs showed peri-
bronchial thickening, more marked at the right apex, probably due to
tuberculosis. The thymus was not enlarged. The gall bladder was
474 K. M. BOWMAN
negative. The liver edge was rather low. The gastro-intestinal series
showed a filling defect of the antrum of the stomach evidently due to a
rather low liver. There was the slightest possible six-hour residue. The
appendix was unusually patent, long and large but not adherent. The
colon was negative except for a small 24-hour residue.
Case 22: X-ray of the skull showed that the sella and sinuses were
normal. The teeth were negative. The terminal phalanges were rather
smooth and rounded. The heart was ptotic type. Otherwise negative.
The lungs showed considerable peribronchial thickening, possibly due to
tuberculosis but doubtful. The thymus was not enlarged. The gall bladder
was negative. The gastro-intestinal series showed the stomach to be
normal. The duodenal cap filled fairly well with no defects. The barium
was present in the terminal ilium and ascending colon at six hours. At
24 hours the barium was chiefly in the rectum. There was a small amount
in the colon generally. |
Case 23: X-ray of the skull showed the sella and sinuses to be normal.
The teeth showed impacted upper right and left third molars. The
terminal phalanges were negative. ‘The heart was rather small and
of the drop type seen in ptosis. The lungs were negative and the thymus
was not enlarged. The gall bladder was negative. The gastro-intestinal
series showed that the stomach was somewhat atonic and slightly dropped.
No filling defect or six-hour residue was made out. The duodenal cap
showed pressure defect on several films (pressure against under sur-
face of liver). At six hours the barium was all in the terminal ilium
and the proximal half of the colon. At 24 hours much of the barium
had passed. There was still some in the proximal half of the colon and
in the rectum.
Case 24: X-ray of the skull showed the sella and sinuses to be
normal. X-ray of the teeth showed a rudimentary tooth between the
apices of the upper central incisors. There was an apical abscess of
the upper right first bicuspid. The terminal phalanges were negative.
The heart and lungs were negative. The thymus was not enlarged. The
gall bladder was negative. The gastro-intestinal series showed the
stomach to be negative except for slight ptosis and slight dilatation.
There was no six-hour residue. The small bowel was negative. The
colon was negative except for moderate ptosis and slight 24-hour delay.
There was no obstruction.
Basal Metabolism
Case No.
Lint, 5 eee eee 5
Ce eee =
Jeri ee) ee == 5 —14 =|)
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA
Case No.
Blood Sugar Curves
Fasting
blood
mgm. glucose
per 100 c.c.
88
1 hour
after
glucose
—30
ay!
ag
— 36
=I
eg
43
feeding
130
110
78
105
185
152
146
148
174
150
1)
103
163
228
146
Al
168
126
145
141
179
183
2 hours
after
glucose
feeding
120
82
73
71
132
88
150
ig
125
182
114
107
106
278
109
78
109
118
eS
138
111
179
475
+4
ah
—10
3 hours
after
glucose
feeding
66
476
Case No.
© & ese fe) 9) to 16
@) «Sie es ens) pe
SS) je 0 @! 6 “110
© 2) ¢) 18: 0: (ene) 16:
¢ e. © 6 8 ee @
a @ 1S wie! 26.06
ee ee we eee
Oe) “eale).6) (eo eure
CUTS Ce Ne a
Ce rN ee
Oe tery ivy cect)
@L.0\@\ ei 0 4 @ @
Se “ee « © ©
a's (e..\0' 7) is ece
2; Chelle tele ups
© (8h Se. re! Ye) ce 1a
@ 6 76) ie, © Ja) fe te
see ee wee
K. M. BOWMAN
Galactose Tolerance Test
© @) @, (6 18-8 hee! e+ 8 Kel ce
ee. a 5e, 10) 46,6) 076 (8 6)
Ist 2 hour
urine spec.
Vier:
Blood Chemistry
Moms. per 100 ee
Non-
Protein
Nitrogen
Urea
Nitro-
gen
—
st
. — —
- ONUFKHDOODACHOONONN
Doo Ow ONORMOCRNOH
)
Sal
COD tO & SIA NICO WUMADWOADWNO COSCO
peer
OV COLONT*® =
DN WO =
WNHNNWNHNWHHNWWWNDHWWUKWNHWWW
Uric
Acid
WIAD OCOND BOUWAGCNAYON UNDYED
Creat-
Acid Nitro- Blood Cal- Phos- Chlor-
inine Nitrogen gen Sugar cium phorus ides
20 91 Sere CRB Se Lh 4) 2 a
pos Loop Or Oee 11.2. 4.9 495
251.072 10S elise 11.3. A eee
ees ae ve 89. 86 Po a
Lome KOnU) LONGER Le 12..65515)0 Sao
vA TTS ub ee oa 4.3 ERS
SS So. a OG 12.0. <5254. 5 gos
49) 0789 10, ORIG. Lig? 488
3° ))6.9 “hb 28e100: 11 7323240 eae
Jo) Offs, Cote ae 13.G0ee 455
72. 6:0 74.6103: LE30> © 430) a8
4.97 5 OSLOS Sao: 11.0.. S27. 3464
00, 7 hone Sosemeae 10:8. “620° 7475
r4o 6 5Da4 sel Ae pemsoe 1007. All pate
52,000 oe One 1022 22.79 as
2 sarc JIN Aet008 879. -<5.2 “473
aaaew. : 85. 11:0. 6440 2488
Zee 85. 10.8 S200 9465
4 6.8 93. 11.2, 322% #409
ORD oie 85. 1124" (8/725 Saas
4 724-5 10°05 0ee Ools.: 592 0esS
4 786 sea eases 13:4; 4.99 #475
<O00. 0 a7 ose 14,0 974.9 e455
2 eOal) sei e090: lik 459% Sets
Pk kk ek ek ek ek ek et peek eek et bt pet feet bet bet pet Pt et
Amino
2nd 2 hour
urine spec.
—
<a
NNPMH, CPHNHNNNSSCOCONNESS
Ae PN PARA
<a ee
Rest Fasting
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 477
Blood Counts
Case Large Small Mast.
Hb. Reps W.B.C. Polys. Lymph Lymph Eos. Trans. Bas. Cell Sm.
Soa 90T 5,448,000 9,000 61 ie Sa) o... Aye ENO
ee 90T 4,848,000 7,100 64 Za 30 1 ‘“ - ne Ol:
on 85T 4,080,000 8,600 69 (dae tic se 4 ie ae *
AN 80T 4,160,000 9,000 65 Zee 2 “1
erent OU Ige5-304,000) c1.15300. 61 Foy PAS 5 Nor.
he 85T 4,656,000 9,200 68 5p OU ¥; By
‘p. 90T 5,520,000 8100 70 be SAS 1 2 Nor.
Nee ACCU Ol emLO/O0bam/ oie a) 820" a. 2 Nor
9... 90T 4,296,000 8,500 60 50 a 2 Nor
L0G oe) 29,016,000) 14.5007 54 AVE 38 3 1 Nor
Pio 25.64 0;000-) 10,300 08. 58 2 49 1 * Nor
f2n- 90T 4,832,000 312.900 -70 Ones aN ee % eee OL
Poors oleae 2 0), 000m Po 0008) 200" 0. & sASe 18... 1 fe Pa eNot
be 5 24,030,000 8.500 7] on) as) if ak a NO
Sloane /5.beeo:/70,000 9 -8.4000 37% Zee 1 3 22a Lae Note
Gree OU 0G0,0007 15,0007 6/0) 2. 26.) Soa eee Of
17... 90T 4,280,000 10,000 72 cee KA is a Nor
Gms ol «3:960,000 58 500% 654 eee oe, m §
19... 90T 4,860,000 7,400 70 te 27. Z Pf oe NoG
20... 80T 5,630,000 10,800 65 12730 Sm. 1 - Nor
Zee 90 153 852,000) 21100 75 ae) 1 2 ee Nor
22%. 85S ©4,800;000° > 7,100 73 Smee i re NOE
2 ee Lge Oe/ 92,0001 9.7 00 & 200 [1d eR ALY Meee Me a ve Nor
24... 85T 4,000,000 11,800 74 te iA | ae 1 1 vee N Ot
* Slight poikilocytosis.
7 Slight achromia.
£ Slight anisocytosis.
§ Anisocytosis.
Kottman Reaction
Light
Case Color Light Dark
No. Change Brown Brown Brown Remarks
1.. Notrecorded 3 min. 5 min. 8 min. Accelerated
om 2% min. 5 min. Notrecorded 7% min.
Je 2% min. 5 min. 10 min.
4° Semin: 7 min. 10 min.
be Ba 5 min. 6 min. 10 min.
OS: 20 min. 30 min. Over 1 hour Retarded
Vik 7% min. 10 min. 15 min.
8.. aris 10 min. 15 min.
OF: Very quick 2% min. 5 min. Accelerated
LGoi 8 min. 10 min. 15 min.
Lice 10 min. 15 min. 20 min. Serum
ite 5 min. 7% min. 10 min. slightly
iPS ie 2% min. 5 min. 744 min. hemolyzed
14.. 5 min. 7% min. 10 min.
ipsa 744% min. 10 min. 15 min.
Lis 24 min. ~ 5 min. 10 min.
7s. 2% min. 5 min. (Mea ashhee
iWohe 5 min. 744 min. 10 min.
19.. 74% min. 10 min. Ape aitis
20 5 min. 10 min. 17 min:
Zi 20 min. 30 min. 40 min.
C2 24% min. Notrecorded 7% min.
oe ip 2% min. Notrecorded 7% min.
478 K. M. BOWMAN
Spinal Fluid
Fasting* Spinal*
Case Blood Fluid ‘Total*
No. Sugar Sugar Protein Glob. Cells Gold Wassermann
te ee 67 59 28 0 0 Neg. Negative
TA ete 98 71 18 ) we Neg. Negative
ob eae 89 68 22 0 0 Neg. Negative
ee: 91 TT 18 0 0 Neg. Negative
Ee oe, 104 69 24 0 0 Neg. Negative
Tine cee 106 80 20 0 0 Neg. Negative
OO es 99 iz 18 0 0) Neg. Negative
OR Pee 109 60 36 0 4 Neg. Negative
1g eh aaa 96 73 a9 0 1 Neg. Negative
ab Be 78 60 19 0 0 Neg. Negative
jit eee 95 55 27 0 ) Neg Negative
ee Se ee 73 49 4] 0 0 Neg. Negative
oer eee 109 63 53 0 0 Neg. Negative
FOr, 99 53 22 0 0 Neg. Negative
LSet 85 62 29 0 3 Neg. Negative
19 Rees 81 51 33 0 0 Neg. Negative
20 ae 101 57 30 1* 2 Neg. Negative
LiNeee cre 84 60 22 0 0 Neg. Negative
PHA NSBR od 118 64 20 0 0 Neg. Negative
PART An Ne? roe lol 80 29 0 0 Neg. Negative
* Mems. per 100 c.c.
Gastric Analysis
Case Free HCL Total Acidity Microscopical Benzidene
No, 2h, GC, “ichrat th Gai rc. bGeealone
ia 0 she 8 64 Ep; celles a7 betaee fer. 0 0
32-82 46 BZ 90 96 Bacteria. No Boas-
Oppler.
ae 0 0 8 6 ip, celss:OcceWeb, C0
Te 0 — 0 — Ep. cells. Occ... W.B:C,- °0° I ihe notdane
fine 0 11 10 36 Ep. cells. Occ. W.B.C
Occ? Bi G.ae eee = 0
Bon 0 27. 12 34 Ep. cells) Raré RiB.C.
Starch granules: 9.2. 5 0
Fo 0 §) 6 42 Gross blood. Many
Se Ri BGS es See oe 0
Gh 0 26 1 54 Occ. “ep. celisetekare
W.B.G, “Oces a Bac-
teria. No Boas-
Oppler. < ae ae ee = 0
13 Ste lS 40 Pa 72 Ep. cells Rare RiBiG) -- 0
14e2,+30 30 40 60 Ri BGs Ep! cellg@ias — 0
16g, eh) 6 7. 63 Ep. cells; yeast; W.B.
__C. B. Boas-Oppler:
ieee eee ae 34 24 62 Negative... 409 ee ea
AO 26 30 41 65 Occ. -ep. cells; 20cc é
Ri BiGe 72 es Gee ee 0
CRUE ek 9G) 10 5 70 Manyeepe céllaus-seee ee 0
A ae Yds 26 46 44 Occisp) cells = ae 0 0
ho Fas 47 34 65 Neéegativergagares eee ee 0
* BIOCHEMICAL STUDIES IN SCHIZOPHRENIA
Phthalein
Renal Function
% excreted in 2 hrs. 10 min.
Spa aS bette 42
Diet n ea ee ie 58
Caer A ere a 74
SERRE POE Do
Copereare fee ua: 38
Su OM ak Pt ee 70
Tiss ese he: 46
PA ond Mtn ee 55
|b 4a pee Gore Pape 60
CANT anes ag eter 80
| ee, Batedne ire or 80
16a ya ene 64
LR se 75
Le pete Scat oe 70
LO erro ae 45
IA Beka a Conn eee 53
WTA) URS eae e hs Ne 42
BOE oe, Paes 80
OAR aa 2 hee ee 68
Oculocardiac Reflex
Pulse Variations
Degree Time of
Case of Greatest
No. Variation Variation
| ohio en + 5 4
eas a ateae — 6 -
SM ae —7 4
Aer as — 2 3
ete anes —50 4
eaceay 66 3
1 Be eae —12 :
ae oa 2
ES paren -— 8 é:
Aree mah 3
Loaata sy —16 3
Geers: — 2 Zz
5 —16 3
i Ve ee — 6 3
| Be pt lee —4 2
US gore — 6 3
LEER Whee — 6 3
Time of
Return to Norma!
2
5 minutes
6 minutes
4 minutes
?
4 minutes
>
3 minutes
6 minutes
?
?
6 minutes
?
5 minutes
6 minutes
5 minutes
6 minutes
479
480 K. M. BOWMAN
Cardio-Ocular Reflex
Blood Pressure Changes
No. of
Case Pulse Tune of Greatest Reading when
No. Systolic Diastolic Pressure Variation Returned to Normal
je, 0 0 0 0 0
owe ails ee —20 4th reading P
oe. — 4 21) — 8 4th reading 8th minute
ae + 2 —2 a4 2nd reading 6th minute
Dae —10 SZ —22 7th minute ?
Se + 2 0 apa 2nd reading 6th reading
ie —10 —14 — 4 2nd reading not: ‘back! ine) Zu
minutes
12.... —10 0 —10 3rd reading 6th minute
LO) eee be () —12 4th reading not back in 10
minutes
ee ee eet + 4 — 8 7th reading 5th reading
15.... —8 + 4 —12 6th reading not back. angers
minutes
spe see, + 4 + 2 3rd reading 14th reading
L7A pene ee +10 —22 12th reading not back ines
minutes
{8ea Sr a0 + 4 2nd reading not back «in 1
minutes
19.... —8 0 — 8 10th reading 12th reading
Vd eee a er aces 0 —2 2nd reading ?
22 78 0) 1 2 6th reading 7th reading
DISCUSSION
The X-ray studies revealed a number of interesting findings.
The X-rays of the skull were negative in practically all cases. The
sella turcica was nearly bridged in three cases but in no case was there
any erosion and there was nothing to indicate a definite disorder of
the pituitary gland. The sinuses were negative in all except one
case and in this case it is probable that the infection occurred by the
patient stuffing foreign bodies up the socket of the tooth. In one
case in which there was a history of head injury there was an area
of bone thinning which was regarded as of possible traumatic origin.
X-rays of the teeth were taken in twenty-two cases. In only five
cases were the findings completely negative. Apical abscesses were
found in seven cases and two other cases showed pericementitis.
Four more cases showed questionable infections of the teeth. Im-
pacted, malposed and unerupted teeth were found in a number of
cases. Examination of the terminal phalanges showed definite tuft-
ing in one case and questionable tufting in two others. The heart
was X-rayed in twenty-three cases and was considered normal in
fourteen cases. In seven cases the heart was of the “ dropped ”
type and in two other cases the heart was considered as “ long and
narrow.” ‘The lungs were X-rayed in twenty-three cases and were
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 481
reported as negative in sixteen cases. Three cases showed question-
able tuberculosis. One case showed healed tuberculosis and three
cases showed peribronchial thickening. There was no abnormal
thymus shadow in any case. The X-ray of the gall bladder was
negative in every case. The gastro-intestinal series were taken in
twenty-two cases. It is difficult to state exactly when findings may
be considered as abnormal and there is considerable dispute as to the
meaning of colonic stasis. As interpreted by the roentgenologist only
two cases were marked as absolutely negative. In no case was a
definite organic condition such as ulcer, cancer or adhesions diag-
nosed, although in one case the question of ulcer was raised. By all
accepted criteria twelve cases could be regarded as showing definite
functional disorders and in eight more cases there were such condi-
tions as ptosis or colonic stasis, concerning which the interpretation
is very difficult. A filling defect of the stomach was noted in seven
cases and in six cases there was a six hour residue. Fifteen cases
showed colonic stasis of varying degree and two more cases showed
ilial stasis.
The basal metabolism was done in twenty-three cases and eleven
or 48 per cent showed an abnormally low basal metabolism. Ten
more cases or 43 per cent showed readings from —10 to —1. In
the other two cases the basal metabolism was 100 per cent in one
case and + 2 in the other. Twenty-one cases out of twenty-three
therefore, showed minus readings and only one a plus reading. This
would indicate a definite tendency towards a low basal metabolism in
schizophrenia.
_ The blood sugar curve was done in twenty-two cases. It is
difficult to define the limits of the normal blood sugar curve with
any degree of precision but roughly twelve cases showed a normal
curve, nine cases showed a high sustained type of curve, and one
case showed a reversed type of curve. Slightly less than half of the
cases, therefore, showed an abnormal blood sugar curve.
The galactose tolerance test was done in nineteen cases. Accord-
ing to Rowe the finding of 3/10 of a gram in the urine indicates a
decreased gonadal function. Fight cases, all females, gave a positive
Leste
The chemical examination of the blood included the determination
of the nonprotein nitrogen, urea nitrogen, uric acid, creatinin, amino
acid nitrogen, rest nitrogen, fasting blood sugar, calcium, phosphorus
and chlorides. In general it can be stated that the findings were
within normal limits in practically all cases and that a study of the
482 | K. M. BOWMAN
blood chemistry in Schizophrenia shows no deviation from the
normal.
Blood counts were made in all cases and in general were within
normal limits. In one case there was a slight reduction of the hemo-
globin and the red cell count. Six cases showed white cell counts of
between eleven and fifteen thousand on the first examination but later
counts were within normal limits. The differential counts and the
stained blood films showed nothing of importance. It would seem
that the cellular elements of the blood in schizophrenia are essentially
normal.
Kottman,(9) in 1920, demonstrated a serum reaction which he
claimed varied with the activity of the thyroid. The increase or
decrease of the function of the gland was assumed to affect the
protective colloidal property of the blood serum of the patient, and
this property in turn affects a certain photochemic reaction of the
serum by means of which, according to his hypothesis, the thyroid
activity could be measured. The Kottman reaction was done in
twenty-three cases with unusually rigid technique. The results
showed a fair degree of uniformity and gave what for Kottman
would be a normal reaction. Further studies made at this hospital
by Kasanin and Knapp (11) have convinced us that the Kottman
reaction is quite unreliable and without much significance. 7
The spinal fluid was examined in twenty cases and showed nothing
anomalous. It is perhaps worth while summarizing the quantitative
sugar and total protein findings. The spinal fluid sugar varied from
49 to 80 mgms. and the average was 64 mgms. The total protein
varied from 18 to 53 mgms. In all but two cases it was below 37
mgms. ‘The average was 27 mgms.
The gastric contents were studied in sixteen cases. There was an
absence of free hydrochloric acid in the fasting contents of nine cases
or 56 per cent. <A positive benzidene test for occult blood was
obtained in five cases or 31 per cent. These findings would strongly
suggest a functional disorder of the stomach and tend to confirm the
X-ray findings. |
The phenolsulphonephthalein test for kidney function was normal
in all cases.
The oculocardiac reflex was undertaken in an attempt to find an
easily applicable clinical method of investigating the tone of the vege-
tative nervous system. First noticed by Wagner von Jauregg as a
means of rousing patients in a stupor it was taken up by Aschner
who noticed that pressure on the eyeball influenced the rate of the
pulse and repiration. It has of late been worked at by many observers
BIOCHEMICAL oO GDIES IN SCHIZOPHRENIA 483
without showing any very definite or well characterized reactions
from which one can draw very definite conclusions. The general
conclusion, however, has been that in an individual with a normal
vegetative nervous system the pulse and respiration were slowed and
the blood pressure raised. In a vagotonic individual the slowing
would seem to be greater and in a sympatheticotonic individual the
rate might even be increased. _Guillaume has termed neurotonics a
group which may show mixed or paradoxical results.
The results of the oculocardiac reflex were not very conclusive.
The. majority of cases fell within the limits of the normal. There
were some variations in both directions, that is to say, in some cases
the pulse and respiration were increased instead of being slowed and
the blood pressure was decreased instead of being raised while in
other cases the usual response of a slowing of the pulse and respira-
tion and a raising of the blood pressure went beyond the limits of
the normal. If we accept the common interpretation of this phenome-
non it would show that the majority of the cases of schizophrenia do
not show an anomalous vegetative nervous system but that in a few
cases there was evidence of vagotonia and in a few other cases
there was evidence of sympatheticotonia. The conclusion would
be that there is no constant disorder of the vegetative nervous system
in schizophrenia.
(To be continued)
SUBARACHNOID HEMORRHAGE FROM A MEDICO-
LEGAL PQUN TS ORS Wee
By Witty Munck, M.D.
OF COPENHAGEN
Legal autopsies very often afford an opportunity of judging the
role which intracranial hemorrhages play as direct or indirect causal
agents of death.
By way of example it may be mentioned that, among 1,009 legal
obductions performed at this institute during the period from 1910
to 1925, there were 139 cases of intracranial hemorrhage, i.e., 13.5
per eent
The interest attached to these hemorrhages manifested itself not
long ago in this country by their being chosen the subject for an
obligatory lecture at the competition for the professorship of medical
jurisprudence at the University of Copenhagen, and the reader is
referred to Professor Knud Sand’s lectures on this subject pub-
lished in “ Ugeskrift for Leger,’ No. 6, 1926.
In most of these cases there is a question of severe traumatic
lesions of the head with fracture of the skull and contusion of the
brain, 1.e., cases where the cause of death, the starting-point of the
hemorrhage and the causal relation between the trauma and the
hemorrhage are very easy to account for.
In those cases, however, where the hemorrhage is the only change
evidenced by the autopsy and, thus, neither fracture of the skull nor
contusion of the brain can be found, it may be extremely difficult
to determine the importance that should be attached to a possible
trauma as a causal agent of the hemorrhage, as well as the whole
mechanism of the hemorrhage may be very difficult to understand.
This applies particularly to those hemorrhages which form the
subject of this work, viz., the isolated subarachnoid hemorrhages.
There has been a series of such hemorrhages at the Medico-legal
Institute, and, as they presented very particular conditions I feel
justified in subjecting this particular form of intracranial hemorrhage
to a closer examination.
“From the Institute of Medical Jurisprudence, University of Copenhagen,
Denmark (Chief Professor Kund Land, M.D.)
[484]
SUBARACHNOID HEMORRHAGE 485
To begin with I must, however, make a few orientating anatomical
remarks.
According to their anatomical localization the intracranial hemor-
rhages may be classified in different groups:
1. Epidural Hemorrhages, where the blood extravasation is found
between the dura and the skull.
2. Subdural Hemorrhages, where the extravasation is found
between the Dura and the arachnoidea.
3. Subarachnoid Hemorrhages, where the extravasation is found
between the arachnoidea and the cortex cerebri.
Some authors distinguish besides between subarachnoid, pial, and
subpial hemorrhages. In my opinion, however, such a distinction
cannot possibly be followed out in practice.
The arachnoid and pia, which are treated separately in descrip-
tive anatomy, are actually not to be distinguished from each other
from a topographic point of view, as they are connected with each
other by means of pillars of connective tissue in such a manner as to
render it very difficult to separate them ; and it is often quite impos-
sible macroscopically to determine whether a pathological process
has its seat in the arachnoid or in the pia, or between them. As for
the construction of the arachnoid Froin states that it consists of two
layers, 1.e., a parietal layer and a visceral layer. The parietal layer
consists of a sheet of endothelial cells which cover the inside of the
dura. ‘The visceral layer consists of a thin, transparent membrane
which is connected with the pia by means of pillars of connective
tissue, strongest on the convexity, less on the base. The arachnoid
extends across the large sulci between the various sections of the
brain and contains but few vessels, while the pia, which extends
downward into the sulci, is rich in: vessels. Both together confine
the subarachnoid space. In various places, especially at the basis,
where the arachnoid membrane makes a bridge across large and
irregular parts, large cisterns are found, such as, for instance, cis-
terna cerebellomedullaris, between the basal side of the cerebellum
and the upper side of the medulla oblongata; by means of Magendie’s
foramen this space is connected with the fourth brain ventricle, a
circumstance which, as will be seen later, is of great importance in
cases of hemorrhage here. Of other cisterns may he mentioned the
cisterna interpeduncularis, between the basis of the pedunculi cerebri.
In this space lies the circulus arteriosus (circle of Willis). The sub-
arachnoid space extends downward around the spinal marrow to
the first and second sacral vertebra.
Now, if a hemorrhage takes place from one of the vessels into
486 aon A MONCE
this-rather large space, it will, in by far the majority of cases, attain
a rather characteristical localization of chiefly coagulated blood, pre-
ferably localized toward basis cerebri, where it envelops the larger
vessels lying here and, partly, the optic chiasm and the anterior
surface of the pons. The blood extravasation usually gains entrance
into the larger sulci, particularly into the sylvian fossa, and as a rule,
it decreases quite symmetrically in thickness from the basis upward to
the convexity of the brain. In some cases the hemorrhage has a less
symmetrical localization, now and again being quite unilateral and
covering smaller or larger areas of the convexity of the brain. If
the hemorrhage be localized to the base of the brain, one also finds
blood in the cisterna cerebellomedullaris and in the subarachnoid
space around the spinal marrow, as a rule preferably around its
lowest part; and, finally, there is frequently found blood in one or
several of the cavities of the brain, sometimes to such a degree as to
fill these completely with blood-clot. As a rule, the greatest quan- —
tity of blood is found in the fourth ventricle, while there is less
in the third ventricle, and the smallest quantities are found in the
lateral ventricles, thus conveying the distinct impression that the
blood has gained entrance from the outside through Magendie’s fora-
men into the fourth ventricle and, thence, into the other cavities. It
will, of course, happen rather frequently that the blood, owing to
rupture in the arachnoid, also invades the subdural space, where it
is able to spread still more easily and more rapidly over a vast
portion of the brain. However, in this work I shall confine myself to
the isolated subarachnoid hemorrhages and, therefore, not enter upon
such factors as may prevail in cases of a combination of a subdural
and subarachnoid hematoma.
The starting-point of these subarachnoid hemorrhages is very
varying. It is natural at first to mention the rupture of aneurismatic
dilatations of the basal arteries of the brain, where the blood extra-
vasation very frequently is just localized subarachnoideally. That
these. aneurisms are by no means rare is evidenced by the great
foreign statistics, such as, for instance, Beadle’s (1907) containing
555 cases; Busse’s (1920), 400 cases; Hey’s 367 cases, 6 of which
in the first decade and 33 in the second. Kolisko states that, among
the annual number of about 1000 “ sanitatspolizeiliche Sektionen ”
(sanitary police autopsies) at Vienna’s medico-legal institute, there
are, aS a rule, found 10 cases of ruptured aneurisms, such being also
mentioned by other medico-legal authors (Brouardel, Schmidtmann,
Balthazard). Fearnsides (1916) in a series of 5,432 autopsies, found
44 aneurisms, that is to say, 0.80 per cent. In the Danish medical
SUBARACHNOID HEMORRHAGE 487
literature such, cases have been described by Harald Mller (1922)
Thorvald Petersen (1921) and Poul Mgller (1921).. Aneurisms are
preferably localized to the internal carotid artery close to its point
of parting to the ramus communicans anterior (10 per cent, Busse),
and to the point of parting of the basilar artery. 7
Aneurisms are often very small and almost impossible to demon-
strate macroscopically, particularly those which are localised to: the
bottom of the sylvian fossa. Still, here the distribution of the blood
extravasation may possibly give a hint as to the site of the aneurism.
The origin of these aneurisms is attributed partly to local degener-
ative changes in the vessels, partly to local inflammatory changes and,
finally, to an inborn defect in the arterial wall.
However, aneurismic dilations are by no means always found at
that point of the artery which is ruptured. The rupture is seen-to
occur in places with arteriosclerotic changes, such as, for instance,
small atheromatous patches, or in places with syphilitic changes.
In other cases one may meet with the rupture of an artery though
without being able, either macroscopically or microscopically ° to
detect any changes in the ruptured place, all the vessels having quite
a normal aspect.
Another source of the hemorrhages is the rupture of pial veins.
However, these are as a rule very difficult to detect. They are rela-
tively frequently met with in cases of subarachnoid hemorrhages. in
newborn children. C. O. Hedrén in his paper on “ delivery-trau-
matic intracranial hemorrhages in newborn children,” reports no less
than 11 cases of isolated subarachnoid hemorrhages of this origin.
The ruptures in the veins are often localized quite above at their
point of inosculation into the longitudinal sinus. Such hemorrhages
are not infrequently seen after rapid and easy deliveries (Seitz).
On other rare sources of subarachnoid hemorrhages may just be
mentioned such as, for instance, effusion of apoplectic hemorrhages
to the surface of the brain, hemorrhages in hemophilia, eclampsia,
insolation, and malignant anthrax.
It happens frequently, however, that one meets with cases—and
those are just the most difficult and puzzling ones—where one is
unable, even after the most careful examination, to determine the
starting-point of the hemorrhage. Ehrenberg (1912) who has col-
lected 31 cases of spontaneous subarachnoid hemorrhage, relates 15
dissected cases in but three of which he succeeded in determining the
starting-point of the hemorrhage. Symonds (1924) has collected
124 cases of spontaneous subarachnoid hemorrhage, in 41 of which
488 W. MUNCK
the starting-point of the bleeding could not be detected. Similar
observations have been made by other authors (Harbitz).
The medico-legal interest is of course particularly attached to the
question as to which factor has given rise to the hemorrhage.
There is no doubt, especially after Ehrenberg’s and Symond’s
works, that isolated subarachnoid hemorrhages are capable of arising
quite spontaneously. Ehrenberg has collected 31 such cases. In
some of these an increase of the blood pressure could be detected, a
factor which no doubt deserves some attention. Vaques and Esmein
speak directly of “ épistaxis meninguée ” (meningeal epistaxis), cor-
responding to epistaxis, purpura and retinal hemorrhage. with in-
creased blood pressure. Schrgder (1919) emphasizes the importance
of kidney diseases associated with increased blood-pressure for the
causation of the hemorrhage.
As has been related, Symonds has not less than 124 cases of
spontaneous subarachnoid hemorrhage and gives a very ample survey
of the problem, viewed particularly from a clinical point of view.
He is of opinion that, in a far greater number of cases than those
successfully stated, the hemorrhages are due to the rupture of small
aneurisms on the vessels of the brain. .
The immediate cause of such a “ spontaneous ” hemorrhage very
frequently is some or other acute increase of the blood pressure, such
as, for instance, may arise from bursts of anger, pressure during
defecation, coition, or the like; however, there are several instances
known, where hemorrhages occur, while the patients are lying quietly
in their beds.
The second chief group is formed by the subarachnoid hemor-
rhages of traumatic origin. These are~certainly very frequent, if
one includes all the lesions of the head. »
Demoulin (1902) goes as far as claiming that “tout traumatisme
cranien d’une certaine intensité epeut s’accompaugner d’hémorrhagie
dans l’espace sousarachnoidien.” Froin states that, in every 5 cases
of head traumatism with hemorrhage in the subarachnoid space, one
encounters one without hemorrhage. Nor are the isolated hemor-
rhages, that is to say, subarachnoid hemorrhages without contusion
of the brain and fracture of the skull, of rare occurrence after
traumatism.
As regards the aspect and localization of the traumatic hemor-
rhages it is often quite impossible (from a pathologico-anatomical
pont of view) to distinguish them from spontaneous hemorrhages,
though, as a general rule, it may be said that the latter are never
Jocalized to the convexity of the brain alone. In most cases will
SUBARACHNOID HEMORRHAGE 489:
absolute certainty of the traumatic origin of the hemorrhage only be
available through the examination of the lesions of the soft parts of
the skull in connection with the anamnestic data (according to the
case reports, police report, etc.).
After these orientating remarks, which should convey an idea of
the great importance these hemorrhages have acquired in recent
years, I shall now proceed to describe my own material which consists
of 9 cases of isolated subarachnoid hemorrhages.
Seven of these cases were examined at the institute of medical
jurisprudence in Copenhagen, the other two at the pathological insti-
tute of the Rikshospital in Oslo; for these two I am indebted to
Professor Francis Harbitz, M.D., who has kindly submitted them
to me.
Case I (Institute of medical jurisprudence): A woman, aged
forty-four; admitted to the mental hospital at M. on 21/VII, 1914.
Hospital diagnosis: Dementia precox. Suffered much from sleeplessness
and has received a good deal of soporifics. On the 24/IV, 1915, she
took her morning tea at 8 a.M., got up afterwards in order to wash and
do her hair, and went to bed again. At 9 a.m. she suddenly collapsed in
bed and died a moment later. The post-mortem examination performed
on 24/IV revealed the following conditions: No hemorrhages in the soft
parts of the skull, no fracture of the cranium. The hard membrane of the
brain normal. There is no free hemorrhage in the subdural space, but
a hemorrhage is found below the soft membranes, increasing downward
toward the base, particularly marked around chiasma, pons and medulla
oblongata, and filling the spaces between these formations. ‘There is
nothing abnormal in the cerebral tissue. The fourth ventricle is com-
pletely filled with blood clot. The vessels on the base of the brain
present nothing abnormal. The remainder of the autopsy reveals nothing
of interest.
Case II (Institute of medical jurisprudence): A man, aged sixty-
two, was found 24/III, 1916, lying dead in a doorway in N. street. A
quarter of an hour previously he had been in a tavern where he had
taken a glass of beer. There was nothing which could have thrown any
light on the case, particularly nothing with regard to a traumatism of the
head.
Post-mortem examination of 27/III, 1916. No wounds on the skin,
no echymoses, especially not on the head. The basal arteries of the
brain extremely sclerotic, though not contracted,.and without detectable
sack-shaped (aneurismatic) dilatations or ruptures. A large subarach-
noid hemorrhage is found, most severe at the base around pons, extending
upward both sides and forming a layer of up to % cm. thickness. There
490° | W. MUNCK
is no hemorrhage in the brain tissue itself and no blood in the ventricles.
The remainder of the autopsy revealed nothing of interest.
Case III (Institute of medical jurisprudence): Farming servant,
aged fifteen. Both bodily and mentally he is said to have been below
the average, being of a violent and spiteful disposition; he has not
had any special diseases. On 29/1X, 1916, he dines with a good appetite
together with the fellow servants. He is reported to have told another
boy that he felt a little sick, though without stating what his indisposition
was like. It is stated that, at about 4 p.m., there did not seem to be
anything particular the matter with him;. since then nobody has seen
him until, on 30/1X, about 2 p.m., he was found dead behind a fence
in the field. He lay in the grass, face downward, up against a mound.
His trousers were unbuttoned, and behind him .were found some soft
excreta, a little of which was also found in his trousers.
Autopsy 30/X, 1916. Besides superficial chaps in the face there
was no sign of external violence, especially no ecchymoses on the head.
There was no fracture of the skull; this had a peculiar shape, being
flattened from the vertex downward to the neck. The dura is normal;
no hemorrhage between dura and cranium, but a diffuse hemorrhage
is found extending across the whole surface of the cerebrum below the
soft membranes, spreading very particularly on the base of the brain
around pons and chiasma, as well as on the little brain and downward
around the medulla oblongata. There is much blood in the third and
fourth ventricle, as well as in the right lateral ventricle. There is no
sign of contusion of the brain; the vessels at the base of the brain are
normal, and one is not successful in finding any ruptured vessel. The
remainder of the autopsy reveals nothing morbid, particularly no
symptoms of syphilis.
Case IV (Institute of medical jurisprudence): A man, aged thirty-
five. On 3/IX, 1922, the deceased together with two other men had
drunk a great deal of alcohol at B. inn. They were expelled from
the inn at 5 p.m. During a subsequent quarrel the deceased received a
strong blow with the fist on his left jawbone. According to the explana-
tions given by his comrades they had found him lying face downward
on a soft field, when they had turned round a little afterwards to see
what had become of him. He was then dead. The autopsy performed
on the 5/IX revealed the following conditions: At the border of ‘the
leit side of the under-jaw a wound was found, measuring 2 mm, and
surrounded by ecchymoses. The hard cerebral membrane was normal.
At the base a very abundant hemorrhage was found below the soft mem-
branes. No hemorrhage in the brain substance, but there is blood in
the third ventricle and in the lateral ventricles. The cerebral vessels
are normal. The starting point of the hemorrhage could not be detected:
‘The remainder of the dissection revealed nothing of interest.
Case V (Institute of medical jurisprudence): A woman, aged
SUBARACHNOID. HEMORRHAGE 491
sixteen. She was. found dead on the high road on 12/II, 1923. About
an hour previously she had left her place cycling and apparently well.
She lay on her back, with arms and legs a little sideways close to a
heap of broken stones. Her bicycle lay beside her toward the stone
heap. She is reported to have consulted a physician a fortnight previously
because of a stomach complaint (?), has suffered from giddiness. The
post mortem examination on 14/II, 1923, revealed the following con-
ditions: On the neck was found an ecchymosis of the size of a 2-kr.
piece in the soft parts of the cranium. No fracture of the cranium,
dura normal; however a considerable ecchymosis is found in the soft
membrane of the brain, extending over an area nearly as large as the
palm of a hand, corresponding to the most salient part of the right
parietal lobe. No ruptured vessels were detected in the pia. The brain
tissue was normal. The remainder of the autopsy revealed nothing
abnormal.
Case VI (Institute of medical jurisprudence): A boy, aged fourteen.
On 24/IV, 1925, at a football ground, he had got into a quarrel with a
young man who suddenly gave him a slap in the face with the back
of his left hand (it being unknown, whether the hand was clinched or
not), hitting him on the right cheek and under-jaw. Several witnesses
declared that it was absolutely not a strong slap. The deceased stared
a moment at the man and without uttering a cry, ran away. After
having run about 17 m., he fell to the ground, face downward. A pay el
cian who was present stated that he was dead.
The post mortem examination performed on 25/1V, 1925, coats
no external lesions. No fracture of the skull. Dura normal. No hem-
orrhage in the subdural space. However a rather extensive hemorrhage
is found in and below the soft membranes, particularly localized to the
base of the brain, around chiasma, pons, cerebellum and medulla oblongata,
decreasing from this point symmetrically upward on both sides. The
brain tissue normal. There is blood in all the cavities of the brain,
particularly in the fourth ventricle. The vessels are all normal, and,
particularly, no aneurisms are observed. The starting point of the
hemorrhage is not found in spite of minute examination. The spinal
marrow is removed in close connection with the examination of the
brain; a very abundant hemorrhage is found in the subarachnoid space,
especially in the lowest part. The spinal marrow is normal. No fracture
of the columna. The: remainder of the autopsy presented nothing of
interest.
Case VII (Institute of medical jurisprudence): A man, aged forty-
five. On the 17/V, 1925, during a quarrel at a tavern, he received a slap
on the right jaw from one of his companions; the slap is said not to have
been strong. He stood for '% minute, whereupon he collapsed and
fell to the ground. He did not knock his head in falling. As he did
not give any sign of life after the lapse of a couple of minutes, he was
492 W. MUNCK
taken to the hospital, where it was stated that he was dead. It is reported
that he had drunk much alcohol that day.
The autopsy performed on 18/V, 1925, revealed: No external sign
of violence. Dura normal. There is found a diffuse subarachnoid
hemorrhage of considerable extension, strongest at the base, decreasing
symmetrically upward on both sides. There is blood in all the cavities
of the brain. The brain tissue is normal. There is a little sclerotic
degeneration of the carotis int. (on both sides). In no place, however,
can ruptures or dilations be detected. There is found blood in the whole
subarachnoid space along the spinal marrow, particularly downwards.
The spinal marrow normal. The remainder of the autopsy revealed
nothing abnormal.
Case VIII (Professor Harbitz): A man, aged twenty-five. He had
drunk much alcohol in the course of the afternoon and evening on
14/XI, 1924. About 11 p.m. he met several men with whom he got
into a quarrel, during which he fell down in the street. It is not known
whether he was hit by anybody. He immediately become unconscious
and was at once taken to the sanitary station, but was then dead. He
is reported to have been given to drinking and to have had delirium
tremens a couple of times.
Autopsy on 15/XI, 1924. No external lesions. No fracture of the
skull. Dura is normal. Very little blood on the interior of dura. There
is a diffuse hemorrhage everywhere in the thin membranes. It is most
pronounced, with the thickest layer around medulla oblongata, and pons,
extending forward along the membranes, around chiasma and upward
bilaterally in the sylvian fossa, decreasing in quantity upwards. The
hemorrhage diffuses into the fourth ventricle, farther into the third
ventricle and into the lateral ventricles (here distinctly secondary, 1.e.,
having leaked down from the base). No generative changes of the
arteries of basis cerebri are found, but a rupture of a little branch of the
basilar artery is detected laterally of pons. Otherwise, nothing particular
at the autopsy.
Case IX (Professor Harbitz): A man, aged twenty-five to thirty.
On 8/V, 1925, he was found dead on the high road. He is reported |
to have been very drunk. A fellow had given him a blow with his
clinched “hand on the right under-jaw, thereby upsetting him so that
he knocked his head against a fence, and, subsequently, against the
root of a tree. He remained lying without giving any sign of life.
Post mortem examination on 11/V, 1925: On the forehead a bloody
spot is found, and on the left temple a scouring mark, 1 cm. long. There
is no fracture of the skull. Considerable and extensive infiltration in
the thin membranes, most pronounced at the basis. No degenerative
changes in the vessels. The brain tissue normal. There is blood in all
the cavities, most in the fourth ventricle. Otherwise nothing particular
at the autopsy.
SUBARACHNOID HEMORRHAGE 493
The material at hand, thus, comprises 9 cases of subarachnoid
hemorrhage, without lesions of either skull or brain tissue, and
without any other detectable morbid states which might have caused
death.
These cases include individuals of very different age, ranging from
sixty-two to fourteen years, the preponderance, however, being de-
cidedly in favor of the younger age. This accords with the statements
made by other authors. Ehrenberg, for instance, has 19 cases below
and 12 cases above the age of forty.
As to sex, there were 7 men and 2 women.
With respect to the starting-point of the hemorrhage the material
contains the following data: Only in one case (VIII) was it possible
to detect the starting-point, i.e., rupture of an ohterwise quite
healthy looking artery branch from a basilaris, laterally of pons. In
two cases (II and VII) were found arteriosclerotic changes of the
vessels, while, in the other cases of this category, where the ruptures
in the vessels were not verified the vessels were quite normal. In
none of the cases has syphilis played any role, nor kidney diseases with
increase of blood pressure, either. As to alcohol being a predisposing
factor, it is a striking feature that 4 of the deceased had been dis-
tinctly inebriated, or, at least, under the influence of alcohol. One
should, of course, be very careful in deriving conclusions with
regard to the role which alcohol plays in such cases; it is very likely
that the increase in blood pressure due to alcohol is an essentially
corroborating factor, but, perhaps, the alcohol has only been instru-
mental in creating the situation (fight, quarrel) in which the indi-
viduals were exposed to meet with traumatisms.
As to the anatomical localization of the hemorrhage, this has in 8
of the cases been typical symmetric localization to basis, and the
hemorrhage has generally been very abundant; in the two following
cases examined (V and VI), there was also plenty of blood in the
spinal canal. In one of the cases (V), the hemorrhage has a more
atypical site, namely on the external side of the parietal lobe.
Finally, we shall discuss that question which is of special interest
to the medico-legal authority, 7.e., which factor is responsible for the
hemorrhage.. The problem presents itself as follows:
In case I it is undoubtedly a question of purely spontaneous
hemorrhage.
In case IJ the first impression is also that of a spontaneous hemor-
rhage, particularly because of the absence of any sign of external
lesion, and, because, in this case, any suspicion of traumatism of the
head could altogether be dismissed. However, it should be borne in
494 W. MUNCK
mind, that even rather severe traumatisms need not leave any marks,
and, that an individual, during a spontaneously occurring illness, can
fall to the ground and, thereby, incur serious traumatic lesions.
In case III, the circumstances associated with the finding of the
dead body indicated that he had been in the act of defecation, when
the hemorrhage occurred. Here, the defecation seems to have been
the blood pressure-increasing factor which has given rise to the
hemorrhage.
In case IV, the deceased had received a blow on the left jaw with
a clinched hand, and had fallen on to a soft pasture-ground. The
external lesions found on the head render it most probable that the
traumatism has been the cause of death.
In case V, the anatomical localization of the hemorrhage is decisive
of the traumatic origin of the hemorrhage. A hemorrhage confined
in such an asymmetric way to the convexity is not seen in cases of
spontaneous hemorrhage.
Cases VI and VII are very difficult to. explain in this respect.
According to reports from eye-witnesses, the deceased had in both
cases received a very light slap on the head. No signs of external in-
jury are detectable, and the hemorrhage has an ordinary, symmetrical
localization. In these cases, there is actually no objective criterion
whatever which permits of drawing a conclusion in one or another
direction. One may just as well imagine that the excitement caused
by the fight or quarrel has given rise to a spontaneous hemorrhage
independent of the blow, especially in the 45-year old man (VIL),
who exhibited slight arteriosclerotic changes of the vessels. There-
fore, in the obductional conclusion, one was compelled to leave this
question unanswered, a point of view which, in these two cases, was
agreed with by the Medico-legal Council to whom the cases subse-
quently were submitted, and which caused the prosecution against the
persons who had hit the deceased, to be dismissed.
In case VIII, the deceased in a state of inebriation had fallen
heavily-to the ground, while, in case [X, the deceased who was also
in a state of great intoxication, had received a blow on the head
and had then fallen to the ground and knocked his head against the
root of a tree. These cases are considered traumatic hemorrhages.
From the above it becomes obvious how difficult it often is for
the dissector to obtain really objective ground for solving the problem
at hand. A careful comparison must be made between the objective
findings and the available data (police report, case report, etc.), as
they will prevail upon the medico-legal expert’s evidence which, of
course, should bear the stamp of extreme circumspection.
SUBARACHNOID HEMORRHAGE 495
Further, it is observed that the hemorrhage has been the cause of
sudden death in all the nine cases. In those of my own cases, where
there was an opportunity of observing the course of the disease, there
have not even been spasmodic fits. There at once occurred deep coma
which rapidly led to death. In these cases it is difficult to form a
positive idea as to the causal agent of such a sudden death. The
decisive factor is certainly that we have to deal with an abundant
blood extravasation which presses on vital centers of the medulla ob-
longata, particularly in those cases, where the blood has passed into
the fourth ventricle, while the ordinary brain pressure and the com-
motion presumably are of minor importance.
In cases of subarachnoid hemorrhage the prognostic is not gen-
erally described very unfavorably (Froin). In order to form an
idea of whether the prognostic of cases, in which subarachnoid
hemorrhages are found, is more serious than in other cases of intra-
cranial hemorrhage, I have examined the material of the Institute
of medical jurisprudence comprising lesions of the head with death
issue. In 21 cases of fracture of the skull with essentially or ex-
clusively subdural hemorrhage, death ensued after 26 hours on an
average, while, in 22 cases with predominantly subarachnoid
hemorrhage, death ensued after 6 hours. In this comparison of
cases, where the other factors (fracture of the skull, contusion of
the brain, etc.), are somewhat similar, those complicated with
subarachnoid hemorrhage seem decidedly to take the most un-
favorable course. A subarachnoid hemorrhage frequently has quite
a different aspect: After a spell of unconsciousness of shorter or
longer duration the patient awakens, and, now, symptoms resembling
meningitis and mental confusion set in. In the ulterior course of
the illness there may recur sudden exacerbations (hemorrhages )
which may lead to recovery or death. With regard to the diagnosis,
the findings after lumbar puncture are decisive; owing to the intro-
duction of the lumbar puncture which, in such cases ought always to
be employed, the relative frequency of these cases becomes obvious
The importance of the lumbar puncture as a therapeutic measure in
cases of hemorrhage is strongly emphasized, among others, by
Schrgder (1919), who gives an ample description of the technique
of the puncture. The spinal fluid is equally sanguineous in both the
first and the last portion and is under an increase of pressure. When
the spinal fluid is standing so that the blood sinks to the bottom, or
on centrifugalizing, the residual fluid acquires a pale orange tint in
cases where the hemorrhage has occurred a few days previously.
496 W. MUNCK |
RESUME
The isolated subarachnoid hemorrhage can be the cause of sudden
death. Nine such cases are on record.
In cases of this type it is often extremely difficult to determine,
whether the hemorrhages are spontaneous or of traumatic origin, as
the pathologico-anatomical picture in both cases can be perfectly
alike, both after rather large injuries and quite small traumatisms.
Very reliable anamnestic data should be demanded, possibly in
connection with signs of external lesions, in order to make sure that
a traumatism is really responsible for the hemorrhage.
In most cases it is impossible to detect the starting point of the
hemorrhage.
As a complication of other cranial or cerebral lesions subarachnoid
hemorrhages represent a greatly exacerbating factor.
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. Ehrenberg. Om spontan Subarachnoidealblgdning. Hygeia, 1912, p. 849.
Froin. Les hémorrhagies sousarachnoidiennes. Thése de Paris, 1904.
. Harbitz. Lzrebok i Retsmedicin, 1918.
. Harbitz. Traumatiske Hjerneaffektioner. Norsk Magasin for Lzegevi-
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9. Hedrén. Forldssningstraumatiske intrakranielle Blodninger hos nyfddte
och deras rattsmedicinske betydelse. Stockholm, 1918.
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11. Kalisko. Pl6tzliche Todesfalle. Dittrichs Handbuch der 4rztlichen
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12. Mgller, Harald. Bibl. f. Leger, 1920, p. 73.
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14. Petersen, Thorvald. Hospitalstidende, 1921, p. 721.
15. Sand, Knud. U. f. Leger, nr. 6, 1926.
16. Schmidtmann. Handbuch der gerichtlichen Medizin. 1907.
17. Schrgder. Om Hemorrhagia meningealis og den diagnostiske Betydning
af Blod i Spinalvesken. Bibl. f. Leger. 1919, p. 319.
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CONTA Urb wo bo
AN INTRODUCTORY STUDY OF THE EROTIC
BEHAVIOR OF IDIOTS * +
By Howarp W. Potter, M.D.
CLINICAL DIRECTOR, LETCH WORTH VILLAGE, THEILLS, N. Y.
DIscussION OF METHODOLOGY
The initial plan was to study the erotic behavior in long section
and cross section of mental defectives of all grades of intelligence
by anamnestic methods applied to the family as well as the patient
and by personal observation of the patient during institutional resi-
dence. The data on erotic behavior so obtained were to be correlated
with physical condition and development through endocrinologic,
neurologic, anthropometric and biochemical studies and also related’
to emotional attitudes and reactions through personality and psy-
chiatric evaluations. After attempting this rather large program,
it had to be given up mainly on account of insufficient personnel.
Nevertheless this attempt demonstrated the tremendous difficulties in
securing real facts about the erotic behavior of those feebleminded
individuals above the idiot level. :
We found that the information regarding erotic behavior ob-
tained by the field worker from the families was sterile or of little
authenticity. In fact we are forced to state that scientifically it is
useless to expect to be enabled to study directly the erotic behavior
of the high grade feebleminded either as to its life history in the
individual or as to its manifestations in the family stock. Memory,
upon which anamnestic material depends, is too inaccurate as to
objective details and too subjective to emotional attitudes and be-
liefs. And again the inability of the high grade defective to stick
to the truth and his inability to be frank about his erotic experiences,
images and desires cuts off the method of approach utilized by in-
vestigators in collecting similar data on college trained individuals.
Therefore the psychosexual development of the high grade feeble-
minded will have to be determind by inference by collecting data
relating to the erotic behavior of groups of these individuals at dif-
ferent age periods and varying mental levels. The basis for such
* Letchworth Village Publication No. 18.
+ Financed in part by the Committee for Research on Sex Problems of
the National Research Council. F
[497]
498 HA Werorm Bk
a method is suggested by the procedure used in this study. How
well one may succeed in gathering data in a purely objective way on
the higher grade defective is also a question. These individuals have
a sufficient level of intelligence to cover up their erotic behavior
while under the observation customarily afforded by an institution.
Even when such data have been secured on the high grade imbecile
or moron group, that part of it relating to homosexual behavior must
be viewed with the complete understanding that heterosexual im-
pulses are frustrated by the restrictions of institutional life in that
institutional life offers no opportunity for heterosexual contacts. The
homosexual behavior may therefore be of environmental origin and
a substitutive outlet rather than an inherent inversion of the eroticism.
The decision to confine our efforts to a cross section study of
the erotic behavior of a large group of idiots seemed advisable
because such types seemed to be comparatively free from difficulties
met with in studying those of a higher level of intelligence. Feel-
ings of guilt or shame, in the idiot, if present at all, are but weakly
developed and are not sufficient to prompt a desire to cover up or
repress erotic desires; in fact, desires of any sort. Such desires are
open to objectivism therefore and an anamnesis from the patient
or the relatives, which from either source experience has shown to
be of only fair reliability, is not essential at least for a cross section
study. Furthermore, the lack of heterosexual contacts in institutional
life would by inference not appear especially to modify the idiots
sex drive because long social acquaintance with the idiot extrainsti-
tutionally brings out few or no complaints regarding his hetero-
sexual behavior. We use “his” advisedly because it is conceivable
that female idiots may have heterosexual relations through no choice
or initiative of their own however. In limiting the scope of the
work to the idiot group we still could not carry out the original plan
of correlating the erotic behavior data with the physical and mental
aspects of the case because even though we had adequate equipment
we were entirely too short on personnel.
THE MATERIAL STUDIED
This is a report therefore of a study of the erotic behavior of
398 idiots—205 males and 193 females. These patients were studied
while living in an institution, being housed in dormitories, sleeping
40 to a ward, the beds being not more than four inches apart laterally.
These subjects retire early and arise early. Able-bodied older
patients are employed at some sort of rough work and a few of the
younger attend an organized hand training class. Weather permit-
Biv, OF THe EROTIC BEHAVIOR OF IDIOTS. 499
ting, the able-bodied group spends most of the day out-of-doors.
Many are crippled, some severe enough to be bedridden, some in
wheel chairs, and some able to get about on crutches or by crawling
on the floor. Many are unable to feed themselves and some do not
appear to know how to feed themselves despite the fact they are
physically able to do so.
Clinically they present a variety of conditions. Mentally some
are alert, others are dull and still others are extremely apathetic.
Some are happy and good-natured, others are irritable, quarrelsome,
resistive and excitable. Intelligence levels are less than four years
by the Terman test with I.Q.s less than 25. Physically there are
all sorts of defects, deformities, palsies, paralyses, etc., due to central
nervous system lesions or developmental anomalies. Many have gross
endocrine dysfunctions of a polyglandular nature. A few are cretins
and mongolians. In actual age they range from six to forty, the
majority being in the second decade of life.
PRESENTATION OF DATA
As we have limited this study to the idiot group we have made
no effort to further subdivide our material with reference to mental
level. In fact it is problematical as to how accurate an estimate
of .the mental level below 3 or 4 years can be obtained by the
Terman or Kuhlman tests. In this study we present our findings
only with reference to genital and physical maturity—pre-adolescence,
adolescence and post-adolescence.
As the problem was approached, three questions arose, viz. :
1. Are there erotic desires in the idiot and if so, how general
are they?
2. If there is erotic desire in the idiot, what is the sex object?
3. If there is erotic desire in the idiot by what sort of behavior
is it expressed ?
THE PRESENCE OR ABSENCE OF EROTIC DESIRE
Patients who were given to masturbation, mutual masturbation,
masochistic or sadistic episodes, stereotyped rocking motions, habits
characterized by sucking almost constantly some object or part of
the body, and perversions of various sorts such as pederasty, cunni-
lingus or fellatio were deemed as displaying desire and were con-
sequently regarded as erotic. ‘Those who displayed none of these
behaviors were regarded as nonerotic. It may be necessary in order
to justify the inclusion of certain of these activities under the term
500 ET OF tik
of erotic behavior to point out that the so-called nongenital behaviors
occurred in the majority of instances in the same patient and were
indulged in synchronously with purely genital practices (Table
1V). This postulates the assumption that the roots of such vicarious.
behaviors tap the sex impulse or libido.
Nearly three quarters of the whole group were erotic (Table I).
Eroticism was present in a larger percentage of the females than
the males (Table I). FEroticism was more prevalent in the adolescent
TABLE I. SHOWING THE PREVALENCE OF EROTIC BEHAVIOR
MALES FEMALES TOTAL
Erotic Nonerotic Erotic Nonerotic Erotic Nonerotic
© o %o % %
Preadolescents.. 350r59 24or41 42o0r87 60r13 77or/2 S0arzs
Adolescents ..'. . 41 or67° 200633 5Slor8Z “llorl8 9201 75) sine
Postadolescents. 51.or60 340r40 6lor73 22o0r27. 1120r67 56o0r33
Total. ..:...127 or 62 78or38 !540r80 39o0r 20 28lor sl site
male group than in either the pre- or post-adolescent group while
the females showed eroticism to be present in a larger proportion
of the pre-adolescent group with a gradual reduction in the adolescent
and post-adolescent groups (Table I). At all periods of life the
females exceeded the males in their proportion of erotic individuals.
THE SEx OBJECT
The choice of the sex object so far as the limitations of this study
are concerned, rests between the subject him or herself or another
subject of the same sex. The possible disadvantage of this limita-
tion of choice of sex object has been discussed previously in
this paper.
In four-fifths of the total number of 281 erotic subjects the erotic
impulse was directed to the self. In the remainder there was in
addition an indication that the erotic impulse was directed to other
subjects of the same sex. In only three instances was the sex drive
cirected to their associates only and then in the form of sadistic
behavior (Table II). Autoeroticism alone was more common:
among the females while autoeroticism accompanied by eroticism
directed to others was more common among the males (Table II).
In each sex autoeroticism alone was more common in the pre-
adolescent and adolescent periods while autoeroticism together with
eroticism directed to associates was more common in the post-
adolescent group.
Das One tierra BEMAVIOK OF THOS 501
Tas_eE II. SHowrnG NATURE OF THE SEX OBJECT *
MALES FEMALES TOTAL
Sex object Sex object Sex object Sex object Sex object Sex object
self only self and others self only self and others self only self and others
%o % Jo Yo %o Yo
Preadolescents. 27 or 77 7or20 36o0r 86 6o0rl4 630r83 130r17
Adolescents.... 35 or 85 6o0r15 44or 86 7or14 79or86 13o0r14
Postadolescents 350r68 150r30 46o0r75 140r23 8lor74 29or 26
Api 97 or 76 2Bor22 1260r82 27orl7 2230r79 55or 20
* Percentages based on the number of subjects showing erotic desire; not on the total
number in the study.
+ There were only three subjects in the whole group of 281 erotic persons who exhibited
behavior indicating that the sex object was another person only. This number being. so
small is not included in the calculations of this table.
MopeE or EXPRESSION OF THE EROTIC DESIRE
Several modes of expression of the sex desire were noted as
follows:
_ Masturbation. Commonly observed in an infantile form. In
but exceptional instances the act consisted of rubbing, scratching, or
squeezing the genitalia which did not apparently result in an orgasm.
In other words, we observed what seemed to be an abortive form of
masturbation.
Masturbation in the form noted above was first in frequency of
the different modes of expressing an erotic desire by either sex of
the 281 erotic idiots. The proportion of masturbation was greater in
the adolescent and post-adolescent males than in the pre-adolescent
males and greater in the adolescent females than in the pre- or post-
adolescent females. It was found in about equal proportion in
each sex (Table II and IV).
Rocking motions. Probably a form of extragenital erotism pro-
duced by the rhythmic movements of muscles and joints. These
were frequently accompanied by a sort of stereotyped slapping or
biting some part of the body or diligently sucking the lips or the
back of the hand or pressing the genitalia. This form of erotic
behavior was second in order of frequency in either sex. It was
more common in the adolescents than in the pre- or post-adolescents
of either sex (Table III and IV). :
Sucking. This is a form of extragenital stimulation’ known
usually as oral eroticism. It was observed as a diligent sucking of
the tongue, lips, fingers, backs of the hands, and occasionally some
foreign object, the individual apparently deriving some sort of a
real satisfaction from it. It often accompanied masturbation, rock-
ing, and masochism. It was the third most frequent erotic activity
practised by either sex and was much more common among. the
502 A eye POTRER an
females than the males. Pre-adolescents and adolescents of either sex
were habituated to this activity more than post-adolescents (Tables
III and IV). | . . See y
Masochism. Noted as self-mutilation. The biting was often
severe enough to draw blood and the striking sufficiently vigorous
to cause a bruising of the tissues. It was carried out in either a
rhythmic stereotyped fashion frequently in conjunction with mastur-
bation, rocking, or sucking or occurred during the course of emo-
tional outbreak or tantrum. It was fourth in line of frequency for
the whole group and the females, but fifth in order of frequency ©
for the males. In other words it was more frequently observed
among the females than the males. Among both sexes it was more
common in the preadolescents and adolescents than the _ post-
adolescents (Tables III and IV).
Sadism. Observed as a definite tendency to cruelty toward asso-
ciates. Such individuals would bite, pinch, kick or strike their
associates often without a display of any temper manifestations.
Sadism occurred fifth in order of frequency for the whole group
and the female group, and sixth in line of frequency in the male
group. It was therefore more common among the females than
the males. Among the males it occurred in about an equal propor-
tion of the pre-adolescents, adolescents, and post-adolescents and
among the females it was more common in the post-adolescents
(Tables III and IV).
Mutual masturbation, ‘The act was quite infantile or abortive.
it consisted of handling, squeezing, or rubbing the genitalia of another
subject and was rarely productive of an orgasm. It was sixth in
order of frequency for the whole group and the female group, and
fourth in the male group, being therefore more common in male
idiots than in female idiots. It was more common in the post-
adolescents or pre-adolescents (Tables III and IV).
Pederasty. Seventh in order of frequency. In each instance it
was passive, the idiot being the subject, apparently willingly, of
some higher grade imbecile or moron. It was seen in only the
post-adolescents. There were only eight cases (Tables III and IV).
Cunnilingus. Eighth in order of frequency and the subject in
each instance was the aggressor. It occurred among three post-
adolescents only (Tables III and IV).
Anal eroticism. Again in a very primitive form, difficult to
determine by observation, usually practiced while on the toilet by
inserting the finger in the rectum. It was not observed among the
females (faulty technic?); was ninth in order of frequency and
503
Si. OnY (OPO PETEROJIG BEHAVIOK OF IDIOTS
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TasLE IV. SHOWING THE VARIOUS COMBINATIONS OF THE MODES OF
EXPRESSING THE EROTICISM
Male Female Total
. Masturbation 4 sos Ce os eee 34 27 61
1
2. Masturbation, rocking. oe ee ee ee 16 23 39
3, .Masturbation, sucking 4.0.30 te ee eee 9 12 21
4. Masturbation,2«analveroticisnia. 22a see ee 1 0 1
5. Masturbation, rocking asuckitio.s) eee eee 5 15 20
6. Masturbation, anal eroticism, sucking ..........- 1 0 1
7. Masturbation, masochisni®.@e-e-e. 2 & a7 ee ee 5 0 3
8. Masturbation, rocking, masothisiiv... 1... ee 1 5 6
9. Masturbation, anal eroticism, sucking, rocking .. 1 0 1
10. Masturbation, masochism, rocking, sucking ..... 0 4 4
11.. Masturbation, mutualamasturbatione. see ee 4 12
12. Masturbation, mutual masturbation, rocking, suck-
ON PON Ae Re ela ie mee =, Le eagles ce ye = 2 Zz 4
13. Masturbation, mutual masturbation, sucking .... 1 0 1
14. Masturbation, mutual masturbation, rocking, pe-
derasty .. «3 a)s"Qasew bites aee eters eee tae eee 1 0 1
15. Masturbation, mutual masturbation, pederasty .. 6 0 6
16. Masturbation, mutual masturbation, rocking, sad-
ISI] . c's b 5 w Slee aes eee hes til ree iene ee em it 0 1
17. Masturbation, mutual masturbation, rocking ..... 0 1 1
18. Masturbation, mutual masturbation, pederasty,
rocking, masochisny +... soe fee eee 1 0 1
19. Masturbation, mutual masturbation, sucking,
rocking, cuntlingus vg 9.2 o ee 0 1 1
20. Masturbation, mutual masturbation, sucking,
rocking, .sadism, “cunmliiausas sae ee 0 1 1
21. Masturbation, mutual masturbation, sucking,
rocking, sadism, masochism, cunnilingus ...... 0 1 1
22. Masturbation= rocking, tellanie se). a) eee eee 1 0 1
23. Masturbation, sadist .tase cae een eee 2 a2 4
24. Masturbation; rocking, Ssadisin 9.) =e eee ae 1 0 ]
25.. Masturbation, rocking, masochism, sadism ...... 1 ~ 3
26. Masturbation, masochisinw sacdiciv en eee 0 Z 2
27. Masturbation, sucking, masochism, sadism ...... 0 2 2
28. Masturbation, sucking, sadism) eee 0 vd 2
29. Masturbation, sucking, rocking, sadism ......... 0 rad 1
30. Masturbation, sucking, rocking, masochism. sad-
ISIN Fs ss oad gels osha ee ee 0 1 1
31. Sucking 2... 0s. pte ee 9 10 19
32.» Masochism 74.500. (seen eee 5 0 =
33,. Rocking 04.2 1.4 <a oe ee ee Og 15 27
34. Sucking, rockin gs) 92) ae een eee ee 0 13 ig
35. Rocking, masochism 4.0.) san eee 0 fe Zz
36. iMasochism, sadism 200 0 ae See 1 5. 4
37. Rocking, masochism, sadism =) ee ee re 1 a
38) Rocking, sadism! 77.1) eee ee 0 1 1
39, Sadism . sa. iw vinaiciew CeCu Nea eee eee eer ee 2 1 3
40. Nome: oe, so cil'eoln hana Rie eee ele eee a ae a 78 39 117
Total 3..-.:5 battle eee 205 193 398
occurred in one adolescent and two post-adolescent males (Tables
III and IV).
Fellatio. There was only one instance—an aggressor and an
adolescent (Tables III and IV). 7
SLUDY OR THE EROTIC BEHRAVIORN, OF IDIOTS 0
tur
on
SUMMARY
A cross section study by objective methods of the erotic behavior
of 398 idiots of both sexes made while the subjects were patients
in a large institution for mental defectives. The prevalence of a
sex desire, its sexual object and its mode of expression were deter-
mined and correlated with the sex and physical maturity of the
individual.
Nearly three-quarters of the entire group showed the presence
of erotic desires, a larger percentage of females than males, and in
general it was present in a larger proportion of the adolescents than
the pre- or post-adolescents (Table |).
Nearly four-fifths of the total erotic idiots were autoerotic only ;
they showed no sex drive directed outside the sphere of their own
body. The remainder, in addition to being autoerotic directed their
sex interests to their associates (of the same sex) as well. There
seemed to be a tendency for the males to be rather more extroverted
in their sex behavior than the females and the post-adolescents of
both sexes displayed more extroversion (Table II) than either the
adolescents or preadolescents.
The erotic desire was expressed in Anant of genital and pregeni-
tal eroticism and perverted eroticism such as masturbation, mutual
masturbation, rocking motions, sadomasochism, oral and anal eroti-
cism, pederasty, cunnilingus and fellatio. These occurred as sole
behaviors or in combinations of two or more (Table IV). The
order of frequency of these forms of sex behavior for each sex is
as follows:
Males Females
1. Masturbation 1. Masturbation
2. Rocking motions 2. Rocking motions
3. Oral eroticism 3. Oral eroticism
4. Mutual masturbation 4. Masochism
5. Masochism 5. Sadism
67 Sadism 6. Mutual masturbation
7. Pederasty 7. Cunnilingus
8. Anal eroticism
9. Fellatio
In general masochism was more common among pre-adolescents ;
masturbation, rocking motions, oral eroticism and fellatio among
adolescents ; and sadism, mutual-masturbation, pederasty, cunnilingus
and. anal eroticism among post-adolescents. In fact there were
only eight cases of pederasty (all passive), three of cunnilingus (all
506 ee '. ALW. POTTER
active), each among post-adolescents and only one case of fellatio
(active) which was in an adolescent (Table III).
Masturbation and mutual masturbation was more common among
the males, while rocking, oral eroticism, masochism and sadism was
more common among the females. |
COMMENT |
This study, incomplete as it is, points to some very definite rela-
tionship between intelligence and sex behavior. These idiots do not
present a sexuality any more organized than their primitive intelli-
gence. We may well ask ourselves, Is their infantile sexuality fixed
by their primitive intelligence or is their intelligence, in some
instances, primitive on account of an infantile fixation of their
sexuality or are both dependent on something more fundamental ?
Let us discuss these various hypothetical relationships.
First as to their sexuality being fixed by their primitively devel-
oped intelligence. L. Pierce Clark in a recent communication, “A
Psychological Study of the Nature of the Idiot,” suggests the idea
that the severe limitations placed on the idiot by his damaged intelli-
gence (defects of organic brain disease) frustrates objectivation of
his libido, as a result of which he is forced to become an introvert
and indulge his satisfactions in narcissistic activities. Such a hypothe-
sis would explain the domination of infantile or narcissistic erotic
behavior of the idiots in this study. We must also not leave out of
consideration the unknown effect which normally developing intelli-
gence and the stimuli which are gathered from the environment by
an adequate intelligence may have on psychosexual development.
This immediately suggests a field for more adequate evaluation of
the intelligence of persons suffering from transference and narcissistic
neuroses or cycloid and schizoid psychoses which would be of value
in determining if psychosexual development does depend for at
least a part of its normality on the type of intellectual equipment.
Now as to the second question, “ Does the infantile fixation of
the psychosexual life result sometimes in also a fixation of the intelli-
gence at a low level of development?” When an adolescent develops
dementia precox and there is in evidence definite narcissistic modes
of behavior, he seems to become, with a rapid deterioration, intel-
lectually blocked. We do not diagnose him as mentally deficient
however, because we have another and more appropriate diagnostic
category to fit him into. Furthermore, we find in certain idiots
those stereotyped movements, grimacings, gestures, etc., commonly
observed in some of the chronic psychoses, notably dementia precox.
DU OP PE EROJIC BEHAVIOR OF IDIOTS. 507
The reference is to those forms of motor stereotypy associated with
reversion rather than hallucinatory reaction types of behavior. We
offer merely as a suggestion therefore that in certain instances, there
may be such an overwhelming narcissism in the infant as to prevent
the outflow and onflow of that portion of the libido which perhaps
furnishes at least a part of the urge needed for the development
of intelligence and as a result the intelligence becomes fixed at an
idiotic level of development. More widespread necropsies and patho-
histological studies of the brains of apparently nonorganic idiots
would go a great ways in clearing up this question.
Now the last question, “Are both the intellectual deficiency and
the psychosexual fixation dependent on a more fundamental situa-
tion?”’ This question immediately suggests carrying out what had
been intended in this study, the relation of physical, emotional, and
biochemical states to the sex behavior and intelligence level.
In this whole subject, whichever way we may look at it, we see
illustrated the biological law of survival of the fittest. No matter
how these individuals arrived at their biological unfitness, the lack
of adequate procreational urge seems to have been specifically and
purposely provided in order to insure the dying out of the stock.
SOCIETY PROCEEDINGS
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY
REGULAR MEETING, THURSDAY, NOVEMBER 18, 1926. DoNALD
GrecG, M.D., PRESIDENT, IN THE CHAIR
MUCINOID DEGENERATION:-OF THE OLIGODEN--
DROGLIA
PERCIVAL BAILEY, M.D., AND GEORG SCHALTENBRAND, M.D.
During the routine pathological examination of the brain from
a case of Schilder’s encephalitis periaxialis diffusa, the authors have
been able to prove that the acute swelling of the oligodendroglia as
described by Penfield and the mucinoid degeneration of Greenfield
are identical. The article will be published im extenso later.
Discusston: Dr. E. W. Taylor: I should like to ask whether
mucoid degeneration occurs in any other form of cell. |
Dr. Bailey: No. We have examined our material very carefully
and have not seen it in any other cell. It is purely a process which
affects the oligodendroglia.
Dr. Donald Gregg: What is the diseased condition?
Dr. Bailey: Encephalitis periaxialis diffusa of Schilder. Dr.
Greenfield has examined many normal brains for this type of lesion
and has not found it. The work of Greenfield has not been generally
accepted. Different people have tried to repeat it and have rather
cast doubts on the validity of his conclusions. When we first tried
on this brain we did not get anything. We found that in order to get -
good staining we were obliged to refix the tissue in corrosive sub-
limate. I think that very probably explains the failure of other
people to get results.
Dr. D. J. MacPherson: Dr. Myrtelle Canavan of the Psychopathic
Hospital found a very similar type of degeneration in the mid-brain
of an individual dying of encephalitis lethargica. She was very much
intrigued by the lesion and asked for a diagnosis from several differ-
ent laboratories, but she found no one at that time who would express
a definite opinion as to the nature of the degeneration.
Dr. Bailey: It is interesting to me because it is exactly where you
would expect to find the degeneration, since the oligodendroglia lie
mainly in the white matter of the brain.
[508]
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 509
THERAPY IN PARALYSIS AGITANS
MaxweE Li E. Macponatp, M.D.
A series of cases showing Parkinson’s syndrome was selected for
a comparative study with various methods of therapy. Several meth-
ods of therapy, for which symptomatic results have been claimed,
were tried:
a. Drug therapy :
1. Parathormone
2. Bulbocapnin
3. Sodium salicylate
4. Hyocin hydrobromide
b. Physiotherapy :
1. Passive—massage and heat
2. Active—conscious reéducation
A careful physical and neurological examination was first made.
The laboratory work included blood Wassermann, blood calcium,
blood COs (in a few cases). In some of the cases spinal fluid exam-
ination was made, which included pressure readings, cell count,
globulin, Wassermann, gold sol, total protein, calcium. A few of
the cases had electromyograms.
The neurological examination seemed to divide the groups clin-
ically into those with a history of encephalitis, showing as the pre-
dominating sign rigidity with but relatively little tremor, and the
so-called idiopathic group, which showed tremor to a much greater
extent. Most of the cases showed pyramidal as well as extra-
pyramidal signs. Two' cases showing no clinical evidence of tremor
did show on electromyographic studies a beginning of a periodic
excitation. Within the time of the series one of these developed
a tremor which could be noticed.
Parathormone (Collip’s parathyroid extract): Reports have been
made of symptomatic improvement following the use of parathyroid.
We decided to use Collip’s preparation because of its definite action
in increasing the blood calcium. The blood calcium figures in
untreated cases fell well within normal limits. Parathormone was
given, subcutaneously, in from 10 to 20 unit doses, with an average
increase of blood calcium of 3317/3 per cent. In one case an increase
of 75 per cent resulted. An attempt was made to vary the hydrogen
in concentration by giving ammonium chloride. In these cases a
daily blood carbon dioxide was done. It is interesting to note that
the blood calcium curve followed in an increase ratio to the CO: curve.
In other words, the calcium figure was highest at the height of the
acidosis. There was no obvious clinical improvement in any of the
cases in which parathyroid was used.
Bulbocapnin: The use of this alkaloid in various tremors was
described by de Jong and Schaltenbrand in 1924. We used-it in 0.1
gram to 0.2 gram doses subcutaneously. Our experience would lead
us to make the statement that it is not effective in paralysis agitans
following epidemic encephalitis and only in a part of the cases of the
510 BOSTON SOCIETY OF PSYCHIATRY AND NECGKOLGG
other group. In a few cases of very severe tremor it worked in a
splendid manner, stopping the tremor in a few minutes and lasting
several hours. ‘The field for its use seems to be sharply drawn.
Sodium Salicylate: The intravenous use of sodium salicylate
followed from the optimistic reports of the Paris clinics. We have
not done enough with this to draw any definite conclusions but cer-
tainly in a few cases of the chronic encephalitic type there was a
distinct relief of symptoms. ‘There was a diminution of the tremor
which was noticeable, and a subjective relief of the rigidity. We
used 50 c.c. of a 4 per cent solution three times a week. ‘This is worth
further trial.
Physiotherapy: We found that while passive methods of physio-
therapy gave some immediate relief, there were no lasting results.
We came to the conclusion that it was not worth a great expenditure
of time. On the other hand, I feel that a conscious attempt on the
part of the patient to do a series of graded exercises, for the correc-
tion of posture, leads to distinctly beneficial results. ‘This seems
rather surprising in view of the extreme rigidity in some cases, but
it is a valuable adjunct to any treatment.
Hyoscin Hydrobromide: This still remains the most satisfactory
drug for routine use. Given in 1/200 to 1/100 grain doses, one to
several times daily, most of the cases were relieved to some extent.
Clinical trials were made of parathyroid therapy, with laboratory
control of blood calcium level in a series of cases of paralysis agitans
with negative results. Bulbocapnin was very effective in stopping
the tremor in a limited number of cases. Sodium salicylate intra-
venously gave relief of tremor and rigidity in some of the chronic
encephalitic cases. Hyocin hydrobromide gave some relief in most
of the cases. Physiotherapy was effective only as voluntary con-
trolled effort.
It seems to me that inasmuch as clinical and pathological evidence
point to a progressive disease in the paralysis agitans following
encephalitis, we should call this chronic encephalitis instead of post-
encephalitis. Our efforts towards effective therapy should be directed
te the discovery of the cause of the infection and the development of
specific therapy. As about 90 per cent of the cases in our clinic at
this time are of this type, it obviously stands out as the most important
group for therapy. In addition to this numerical preponderance is.
the fact that many of the cases are young people.
Discussion: Dr. E. W. Taylor: I was particularly interested in
what Dr. Macdonald said about the use of hyoscin and in the action
of its closely related drug which he did not mention. I want to ask
if he makes any distinction between hyoscin hydrobromid and
scopolamin hydrobromid. Certainly these are put out as separate
preparations, and I have been under the impression that their action
is probably a little different. Personally, I use scopolamin exclu-
sively, and my results have been quite different from those Dr. Mac-
donald mentions. He says, so far as hyoscin has been useful at all,
it has been helpful in stopping tremor. I have found it extremely
useful in controlling rigidity and not so useful in cases of tremor. I
BOSTON ‘SOCIETY OF PSYCHIATRY AND NEUROLOGY 5i1
recall one case of parkinsonian syndrome following encephalitis of
the most severe type. The man was a car driver; he was com-
pletely helpless, drooling, unable to feed himself, slovenly, not able to
get about; apparently in a very low state. I gave him a large dose,
1/100 grains three times a day, and in about a week or ten days he
came in alone to see me at my office, well dressed and entirely capable
of getting about and taking care of himself in every respect. The
improvement, however, was by no means complete, and he has
remained in a state of partial disability. The primary improvement
was little short of miraculous. I have used scopolamin regularly,
and I almost invariably meet with favorable results. I have seen
practically no effect upon the tremor.
Dr. D. J. MacPherson: I had one patient with marked muscular
rigidity and moderate tremor. He could not shave himself and could
not walk. He was given hyoscin with complete release from rigidity
but his tremor remained exactly as before. After three months
hyoscin lost its effect. He was given scopolamin and the rigidity
again disappeared. Scopolamin, too, lost its effect, and he was put
back on hyoscin, which again relieved the rigidity. He has since
shifted from one to the other. It would seem from this experience
that there is some slight physiological difference in the effect of the
two drugs. I would agree with Dr. Taylor that in most cases the
rigidity can be diminished, but I have seen only slight change in
the tremor. In one case, small doses of strychnine seemed to stop the
tremor to some extent.
Dr. T. J. Putnam: I have no first-hand knowledge of bulbo-
capnin, but Dr. Schaltenbrand asked me to show some of his lantern
slides. I saw some of the patients with whom he was working in
Amsterdam. They studied only cases of idiopathic senile agitans
and did not have the opportunity to try the drug on any cases of post-
encephalitic agitans. Not all cases responded favorably to the drug.
Some were quite unaffected by it. In some of these hyoscin and
scopolamin seemed to have some effect, and in other cases bulbocapnin
had an effect in decreasing the tremor where other drugs were use-
less. In a recent article by Lewy, Dr. Schaldenbrand told me that
he reports a number of cases, some of the idiopathic senile paralysis
agitans and some of the encephalitic form, and found there was
probably never any effect in the post-encephalitic cases with bulbo-
capnin. Other articles have appeared reporting a much larger num-
ber of senile agitans, and about one-third of his cases were unaffected
by the drug. It was the impression of Dr. Schaltenbrand and Dr.
de Jong that the tremor was favorably influenced by bulbocapnin, but
that this had no effect on the rigidity; and while it is perfectly true
that it would be more preferable to have a truer agent to combat
paralysis agitans, in the lack of that we turn to symptomatic meas-
ures, and in some cases (probably not a very large proportion) in
which the tremor annoys the patient more than the rigidity, or in
which the tremor is annoying to the patient in addition to the rigidity,
bulbocapnin may find a place. I think there is no doubt its use still
remains to be defined.
512 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY
CLINICAL CONSIDERATION TORS SPECIAL ya
ABRAHAM Myerson, M.D.
This is a summary of a study carried on at the Wrentham State
School under the direction of Drs. H. B. Elkind and A. Myerson.
It was undertaken to see whether or not figures at the Wrentham
State Hospital would corroborate or disprove a different type of study
carried on at the Walter E. Fernald State School at Waverley. In
the earlier study (the one carried on at the Walter E. Fernald School,
which has already been reported on before the Society ), the statistical
analysis was secondary to an intensive individual and clinical study.
(1) There were 1,044 cases at the Wrentham Hospital whose
histories were studied. Most of the information, however, concerns
smaller numbers. The following appears to be the case concerning
these 1,044 inmates: There were 95 per cent white and 5 per cent
colored; 42 per cent males and 58 per cent females.
(2) It is evident on a close study of admissions and the causes of
admissions that there are more females in Wrentham largely because
feeble-minded females seem to get into more social difficulty, or are
regarded with more social concern, than are the males. This is
evidenced by the fact that the admission age of the females is much
higher than the males, and is nearer the age of puberty. i
(3) In general, the social level of the families of the group is
much lower than that of the general population; many more are from.
dependent families and institutions.
(4) There are more morons among the females, and the males
have more idiots and low imbeciles. The study of the reasons for
coming to the institution explains this. Idiots and low imbeciles
come in largely because they are more difficult to care for; morons
come in because of immorality either in their personal lives or in
their background, and for delinquency. Thus it is evident that a
social rather than a biological selection takes place. In Massachusetts
there are far more agencies concerned with girls than there are those
concerned with boys, and this also helps to account for the larger
number of females of the moron type and of the adolescent age.
(5) Size of families: This bears on the mooted problem of the
prolificity of the feeble-minded. The average family, at Waverley,
from which the inmates come is 3.8; the average Wrentham family
is 4.5.> The Wrentham family is but slightly larger than that of the.
general population of Massachusetts, but not larger than the cultural
level of the group from which the inmates come leads one to expect.
It is well known that the higher the cultural level, the lower the birth
rate. Independent of the mental status of the families from which
these patients come, their lower cultural status explains the slightly,
increased birth rate. At any rate, no matter how regarded, there is
no evidence either in this study or in the study of the late Dr. Walter
E. Fernald on the discharged patients from the Waverley institution,
to show that the families from which the feeble-minded come have
a high birth rate.
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 513
(6) Siblings of the feeble-minded:
(a) The statistical analysis of the number of feeble-minded
siblings in relation to the size of the family has not been completed,
and the figures are too small to be of great value. Among the
known cases of the males, the patient was the only member of the
family that was feeble-minded in two-thirds of the cases. The figures
for females differ but slightly from those of the males. A cursory
survey of the figures does not indicate that feeble-mindedness runs
nearly so strongly in families as has been alleged. This corroborates
our Waverley studies.
(b) Relationship of feeblemindedness to mental diseases: The
number of siblings of the patient who have mental diseases is negligi-
ble. This, of course, is easily explained on the ground of the age
of the siblings who are, in a general way, too young to have recog-
nizable mental disease.
(c) The number of siblings with epilepsy: There are few sib-
lings of the cases with feeblemindedness who have epilepsy; we
feel not greater than one would expect in view of the prevalence of
epilepsy in the community. It is the experience of every general
hospital that epilepsy is very common, probably more common than
feeblemindedness or the mental diseases.
(7) The descendants of these feebleminded individuals in Wren-
tham are too few and, in a general way, too young to show much of
importance. We have 57 cases in which we know that there are
children. Twenty cases have been followed up, and in only two
of these cases was there feeblemindedness. Walter E. Fernald’s
figures are of interest in relationship to this—646 patients were
discharged from the Waverley institution during his incumbency as
superintendent; 27 of these people married, there were 50 children,
and 33 of these children survived. (This does not indicate a high
prolificity of the feebleminded.) His examination of the children of
these feebleminded mothers showed them to be nonfeebleminded in
every instance.
(8) The study of the parents of the feebleminded:
(a) At Wrentham, this study is associated with great difficulty,
and the conclusions have not yet been analyzed, but they indicate as
follows: Both parents were apparently normal in 69 per cent of the
male patients ; both parents were normal in 54 per cent of the female
patients. In 10 per cent of both groups, one parent was feebleminded,
and in 6 per cent both parents were feebleminded, showing that the
feeblemindedness of the parents is a significant factor. There was
not enough epilepsy in the parents to be of significance.
(b) In regard to mental diseases, there were 3 cases where both
parents were mental, as contrasted with 49 where both parents were
feebleminded ; there were 35 cases with on parent mental as contrasted
with 70 cases where both parents were feebleminded. The study
of these 35 mental cases shows a good many conditions which we
do not regard, on the basis of a published study of the inheritance of
mental diseases (Myerson—‘ Inheritance of Mental Diseases ’’),
as significant ; in other words, they are exogenous rather than endoge-
514 BOSTON SOCIETY_OF PSYCHIATRY, AN DINEGKOCLOGs.
nous. There were 4 alcoholic psychoses, 5 cases of general paresis,
and two cases of toxic psychoses after pregnancy.
It is very significant that of these 35 cases with mental disease,
there were 10 cases who were diagnosed in institutions as feeble-
minded and not insane. Seven finally simmered down to endogenous
mental disease; 4 cases of dementia precox, 2 cases of manic-depres-
sive, and one case of cardiorenal vascular disease. Studying these
cases, we do not feel that, in the main, mental diseases of the
parent can be stated to be of relevance in the history of a person
with feeblemindedness.
(9) Relationship of syphilis to feeblemindedness: This study
shows 3.5 per cent of the patients had positive Wassermanns. The
Solomons, in their study of “ Syphilis of the Innocent,” showed that
reports concerning the incidence of syphilis in the young are very
contradictory, but they conclude that about 5 per cent would show a
positive Wassermann. ‘Thus the reaction of the population at Wren-
tham is certainly not more than that of the community. It is a very
significant thing that 35 per cent of these were females, morons
with a history of irregular sexual life. In other words, the chances
are very strong that, at least amongst the females, there was acquired
syphilis instead of congenital.
In our Waverley study, we stated our reasons for concluding that
syphilis did not play a role in feeblemindedness; our Wrentham
studies seem to corroborate this. If it plays a role, it is that of a
minor, unnamed supernumerary, instead of that of star performer.
The importance of syphilis in a pathology of feeblemindedness has
been distorted by the traditional issues which intrude themselves into
science with every reference to sex and morals.
(10) We introduce the concepts of relative feeblemindedness and
technical feeblemindedness to account for a good deal of the sporadic
cases of feeblemindedness and much of the familial feeblemindedness.
In every human quality there is fluctuation up and down, and intelli-
gence is no exception. Ina high grade family a fluctuation downward
is not as apt to produce a moron as it is to produce an individual
lower than his group, that is, a relatively feebleminded person. In
the case of a low grade group, above the technical feebleminded level,
a fluctuation downward is apt to produce a technically feebleminded
person. The term “technically feebleminded person” is used to
indicate that the concept of feeblemindedness is not an absolute one,
and cannot be scientifically defined or justified.
Discussion: Dr. G. L. Wallace: We are much indebted to Dr.
Myerson and his coworkers for the splendid work they are doing.
When the pathological groups, the Cretins, Mongolians, Spastics,
and a few special groups are separated from the mass, we then view
feeblemindedness, as Dr. Myerson outlines it, as a condition and not
as a medical disease. It is a pathological disease but social, not
medical. I am sure in saying that to a medical audience I am not
going to be misunderstood for, primarily, from its origin we must
consider it as a medical problem, but the problem as the community
meets it, is a pathological social condition. This condition which:
BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 515
is easily classified to-day within the realm of feeblemindedness, ten,
fifteen or twenty years ago was not within that realm. A few years
ago, before the social order of things became so complex and exacting,
many of these people with low mentality and disturbed emotional
natures were able to make better adjustments with their environment
than they are to-day. And then, when they were out of alignment
with their environment, they were not classified as feebleminded
but received consideration by the courts and various social organiza-
tions and treated in accordance with the symptoms they presented.
Dr. Myerson has clarified the problem to a great degree by separating
it from mental diseases and from the pathological groups of feeble-
mindedness. By so doing, he places this problem where it may be
viewed as one strata of society. But even so, it is none the less a
serious and significant problem. I quite agree with Dr. Myerson
that it is not a problem of intelligence that we are dealing with in
abnormal behavior in the higher Moron age levels. In our survey
a few years ago, of one hundred girls with a mental age of eleven
and eleven plus, we found on investigation of the family histories
that the member of the family that we were dealing with in each
instance was simply a cross section of the family. The reactions of
our cases were quite similar to those of their brothers, sisters, fathers,
mother, uncles, aunts and grandfathers and grandmothers. We found
that the reactions of these families for generations were out of align-
ment with the social requirements of the communities in which they
lived. It seems that there are very potent, positive and powerful
biological factors dominating this great problem of the unclassified
feebleminded. Since Dr. Myerson has so successfully segregated this
large group of unclassified feebleminded, we are now anxiously await-
ing the next step which, I hope, will be the breaking up of this group
into well defined sections.
Dr. Myerson: It is astonishing how many children are born with
blood in the spinal fluid. The work of Sharpe, and of others in Ger-
many, shows that children who are apparently born normally have
had either a subarachnoid or an intraventricular hemorrhage, or, at
least, blood has found its way into these situations. Blood in the
spinal fluid does not, of course, adequately represent damage in the
cortical or subcortical areas.
A very interesting series of articles has appeared on the effect
of encephalitis upon the mentality of children, showing that mental
defect follows in at least a small proportion of cases. A personal
follow-up of children who had encephalitis, and who had been treated
at the Boston Children’s Hospital, showed that mental deficiency was
to be expected in some instances. The number of cases was too small
to be dogmatic about.
Dr. Elkind’s statement that we are dealing with a selected group
is true, but the point is that we have selected the worst group from
the standpoint of heredity, the public institutional cases, and that
groups in the community and public schools would have still less
heredity.
516 BOSTON SOCIETY OF PSYCHIATRY AND NEURCLOG as
In regard to Dr. Wallace’s remarks—the most of girls with a men-
tal age of eleven do not get into trouble, but those who do are
sent to his institution, or other schools for the feebleminded. There
are girls of the same temperament, but with a higher mental age, in
the reform schools. We had better invoke heredity as explaining
things only when we can prove it—not as a working hypothesis. As
a working hypothesis, it kills research into more easily handled causes.
Our ignorance of causes has usually paraded as heredity. Witness
the history of tuberculosis, goitre, and epilepsy.
CURRENT LITERATURE
I. VEGETATIVE NEUROLOGY.
1. VEGETATIVE NERVOUS SYSTEM.
Lintz, W. Broncur1aL ASTHMA Due To Mice. [N. Y. Med. Jl. and
Med. Rec., June 20, Vol. CXXIX.]
This is an interesting clinical report in which the removal of a few
dead rats from beneath the boards of the bedroom floor of the patient
freed her from attacks of bronchial asthma for three years.
Stivelman, B. P. PLEUROPULMONARY REFLEX. [Am. Jl. of Med. Sc.,
Jane, Vol CLEXYV. J. AoM, A.)
Stivelman reviews his experience gained from pleural punctures in the
course of therapeutic pneumothorax. Among 162 primary punctures,
pleuropulmonary reflex was encountered in seven patients, in three of
whom the attacks recurred on subsequent attempts to enter the pleural
space. The most severe and outstanding symptom during the attacks
was cardiorespiratory embarrassment. It was present in all. This dis-
tressing symptom was of the vagoinhibitory type in three cases and
vasomotor in seven cases, the former being characterized by slowing
of respiration and decreased frequency and increased force of the pulse,
the latter by rapid, shallow and arrest of respiration, and rapid, feeble
and ultimately imperceptible pulse and heart beat. Among 1,824 punctures
for refills, i.e., thoracentesis performed in those cases in which the pleural
surfaces were widely separated from each other by pneumothorax so that
the needle could not possibly injure the visceral pleura and underlying
lung tissue, the accident occurred but twice. Stivelman believes that
injury to the inflamed visceral pleura and lung tissue underlying the point
of puncture is a definite factor in the causation of this symptom complex.
When symptoms pointing to the reflex make their appearance, the needle
should be withdrawn at once. If the cardiorespiratory failure is of the
cardioinhibitory type, reassurance of the patient and a little patience on
the part of the physician is all that is necessary, although atropin may
be given subcutaneously in severe cases, none of which, however, have
proved fatal. If the cardiorespiratory failure is of the vasomotor type,
epinephrin should be given subcutaneously at once and stimulation should
be resorted to. Hot coffee per rectum, caffein and camphor subcutane-
ously, have been found most useful. The temporary paralysis and
[517]
518 CURRENT LITERATURE
amblyopia, as a rule, clear up completely within a few days and require
no special treatment.
Terrien, F. OcuLar DIsTURBANCES IN RESPIRATORY AFFECTIONS. [Paris
Méd., Jan>27% VoksL Vila ae)
Terrien reviews the mutual relations of ocular and respiratory dis-
turbances. Even a normal inspiration and expiration is accompanied by
a slight dilatation and contraction of the pupil. This is of nervous origin
and not due to changes in the blood content of the iris. In pneumonia,
herpes of the cornea is comparatively frequent. The defect of the
epithelium may be easily discovered by the fluorescein test. Dilatation
and subsequent contraction of the pupil on the side of a pneumonia or
spinal lesion has been found by Chauffard. Three weeks after pneumonia
a paralysis of the ciliary muscle (not of the sphincter of the pupil)
similar to a postdiphtheric palsy may occur. Sarcomas of the lung and
mediastinum may lead to metastasis in the choroid. On the other hand,
affections of the eye may have an influence on the respiratory tract:
Compression of the eye retards expiration. Irritation of the cornea may
stop spasm of the glottis. Strong light can provoke sneezing in some
individuals. This is probably due to an increased flow of tears, which
irritates the mucous membrane of the nose.
Martini, A. de. HrmMoptysis AND VAGOSYMPATHETIC Tonus. [Riforma
Med., Vol. XL, April 14.]
The vegetative nervous system tests, such as oculocardiac reflex,
epinephrin, pilocarpin, eserin and atropin were applied by this author in
patients with hemoptysis and in the majority signs of vagotonia were
present. Atropin was definitely valuable in a number of cases.
Pack, G. T. THe SENSATION oF Tuirst. [Amer. J. of Phys., Vol. LXVI,
July) Austen on
Pack states that the theory that thirst is of the nature of a general
sensation, with a secondary local reference to the pharynx, has received
widespread and almost universal credence. According to this view the
loss of water content of the tissues increases the salt concentration of the
body fluids and this condition is responsible for the origin of afferent
impulses from the various viscera or for the direct stimulation by the
hypertonic blood of the unknown center in which the sensation of thirst
is represented. According to Cannon thirst is due to a relative drying of
the mucosa of the mouth and pharynx due to either a diminution or
absence of the salivary secretion, a condition brought about by any
dehydrating factor or by such local factors as mouth breathing, prolonged
speaking, et cetera. The thirst produced by physiological doses of atropin,
by such emotional states as anxiety and fright, he explains as due to a
diminution or absence of the salivary secretion. The author has in-
vestigated the subject from the point of view that if an increase in the
VEGETATIVE NEUROLOGY 519
flow of saliva will appease the desire to drink, then it might be inferred
that pilocarpine would be an efficient agent in relieving thirst. Rabbits
were subjected to seven day periods of fasting, food and water both being
withheld. At the end of this period pilocarpine hydrochloride was admin-
istered subcutaneously. When salivation became profuse, measured
amounts of water were placed in their cages and left for an hour. Control
animals were given a hypodermic injection of equivalent amounts of
water so as to eliminate the psychic factor. The rabbit controls drank
sixty-two to one hundred and thirty-seven cubic centimeters within the
first half-hour. The rabbits salivating from pilocarpine either refused to
drink or, as in two cases, drank fifteen to twenty-five cubic centimeters
of water within the hour. The difference can be interpreted as due to
quenching of their thirst by drinking their own body fluids. Pilocarpine
brings about an exceptionally high blood concentration, especially when its
administration is superimposed upon prolonged water deprivation so that
thirst cannot be of the nature of a general sensation.
Belgrano, Raul Ortega. —TREATMENT OF VAGOTONIC VOMITING. [Prens.
Méd. Arg., March 30, Vol. X.]
Excessive irritability of the vagus center was present in the two cases
here reported. One patient with intense headaches and uncontrollable
vomiting, with pulse of 52, was relieved immediately by amyl nitrite, its
action prolonged with belladonna, and the hypertension was combated with
30 per cent solution of glucose. Uncontrollable vomiting and brady-
cardia of 40 after excesses were the symptoms in a second patient. Both
were syphilitic, but the vomiting was not influenced by specific treatment.
It yielded at once to vagus inhibitory drugs.
Holler. TREATMENT OF CHRONIC GASTRIC AND DUODENAL ULCERS.
[Med. Klin., March 25, Vol. XIX.]
In two cases of ulcers of the duodenum oblongata changes were
found. Parenteral protein treatment was tried, and found that, unlike
normal persons, disappearance of hemoclastic crises occurs. Large
amounts of alkali are beneficial.
Tscherning, R. PRepIsPposITioN TO Gastric Utcer. [Arch. f. Verd.-
Peradkeeliiy. Vol NAIL. fF. ALM: A,]
Tscherning states that not all gastric ulcers fit into his frame, but it
includes the overwhelming majority. The main type is tall, slender, with
a blending of asthenic and athletic elements, vasomotor instability and,
in a large proportion, endocrine-genital anomalies tending to the eunuchoid
type. The persons examined were all men under social insurance, and he
tabulates the body measurements by the averages for the group. Decided
vagotonia or sympatheticotonia was never observed. There were only
two instances of another gastric ulcer in the family.
520 CURRENT LITERATURE
Lowy, M., and Tezner, O. AtTROoPIN, PILOCARPIN AND GAstTRIC Motor
Funcrion. [Mon. f. Kind., Vol. XXVIII, July.]
X-ray examination of gastric motor function in eighty-five children
between five and fourteen after subcutaneous injection of atropin or
pilocarpin are here reported. Atropin retarded the evacuation of the
stomach in every case when 2 mg. was given. In 50 per cent pilocarpin
retarded it.
Hatcher, R. A., and Weiss, S. StupiEs oN Vomirinc. [Jl. of Phar.
and’ Ex: Ther. Octsal923 20 ee |
Vomiting was induced by Hatcher and Weiss after destruction of the
quadrigeminal bodies, the cerebellum and the area described by Thomas
as the vomiting center in the cat, and of the latter area in the dog.
Vomiting was not induced after destruction of the sensory nuclei of the
vagi in cats, nor after destruction of the nucleus of one side in any of
six experiments on cats and one experiment on a dog, but it was induced
in one such experiment in which the destruction of the nucleus may have
been incomplete. The results of experiments indicated that the sensory
nuclei of the vagi are essential for vomiting in the higher mammals,
however it is induced (possibly with exceptions so rare that they do not
enter into this discussion). Hatcher and Weiss feel justified, therefore,
in stating that the vomiting center is embraced within the sensory nuclei
of the vagi. Twenty-seven substances were used in thirty-five experi-
ments on dogs and cats in which ninety-seven applications were made
to the floor of the fourth ventricle just above the obex. Thirteen of the
substances induced vomiting in dogs and one drug caused vomiting in
cats. The vomiting center is sensitive to the depressant action of
apomorphin and other substances, and when moderately depressed in this
way it is not stimulated by the application of other substances that com-
monly increase its excitability, but it is still capable of being excited
reflexly from the stomach. The intravenous injection of a relatively
small dose of mercuric chlorid induces vomiting, probably reflexly from
the heart. The authors were unable to induce vomiting by the local
application to the center of pilocarpin, quinin, tartar emetic, veratrin, or
any of the digitalis bodies (previously reported), all of which induce
vomiting in the eviscerated dog, nor was vomiting caused by the applica-
tion of cocain, caffein, or atropin, toxic doses of which induce vomiting
in the intact animal. These experiments furthermore proved that there
is a defecation center in the floor of the fourth ventricle.
Savignac, R. Gastric AND DuopeNaL Utcer. [Paris Médical, Jan. 12,
Vol. LIII.]
In this clinical study two types of pain which appear characteristically
after a meal and which are relieved by alkalis are reported. In case of an
ulcer in stomach or duodenum, these pains return regularly for four or
VEGETATIVE NEUROLOGY 521
five days at least, and then—at first—are followed by a period of relief.
In affections other than ulcer (dyspepsia with gallstones, colitis, ptosis,
etc.) the periods are either consistently irregular or the pain occurs
regularly every day from the beginning of the affection.
Daniélopolu, D., and Carniol. INFLUENCE oF SLEEP oN Morttity oF
- Sromacu. [Arch. d. Mal. d. ’App. Dig., Vol. XIII, March.]
In three patients with stenosis of the pylorus observed by these
authors, there was a marked inhibition of movements of the stomach
during sleep. The gastric contractions started and increased progressively
to the usual strength on awakening.
Timbal, L. Motor FUNCTIONING OF THE STOMACH IN NEUROPATHS.
bharis, wed, Feb.c9) Vol LIT: [7 A. M.A.)
Timbal says that a general neuropathic diathesis, erophagy, modifica-
tions of the normal gastric motility, malaise, griping pains and vomiting
after meals, with unpleasant sensation of pressure and tension, are the
main features of the disease dealt with. The patients are young, men
rather than women, all being neuropaths. Radiologically, the stomach
proves to assume a more horizontal position, and its shape resembles
somewhat a cow’s horn. Localized spasms at the pylorous or cardia are
also demonstrable. Careful differentiation from ulcer should be made.
Among his thirty-six cases there was only one with hyperchlorhydria and
two others with both hypochlorhydria and hypacidity, these latter with
positive Wassermann. Causes of the trouble, besides the predisposing
factors, are found in traumatism, weakening after other diseases, but
especially overexcitability of the vegetative nervous system. Therapy
consists in quieting the pneumogastric nerve and the solar plexus with
camphor, bromin, opiates, hyoscyamus, cocain or codein; hydrotherapy
also is advocated. Syphilitics were given specific medication, after which
their gastric anomalies ceased.
2. ENDOCRINOPATHIES.
McCarrison, R. PATHOGENESIS OF DEFIc1ENCY DisEASE. No. XI. [Ind.
Jl. of Med. Res., July, 1923. J. A. M. A.]
The results reached by McCarrison in the course of his experiments
with pigeons may be summarized as follows: Confinement in cages that
became grossly contaminated by the animals’ own excreta is a potent cause
of thyroid hyperplasia and enlargement. It can be prevented by scrupu-
lous cleanliness and to a less extent by the administration of chlorin
water. The thyroid hyperplasia under these circumstances is not due to
inadequate supply of iodin in the food, but is probably due to the inade-
quate absorption, assimilation or utilization of iodin consequent on the
conditions provided by dirty animal cages; of these conditions gastro-
522 CURRENT LIT PRARGKE
intestinal infection is considered to be chief. An excess of butter or
of oleic acid in the food may, in certain cases, enhance the goiter
producing action of insanitary conditions of life, such as are present in
dirty animal cages; or, the goiter producing influence exerted by an
excess of fats in the food may be enhanced, in certain cases, by such
insanitary conditions of life. There is a reason to believe that the effects.
of fat excess in determining thyroid hyperplasia may be related in some
way to bacterial intervention in the digestive tract. Cod liver oil affords
complete protection against goiter induced by insanitary conditions of
life, such as are present in dirty animal cages. A relation exists between
the intake of fats in the food, the amount of available iodin in the food
and the functional perfection of the thyroid gland.
Glanzmann, E. VITAMINS AND ENpocRINE GLANDs. [Jahr. f, Kind.,
VolaLVeeieb
Rats were kept by this experimentor on a vitamin-free diet until the
growth stopped. One gm. of dried thymus from calves was then given
and the growth again was resumed to cease as soon as the thymus was
no longer given. Other glands—except the sexual—have no effect in
such doses. The central organ for metabolism of vitamins in young
animals is the thymus. Vitamins are stored in the sexual glands and
provide thus the first endowment of the progeny after puberty.
Kingsbury, B. F. ENnpocrine Orcans. [Endocrin., Vol. VIII, Jan.]
A general thesis bearing on the complex interrelationships of the endo-
crines. [Why not the whole body?]
Mouriquand, G., et alk ENpocrINE GLANDS AND DEFICIENCY DISEASES.
[ Rev. Fr, d’End., Vol. 1, -May.]
Mouriquand, Michel and Sanyas found that deficiency diseases devel-
oped in their ninety-two guinea pigs earlier and more pronounced when
they were given thyroid extract. No effect in this line was observed
from epinephrin, even when kept up for 240 days.
Schick, B., and Wagner, R. PLuRIGLANDULAR ATROPHY FROM DEFI-
ciency Dier. [Zeits..f.. Kind, Vol. XXX ViL Jone 7.9) ) cee
In this second communication on this subject, Schick and Wagner
describe the outcome in their two previously published cases, and report
three new instances. Necropsy in two cases confirmed the extreme atrophy
of the thymus and thyroid, suprarenals and pancreas, of the tongue, and
of the mucosa of the entire intestine. The ductless glands atrophy more
and more. Treatment should aim’to stimulate and exercise these glands
rather than to spare them. One child, aged nine, had been repeatedly
underfed in treatment of digestive disturbances, and had been brought to
the clinic as a hopeless case of ulcerative enteritis and peritonitis, although
tuberculin tests were negative;.the stools were of the diarrheic fat and
VEGETATIVE NEUROLOGY 523
fermentation type. Under mixed feeding with suitable calory and vitamin
content, the child began to thrive at once. In the two fatal cases in
infants, there was pronounced exophthalmia, edema and a hemorrhagic
tendency. Probably many cases of cachexia and hemorrhages in the past,
ascribed to other causes, were in fact deficiency disturbances from lack
of vitamins. The tongue was atrophic, smooth and red in their five cases.
The condition has been described as “celiac disease,’ and “ digestive
disturbances beyond infancy,” but the avitaminosis sets up a vicious circle
which results in actual starvation.
Clark, A. J. EXPERIMENTAL Basis oF ENDOCRINE THERAPY. [Br. Med.
Jl., July 14, 1923. J. A. M. A.]
The therapeutic action of but a few of the endocrine extracts is
established. Polyglandular therapy is still empirical. These shotgun
prescriptions usually contain dried thyroid, extract of the posterior lobe
of the pituitary, thymus, suprarenals, and extract of testes or ovaries, and
are usually given by the mouth. Of these constituents the thyroid is
beneficent if the patient chances to be suffering from thyroid deficiency,
and in other cases there is usually too little present to do any harm.
Pituitary extract is inactive when given by the mouth, except as regards
its effect in reducing carbohydrate tolerance in cases of pituitary tumor
deficiency; this action would be assisted by the thyroid, but it is difficult
to see what benefit it would produce for the patient. Pituitary deficiency;
as manifested by Frohlich’s syndrome or by diabetes insipidus, is very
rare, and outside these conditions there is no rational indication for the
use of pituitary extract, other than its usual use as a temporary stimulant
to the uterus, intestine or blood vessels. It is not known whether the
thymus even has an internal secretion, nor is it known whether its extracts
have any therapeutic action. As regards epinephrin, it is not certain
whether it is essential for the normal health of the body. The low blood
pressure and asthenia in Addison’s disease are not simple results of
epinephrin deprivation. Epinephrin, when given by the mouth, may be
of benefit in gastric hemorrhage or to relax esophageal spasm, but other-
wise there are few actions that it has been shown to exert when given by
the mouth. Finally, nothing is known for certain about the action of
extracts of the gonads. Clark suggests that the administration of a
mixture of the above nature is as far removed from rational therapy as
is the writing out of a charm on a piece of paper and giving that to the
patient to swallow. He says that the extracts on the market have as high
a degree of potency as any that it is possible to produce. ‘This is, of
course, an unwarranted assumption, for in the case of those extracts for
which a test of activity has been found, and a.correct method of extrac-
tion discovered, it frequently happens that some slight error in extraction
may result in an inactive preparation being produced; this can ‘occur,
for example, with insulin and with extract of the posterior lobe of the
524 CURRENT LITERATURE
pituitary. Obviously, when there is no reliable test for the activity of
extracts, it is impossible even to know which is the best method of
preparation, and the odds against such preparations having any activity
whatever are very heavy.
Eggenberger, H. THE PREVENTION OF GOITER AND OF ITS RECURRENCE.
[Schweiz. med. Woch., LIII, 245. Tice.]
The exact amount of iodin secreted by the thyroid gland, and the
mechanism of its action are not definitely known. Its great importance
in the maintenance of health has, however, been proven. Like other
inorganic substances in the body, it probably follows a systematic cycle
of excretion and production. However, the extent of this iodin
metabolism is yet to be determined. On the basis of the sodium chlorid
metabolism, Eggenberger estimates the daily production of iodin by the
body to be 0.0001 gram.
The favorable effect of a diet of eggs, green vegetables and seafish
in goiter is undoubtedly due to the iodin content of these foods. The
fact that goiter is rare in regions in which the air and soil contain an
abundance of iodin is well known. The influence of constitution in the
production of goiter consists in a decrease in the iodin resorption, and
also in the presence of abnormal demand for iodin. Alcoholism, neu-
rasthenia and chronic subfebrile tuberculosis increase the general restless-
ness, therefore the iodin demand accordingly predisposes to compensatory
goiter.
Common salt is the best medium for iodin. An effective prophylactic
measure against goiter consists in the consumption of adequate quantities
of iodized salt. An overdose of iodin is not possible, as the tolerance for
salt is comparatively low.
As the iodin content of salts from various regions differs, the varieties
sold for consumption should be tested, and the requisite amount of iodin
added if the content is deficient. This precaution will not only serve as
a prophylactic measure, but will also prevent recurrences of goiter follow-
ing strumectomy.
Boothby, W. M. DirrerentiAL D1aGNosis oF THyrRoIp DISEASES.
[Annals of Surgery, Vol. LX XIX, November.]
Boothby discusses the importance of correct differential diagnosis in
surgery of the thyroid gland in particular, as it affects four kinds of
thyroid disease, namely, diffuse colloid goiter, adenomatous goiter without
hyperthyroidism, adenomatous goiter with hyperthyroidism, and exoph-
thalmic goiter. Among the points which he brings out are the follow-
ing:
Diffuse colloid goiter is a symmetric enlargement of the thyroid
gland, characterized pathologically by an excess of colloid in the acini,
and unassociated with symptoms of hyperthyroidism. On palpation the
gland feels quite similar to that in typical exophthalmic goiter, and there-
VEGETATIVE NEUROLOGY 525
fore, 1f the enlargement occurs in a nervous unstable person who has
symptoms recognized as “effort syndrome” or “ disordered action of the
heart,’ a mistaken diagnosis of exophthalmic goiter is readily and un-
wittingly made. The basal metabolic rate is a great help in distinguishing
these cases from exophthalamic goiter, because the rate is not only not
persistently elevated in diffuse colloid goiter, but is usually somewhat
below normal, while in exophthalmic goiter, with rare exceptions, it is
more than 20 per cent above normal. Operation is indicated only if the
goiter becomes excessively large and does not respond to medication;
such failure of medication indicates that the enlargement may be due to
colloid adenomatous tissue, and not to typical diffuse colloid goiter.
Patients with diffuse colloid goiter are safe operative risks; they also
get well under medical treatment; therefore, the surgeon, by including
the condition in the classification of exophthalmic goiter, will greatly
reduce his mortality rate, and similarly the internist will increase the
number of patients getting well under medical treatment. At the Mayo
Clinic, no patient with diffuse colloid goiter and a normal basal metabolic
rate has been operated on during 1922.
Adenomatous goiter masses, as a rule, do not respond completely to
thyroid or iodine medication; in fact, iodine is particularly dangerous
in cases of long standing of adenomatous goiter without hyperthyroidism,
because the iodine is likely to stimulate, or rather aid the adenomatous
tissue to hyperfunction.
Operation is indicated for adenomatous goiter without hyperthyroidism
for cosmetic reasons, for the relief of pressure symptoms, and as a pre-
ventive measure against future hyperthyroidism. In order to estimate the
probable risk to the patient, accurate distinction must be made between
it and adenomatous goiter with hyperthyroidism. For this purpose the
basal metabolic rate is of great help, because if it is within normal limits
it excludes hyperthyroidism.
Adenomatous goiter with hyperthyroidism is a constitutional disease
due to the presence in the thyroid gland of adenomatous tissue.
From the surgical viewpoint, the fact that the constitutional symptoms
are due to the activity of the tumor is very important, because it permits
the surgeon to assure the patient, before operation, of almost certain
cure, provided the disease has not lasted long enough to produce perma-
nent and irreparable damage of the heart or other organs. The operative
risk is, however, much greater than in cases of adenomatous goiter with-
out hyperthyroidism, and may be higher than in cases of exophthalmic
goiter.
Exophthalmic goiter is a constitutional disease, apparently due to
excessive, probably abnormal, secretion of an enlarged thyroid gland with
pathologically diffuse, parenchymatous hypertrophy and hyperplasia. The
condition is characterized by an increased basal metabolic rate and the
resulting secondary manifestations, by a peculiar nervous syndrome, and,
526 CURRENT LITERATURE
usually, by exophthalmos with a tendency to gastrointestinal crisis of
vomiting and diarrhea. The cause of the altered pathology and disturbed
function of the thyroid gland is not known.
In reply to the question: “ If both exophthalmic goiter and adenomatous
goiter with hyperthyroidism are due to an excess of thyroid secretion,
can there be a differentiation into two diseases?” several hypothetical
answers are possible, but the one held by Plummer as the most probable
is briefly as follows: |
The symptoms of adenomatous goiter with hyperthyroidism can be
produced by the administration of an excess of thyroid extract or
thyroxin; therefore, adenomatous goiter with hyperthyroidism is regarded
as due to the presence in the body of an excess of normal thyroid secretion.
The symptoms of exophthalmic goiter, however, cannot in their
entirety be produced by thyroid feeding. The symptoms which are not
produced in characteristic form are exophthalmos, the typical gastro-
intestinal crisis, the peculiar nervous phenomena, and finally the metabolic
status, as a result of which a post-operative reaction may arise which
terminates in death within about thirty-six hours.
All of these symptoms which are characteristic of exophthalmic goiter
can probably be explained on the assumption that the secretion of the
thyroid gland is not only present in excess, but that it is also an abnormal
product.
II. SENSORI-MOTOR NEUROLOGY.
3. SPINAL CORD.
Rivarola, R., and Obarrio, J. M. Tumor or tHe Sprnat Corp. [Arch.
Lat.-Ams d. -Pediejalys 19235}
This patient, a boy of 9 years, had symptoms of compression of the
spinal cord from the seventh cervical segment to the first and second
dosal segments. The cerebrospinal fluid was yellow, and it coagulated
completely. It contained no cells and gave none of the reactions specific
to syphilis, but the albumin content reached 1 per cent. A large tumor
was found in the cord instead of being, as was expected, outside of the
cords) ==
Schaller, W. F., and Gilman, P. K. Spastic PARAPLEGIA IN FLEXION.
[Am. Arch. of Neuro. and Psych., X, 512.]
A spinal tumor in the anterolateral aspect of the cord presented
an unusual feature of flexion paraplegia. A woman, 55 years of age,
had pain and stiffness in both lower extremities. The limbs became
paralyzed, and she has partial bladder impotency. On examination, there
was bilateral atrophy of the dorsal interossei and hypothenar muscles,
more marked in the left hand. The patient lay with the thighs flexed on
the abdomen forming an angle of about 135 degrees; the legs were flexed
SENSORI-MOTOR NEUROLOGY 527
on the thighs at approximately 90 degrees. The lower extremities were
pressed together by contraction of the abductors but could be forcibly
separated. Slight, if any, active motion was possible in any segment of
the extremities owing to the spastic contracture of the flexors and ab-
ductors. Pain sensation was disturbed and hot and cold stimuli were
confused below the segmental level of the second dorsal root. The spinal
fluid was of a striking yellow color, and there was a marked globulin
reaction. Laminectomy was done, and a dural endothelioma 4.75 cm. in
length was found compressing the anterolateral region of the cord and
extending from the middle of the fifth lamina downward to a little beyond
the seventh lamina. Four months after removal of the tumor, the patient,
who. had been fitted with braces, could stand and walk with assistance.
Voluntary motion was returning in the left lower extremity, sphincter
control was regained and sensation was returning.
No definite conclusions can be drawn as to the mechanism of the
flexion paraplegia which occurred in this case. The location, localization
and extent of the tumor may one or all have been factors in its produc-
tion. The fact that slight, if any changes have been observed in the
pyramidal tracts in similar cases might suggest that the location of the
tumor in front of the dentate ligament may have spared the lateral
pyramidal tracts from degeneration, but may have involved the extra-
pyramidal long fiber tracts, namely the vestibulspinal and _ tectospinal
tracts, which descend in the anterior white matter of the cord between
the anterior horn and the periphery.
Fraser, J. Paratysis oF Pott’s DIsEASE—OPERATION FOR Its RELIEF.
hecin. Med. |i sSept., 1923. J. A. M. A.]
The operation devised by Fraser has been undertaken to relieve those
cases of paralysis secondary to Pott’s disease which have failed to respond
to conservative treatment. A thorough trial is given to conservative
measures, but, if no success is obtained, the paralysis is becoming more
extensive, and there is danger of the cord degenerating, resort is had
to operation. The operation entails division of the laminae of the affected
vertebrae and of one or two laminae above and below the site of the
lesion. Fraser asserts that the operation is invariably followed by early
and progressive improvement in the paralysis, and, if care is continually
exercised in regard to postoperative rest, recovery is complete and
permanent. No weakening of the spine follows the operation. This report
is based on the records of four cases, in all of which the operation was
successful, though in one instance want of care in postoperative treat-
ment resulted in a temporary relapse. The outstanding advantage of the
operation is that it appears to relieve the spinal pressure that is maintain-
ing the long standing paralysis, and which, if unrelieved, may result in
spinal cord degeneration.
528 CURRENT LITERATURE
Sénéque, J. ANOMALIES OF SEVENTH CERVICAL TRANSVERSE PROCESS AND
Errects ON BRACHIAL Piexus. [J. de chir., XXII, 113-33. Med.
Sc.]
It is considered that there is some confusion in the nomenclature of
the bony swellings in relation to the seventh cervical vertebra that may
cause symptoms by interference with the brachial plexus. Nervous
lesions may be produced by enlargements of the transverse processes of
the seventh cervical vertebra which are not costal elements. A distinction
is drawn between enlargements that definitely belong to the anterior
tubercle of the transverse process and those that do not; it is pointed
out that the latter kind may be met in association with cervical rib, their
coexistence demonstrating their diverse characters. The eighth cervical
nerve is stretched over the enlarged transverse process. The observations
of Telford and Stopford are discussed and disagreement is expressed with
their view that stretching of the first thoracic nerve over the normal
first rib in certain cases may cause the symptoms usually attributed to
cervical rib. The symptomatology is not discussed, as it is identical —
with that of cervical rib. An operation for removal of the transverse
process through an incision in the posterior triangle is described. Notes
with radiograms of seven cases are given, including five cures, one
unilateral success in a bilateral case, and one complete failure.
Sternschein, E. THe SUPERIOR CERVICAL GANGLION AFTER PRE- AND
PosTGANGLIONIC Sections. [Arb. a. d. Neurol. Inst. Wien., XXIII
CH. 2)) 155. ated aace
Experiments were chiefly made in rabbits. In some of them the
sympathetic was cut either a little above or immediately below the superior
cervical ganglion. In a few animals all nerve connections of this ganglion
were severed and in two the neck sympathetic was faradized. In two
rabbits the carotid artery was ligated on one side in order to deprive the
corresponding ganglion of its blood supply. The following results were
obtained. After the preganglionic section of the sympathetic, most nerve
cells of the ganglion involved undergo a process of partial atrophy
associated with diminution and shrinkage of the Nissl substance, which
stains more intensely than normally; a spongy aspect of the cytoplasm
and a~shrinkage of the nucleus are frequently observed. These changes
are probably due to the cessation of a tonicotrophic influence which the
preganglionic fibers probably have on the ganglion cells. After the
postganglionic section of the sympathetic, most nerve cells of the ganglion
affected rapidly undergo the well known phenomena of axonal reaction
and totally degenerate; neuronophagia and an active proliferation of the
capsule cells are observed. After section of all nerve connections of the
superior cervical ganglion, all nerve cells undergo severe alterations which
can be considered as the sum of the changes found under the experimental
condition above mentioned. Prolonged faradization of the sympathetic at
SENSORI-MOTOR NEUROLOGY 529
the neck causes an initial chromatolysis of most nerve cells of the superior
cervical ganglion, this change being identical with that seen by other
authors under similar conditions. After ligature of the carotid, only a
certain degree of vacuolization of some nerve cells of the corresponding
superior cervical ganglion is occasionally noticed.
Bergamini, M. TREATMENT OF EprpeMic PotiomMye itis. [Arch. d.
Med. d. Enf., Vol. XX VI, Sept, |
Bordier’s method of treatment was applied on an extensive scale with
encouraging results in this 1921 epidemic at Modena. It consists of a
combination of roentgen-ray exposures and diathermy. This combined
treatment was applied as soon as the subacute phenomena had subsided.
Sixteen patients from 5 months to 6 years of age were treated. Four
of the children were practically cured; 8 were decidedly and 2 only
moderately improved. The 2 others failed to complete the course. The
benefit seemed to be proportional to the promptness with which treatment
was begun. The best effects were realized when the interval from the
onset of the paralysis was not more than 20 or 30 days. The radiotherapy
consisted of three sittings on consecutive days each month, exposing the
side of the spinal cord in the lumbar or neck region according as the leg
or arm was affected. The dose each time was about 6 X units. The
diathermy was applied in four or five ten minute sittings in each series,
with a 500 or 600 ma. current. A month generally sufficed to overcome
the hypothermia and bring the limb to an approximately normal tempera-
ture. Then it was ready for the third part of the treatment, rhythmical
galvanization of the paralyzed muscles. Twenty daily sittings of 15 to
20 minutes, were followed by 30 or 40 days of rest. The current should
not be over 3 or 4 ma. but this electrotherapy should be kept up per-
severingly for months and years if necessary. Considerable improvement
has been obtained even when the reaction of degeneration was complete.
Sicard, J. A., Paraf, J.,and Laplane, L. [Presse Médicale, Vol. XXXI,
Oct. 24.]
A new technic of subarachnoid injections of iodized oil for roentgeno-
graphic examination of the spinal canal is valuable for localization
problems. The iodized oil is absorbed extremely slowly (over two years)
but thus far has not shown any ill effects.
Peremans, G. RecURRENT INFANTILE PaRAtysis. [Le Scalpel, Nov. 17,
ome DM), |
There are exceptions to the general rule that one attack of infantile
paralysis produces immunity. Levaditi, Flexner, and Lewis have demon-
strated the presence of antibodies in the blood of patients who have re-
covered. Nevertheless, well authenticated cases of second attacks have
been recorded, including two cases in New York during the 1916 epidemic.
Peremans reports the case of a girl, aged four and three-quarter years,
whose appetite had been failing for a month, when morning vomiting
530 CURRENT LIPLERALURE
began, which increased in frequency, and she had two convulsions, of two
minutes’ and twenty minutes’ duration respectively. On admission she
was very weak, tremulous, and held her head between her hands. The
pupil reactions were slow; there was slight stiffness of the neck, and
Kernig’s sign was present on both sides. The knee-jerks were normal;
Babinski’s sign and ankle-clonus were absent. ‘The temperature was
38.5° C., the pulse rate 104. Tuberculous meningitis was suspected, but
no clinical nor laboratory tests substantiated this diagnosis. In fifteen
days the patient made a good recovery and was discharged, the final
diagnosis being “anterior poliomyelitis.” For three months morning
vomiting continued either before or after breakfast;. she frequently
awoke and cried at night, and eight days before her readmission per-
sistent bilious vomiting set in. The child remained in bed complaining
of pain in the left loin and the right side of the head; the temperature
was normal. Four days later she could not move her legs and screamed
if her head were touched; there was no loss of consciousness. Her neck
movements were limited and painful, with some stiffness; deglutition was
normal and passive movements of the lower limbs did not cause pain.
There was flaccid paralysis of the left leg; the left arm was also weak
and the left hemithorax moved less than the right; the left abdominal
reflex was feeble and the left knee-jerk absent, whilst the right knee-
jerk was active. The Babinski, ankle-clonus, and Oppenheim signs were
all absent; the temperature 38° C., and the pulse rate 110. The diagnosis-
of infantile paralysis was confirmed by laboratory tests. A year later,
in spite of orthopedic treatment, she had developed talipes equinus. In
August, 1922, there was a third attack, accompanied by similar symptoms
to the second, but affecting the upper limbs to some extent. She recovered
from this, with the exception of a slight atrophy of the intrinsic muscles
of the hands.
Cadwalader, W. B., and McConnell, J. W. SrQUENCE AND MODE OF
DEVELOPMENT OF SYMPTOMS AS AN AID TO THE D1IAGNOsIS OF MUL-
TIPLE SCLEROSIS IN THE Earty Staces. [American Journal of the
Medical Sciences, Vol. CLXVI, 165.]
These authors think that the apparent infrequency of multiple sclerosis
in America is probably due to errors in diagnosis. Opinions differ as to
the symptom-complex which is pathognomonic of the disease, especially
during the early stages. A diagnosis of multiple sclerosis may be justified
even in the absence of the classic Charcot triad of intention tremor, scan-
ning speech and nystagmus. However, in establishing the diagnosis, great
attention should be paid to the sequence in the development of the sub-
jective and objective symptoms. The disease to them is a distinct entity,
and is, they believe, infectious and inflammatory. However, the same
symptoms have been observed following other diseases, such as malarial
fever, syphilis, arteriosclerosis, influenza, and epidemic encephalitis. Dur-
SENSORI-MOTOR NEUROLOGY 531
ing the earliest stages the symptoms are mild and can be overlooked.
They may subside without leaving a trace, and recur later, becoming
progressively more intense. The most careful observation is therefore
necessary to determine the mode of appearance of these early manifesta-
tions. If spastic paraplegia, intention tremor, scanning speech, optic
atrophy, and nystagmus are all present, there is no difficulty in diagnosis.
Only the early stages present difficulty. Isolated objective signs, such as
impairment of vision, ocular paralysis, weakness of one or more of the
extremities, and paresthesia are common. They are, however, transitory,
and are liable to be overlooked. Most cases present remissions alternating
with periods of acute disturbance due to focal lesions. Transitory paraly-
sis may constitute the only objective sign of the disease, and may recur
and subside at regular intervals, for months or years, gradually becoming
permanent; other manifestations characteristic of the late stages of the
disease may subsequently occur. In one case reported the only early
manifestation was intermittent diplopia occurring over a period of three
years before other characteristics appeared. In another case, irregular
attacks of transient blindness preceded the development of optic atrophy.
In one case bilateral oculomotor paralysis developed rapidly, and per-
sisted for eighteen months in the absence of other manifestations. Tremor,
scanning speech, and weakness of the extremities, later developed. One
case presented signs typical of hemiplegia of rapid onset, which had been
mistaken for the results of an apoplectic attack due to vascular occlusion.
These signs persisted for some time before other manifestations appeared.
The classic Charcot symptoms differ from other signs of the disease
only in that they are less frequently remittent; however, they may appear
as isolated signs. Once established, they tend to become permanent, and
to progress. These symptoms indicate more or less widespread distribu-
tion of the inflammatory lesions, and are therefore of more importance
in diagnosis than are other single signs. Scanning speech, or any other
dysarthria, indicates a disturbance in the combined motor function of the -
respiratory, laryngeal, palatal, lingual, and lip muscles supplied by different
cranial nerves; each of these nerves has its origin at a different level
within the brainstem, and therefore a lesion sufficiently severe to destroy
all of these areas must be extremely diffuse. A purely spinal type of
multiple sclerosis is extremely uncommon. The diagnosis of the disease
in the presence of spastic paraplegia and loss of abdominal reflexes, with-
out involvement of the brain, is not always justifiable; although the
disease may occasionally appear in this form. If these symptoms are
followed by the Charcot triad, the diagnosis is clear.
In conclusion the authors emphasize the importance of observing the
association and mode of development of symptoms, rather than the isolated
manifestations themselves. The appearance of cerebral symptoms pre-
ceding or following spinal manifestations is indicative of dissemination
of the pathologic process.
532 CURRENT LITERATURE
Grigsby, G. P.. Spina BrripA witH HyprocepHaAtus. [Ken. Med. JL,
Dec., 1923. J. A. M. A.]
The outstanding features of interest in Grigsby’s case were: (1) the
unusual size of the spinal bifida and the large amount of contained fluid;
(2) that the rather sudden release of the spinal fluid apparently had no
deleterious effect on the child; (3) that the left-sided paralysis which
existed prior to operation has now disappeared; (4) that the extensive
spinal defect was satisfactorily closed; (5) the reduction in size of the
head and decided improvement in mentality during the last ten days.
5. CEREBELLUM; PONS; PEDUNCLES; MID-BRAIN.
Schaltenbrand, G. Disorpers or MovEMENT IN ACUTE BULBOCAPNIN
Porsontnc. [Arch. f. exper. Pathol. u. Pharmakol., CIII, 1.]
De Jong, H., u. Schaltenbrand, G THe Errect or BULBOCAPNIN ON
TREMOR IN PARALYSIS AGITANS AND OTHER Matapigs. [Klin.
Wehnschr., III, 2045; Med. Sc. ]
Bulbocapnin is an alkaloid obtained from the root of Corydalis cava.
According to Peters it is a folk-remedy for tremor, paralysis, and other
supposed nervous disorders. This observer (1904) found that in animals
it produced a cataleptoid condition of the musculature, increased tear and
salivary secretion, and a slowing of respiration. Chemically it is related
to apomorphine, but differs from it in the presence of oxygen side-chains
and in being dextro-rotatory. According to Frohlich and Meyer (1920)
it produces a tonic contraction in muscle which is unaccompanied by an
action current, but de Jong in some earlier recorded experiments found
that there is a continuous action current and that de-afferentation of the
tonic muscle by intramuscular injections of novocain does not abolish the
cataleptoid state therein.
Schaltenbrand repeated Peters’ experiments, using various animals as
well as the human subject. Hypodermic injections of bulbocapnin were
employed. In man there is a general blunting of sensibility and lethargy
persisting for some hours. In animals, in which larger doses could be
used, other results were observed. The animal stood in a drooping attitude
of general flexion, there was some palpable muscular rigidity, while in
dogs and monkeys a fine rhythmical tremor developed. In two animals,
epileptiform seizures occurred. Examination revealed diminution or aboli-
tion of the tonic neck and of the righting reflexes. The animals were
apathetic, show dilated pupils and, in some instances, salivation.
De Jong and Schaltenbrand, regarding these effects upon the muscu-
lature as “ hypokinetic ” in nature, deemed it probable that bulbocapnin
might be employed with favorable results in tremor of organic nervous
origin in man. A series of patients with tremor of diverse origins were
given injections ranging up to 0.2 gm. Their paper records the results
SENSORI-MOTOR NEUROLOGY 533
obtained from four cases of paralysis agitans, one of cerebellar tremor, and
one of “essential tremor.’ In every case bulbocapnin injection led to a
remarkable diminution in the amplitude of the tremor, and this equally in
paralysis agitans and the other conditions. Graphic records illustrate
these results. Further observations are promised. [See Psychiatrische
en Neurologische, Bladen, 1925 (in English). Ed.] [F. M. R. Walshe. |]
Snessarew, P. PATHOLOGICAL ANATOMY OF CHRONIC PROGRESSIVE
CuHoreEA OF Huntincton. [Ztschr, f. d. ges. Neurol. u. Psychiat,
XCI, 463; Med. Sc.]
A very brief description is given of the pathological changes in various
parts of the central nervous system in an isolated case of Huntington’s
chorea. A more detailed account of neuroglial cells follows: two main
types were present, namely, a small cell with a darkly staining nucleus and
a larger cell with more protoplasm and less deeply staining nucleus: the
latter is classified as “ amoeboid.” Both types of cells were widely dis-
tributed. Many granules were also observed and the author passes into
very great detail as to their microscopic and staining character. Very
small, ovoid, and fuchsinophil granules were found in the glia cells and
endothelium of the vessels. Along the fibrils of the neuroglia further
small granules were observed. ‘The author suggests that these granules
have some relation to an internal secretion of the neuroglial cells and
discusses at length this relation to the fibrinoid bodies of Alzheimer, to
the corpora versicolorata of Siegert, and to the corpora amylacea. ‘The
pia mater also exhibited pathological changes, especially certain granular
changes in the cells. In conclusion, the general hyperplasia of neuroglial
tissue is regarded as primarily of hereditary origin, which leads to a
“reaction’’ process as demonstrated by arachnoid neuroglial cells, and
eventually to an altered secretory function of the “ gliosomes.” Practically
all the author’s theories are based upon various staining reactions shown
by very minute bodies which have as yet not been definitely classified.
This leaves much ground for criticism and doubt as to the true value of
the interpretation laid upon their presence.
Macalister, C. J. CLASSIFICATION OF CHOREA IN RELATION TO ITS
Geuses. [British Med, JI, Nev.8, 1924; JeA. M.A.]
Macalister divides choreas into three groups: (1) The ordinary:
rheumatic or toxic type; (2) “ stock-brained” cases, related to an inher-
ited tendency, and (3) a climacteric type. There is often little to distin-
guish these cases so far as the movements of incodrdination are concerned,
but some of the associated phenomena present considerable distinctions.
The interesting fact was revealed that in the so-called “ fright” choreas
the children were sometimes left-handed or, being right-handed, came of
a left-handed stock, whereas the rheumatic children presented this sort of
history in a very limited number of cases—probably representing rheuma-
534 CURRENT LITERATURE
tism in children having the hereditary factor referred to. It was on this
account that the nonrheumatic cases became ‘“ stock-brained choreas,”’ and
it is these cases that Macalister discusses. In a few instances children
suffering from this form of chorea have belonged to families in which
there were stammerers. The choreic movements probably represent a
gross motor ataxia or incodrdination which may be regarded as analogous
to vocal stammering. As a consequence of fright or other disturbance an
unbalancing of codrdination is brought about, owing to some unusual
relationship of function on the opposite sides of the brain.
Riese, W. Tract ANATOMY OF THE BASAL GANGLIA. [J. f. Psychol. u.
Neurol., XX XI, 81; Med. Sc.]
The observations are based upon the histological study of a series of
human and animal brains. The author claims to have amplified our
knowledge in respect of the following conclusions: the striopallidal fibers
form the great part of a striofugal fiber system. In degeneration prepara-
tions they are characterized by their fine caliber. Another component of
the striofugal system is a tractus strio-mesencephalicus ad substantiam —
nigram. This arises in the head of the caudate nucleus, traverses the
globus pallidus, and ends in the stratum intermedium of the substantia
nigra. The fibers composing it are of fine caliber and are myelinated
after birth. The term “ ansa lenticularis ” is purely topographical and the
structure so named includes a thick fiber tract lying ventral to the basal
ganglion, bordering the internal capsule and reaching the thalamus, and
fibers passing along the tract Hs, which in so far as they are of striatal
origin arise in the pallidus. The bundle H, is predominantly striopetal,
but also contains fibers of pallidal origin. The posterior longitudinal
bundle is in close connection with the pallidum, both phylogenetically and
in respect of its myelination. The basal ganglia and the red nuclei are
connected by fiber systems, which are afferent to the latter. There is no
evidence of a direct connection between the striatum and the cerebral
cortex, but, following lesions of the frontal poles, there is degeneration
of fibers passing to the globus pallidus. [F. M. R. Walshe. ] |
Battain, M. Spasmopic LAUGHING AND WEEPING. [Rif. Med., Aug. 4,
Vol. XL.) ;
A clinical study and general discussion of the changes in the putamen
found in cases which have had attacks of involuntary laughter or weep-
ing. Unilateral lesions are sufficient to produce it, as well as interruption
of pathways from the cortex, as well as direct irritation of the center(?).
Spiegel, A. E. Bopy Posture AND THE Corpus Srriatum. [Klin.
Wcehnschr., XX XV, 1568; Med. Sc.]
In a series of experiments on rats and cats, the author and Brouwer
found that after hemisection of the cord, or extirpation of one-half of the
SENSORI-MOTOR NEUROLOGY 535
cerebellum, the tetanus spasm produced in the hind limbs by injection.into
both of them of tetanus toxin was less marked on the side of the lesion
than upon the normal side. They conclude therefrom that supraspinal
centers have an influence on the development of the spasm. On the other
hand, unilateral cerebral lesions involving the cortex only have no influ-
ence on the spasm produced in this way, but as soon as the corpus striatum
is reached and involved the spasm in both hind limbs, especially on the
homolateral side, changes from the customary extensor rigidity to rigidity
of the hind limbs in flexion. If, in addition, the fibers of the internal
capsule be involved, no modification of the spasm appears, indicating a
striatal origin of the flexor spasm. Such an animal injected with strych-
nine still shows the characteristic extensor spasm, despite the absence of
one corpus striatum. Spiegel takes this differentiation to indicate that
while tetanus spasm is an increased tonic response, strychnine spasm is a
function of the phasic variety of contraction, and consists in the fusion of
twitch contractions and not in an increased tonic contraction. Hence, the
corpus striatum may be regarded as concerned in the development and
maintenance of tone, but not in the innervation of phasic contractions.
These conclusions cannot readily be correlated with the observations of
Magnus on the “ mid-brain” and “thalamus” animals, both of which,
deprived of their corpora striata, show a perfectly normal distribution and
intensity of muscle tone, and possess all the tonic or postural activities of
which the intact animal is capable. [F. M. R. Walshe. ]
Hess, L., and Pollak, E. Crrresrat Dyspnea. [Med. Klinik, Oct. 12,
WiOle AT
Hess and Pollak found grave changes in the locus ceruleus in two
cases of diabetic coma. Similar changes were also observed in other
dyspneic conditions of cerebral origin. They consider this part of the
brain as another respiratory center.
Long. A Corpus StRIATUM SYNDROME OF TRAUMATIC ORIGIN. [Rev.
Méd. de la Suisse Romande, XLIV, November, p. 774.]
Long reports to the Geneva Medical Society a case of a corpus
striatum syndrome of traumatic origin. Some days after a fall from a
bicycle, with a resulting scalp wound, a meningitic state appeared.
Though radiography was negative, trephining showed a fissure of the
parietal bone and a subjacent hematoma infected with staphylococci and
streptococci. A left hemiparesis resulted from this unilateral lesion, but
on the right side synkineses appeared with athetotic movements of the
hand and foot, of variable intensity and duration, and without any signs
of pyramidal involvement. The persistence of the suppuration with
irregular febrile attacks suggested the presence of infectious metastatic
foci, and possibly even a central abscess, and the symptoms showed their
principal localization: the corpus striatum of the side opposite to the
lesion. [Leonard J. Kidd.]
536 CURRENT LITERATURE
Greenfield, J. G., Poynton, F. J., and Walshe, F. M. R. ON PROGRESSIVE
LENTICULAR DEGENERATION (HEpATO-LENTICULAR DEGENERATION ).
[Quart. Journ. of Med., Vol. XVII.]
This paper discusses the relationship of the condition called by Wilson
in 1912 “ Progressive Lenticular Degeneration ”’ with that which Fleischer
described in the same year as “ Pseudo-sclerosis.” In the case described
in this paper the presence of a deposit of granular greenish-brown pig-
ment in the peripheral zones of Descemet’s membrane, and the absence of
any gross cavitation or other obvious lesion of the brain, allied the case
to Fleischer’s pseudo-sclerosis, but the clinical appearance and history, the
atrophy of the putamen to half its normal diameter, and the typical
cirrhosis of the liver left no doubt that it was a true case of “ progressive
lenticular degeneration.”
In a review of the literature the authors come to the conclusion that
all the cases of so-called ‘“ pseudo-sclerosis ” in which the liver showed a
multilobular cirrhosis at autopsy are true cases of “ progressive lenticular
degeneration,’ and that the name “ pseudo-sclerosis’’ (based as it is on a
superficial and fallacious resemblance of the symptoms to those of dis-
seminated sclerosis) should be dropped from the literature. At the same
time they plead for a broadening of the clinical conception of the disease
to include cases with rigidity but without tremor or other involuntary
movements on the one hand, and those of so-called ‘‘ torsion spasm” on
the other.
Pathologically they find that the lesion is by no means confined to the
corpus striatum (although atrophy of the putamen is a constant feature),
but that it has, in a large proportion of the recorded cases, been found to
attack also the cerebral cortex, the brain stem and the cerebellum. There-
fore ‘‘ progressive lenticular degeneration’? can no longer be accurately
spoken of as ‘“‘a system disease of the corpus striatum,’ and the deter-
mination of the functions of the corpus striatum from the examination of
clinical material of this nature is impossible. [Author’s abstract. ]
Ill. SYMBOLIC NEUROLOGY.
1. PSYCHONEUROSES; PSYCHOLOGY.
Chantriot, P. THe Aupirory Function 1n RELATION TO TALENT FOR
Music. [Paris Letter, JCA. Mae eV obes eeinines! ou
Dr. Pierre Chantriot recently discussed before the Faculté de médecine
of Lyons the early manifestations of musical genius. Chantriot is a
musician himself and is sprung from a family of musicians. He stated
that it was his endeavor to penetrate the thick cloud which enveloped
musical genius and its first manifestations. He studied, in this connec-
tion, auditory sensibility and sensory and motor function in musicians,
SYMBOLIC NEUROLOGY 537
after having performed several experiments on psychomotor reactions.
He would like to have completed his study by researches on the cranium
and ears of great masters; but he did not meet with the codperation of
musical conservatories that he had hoped to find.
It is self-evident that the ear constitutes the basis of musical genius.
The ear is to the musician what the eye is to the painter. But, though
the ear is indispensable for the education of the musician, for the com-
poser it is only secondary aid, for had not Beethoven lost his hearing com-
pletely when he composed the wonderful Ninth Symphony, the climax of
his immortal work? It has not been proved that the ears of composers
are particularly good or characterized by any peculiar formation, as some
writers have asserted who claim to have noted in musicians a peculiar
inclination of the tympanic membrane: It is doubtless true that, in the
development of musical genius, the ear plays a paramount part, since it
alone can transmit to the cerebral cortex the impressions that constitute
the basis for the ideas of the future composer. It does not necessarily
follow that the organ of hearing possesses special physical qualities—at
least not such as are perceptible to the investigator; but one must admit
that practice may cause the ear to acquire a certain special quality—a
certain finesse—that is distinct from auditory acuity. Excellent musicians
often possess only a mediocre auditory acuity, associated with an intense
musical sensibility.
According to Chantriot, a child acquires a sensibility to rhythm very
young. An appreciation for relative height of tones and the relation of
tones to one another develops later, except in the case of precocious sub-
jects such as Mozart and Saint-Saens. From his study of psychomotor
reactions in musicians and nonmusicians, Chantriot reached the unex-
pected conclusion that the auditory psychomotor reaction is longer in
musicians, and that the more gifted the musician, the longer the reaction.
Genealogical tables published by Chantriot show how great is the influ-
ence of education on the musical development of individuals. Rare have
been the instances of great composers who have not trained their ear from
birth amidst familial musical talent. John Sebastian Bach was less
indebted to heredity for the unfolding of his genius than to the fact that
he constantly heard musical masterpieces executed by his father, brothers,
uncles and others.
Alibutt..0..et al. SpPrrtruan Heatinc. [J. A. M..A., Vol. 83, Feb. 2;
London Letter. |
The report of the committee appointed by the Archbishop of Canter-
bury to consider and report on the use with prayer of the laying on of
hands, of the unction of the sick, and of other spiritual means of healing,
has been published by the Society for the Promotion of Christian Knowl-
edge in a pamphlet entitled “The Ministry of Healing.’ The committee
included a number of bishops and other clergy and leaders of the medical
profession. Among the latter were Sir Clifford Allbutt; and medical
538 CURRENT LITERATURE
psychologists, such as Sir Robert Armstrong Jones, Dr. William Brown,
Dr. Hadfield and Dr. W. H. Rivers. The committee decided that there
were three main lines for its work: 1. The historical question, What is
the evidence for what is called “the ministry of healing”? and What was
the character of such a ministry if it existed? 2. A comparison between
the different methods of healing and their relation to Christian thought.
3. Should a ministry of healing now be recognized? In regard to the
second point, after prolonged discussion the committee concluded that
religious treatment of bodily illness must be related to other methods of
treatment, and that religious treatment aims at something more than the
cure of bodily illness and has in view the restoration of the patient’s whole
nature. The power which heals the body makes use of three methods:
(a) material, as surgery and drugs; (b) psychic, as suggestion and dif-
ferent forms of mental analysis; (c) devotional and sacramental. Spir-
itual healing may be said to be that which uses any of these in reliance
on God, though in popular use the term is often confined to the last.
In all these methods of healing, faith may be an important element; but,
as far as purely physical healing goes, faith works irrespectively of the
ground on which it rests. In the third method, in which something more
than physical healing is in view, the character of the faith is of primary
importance. Treatment from the material side rests on the scientific
doctrine that there is a real and objective virtue in certain vegetable and
mineral products. At the same time, drugs often depend for their effect
on the confidence of the patient both in the physician and in the prescrip-
tion; that is, faith and suggestion are already at work.
The general name of the second method is psychotherapy. It includes
three main departments: (a) Reeducation and persuasion aiming at
mental and moral adjustment by reason and argument. Such cases as
aphonia or functional paralysis can often be thus treated effectively.
(b) Suggestion aiming at influencing subconscious processes, for it is in
the subconscious and unconscious parts of the mind that the source of
many mental and moral ills lie. (c) Analytic methods, which aim at
investigating what are assumed to be the deepest layers of the mind, and
depend for success on the discovery of latent “ complexes” and morbid
processes which have given rise to symptoms. Whether the theories as
to the ultimate origin of nervous disease, such as propounded by Freud
and Jung, will be confirmed by future investigators, the committee does
not feel competent to say. But as spiritual disorder often leads to moral
and mental disorders, and indirectly to such physical disorders as hysteria,
those who have the “cure of souls” should study the psychologic prin-
ciples which lie behind the methods of psychic treatment. However,
analysis should not be undertaken by persons without considerable medical
experience and without working in close connection with a physician.
With the third method—the devotional and sacramental—the com-
mittee was more immediately concerned. “Here,” it observes, “the
appeal is direct to God as the immediate source of all life and health,-
)
SYMBOLIC NEUROLOGY 539
without the use of any material means. The appeal has taken.various
forms, as in Christian science and kindred doctrines. Within the church
it has occasioned the revival of systems of healing based on the redemp-
tive work of our Lord. They all spring from the belief that Christ taught
that the power of spiritual healing is the natural heritage of Christian
people. All healing assumes that disease is an evil to be combated.
Theologically stated, this means that health is God’s primary will for all
his children and that disease is a violation of this orderly condition to be
combated in God’s name and as a way of carrying out his will. Disease,
like other forms of evil, may be permitted by him to exist as a result of
man’s misuse of his freedom, as a stimulus to human sympathy and
research, or as a means of spiritual discipline. Spiritual healing must
not exclude medical: means. The former not only heals the disease but
also raises the whole nature of the patient to a higher level. In other
words, in spiritual healing, the healing of the spirit is primary, of the
body secondary.
The committee found that those who were applying the truths of
Christianity to patients suffering in mind or body, with the definite sug-
gestion that it was the will of God that sickness as well as sin should be
overcome, were obtaining remarkable results. But there was no evidence
of healing which could not be paralleled by similar cures wrought by
psychotherapy without religion, and by cases of spontaneous healing
which often occurred even in the gravest cases in ordinary medical prac-
tice. No cases were found of those working within the church who did
not desire to cooperate with the medical profession. But from religious
influence greater results might be expected than from nonreligious
methods. No witness desired the licensing of “healers.” The committee
evinced a general desire for the authorizing of “anointing.” There was
considerable doubt as to the value of “services of healing,’ to which
crowds of sick folk were invited to come.
Of the medical members of the committee, Dr. W. H. Rivers, the
medical psychologist and anthropologist, died in July, 1922. Sir Clifford
Allbutt and Sir Robert Armstrong-Jones signed the report with the inti-
mation that they desired not to associate themselves with recommendation
on the use of unction.
Donath, Julius. SIGNIFICANCE OF THE FRONTAL Loses For THE HIGHER
INTELLECTUAL Activities. [Deutsche Zeitschrift f. Nhk., March,
Vol. 88. ]
The author who always merits respectful attention, seeks to establish
practically the same conclusions as does Bianchi in his work of similar
character although strange to say he does not refer to the Italian author
in his considerable bibliography. He first considers the motor centers of
the frontal lobes; namely (1) the motor speech area of Broca, (2) the
direct fronto-pontine tract which proceeds through the pons to the cere-
bellum, probably from the first and second frontal convolutions and has
540 CURRENTS IT BRAG URE
to do with the equilibratory function of the cerebellum, so that it is a
well known fact that frontal lobe lesions may give rise to cerebellar ataxia,
(3) projection fibers through the subcortical ganglia, (4) association
tract bundles, (5) Monakow’s fasciculus fronto-centralis carrying
impulses for motion from the frontal lobe to the precentral convolution.
(6) Two other motor centers, for writing and for music whose exact
location is uncertain. That for writing is probably in the second convolu-
tion just anterior to the precentral gyrus while that for music is still
problematic and very probably closely associated with hand and finger
movements in the precentral gyrus. In this connection the author passes
on to consider whether or not frontal lobe tumors are responsible for
paralysis agitans syndromes and further, whether incontinuence of urine
and feces may result from their lesions. Parksonian pictures have
apparently resulted from tumors of the frontal lobes but were probably
due to pressure affect upon the basal nuclei; bladder and rectal inconti-
nence upon the other hand, in the absence of spinal cord lesion, is prob-
ably due to involvement of a center in the frontal lobes, witness the apathy,
stupor, confusion attending the incontinence in mental cases as well as
early experience with infants. In fairness the findings of many authors
where lesions of the frontal lobes apparently have not involved the higher
intellectual faculties are quoted at some length. That of Ranschburg is
particularly interesting in which a war wound with abscess formation in
the frontal lobes resulted in no noteworthy alteration in the intellectual
activities, nor those of comparison, perception, abstract thinking, memory
and the more intimate relationships of the personality. Also tumors have
been found upon autopsy in cases where there was no reduction in men-
tality beforehand. In regard to such negative findings the author falls
back upon the conclusion that more careful investigation would have
revealed symptomatology. Upon the other hand a considerable number
of cases are cited to support the author’s contention, cases in which a
disintegration of personality followed from the development of lesions of
the frontal lobes. A notable case is that of a twenty-year-old soldier who
was shot through the frontal lobe about the height of the first and second
gyri. Following the injury there occurred a transitory loss of conscious:
ness, then for two months a mental disturbance resembling a catatonic
stupor in which the patient showed no spontaneity of movement, suffered
incontinence, could not swallow food placed in his mouth and at times
laughed in a foolish manner. At the close of three months this condition
improved and he gradually returned to normal. Up to this time there was
also a disturbance of gait in which the patient upon all attempts to walk or
to stand made incoordinate movements with the trunk and limbs. Another
case with a similar history and symptomatology showed a tendency toward
perseveration and stereotypy as a final result and remained with a weakened
memory, an uneven reduction of intelligence, lack of intuition, euphoria,
some excitability, unconsidered behavior. Cases of tumor are also cited
and reference made to symptoms of euphoria and jocosity. Passing
SYMBOLIC NEUROLOGY 541
attention is paid to the function of the corpus callosum and the psychic
disturbance: found almost without exception when it is affected, since so
many closely associated tracts are involved. Agenesis is usually accom-
panied by severe mental and physical symptoms, but of late a brain has
been investigated in which there was no corpus callosum, although the
subject so far as could be ascertained had shown no grave defects as to
morality and intelligence, nor in the practical conduct of life. This same
reporter had found 12 other similar cases in which only minor mental
defects had occurred and explained this by suggesting that in these cases
the one hemisphere had taken over the ordinary coordinate movements
of both halves of the body and that associative function had been con-
fined to this same hemisphere while the other remained practically fune-
tionless. “The clinically ascertained psychic disturbances resulting from
lesion of the frontal lobes seem to be disturbances of memory such as
retrograde amnesia and confabulation, disorders of perception and of the
association of ideas, feeble-mindedness and dementia. Weakness of intel-
ligence with inadequate reaction to outer stimuli reveals itself in euphoria,
hypomania, jocosity, childish behavior, etc. These are all accompanied
by lack of insight. Emotionally there is irritability, a negativistic tend-
ency, loss of sense, etc. The lack of spontaneity results in apathy, care-
lessness, even catalepsy since thinking is not carried over into movement
in spite of the persistence of the necessary reaction patterns. Frantz is
quoted at some length to the effect that the frontal lobes probably serve
for the acquisition of new information while such as has already been
established is preserved in other parts of the brain and therefore not lost
after extripation of the frontal lobes. To this the author adds a plea for
the conception of the vicarious activity of nerve cells and tracts. And
finally the author refers to the relative area of the frontal region in vari-
ous animals; for example, in man it constitutes 29 per cent of the entire
brain cortex; in chimpanzees 16.9 per cent, in a lower grade of monkey
11.3 and in a still lower one 8.3. In dogs the percentage is 6.9, in cats
3.4 and in rabbits 2.2—the boundaries of the analogous region being deter-
mined by their cellular architecture.
Sachs, H. Tue Tempest. [Int. Jl. Psa., Vol. IV, Nos. 1, 2.]
This is largely an historical study relative to the date of the publica-
tion of this play, its origin, its purposes, and finally a very penetrating
inquiry into its artistic sublimation values relative to Shakespeare’s
fixations upon his younger daughter Judith and the delivery of her libido
over to her husband shortly after which Shakespeare died. It is a most
scholarly and fascinating study which should be read in the original so
detailed is the analysis.
Buzzard, E. F. Traumatic NEurASTHENIA. [Lancet, Dec. 15, 1923.]
The signs and symptoms of traumatic neurasthenia, according to Buz-
zard, are those of an anxiety neurosis. It should be regarded as an emo-
542 CURRENT LITERATURE
tional state, dependent not on any physical disturbance caused by trauma
but on a number of psychologic factors. Although the knowledge that
an injury has been sustained exerts a powerful influence in the develop-
ment of neurasthenia, the latter is not the result of trauma. Buzzard
prefers the term “anxiety neurosis following trauma.”
Kleitman, N. THe Errects oF PROLONGED SLEEPLESSNESS IN MAN.
[Am. Jl. Phy., Vol. 66, Sept. |
Considering the importance of sleep for the human economy surpris- |
ingly few investigations have been made on the subject. Six young male
adults underwent periods of experimental insomnia varying from forty
to one hundred and fifteen hours. In order to prevent the subjects from
sleeping it was found necessary that they should carry out almost con-
tinuous slight muscular exercise by moving about with short periods of
rest. Careful observations were made. It was found that muscular
relaxation induces sleep under normal conditions, but practically precipi-
tates sleep under conditions of experimental insomnia. Blood sugar,
alkaline reserve of the blood and plasma, percentage of haemoglobin,
percentage of corpuscles, red and white cell count, body weight, basal
metabolic rate, appetite, temperature, ability to name letters and to do
mental arithmetic, all showed no variation from the normal during the
period of sleeplessness. Respiration, heart rate and blood pressure
showed a definite decrease in insomnia, but this decrease was mainly due
to greater muscular relaxation of the sleepy subject. A Babinski reflex
could be elicited in every subject tested during the sleep that followed
insomnia. It is interpreted as indicating a functional block in the pyram-
idal system of fibers. There is a greater excretion of phosphates and
acid at night; but on reversed routine with the subject sleeping in the
daytime this condition is reversed, indicating that increased secretion is
due to sleep. The excretion of total nitrogen and of creatinin shows little
diurnal variation and is unaffected by either insomnia or reversed routine.
There is some evidence that the diurnal temperature variation is due to
alternation of sleep and wakefulness and the temperature wave tends to
be effaced during prolonged insomnia. The onset of sleep is probably
due to complete muscular relaxation, voluntary or involuntary.
Escomel, E. Criimatic PsycHoneurosis. [Rev. de Med. y Cir., Sept.
24923. 7 eee
In Arequipa, Peru, a large number of individuals complain of peculiar
moods of depression or exaltation on certain days. Arequipa is the second
largest city in Peru, and has an altitude of about 7,000 feet. On these
days the author states the air is charged with electricity, and even animals
and children are restless and different. All classes are affected, but brain
workers and nervous women suffer most. [Hellpach has written an
interesting medical work on these geographical reactions. Ed.]
SYMBOLIC NEUROLOGY 543
Baldi, F. Instincts ANp Neuroses. [Ann. di Neur., Aug. 31, 1923.]
In the war neurosis a clear example of the working of a “ defense
instinct.” Mental health depends on an equilibrium between the instinc-
tive tendencies and the forces which control them. The neurosis is an
expression of predominance of the biologically older instinctive forces
over the more recent higher psychic qualities.
Elder, W. THe Lert-Hanpep Cuixp. [Corresp. B. M. J., June 14, 1924.]
“ Over twenty-five years ago I made some observations on this subject,
which I published in my book on Aphasia and the Cerebral Speech
Mechanism, and in an article on mirror-writing in the Encyclopaedia
Medica. It would take too much space to go into the explanation there
suggested of how mirror-writing is produced, but I may shortly say that
I believe that the movements which produce mirror-writing by the left
hand are initiated, influenced, and guided by the cortical neuron group-
ings of the left cerebral hemisphere—that is, the same cortical neuron
groupings that guide the right hand in writing. Mirror-writing is a well
recognized peculiarity, but is not so uncommon as is supposed. From my
investigations of a large number of individuals of different ages I found.
a certain percentage were mirror-writers, some quite expert, others show-
ing a tendency to it more or less. I found that it was more common in
those over fifteen years of age and in expert writers than in those under
fifteen and those who were only learning to write.
It is sometimes shown by hemiplegics, and Ireland found it exhibited
by a proportion of weak-minded children. Mills of Philadelphia records
that “the left-handed show a physiological tendency to mirror-writing.”
It is interesting to record that one of Leonardo da Vinci’s manuscripts is
an example of mirror-writing—some suppose to preserve the work from
superficial readers, but another explanation may be that, according to a
priest who visited Leonardo during the last years of his life, Leonardo
had paralysis of the right hand and so may have been an example of a
mirror-writer after cerebral disease.”
“ An interesting fact is that, in those who can write with both hands
-and exhibit true mirror-writing with the left hand, the writing with the
left hand is exactly like that with the right hand when the one is looked
at in the mirror. Both are seen to be the same handwritings. By true
mirror-writers I do not mean anyone who has simply trained himself to
write mirror fashion with the left hand. Such a one has simply trained
his left hand to do certain expert movements. Such writing may or may
not be like the right-hand writing. But true or natural mirror-writing has
a singular resemblance to the usual handwriting. An example will be
found illustrated in my book above referred to, in a hospital patient who
was not an expert writer.
“ The patients of your two recent correspondents are somewhat unusual,
in that they seem both to show the left-handed tendency to an extreme
extent, just as some people are abnormally right-handed and can hardly
544 CURKENTVLITERALORE
do anything requiring precision with the left hand. It is a congenital Or
inherited preéminence of the whole or part of the right cerebral hemi-
sphere instead of the left, as in the majority of persons. Education can
do much in developing the use of the hand which from birth has taken
the second place in all special or expert movements. A child showing
sinistral preéminence can by training become ambidextrous, but it is
much more difficult, if at all possible, to develop it in a child showing
dextral preeminence. The reason of this is probably to be found in the
congenital structural associations of the neurons. Unless there has been
some disease or congenital defect of the nervous system, patient persistence
in training the right hand will ultimately succeed. Allowing the child to
write mirror fashion with the left hand whilst the right is being trained
will not, I think, prevent success, because a considerable number of people.
if a pencil is put into each hand, are able to write in the usual way with
the right hand whilst the left hand writes at the same time in the mirror
fashion.
‘In answer to the question of Dr. Clowes (April 19, p. 729), I cannot
see that there can be any danger to the nervous system in patiently training
the child to write with her right hand. She may find it irksome at first,
just as some of us did when we first mounted a bicycle, but with patience
and perseverance we gradually became expert, and what was at first
irksome became a pleasure.
Meagher, J. F. W. Menrat HyGiene, Some or Its More Important
Aspects. -[Jl..Med. Socsof N._Js,-1923.] .
The majority of “ functional nervous disorders” belong in the realm
of mental hygiene. Some of the aims of mental hygiene are to keep
body and mind in harmonious working order; to avoid unnecessary stress
and strain and needless worry; to get the individual to really know him-
self and to learn how to. supplant persistent dissatisfaction by contentment ;
to be useful not only to himself but to society; to direct him’ to that
profession or industry where work is satisfactory, and becomes a pleasure;
to learn how to follow the standards of the herd (society) comfortably,
and at the same time to gratify his own wishes in a socially approved
way; and by no means the least important of all, to develop a happy
emotional tone in his family life. There are certain bad traits and trends
which, if in excess, favor mental upsets. An individual with numerous
satisfactory outlets for his feelings has no occasion for brooding. One
must always distinguish genuine traits from compensatory ones. The
emotional life has the greatest determining value on conduct; the intellect
exerts chiefly a discriminative or restraining influence. Mental readjust-
ments cannot be made by surgery nor by endocrines. Every patient may
study his capabilities and limitations. All students of mental hygiene
agree that the first five years of life are the most important from a
psychological standpoint. It is during this time that the genuine traits
and trends are formed. The attitude of the parent is of more importance
SYMBOLIC NEUROLOGY 545
than what she says. In inculcating necessary repressions in the child, it
is not necessary to harshly subdue the child. It is a fact that in treating
some nervous patients, unless you also treat some other member of the
family, you will not get results. Normal family love is stimulating, but
for an individual to be fastened to a family to the point of losing interest
in all outside affairs is crippling. It is a mistake for physicians to advise
marriage as a panacea for all sorts of nervous ills. Whether it will be
beneficial or not will depend on the traits and trends of the two individuals.
For sex, which psychobiologically is of the greatest importance, is often
a hard problem for a neurotic to properly adjust to. Too many people
react to all questions of sex either prudishly or vulgarly. The important
causes of mental upsets should be stressed,—as fear, anxiety, hatred,
various conflicts, feeling of insecurity, unhappy home, etc. The fear of
insanity is a haunting fear of many of these patients. We prefer to
stress the importance of environmental influences over heredity on prac-
tical grounds: you cannot influence the latter. In treating these cases,
platitudes will not supplant intelligent analysis,—nor will surgery or
drugs. Trips for these patients are more often harmful than beneficial.
The patient must learn to know himself and how to handle his conflicts;
he must learn to develop normal personal, family, and social attitudes, and
have enough healthy outlets for his energies. To be mentally sound and
happy, every adult must have an aim and object in life. Abnormal selfish-
ness is a poor aid for recovery. The value of psychoanalysis has been
proved, but it must be used in the treatment of disease by medical men
trained in this method. They know which patients should be analyzed,
and which it would be a danger to analyze. Even the critics of psycho-
analysis admit the dynamic value of the wish. Nervous patients are the
particular object of the quack. If these patients had an intelligent idea
of mental hygiene, they would not so easily fall victims to quacks.
[Author’s abstract. |
Chapman, R. McC. Conrror or SLEEPLESSNESS. [Am. Jl. Psych., Vol.
Oe fans}
The two most important hydrotherapeutic procedures for sleeplessness
in psychotic cases are, the continuous bath and the cold wet sheet pack.
The use of drugs in sleeplessness should be forbidden save in exceptional
instances. Among the drugs that are most valuable, Chapman includes
the bromids, trional, barbital (veronal), sulphonal and_ paraldehyd.
Chloral hydrate is useful, but decidedly undesirable for frequent adminis-
tration. Drugs should be varied, no one drug being used over a long
period of time. There should be frequent discontinuance, and a placebo
substituted if desired. In the psychoneuroses, the scientific and most
desirable treatment must be, when possible, the release through psycho-
analysis of the underlying conflict, with the consequent relief of sleepless-
ness and other symptoms.
Book REVIEWS
Alexander, G., Marburg, O., and Brunner, H. HANbDBUCH DER
NEuROLOGIES DES OnreEs. III Band. [Urban und Schwarzen-
berg, Berlin u. Vienna, Mk. 60. |
This magnificent piece of work draws to a close in this Vol. III,
and editors and publishers alike are to be congratulated upon the
bold conception, the faithful portrayal of the subject-matter and
the excellent bookmaking which sets the contents off to best
advantage.
In the present volume Marburg opens with a masterly chapter
upon the tumors of the cochlear and vestibular systems and of the
cerebellum, including cerebello-pontine angle tumors, tumors of the
pes, tumors of the corpora quadrigemina, pons and medulla. The
chapter is a complete monograph in itself, copiously illustrated from
macroscopic and microscopic sources and gives complete clinical and
pathophysiological details. Prof. W. Denk of Vienna contributes a
chapter upon the removal of brain tumors of value to the neuro-
surgeon. A short but useful chapter is contributed by M. Sgahtzer -
of Vienna upon X-ray treatment of the tumors of this region.
In chapter 7 Dr. E. Pollak of Vienna discusses very exhaustively
the dyskinesias and dystonias with special reference to the involve-
ments of the cochlear and vestibular apparatus. This chapter is
rich in clinical novelties by reason of a thorough entrance into the
anomalies of these systems in encephalitis cases. The general prob-
lems of tonus are well discussed.
Chapter 8 upon the neuroses and psychoses involving ear mech-
anisms is particularly valuable since there has been but little sys-
tematic gathering of the literature along these lines. Drs. R. Leidler
and P. Loewy Raimann, Urbantschitsch, Stransky, Ohm, Abels,
Spiegel, Zappert and Palthe are the authors of the respective sections.
Finally G. Alexander and J. Bauer and Stein contribute a hun-
dred pages to the endocrine relations of the ear apparatus.
The-work is of value not only to neurologists and otologists but
to all medical men since the auditory and vestibular mechanisms
play so large a role in daily living and are.subject to so many
disturbances.
Freud, Sigm. STuDIEN zuR PsyCHOANALYSE DER NEUROSEN, AUS
DER JAHREN 1913-1925. [Internationaler Psychoanalytischer
Verlag, Leipzig, Wien, Zurich, Mk. 8.]
A collection of papers written in the past twelve years upon
various neuroses is here brought together. The chief reason is the
close relationship in subject-matter which permits the development
[546]
BOOK REVIEWS 547
of the author’s conceptions to be unfolded more readily, to the reader,
than in the reading from the collected works. Here are discussed
the disposition to the compulsion neuroses, two childish lies, paranoia,
instinct displacements particularly anal eroticisms, a child is being
beaten, idea associations of a four-year-old child, psychogenesis of
a female homosexual, paranoia and homosexuality, infantile genital
organization, the economic problem in masochism, reality loss in
the neuroses and psychoses, resistance to psychoanalysis, negation,
the psychical results of genital differences in the sexes.
These are the titles of the papers here brought together. Need-
less to say they are welcome in this form, especially when they can
be carried in the pocket, and as stated, develop so consistently the
advancing series of working conceptions of the neuroses in com-
parison with which all other conceptions seem like groping in the
dark of self-deception.
Roffenstein, Gaston. DAs PROBLEM DES PSYCHOLOGISCHEN VER-
STEHENS. [Julius Puttmann, Verlagsbuchhandlung, Stuttgart.
Mk. 7.50.]
A Study of the Foundation of Psychology, Psychoanalysis and
Individual Psychology is the subtitle of this No. 15 of the Kronfeld
series of Kleine Schriften zur Seelenforschung. It is not a large
work but it is closely printed in small type and not only are there
many words, but the thoughts are closely knit, making it a book one
must study attentively.
What is meant by “ understanding ’’—ourselves, others, a natural
phenomenon, a law—this is an old problem, and without writing
a complete work upon epistemology the author enters into the
many efforts to portray the processes and define their nature.
One must read the book to get at it—it defies summarizing in the
space at our disposal. It is not easy reading but it is promising and
stimulating.
2)
Cornelius, et al. BrriciT DER SONDERTAGUNG DES VEREINS DER
AERZTE FUR NERVENMASSAGE. [Verlag von Georg Thieme, Leip-
gime Nii 3.60)]
In Germany there are enough physicians interested in nerve-
massage to have a congress. There are 150 members of this society
and the present volume of 100 pages contains the papers or abstracts
of those given at the meeting in Berlin on the 14-15 April, 1925.
Dr. Cornelius, whose work is fairly familiar to neurologists opened
the congress with a short paper on the history of the movement and
how he came to learn, through an illness of his own, of the signifi-
cance of painful points in the muscles and tendons and of the means
‘to influence them. Eighteen papers are presented upon various
issues bearing upon massage in general, but more particularly upon
“nerve point massage.’
It is an interesting series of papers upon a small but important
field of neurological therapy.
548 BOOGK REVIEWS
Robitsek, Alfred. Der Kotitton. Ein BerrraG zur SEXUAL-
SYMBOLIK. [Internationaler Psychoanalytischer Verlag, Leipzig,
Vienna, Zurich. |
A small monograph of forty pages, reprinted from the pages of
“Imago,” dealing with dance symbolism and particularly that form
known as the cotillon—now hardly to be seen, save on special occa-
sions. The unconscious sexual significance of the various figures,
dresses, favors, etc., etc., is interestingly told. Since man sexualizes
everything in the course of civilization and culture this is a study
well adapted to show just how the unconscious repressions work to
gratify the instinctive cravings through indirect channels.
Bruni, Champy, Gley, Lugaro, Thorek, e Voronoff. La Fun-
ZIONE ENDOCRINA DELLE GHIANDOLE SESSUALI. [Dell Istituto
Sieroterapico, Milanese. |
This work of 240 pages contains papers by the authors of our
title given at a conference of the serum institute of Milan. Champy
writes upon the sexual characters, their determination and their
biology; Gley upon the action of the hormones, upon secondary sex
characters; Bruni upon the anatomical basis of ovarian correlation ;
Lugaro deals with the. correlations between psychical function and
the gonads; Vornoff upon rejuvenation, and Thorek upon clinical
aspects of the endocrinology of the testicles. A valuable series
of papers.
Heller, Theodor. GRUNDRISS DER HEILPADAGOGIK. [Dritte, um-
gearbeitete Auflage, Wilhelm Engelmann, Verlag, Leipzig. ]
A book of over 700 pages which reaches a third edition must
certainly have some merit. Furthermore the author is director of a
Heilpadagoschen Anstalt in Vienna and therefore speaks from
experience. Pedagogy for the inferior variant, chiefly for various
grades of feeblemindedness, we are told, has not stood still in recent
years. In spite of the war and most unfavorable social-economic
conditions an advance has been made. School reform has been going
on in the meantime, but inasmuch as the “ heilpedagogic ” methods
have anticipated these it has little to learn from so-called ‘ normal ”’
pedagogy, in fact, the reverse has been the real situation. Care and
training of psychopathic children has been advanced considerably
and the author discusses the methods which have arisen to take care
of the education of all children who are not well handled in the
schools.
A glance at the chapter headings will reveal the scope of the
book. Part I. General psychical developmental defects. Here are
considered: idiocy, imbecility, morons, acquired feeblemindedness
as with epilepsy, speech disturbances, infantilism, Cretinism, Mon-
golianism, etc. Part II deals with the pedagogic therapy and
prophylaxis of nervous and psychopathic constitutions. Here chap-
ters deal with nervous constitutional anomalies, psychopathic con-
stitutional anomalies and those suffering from hysteria.
BOOK REVIEWS 549
The work is modern, thoroughly worked out and quite practical.
It is well worth reading and holding for reference.
Bream Te Vee Lig eI xATION UND NYSTAGMUS. [Tle shirt,
Copenhagen. |
A clinical experimental study of the numerous problems con-
cerned with eyeball fixation and nystagmus with a series of interest-
ing discussions of the various points of view. After defining “ fixa-
tion” the author discusses passive or vestibular, and active or optic
fixation. Passive optic fixation and passive optic nystagmus are
then taken up, and further fixation with minimal head rotation.
Foveal and extrafoveal fixation are taken up in a later section.
He then passes on to a discussion of the active eye movements in
man, paying particular attention to the slow and the quick move-
ments. This is followed by an experimental study of optokinetic
nystagmus and this delightful little monograph closes with the con-
sideration of optokinetic nystagmus in which a new form of inversion
is described by the author.
Seeling, Otto. Diz PsycHOANALYSE IN PADAGOSCHER BELEUCH-
TUNG. [Pyramidenverlag Ir. Schwarz, & Co., Berlin.|
A short summary of psychoanalytic principles as applied to peda-
gogy, with a few illustrative cases taken from the works of well
known writers interested in the educational aspects of child training.
Brugsch, Th., and Lewy, F. H. Dir BIoLoGIE DER PERSON.
Lieferung 3, Band. 1, pp. 749-1051. Name and Subject Index.
[Urban & Schwarzenberg, Berlin and Wien. Marks 19.80. ]
With this section Vol. I of this new and striking enterprise is
finished. It has 300 pages and contains but two chapters. Dr.
Victor Lebzelter of Vienna writes the chapter upon Constitution and
Pece, Or. EH Uilmann of Berlin that or ~ The Life Span of Man-
kind.” The first constitutes an intriguing chapter upon ethnology,
not limited to color, nor length of hair, nor shape of skull, but includ-
ing disease incidence, susceptibilities to infection, and a host of ques-
tions of medical interest. Naturally much condensation, and not a
little of generalization is found, but this has been skilfully handled,
the modus not being ultra dogmatic. The paragraphs or pages upon
distribution of disease and racial factors are particularly well
documented.
The second monograph opens up with a discussion of the rela-
tions between constitutional make-up and length of life. It, too,
avoids a stilted mathematical boredomness usually found in such
studies, notably those of the life insurance type of statistics. The
life span in the plant world is interestingly totiched upon, then that
of lower animals, then of different races or types of infancy, child-
hood, adolescence, of occupational groups, etc., etc., etc. Even this
fleeting glance at the skeleton of the material indicates the breadth
of the treatment of the subject.
550 BOOK REVIEWS
We feel we can most heartily recommend this work to our read-
ers, especially those dealing with constitutional conceptions.
Birnbaum, Karl. Diz psycHISCHEN HEILMETHODEN. Fur aerzt-
liches Studium und Praxis von K. Birnbaum, H. v. Hattinberg,
G. R. Heyer, E. Jolowicz, A. Kronfeld, E. Wexberg. [Georg
Thieme, Verlag. Leipzig. |
The significance of, and value attached to psychotherapy has
steadily increased since the World War most dramatically pushed its
importance into the foreground. Undoubtedly many of the most
outstanding factors have more or less retreated into the background,
but enough remains to bear witness to the fact that the mental
mechanisms in the human organism are no less valuable than his
somatic activities—in fact the latter have little understanding without
a knowledge of the former.
A certain amount of crystallization in this field has become mani-
fest and the present volume, edited by Birnbaum would set itself the
task to give a systematic review of the more important psychothera-
peutic methods which have come into fairly clear understanding.
Here he has collected a series of smaller monographic presenta-
tions by a number of the younger workers in this domain. In this
volume Birnbaum first outlines the general situation and offers a very
comprehensive review of the entire theoretical foundations of psycho-
therapy. His is a very valuable contribution.
Jolowicz discusses Suggestion Therapy. Heyer takes up Hyp-
nosis and Hypnotherapy. v. Hattinberg deals with Psychoanalysis,
chiefly from the Freudian viewpoint, while Wexberg contributes a
clear outline of the Adlerian Individual Psychology. Kronfeld offers
an extremely philosophical section upon what he calls Psychagogic
or Psychotherapeutic Pedagogy. This is the final chapter.
The work as a whole is one to be most highly recommended. It
shows very clearly the general trends now uppermost in psycho-
therapeutic activities, and, above all, clearly indicates that there is no
sovereign method for all of the complex difficulties of human mental
maladaptations. Its catholic character commends it, especially as
offering a large vision of the field in which myopic tendencies towards
narrower perspectives are all too prevalent.
N. B.—All business communications should be made to Journal of
Nervous and Mental Disease, 64 West 56th St., New York.
All editorial communications should be made to Dr. Smith Ely Jelliffe,
Managing Editor, 64 West 56th St., New York.
OBITUARY
— aiaeeneerme re
LEONARDO BIANCHI
The 13th of April Leonardo Bianchi suddenly died in Naples at
the age of 80. His death is a real loss to neuro-psychiatry as Bianchi
belonged to the very small class of men who consider teaching and
investigation work as a true mission to which they devote their entire
enthusiasm and work capacity.
Bianchi was born on the fifth of April, 1848, in S. Bartolomeo
in Galdo and was graduated in medicine in 1871. He soon was
attracted to the still unexplored fields of neurology and psychiatry
and very judiciously his efforts were at first directed to acquire the
fundamental notions of anatomy and physiology of the central
nervous system. In this early period of his training he contributed
to the advancement of neurology by his important investigations on
the electric stimulation of the motor cortex and by his original studies
on Wernicke’s aphasia. In 1888 Bianchi was made professor of
psychiatry at the University of Palermo and in 1890 transferred,
by invitation, te the chair of nervous and mental diseases of the
university at Naples, which he occupied until 1923, when he reached
the age limit for the professorship.
Among the most important contributions of Bianchi to neuro-
psychiatry I will only mention his studies on the parietal syndrome
which has been called by some authors “ Bianchi’s syndrome,” his
studies on the associative bundles of the cerebral cortex, his studies
‘on acute delirium and those on aphasic dementia. In this country
the name of Bianchi is especially linked with his very important and
very original work on the mechanism of the frontal lobes which is a
quite vivid reflection of his brilliancy of mind, dominant character
of Bianchi’s personality. He also collaborated in many international
treatises of medicine and has published the well known textbook
on psychiatry, translated in English, and which is a clear exposure
of Bianchi’s conception of mental diseases. Lately he was deeply
interested in eugenic and mental hygiene problems.
Brilliant talker and exceptional teacher, Bianchi had fortunately,
during his life all the recognition and credit that really was due him.
Politically he also reached the highest positions, having been deputy,
senator and secretary of state once in the Department of Public
Instruction (1905). Italian science is indebted to him for the
[551]
552 OBITUARY
LEoNARDO BIANCHI
establishment of a university chair in anthropology, a chair which
was first occupied by such a man as Cesare Lombroso, A. FERRARO.
Vou. 65 | JUNE, 1927 . No. 6
The Journal
OF
Nervous and Mental Disease
An American Journal of Neuropsychiatry, Founded in 1874
ORIGINAL ARTICLES
ete oe NA EO) ED ILAGNOSIS IN STATES
OF COMA *
By Wititi1Am C. MENNINGER, M:D.
TOPEKA, KANSAS
Many patients are first seen in a state of coma. The absence of
a history makes the physical signs of primary importance in a
diagnosis. Although many suggestions have been made regarding
various points in the diagnosis of such cases, few studies have been
made regarding the pupils. Examination of them can be readily
and frequently made and consequently they may be a significant key
to the solution. The interpretation of their reactions is difficult |
because of the darkness enshrouding their physiology, but an attempt
is made in this paper to show that in some cases they may be an
important aid in a differential diagnosis.
Since their interpretation will only be possible as based on a
large series of observations, the present study was made of the
pupils in some of the most common forms of coma: alcoholism,
diabetic coma, uremic coma, cerebral hemorrhage, pontine hemor-
rhage, carbon monoxide poisoning, and fractured skull. The cases
were from the wards of the Second Medical Division of Bellevue
Hospital and with only a few exceptions were examined by the
writer. Observations in cases of coma from other causes (heat
stroke, various drug poisonings, epilepsy, etc.) were made, but
because of the small number of cases they are not included in
this report.
* From the Second Medical Division, Bellevue Hospital and Department of
Medicine, Cornell University Medical College.
fsa]
554 WILLIAM C. MENNINGER
| ALCOHOLIC COMA
There were fifty-eight cases of acute alcoholism, the patient being
unresponsive to any form of stimulation at the time the initial obser-
vations were recorded. Cases which were stuporous but not in coma
were not included, since it was desired to determine the diagnostic
value of the pupillary reactions only in cases of complete coma. ‘The
diagnosis in every case was verified by the clinical course and the
history subsequently obtained. Only one case was fatal, the diagnosis
being verified by necropsy.
The findings are given in Table I:
TABLE?!
Pupits IN ALCOHOLIC CoMA
Total: numberot cases ae ee ee 58
ANISOCOFIAS, (nie ee ee one eee 8 13.8%
Size:
Dilated:-.4)2 Sal ssece Oe ee eee Re ae 7 12.0%
Mid-dilation::; 32 4. Sees eee eee 23 39.9%
Contracted, ¥ ¢.097 eae eee 25. AS51%%
Not «piven: F zaic gee cee ae ee yet wad ee ae
Reaction to light:
Promptly. 2... eee ee 26 44.8%
Sluggishly.*. 34. 2 Awe see eee ee eer eee 1t 19.0%
Fixed... sacs ee ee ee eee 21-3082 6
Anisocoria: Of the fifty-eight cases, eight presented pupils of
unequal size. In three of these cases the patient was over sixty-five
years of age, and the inequality may have been due to changes with
age. However, one of these cases presented equal pupils subsequent
to his intoxicated state. This was also observed in several of the
other cases with anisocoria, although not in all.
Inequality of the pupils is regarded by many as a normal develop-
mental or physiological condition and others always regard it as a
pathological condition. Its frequency in alcoholism as indicated by
this small series of complete comatose cases is high. Rolleston (49)
and Hall (18) both briefly state that the pupils are equal in this con-
dition. On the other hand, Hunt (23) states that inequality is espe-
cially common; Lewis (29) lists alcohol as a cause of anisocoria,
and Uhthoff (56) in 1,000 cases of alcoholism found a marked dif-
ference in the size in twenty-five cases. Lundsgaard (31) notes
anisocoria 22 times in 157 cases studied. Vogt (57) reports a case
in his series in which the pupils reacted unequally to light, conse-
quently being of different size.
The significance of this feature of the pupils in alcoholism seems
slight. It seems questionable to the writer whether there is any
relation between its occurrence and the intoxication. Ubhthoff’s figure
POLS IN “SEATES CF COMA 4h
is considerably below the frequency of this condition, which the
writer has observed in a large number of apparently normal
individuals.
Size of Pupil: In the present series of 58 cases, only 7 were
dilated (over 4 mm.), 23 were in mid-dilation (between 2 mm. and
4 mm.), 25 contracted: (2 mm. or less), and in 3 cases no note was
made of this point. The “ pin-point ” pupil was relatively infrequent.
It is of special interest that the majority of the cases presented a
contracted pupil, in view of the fact that many writers on this sub-
ject describe them as dilated (Osler and McCrae,(44) Purves-
Stewart,(46) Fussell,(14) Pick and Hecht,(45) Rolleston,(49)
Caille (7)). Others, while noting contraction in certain cases,
describe the pupils as “ more commonly dilated ” (Wilson,(64) Hol-
land (21)). Hall (18) states they are normal in size or dilated.
Wilbrand and Saenger,(62) who have devoted an entire volume to
the disturbances of the pupil, describe the pupil in acute alcoholism as
contracted. Scudder (50) briefly describes the pupils of alcoholic
coma as “ normal.”
Reaction: Of 58 cases, 37 reacted to light stimulation and 21
were fixed. Of those reacting to light, 11 were sluggish.
Sluggishly reacting or fixed pupils have been noted by many
workers, although Fussell,(14) under the discussion of alcoholic
coma, states that irresponsive pupils “ will be absent.” Crothers (8)
states that the light reflex may be abolished. Holland regards sensi-
tive pupils as a good prognostic sign, and Purves-Stewart (47) states
that sluggish pupils are the usual finding. Gudden (17) noted vari-
ous stages from diminished pupillary light reactions to complete
iridoplegia and that following the intoxicated state the pupillary dis-
turbance was much less marked or returned completely to normal.
Cases in which mental cloudiness persisted presented pupillary
disturbances of longer duration.
In an analysis of these cases it should be considered that many of
them are unquestionably chronic alcoholics, and the pupil fixation may
be the result of chronic alcoholism. Siemerling (52) describes pupil
fixation as a common finding in this condition. Uhthoff (56) collected
pupillary data on 4,000 cases of mental disease reported by Moeli, (38)
Thomsen, (54) and Siemerling,(52) 492 of which showed iridoplegia ;
of this number 11 (2.2 per cent) were cases of alcoholism. Retz-
laff (48) noted in 285 cases of chronic alcoholism four cases with
pupil fixation and 28 with sluggish reactions. Nonne,(39) in 1,460
cases of alcoholism examined in Hamburg from 1905 to 1907, found
18 cases with fixed pupils and 60 cases with sluggish pupil reactions.
556 WILLIAM C. MENNINGER
Lundsgaard (31) noted in 157 cases 5 with “dull reaction” and 1
with Argyll-Robertson pupil. Cases of chronic alcoholism with
Argyll-Robertson pupils, but with entirely negative findings for
syphilis, have been reported by Nonne,(40) Barnes,(2) Mees, (34)
Fuchs,(13) Menninger,(35) Kramer,(26) Oppenheim. (42)
The question of Argyll-Robertson pupils of alcoholic etiology
with entire absence of syphilis has been repeatedly discussed. Wil-
brand and Saenger regard some of the reported’ cases as presenting
this single somatic symptom of organic disease of the nervous system
as the result of alcohol and not as the expression of peripheral centrip-
etal optic nerve disease or as a sign in the development of a previous
existing syphilitic disease of the brain or spinal cord. Bumke (6) is
pot convinced that it is as common in alcoholism as the many obser-
vations would indicate, since many such records were made before
the serologic diagnosis of syphilis was perfected. However, he is
certain that alcohol aids in the formation of this phenomenon and
that consequently it occurs in both drinkers and syphilitics. He
states further that “ we could also demonstrate that the most frequent
disturbance of innervation of the iris in alcoholism is sluggishness of
the pupillary reactions, rarely an absolute fixed pupil. And that in
one stage of the disease during recovery of this condition there is a
transitory convergence reaction better than the light reaction so that
the picture will simulate the Robertson phenomenon.” Wilbrand and
Saenger quote Weilers (59) that in over 1,000 alcoholic cases exam-
ined, they come to the conclusion that persistent pupil fixation
following alcoholic abuse as the only cause is not observed.
Vogt (57) examined the action of alcohol on the pupillary reac-
tions in mental disease. In normal individuals he observed no effect.
In about a third of the mental cases delayed reactions occurred after
small single doses of alcohol. Weber (58) points out that “ imbe-
ciles, degenerates, and cases of exhaustion” show the symptom of
fixed pupils after quantities of alcohol which do not produce psychic
disturbances. Stapel (53) also studied the reaction in mental cases
and found the pupillary alterations more pronounced in mental cases
than in normals, appearing with smaller doses, more quickly, more
intensively, and more continuously. 7
The actual pharmacodynamics of alcohol should be considered in
determining the effect on the pupil. Despite the many studies made
of alcohol, its pharmacology does not seem clear. Hatcher (19)
states that the “vagus center . . . is probably more affected
directly.” He mentions various evidences of sympathetic stimula-
tion—rapid pulse, vasodilation and rapid breathing, but calls attention
PUPILS IN STATES OF COMA 557
to the fact that large doses slow respiration, this being probably a
central action. Cushney (10) states that flushing seems to arise from
vasomotor action but is not clear. Consequently while alcohol pro-
duces certain definite and obvious effects, the mechanism is not clear.
DraBetic CoMaA
Observations were made on 10 cases of diabetic coma, of which
6 were fatal cases. The blood Wassermann test was negative in
every case. ‘The findings are given in Table II: |
TABLE TY
Pupits IN D1rasetic CoMA
DMISOCTEOlECds CS a Erte mene ted asks So. gaeg’s os. oy 10
PATS COM ile meet eit ea eer a MPO Pe Re et ee etl et 0
Size:
VT Ce ae ee hs SPE er a Gn eee ee Oy f
Midere hati erates veel eee da aiid key Lambe es lols, 6
CONT ACCC ee tee ere engin NL Ou Se “
Reaction to light:
On ee am PRE re ian 3 IAN ASL ul. 6
VEEN AUN 25k ihet Se Vo Re IL AR 2
PC Cn ee een rey eT tee Wm VOM fee rh I eR NN dL , 2,
The only reference to the status of the pupils in diabetic coma
found was in a differential diagnosis given by Crothers, who only
states the pupils are dilated.
One should also consider in these cases the possibility of changes
present in the pupil before the onset of the comatose state. Leber (27)
has described dilated fixation of the pupil in diabetes. Fischer (12)
has observed sluggish pupil reactions in two cases, but in both cases
tabes could not be entirely ruled out and both were chronic users of
nicotine. Nonne (41) reported a case of myotonic reaction in a
diabetic and another case in which the light reflex was fixed and the
convergence reaction sluggish. Grube (16) has published two cases
of absolute paralysis of the pupil in diabetes. Westphal (61) has
reported a mental case in which there was entirely negative serology
for syphilis who developed fixed pupillary reflexes during a severe
stage of the diabetes which cleared with the diabetes. Biermann (3)
also reported a severe case of diabetes with pupil fixation in which
he is certain he has ruled out alcohol, syphilis, and tuberculosis.
Liebers (30) describes a case of cerebellar disease associated with
diabetes mellitus in which there was a bilateral pupil fixation.
Bumke,(6) in 1911, reviewing some of the reported cases, regards
the reports as unconvincing that a typical reflex paralysis of the pupil
occurs as the result of diabetes. Wilbrand and Saenger (62) also
question the direct association but accept the reported cases, although
558 WILLIAM C. MENNINGER
regarding them as failing to prove whether the fixed pupils are the
result of intoxication or hemorrhage in the region of the sphincter
nucleus or whether the primary basis for this sign is here also to be
sought in syphilis.
In the cases of this series there is no uniformity in the occurrence
of any anomaly. It is of interest to note that two cases, both of
which were fatal, showed fixation to light, and although the serum
Wassermann was negative, syphilis cannot be entirely ruled out. It
seems purely speculation as to the mechanism in cases of pupillary
anomalies occurring associated with diabetes mellitus, but some form
of intoxication seems more likely than a local lesion.
UrEmMiIc CoMA
Eight cases of uremia in complete coma were observed. Complete
studies were made of all of these cases and little doubt remains as to
the correct diagnosis. All eight cases were fatal. The lowest blood
nonprotein nitrogen in any case was 104 mgm. per 100 c.c., and the
highest was 319 mgm. per 100 c.c._ The state of the pupils in these
cases was as follows:
TABREAAT
Pupits IN Uremic CoMA
Total cases. 2-2. Se ee oi en 8
Anisocoria: 24) oeAn 28 9 ogo ies OL a eee 1
Size:
Dilated.’. s whe See ee ee eee ee ee eee 0
Mid-dilationcé.), 4:46 ee ee eee 4
Contracted.2. 5.4) 4%,.2 » see eae ee ee 2
Not’ noted... 3.3 SR ae eee ee ee ee eee Zz
Reaction to light:
Prompts ohc0y (ears ote crass as fete een cee i wi)
Retarded 24's 2 eR ee 2 ee ee Z
Sluggish... cian oe ede Ae a ee ee 5
Fixed. e600 e as las Soe be en ee 7
The status of the pupils in uremia has been subject to some con-
troversy, but much less attention has been paid to them than in most
other forms of coma. Senator (51) states that at the height of an
attack they are dilated and react sluggishly or not at all to light. It
might be said that the five cases above reported as acting sluggishly
all reacted through a very small arc. However, Senator further
states that a noteworthy point of distinction between chronic and
acute uremia is the frequency of myosis in the former. This agrees
with B. von Wernigk,(60) who found that one of the first signs of
an uremic state was dilation of the pupils, and Brooks,(4) who states
they are wide and fixed in uremic convulsions. Wilson (63) describes
the pupils as more commonly slightly contracted than dilated but are
LOI PO UNS STALE SSO COMA Baw)
without diagnostic significance. Crothers (8) briefly states that the
pupils are normal or dilated; Scudder,(50) that they are dilated and
sluggish; and Hall’s (18) summary of the signs of uremic. coma
includes “ normal and equal pupils.”
The findings 1n the coma cases in uremia are more uniform than
in the other causes of coma. All the noted cases were either in mid-
dilation or contracted; all presented some delay or entire fixation to
the light reflex. In view of the majority of opinions in the literature
that the pupils are unusually dilated in this condition, there undoubt-
edly must be an unreliable variation as to their size. There is nearly
uniform agreement as to their sluggish reaction.
CEREBRAL HEMORRHAGE
Observations were made of 46 cases diagnosed as cerebral hemor-
rhage, 10 of which were verified by autopsy:
LABLE -[V
PuPILs IN CoMA OF CEREBRAL HEMORRHAGE
SASS RMES OSL a eat OVO a ek oad oa ors a a oe ere eS ae 10
PRTC OCOL 1a eerie ee ate eR wo Mire are bale sie so his 6
Size:
ES leet © Cl Seen aR IED face SMP PES ata vlan eS oe pe 8 sco 5
VEN SCA LLC een ile arse eke UP ay cae) cere seats ej es 1
GON clec Me ee ees Fee Pes Gy in abe wenn Views oe pa &)
Reaction to light:
IRIRSRCIN Oe lk” fucks Ae ag ees ae etree rena ee 0
SY RER SGU ESOL, nes vhs gp ein Oh ka We Ag nate ae re f
ES ce Ul ee Teer bit cn Oeaiapnte-s alae soe Sane Ck. 9
(aceomiOtraULOp Ie Ue se cee ha heeds ct tke Pet wugiotecn) 36
IGT SCR OTIRE Ny OG dar tho a Ap eo es Oe arn Re ea 28
Arete oiasidcr Ore paralysis... cea ay a Wom he shoe 2h ge «ats 13
deareer on opposite side, Ola paralysis... o..6c a... 4: « 15
Size:
ASE] ex Lec hea erate re eo to NR ere etc ooh oh tft She Crew Sign betaine 4
J Wlee Eahe hala) ce cay ante. a, Perma ee, ete eee ene eae Tr eae 10
Won tracter ey = cee ee ee ike Coa Vine eee eran ina is he
N(R OLCC Rea iment tee: Ae Sie tty, cit cles tam oh wots Z
Reaction to light:
re as ue ee eae eee aay es date vee dena ate Satta 5
eUbbNiateaC Waleed, Ae A cee tate pepearn er te Pe eraen ieee raeg 20
ice Pee re cet Pn Ae On try atid site ato ne Se 1
It is generally recognized that the pupils in cerebral hemorrhage
are too variable to give much help in diagnosis. Such a view is held
by Tooth,(55) Elsner,(11) Browning,(5) LeCount and Guy,(28)
and many others. While there are many variations in the findings,
certain features of the pupils in this condition are more constant than
in almost any other form of coma.
Anisocoria: Inequality of the pupils occurred in 34 out of the
total of 46 cases, or 73.9 per cent. This inequality is a feature which
560 WILLIAM C. MENNINGER
has been noted by many writers and depends on the location of the
_ hemorrhage. In those cases in which it is localized in the cerebrum
there is usually dilation of the pupil of the same side; in the cases
where it is located in the brain stem there is usually dilation of the
pupil of the opposite side. However, the majority of hemorrhages
occur in the cerebrum, and as a consequence the pupil of the same
side is dilated. Special attention has been called to this so-called
focal lesion, by many writers (Cumston,(9) Browning,(5) Adrogueé
and Balado,(1) etc.). In an important contribution to this subject,
Koppel and Weil (24) observed a marked and persisting inequality
of the pupils in about 40 per cent of all cases. of cerebral hemiplegia.
During the continuation of the coma, the pupil: was contracted on the
paralyzed side (on the opposite side of the cerebral lesion), but was
dilated when the patient was not in coma. They regard the constric-
tion during coma as depending upon the retardation of the affected
hemisphere and the dilation after the cessation of the coma as depend-
ing upon an irritation of the hemisphere. This inequality of the
pupils during coma does not argue against the acceptance of a cere-
bral hemorrhage, but weakens, under some conditions, the diagnosis
of an hysterical hemiplegia. Koenig (25) reports 20 cases of a
series of 72 cases of infantile cerebral paralysis, in which there was
an inequality of the pupils with a normal reaction. In six of these
there was either a mono- or a bi-lateral sluggish or absent reaction
to light and convergence. |
In the four cases .of the present series with equal pupils which
came to autopsy, one presented a diffuse intermeningeal hemorrhage ;
the second, a diffuse subarachnoid hemorrhage with both lateral
ventricles filled; the third, a ruptured aneurysm at the base associated
with a generalized subarachnoid hemorrhage, and the fourth, with an
extensive left thalamic hemorrhage which had filled both lateral
ventricles.
Size: The majority of opinion regards the pupils in cerebral
hemorrhage as being most commonly dilated (Osler and McCrae, (44)
Oppenheim, (43) Scudder (50), although here again the variation is
so great that a rule of thumb is not reliable. In the present series
more cases were contracted than dilated. The question of dilation
or contraction depends entirely on the location of the lesion. If it is
so located that it causes pressure on the nucleus of the third nerve,
the pupils are contracted (hemorrhage into the pons or ventricles).
In the present series certainly the majority are severe cases, and if
judged by the autopsied cases the hemorrhage extensive. Conse-
Otis Hyrst 4 res, Or GOA 561
quently it is probable that more of this series would show contraction
than in cases in which there occurs only a monoplegia or a mild
hemiparesis, and in which coma was not present, and the lesion
relatively small.
Reaction: Oppenheim says that the pupils generally do not react
to light, and Osler and McCrae, that they are always inactive in deep
coma. Thomas, and also Gordon, state that during coma the light
reflex is absent. Elsner modifies this opinion by stating that in the
most serious cases the light reflex is abolished, while in the milder
cases the reactions continue, although they may be abnormally slug-
gish. Of the total of 46 cases in the present series, 20, or 43.4 per
cent, were fixed to direct light stimulation, while 21 others were dis-
tinctly sluggish. On the other hand, 5 reacted to light promptly,
though not in every case through a normal arc.
PoNTINE HEMORRHAGE
The series includes five cases, two of which came to autopsy:
TABLE
Pupits IN CoMA OF PoNTINE HEMORRHAGE
tO SIGUE CABG mee meee tte cel Mle at Sishe Seals Gavi okats oreo 5's Ze
Sea etvaYer ay gh iio a: OM 93S Rp ege -epeane U ee i i eA Re 1
Size:
POUT Gel CLEC eer tern Meee eed ta ia olan. oR tear etoile wa 2
Reaction to light:
Ee Cce a ae ea te ere) Cy euhe a Cat ic eaie ye C4 ale a’ be 1
Se Oe warm eet othe ott aie t adal'e «hes a otterg ole 1
CASReydiG HAULOD SIGUA UE rates i fate gi a cease eb tule waa Sree 3
PISOCOTIAMCSIT we L1G) een a cre sal ire lly ong ov diel ara oe olaya sa wake 2
Size:
GOnteaCted Fer ee ae FEC EO as Aas 3
Reaction to light:
dM Pele Bd Ag We ge -L a, 8 AUER Ae UO ae Rays oP eee ee © aA a We
SLUGS ISI Moka al Clee eerniy oats cpu MU ianeee wavs MeRE isha. coat eN 1
The pupils are characteristically contracted in pontine hemorrhage
(Osler and McCrae,(44) Elsner,(11) Oppenheim (43)). They
were contracted in all five of the present series, three of which were
fixed and two very sluggish in the reaction to light. All of these
cases were fatal, three with a temperature of 105° or over. Four
presented crossed signs (paralysis of left face and right body) and
one with a general flaccidity.
CarBON MoNOXIDE POISONING
In 43 cases of gas poisoning, which were in complete coma when
the observations were made, the following status was found:
562 WILLIAM C. MENNINGER
TABLE VI
Pupits IN GAs POISONING
Number ofcases. 2c..0 ee ok ee eee 43
Anisocorias oo ai Ree eee eee 4 9.7%
Size:
Dilated. fe ee ee ee 6 13.8%
Mid-dilation: 2205 eee eee ee 22 50.6%
Contractéedécijcgee te foie ee eee ee 15) 34.5%
Reaction to light:
Prompt? 27 .chee tice eee ee ie een 21 48.3%
Slug eish:, 370 wee aac ee ere ee are 5 21135%
Fixed, 4... Ae Geeaen eas se eer ee nee 17 29.1%
It will be noted that there is a marked variation in these cases
both as to the size and the reaction. A large number of the cases
with fixed pupils to light stimulation reacted following the regaining
of consciousness. In the great majority of gas poisoning cases the
history is usually known and consequently the pupillary status is of
minor interest. No references were found in the literature regarding
the pupils in this condition.
FRACTURED SKULL
Under this heading might also be included a large group of cases
who are admitted to the hospital in an unconscious state from head
trauma due to cerebral concussion or even contusions of the skull,
without skull fracture. However, for the sake of clearness in the
conclusions, only cases of fractured skull, or probable fractured skull,
are included.
The cases are divided into two groups: one, of 25 cases of proven
skull fracture by palpation, roentgen-ray, operation, or autopsy, and
a second group of 30 cases of probable skull fracture as evidenced by
neurological signs, bloody spinal fluid, or bleeding frorm the ear, all
of course with evidence of head trauma.
TABLE: VEI
CASES OF SKULL FRACTURE
I. Proven (cases '.% se. as eee ee ee 25
(4 were conscious at the initial examination)
Anisocoria; 372 >. 255225 cee on ee ee ee 8
Size:
Dilatéd. co... ee A Re eee 4
iMid-dilation. 2 1.44 ee ee ee 10
Contracted. is > :20uy oe eee Sot!)
Not “noted. <....cL.:.agn, eee ee 2
Reaction to light:
Promptly. . 2 faves ee eee 7
Sluggish: i}. Savalas ee ee ee 8
Fixed in. 9. seclh ou eee ee ee eee 10
Il. Probable "cases 2. ee ee ee eee 30
(4 were conscious at initial examination)
PUPILS IN STATES OF COMA 563
PAUISCCO LI weet mt, or eee Sa arta oR oh. Gene hed Bes 13
Size:
NEN CUM ete Pe tire hic mA Ane Ut ie Ea 2s ee 7
Wis iatiOne berm Mae. cee oe ed See a ede 4
APONTE AGUAC Pete Ne eh os W's saw nlale ow en kn el 5
EVR SHC Xela (2 EO I af io I aa or a 14
Reaction to light:
JET Op aE OTA BTR) SAMS Ren ore ok! OAR lg ae RIE CAeORER oe ROE 10
Sie 1s ante, woe te tale ole Kale oS ace eee 5
ESC sere eae steht), ciate ters Sono viata does Maks 1S
VAKGNE TaWeye Sele ert da al cl Coe me 2
Antsocoria: In the eight proven cases in which it occurred, the
pupil on the side of the trauma was dilated in every case, at some
period following the trauma. In the 13 cases of probable fracture
in which anisocoria occurred, the dilated pupil was on the same side
as the trauma in 9 instances and contre-coup in the other 4. It is
necessary in these cases to watch the pupils closely to detect aniso-
coria, since it is often of a transient nature, being present in some
observed cases only a few minutes. Its fleeting nature as well as
the unilateral dilation as an aid in locating the lesion for surgical
interference is stressed by Holman and Scott,(22) Hoessly,(20) and
Brooks. (4)
Size of Pupil: A great variety of lesions may of course cause the
variation in the size, and the latter will vary, depending on the status
at a particular moment. There may be a mydriasis due to the tem-
porary paralysis of the oculomotor nerve, which is more common than
an irritation mydriasis (irritation of the cervical sympathetic). In
the case of damage to the sphincter, sphincter nucleus, or efferent
tracts, the result is mydriasis. These same lesions may apparently
cause a myosis when they serve as an irritation or stimulation of the
pupil contracting fibers of the third nerve. Thus any statistics as
to the size of the pupils in skull trauma have little significance and are
known to change frequently. It is more commonly contracted in
these cases, which is stressed by Magitot,(33) which he regards as
a spasm of the sphincter.
Reaction to the Light: In cases of skull fracture, there is a great
deal of variation in the response to light, depending on the location
of the lesion. Wilson (64) discusses the subject after classifying
reported cases into those in which the injury occurred to the eye or
behind it and those to traumatic lesions. He reviews eight cases of
traumatic Argyll-Robertson pupils. Bumke (6) also discusses the
question of pupil disturbances in trauma, depending on the location
of the trauma.
The occurrence of a fixed pupil (Argyll-Robertson) as the result
of trauma has received considerable discussion. It occurred 23
564 WILLIAM C. MENNINGER
times in the 55 cases here reported in either one or both eyes. The
possibility of active neurosyphilis was ruled out in practically every
case by lumbar puncture. Fixed pupils have frequently been
reported: Wilbrand and Saenger (62) briefly review 25 observa-
tions, 8 bilateral, 16 unilateral, and 1 beginning bilateral but finally
resulting in unilateral fixation; Wilson (64) reviews 6 additional
cases; Bumke (6) discusses 3 of those reviewed by Wilbrand and
Saenger. Scudder (50) quotes Lovett and Monro that the pupils
failed to react in 39 out of 59 fatal cases of basal fracture, and
reacted in 11 out of 12 cases in which recovery occurred. Nichols
records 54 cases of head injury with fixed pupils, 4 of which died.
It would appear from the observations made on the present cases
that an unilateral dilation of the pupil is a frequent and important
localizing sign, although this dilation may be contre-coup, and may be
absent. It is often fleeting in its duration and must be closely
watched for. The size varies, but perhaps is most commonly con-
tracted. All stages of the response to light may be present and fixed
pupils are a common occurrence. Their significance is difficult to
interpret since they occur both with trauma to the eyeball as well as
central lesions.
SUMMARY
The pupillary status, including equality, size, and reaction to
light, has been analyzed in 225 cases of complete coma.
1. In 58 cases of alcoholism, inequality occurred in a sufficiently
large number of cases (13.8 per cent) to suspect it as more than an.
accidental occurrence. The majority of the cases were contracted
(43.1 per cent) and nearly half (44.8 per cent) responded promptly
to light stimulation, although another third (36.2 per cent) were
fixed. It would appear that the pupils show too great a variation in
this condition to be of much diagnostic importance.
2. In 10 cases of diabetic coma, there was no uniformity in the
findings. Two cases of fixed pupils occurred, both of which
terminated fatally.
3. In 8 cases of uremic coma, there seems to be a variation in
the size, but the light reflex was impaired in varying degrees in
every case, one of which was fixed. Inequality occurred but once.
4. In 46 cases of cerebral hemorrhage, nearly three-fourths (73.9
per cent) of them showed anisocoria. The dilated pupil usually
occurs on the side corresponding to the hemorrhage, but this depends
on the location and extent of the hemorrhage. There is no uniformity
in the size of the pupils; in this series a slight majority were con-
PUPILS IN-STATES OF COMA 565
tracted. Nearly half the series (43.4 per cent) were entirely fixed
and 21 other cases (45.0 per cent) were distinctly sluggish.
5. In 5 cases of pontine hemorrhage, all were uniformly con-
tracted, and either very sluggish or fixed to light stimulation.
6. In 43 cases of carbon monoxide poisoning, there is a marked
variation in the size and the reaction to light. Just half (50.6 per
cent) were in mid-dilation and about a third (34.5 per cent) con-
tracted. Approximately half of the cases (49.3 per cent) reacted
promptly although nearly a third (29.1 per cent) were fixed. It
would seem that they have little diagnostic importance.
7. In 55 cases of fractured skull, inequality of the pupils occurred
in over a third of the cases (37.8 per cent); in 81 per cent of these
cases there is either proof or evidence that the dilatation occurred on
the side of the brain trauma. In the remaining cases it is probable
that the fracture was contre-coup from the point of trauma, and con-
sequently the dilatation agreed with the side on which there was brain
trauma. ‘The inequality is recognized to be fleeting in many cases,
and when observed is a noteworthy localizing sign for surgical inter-
vention. The size varies at different stages and is not uniform. Not
quite half the cases (41.4 per cent) were fixed to light and an addi-
tional 23.4 per cent were sluggish in reaction. Hence we may regard
pupil fixation as a relatively common occurrence in skull trauma.
CONCLUSION
Pupils may be an aid in the diagnosis of comatous states when
that state results from brain trauma (hemorrhage or pressure).
They are of little or no diagnostic importance when the coma is due
to alcohol poisoning, diabetes, uremia, or carbon monoxide.
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568 WILLIAM C. MENNINGER
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BLOOD GROUPS IN MENTAL DISEASES *
By FREDERICK ProEscHER, M.D., anp A. S. Arxusu, A.B.
AGNEW STATE HOSPITAL, AGNEW, CALIFORNIA
When Landsteiner in 1901 (1) discovered the so-called “ isoagglu-
tinins”” his discovery was considered merely as an interesting scien-
tific fact without practical application.
Moss,(2) von Dungern and Hirszfeld,(3) Ottenberg,(4)
Lattes,(5) and others apply the phenomenon of isoagglutination for
selecting proper donors for blood transfusion, for solving anthropo-
logical, medico-legal and constitutional problems.
Hirszfeld,(6) and his co-workers have made most important
studies concerning the relation of the blood groups to diseases. They
have shown for example, in diphtheria, that the immunity for this
disease is not connected with a certain blood group, but inherited to-
gether with the group. Other investigators have tried to connect
malignant tumors (7) and mental (8) diseases with certain blood
groups, but so far without definite results. |
When we attempt to determine the cause for the existence of
immunity or susceptibility in certain individuals; when we try to
find a practical explanation for the biological varieties in mankind,
we naturally look for aid to the principles of evolution and racial
adaptation. If this is justified it becomes desirable to recognize the
specific types and to do this we resort to the use of various indices.
Thus we attempt to relate biological reactions on the one hand, with
anthropological measurements, chemical reactions, blood groups,
facies, complexion, etc. on the other hand. It is evident that the
index of greatest value will be that which most accurately and con-
veniently separates into practicable groups the members of the
human race. The index is a reflector of nature. The results of the
Hirszfelds and others indicates that blood groups may, for some
purpose at least, fulfill the requirement quite well.
In the following we wish to report our findings on the distribu-
tion of blood groups in mental diseases. In order to make this clear,
*From the Pathological Laboratory, Agnew State Hospital, Agnew,
Calits
[569]
570 .- PREDERICK PROESCOH ERAN Dy eae
a brief review of our present knowledge of the blood groups and the
main facts about the phenomenon of isoagglutination will be given.
Tsoag glutination
When a homogenous emulsion of red cells is mixed with the
serum from another individual of the same species and prompt
clumping takes place, this phenomenon is known as isoagglutination.
Under certain conditions the agglutinated red cells may be hemolyzed
(isohemolysis) as definitely shown by Mino.
Ehrlich and Morgenroth demonstrated by immunization of animals
with blood of the same species differences in the blood structures.
The serum of an animal immunized with his own blood or blood from
another one of the same species possessed agglutinative or hemolytic
properties for the blood of some animals of the same species.
Similar differences were noted in the blood of human beings at
about the same time by Shattuck and Greenbaum and were mis-
takenly supposed to be the result of disease.
Landsteiner in 1901 made the first correct interpretation of the
phenomenon and showed that it is not due to disease, but is a normal
occurrence following a definite invariable law. From his observa-
tidbns he concluded the existence of three blood groups.
Jansky in 1907 (9) and Moss in 1910 discovered the fourth
group, which escaped Landsteiner’s observations, because of its
rarity.
Decastello and Sturli, von Dungern and Hirszfeld, confirmed
Landsteiner’s, Jansky’s, and Moss’s observations that all human
beings, relative to their blood, can be divided into four groups.
According to Landsteiner the human blood has two properties.
One is anchored onto the red cells; the other is found in the serum.
They do not react on the same blood. If we designate the serum
properties as Anti A and B (antibodies against heterologous blood
cells which have the properties of an antigen) and the red cell prop-
erties as a and b, we have the following:
TABLE [|
Group I Group II GroupIII Group IV
Serum contains Anti A-Be) AntieBee Anti O
Red cell contains O a b a-b
Agglutination takes place only when Anti A with a or Anti B
with b act together as shown in the following:
BLOOD GROUPS IN MENTAL DISEASES SAE
TABLE II
Erythrocytes of group
exe) Liga Hie b IV a-b
Serum I Anti A-B zoe a. a1 a
Serum II Anti B eee ine =e ate
serum [Il Anti A — ts eas ai
Serum IV O a
The fundamental work of von Dungern and Hirszfeld (10) in
1910 proved beyond doubt the inheritance of the blood structure or
specific substances according to Mendel’s Law. These investigations
were based on the examination of the families of professors of the
University of Heidelberg.
Von Dungern and Hirszfeld gave the following rules for the
inheritance of the blood properties :
I. The blood properties may be inherited, but not necessarily.
II. Blood properties not present in either of the parents are not
found in the blood of their offspring.
III. The properties a and b may be independently inherited. If,
for example, the parents belong to group ab the children may
belong to the group a, b, or ab.
Decastello and Sturli (11) have shown that in embryological de-
velopment the specific agglutinogen or agglutinability of the red cells
appears first and is usually present at birth (von Dungern found it
in a six months old embryo) while the agglutinins, which are agglu-
tinative properties of the blood serum, may be present at birth, but
usually appear several months later. In rare instances they may not
be observed for several years. According to W. M. Happ (12) the
group is usually established by the first year and after two years is
as fully developed as in adults.
All workers agree that group specific substances are permanent
throughout life for each individual. It is true that there are investi-
gators as Eden,(13) and Diemer (14) who believe that the blood
groups can be changed by drugs, roentgen rays, narcosis, electric cur-
rent, etc., but K. Nather,(15) Meyer and Ziskoven,(16) Jervell,(17)
Mino,(18) Hoche and Mortisch (19) could not confirm their findings
and opinion is very much one-sided. A change in the group specific
substances could not be demonstrated by the above agents.
Distribution of Blood Groups in Human Races
During the world war L. & H. Hirszfeld (20) made important
investigation as to the distribution of certain blood groups in human
572 PREDERICK PROASCHER AND PAR Se Aa RUS
races. They grouped Germans, French, English, Italians, Serbs,
Greeks, Arabs, Roumanians, Turks and other Mohammedan races,
’ Russians, East Indians, Negroes, Anamites and Jews. Likewise
Halber and Mydlarsky (21) examined Poles, Polish Jews; Verzar
and Weszeczky,(22) Ungars, German settlers in Ungary and
Gypsies; Liu Heng and Wang,(23) Chinese; Fukamachi,(24)
Koreans and Japanese; Terbut and Connel,(25) Australians; Coca
and Deibert,(26) American Indians; Harvey Pirie,(27) South
Africans ; Schuetz and Woehlisch,(28) the North German popula-
tion in Holstein and the adjacent islands.
These investigators demonstrated the presence of all four groups
in every human race, but in different percentage distribution. L. and
H. Hirszfeld found that agglutinogen A (antigen of the red blood
cells of Group II) predominates over B in the races in Northern
Europe and agglutinogen B (antigen of the red blood cells of Group
III) predominates in Asia and Africa. In certain intermediate races
A and B are about equally divided. The ratio of the percentage of
A to that of B they called “racial index ”’ and classified the popula-
tion on this basis. Races with an index of more than two were
assigned to the European type, with an index of less than one to the
Asiatic type and with an index of between one and two to the
“intermediate type.”
L. and H. Hirszfeld advanced the hypothesis that A and B had
different points of origin and made the assumption of two different
biochemical races; one race (A. Group II) should have its origin
in North and Middle Europe while the other had its nucleus in
Asia. Through wandering and intermingling of the various races
the present geographical distribution of the four groups has come
about. )
This classification of the Hirszfelds’ is inadequate since they
entirely disregard Group I. Since their investigations a large amount
of material has been collected which differs considerably in the per-
centages of its tables. Hence the “ racial index” is not sufficient for
future elassification.
Ottenberg (29) has regrouped the entire material so far available
to 1925. He placed together those races which resemble each other
in percentage of the different blood groups. According to his classi-
fication the races so far grouped seem to fall into six strikingly
different types; the European, intermediate, Hunan, Indo-Manchu-
rian, Afro-South, Asiatic and Pacific American type. This classifi-
cation is at present the most logical and shows that no two types are
alike, that the individual races of each type closely resemble each
BLOOD GROUPS IN MENTAL DISEASES 573
other in their percentage distribution, and demonstrates a most
striking geographical relationship.
The original classification of the Hirszfelds’ and Ottenberg’s
new table are only tentative until we have more complete data on all
the races. For further detail we refer the reader to Ottenberg’s
interesting article.
No matter which classification one accepts, so much is certain,
that in all future statistical investigations dealing with blood group
conditions the percentage distribution of the groups peculiar to the
races investigated must be considered.
Correlation of Blood Groups to Constitution and Disease
When the constancy of blood groups in individuals became
known, it was of interest to investigate the existence of a relation-
ship between blood groups, size, weight, constitutional type, skin, and
hair color. Alexander,(30) for example, sought to demonstrate
that individuals belonging to Group I & III are more liable to suc-
comb to malignant tumors, especially carcinoma, than members of
the other groups. However Cavalieri,(31) Dossena and Lanzara, (32)
Buchanan and Higley,(33) as well as Hoche and Mortisch,(34)
have shown on a much larger scale that such a relation does not
exist.
The latest investigations of L. & H. Hirszfeld with diphtheria
have shown that the isoagglutinins have no direct relationship to
diseases. Individuals of all groups may be either susceptible or
immune to diphtheria (Schick negative or positive), but indirectly
there exists a correlation between the isoagglutinins and the natural
immunity against diphtheria. The ability to produce normal diph-
theria antitoxin is coupled onto the blood group and inherited with
it. In other words if the parents belong to different blood groups
and if one of the parents is Schick positive (diphtheria susceptible )
and the other Schick negative (diphtheria resistant) the children
with the group of the positive elder are positive while the group of
the negative elder are mostly negative and very rarely positive.
In malaria similar conditions were found by Ljachometzky.(35)
The clinical course of the disease according to this investigator varies
with the different blood groups.
Under Hirszfeld’s (36) supervision correlation between blood
groups, skin diseases and positive Wassermann reaction was ob-
tained. For instance the rapidity with which the Wassermann reac-
tion disappears in different individuals under specific treatment is
coupled with certain blood groups. As found in Poland, individuals
574 FREDERICK PROESCHERSANL VARS ea oe
belonging to Group O become Wassermann negative in a shorter time
than individuals belonging to Group AB. There are considerable
differences; the Group AB is 2.4 more positive than the Group O.
In what respect the clinical course of syphilis is dependent on the
union with one of the four blood groups, further investigations have
to show. We do not deal here with the direct biochemical affinity
with a pathological noxis; for example, diphtheria with a certain
blood group is only an accidental coupling of the disease, disposition
and chance genes for the respective blood group. Hirszfeld believes
this is due to the close correlation of the respective chain gene in a
chromosome, according to the well known investigations of Morgan.
If this assumption is correct, the mechanism of the connection
between diseases, disposition and blood group is satisfactorily
explained.
Technique of Agglutination
It may not be amiss to give a brief description of the technic of
agglutination for those who like to apply the grouping for constitu-
tional investigations. j
In spite of the simplicity of the test one has to be acquainte
with the sources of error or false and misleading results will be
obtained.
For grouping large numbers of individuals the open slide method
of Vincent,(37) is the method of choice. A drop of serum II and
a drop of serum III are placed on the left and right ends respectively
of a perfectly clean slide. About % of a drop of blood from finger
or ear is added to each drop of serum using a clean glass rod for
each transfer. After thoroughly mixing blood and serum the slide
is gently agitated for several minutes. If agglutination takes place
it usually occurs from 1-10 minutes at room temperature and will
be evident to the unaided eye as a granular or brick-dust appearance
_of the drop. The microscope should not be used for observing the
agelutination.
Roulleaux formation is often confusing and frequently inter-
preted as agglutination. Genuine agglutination is always visible
macroscopically. Before reading the results the slide should be
thoroughly agitated or the blood stirred with a clean glass rod in
order to exclude simple settling of the cells. This is one of the
most common sources of error. Compactly settled cells may resemble
massive agglutination but thoroughly mixed cells make a homogenous
emulsion.
BLOOD GROUPS IN MENTAL DISEASES ike
The following table will give a photographic reproduction of
the macroscopic agglutination test for blood groups:
~ GROUP SERUM
ei
The sera used for grouping must be of the correct groups and
highly potent or errors, particularly in overlooking Group IV cases
will occur. Each serum before it is accepted for use should be
titrated against several sera of Groups II and III since sera from in-
dividuals of the same group vary in their agglutinative power. Like-
wise the corpuscles from different individuals of the same group vary
as to their agglutinability by the same serum. Only those sera
should be used which show agglutination up to a dilution of 1-10
since their potency gradually diminishes, no matter how they are
preserved. Some deteriorate in a few weeks while others may keep
for months or even years. Two precautions are especially important
for reliable work:
576 FREDERICK, PROESCHER AND AVS 2kkK USO
1. Test sera must be potent at the time of the test. .
2. Each test should be duplicated with two different sera of
Groups IT and III.
As mentioned above, isohemolysins may be present but never
without the corresponding agglutinins. If complete hemolysis takes
place and it is easily recognized, it is equal to agglutination in label-
ling the group. Hemolysis can be prevented if the serum is inactiv-
ated and the red cells washed, or if the test is done at ice box
temperature. This should be done in case of incomplete hemolysis
and weak agglutination where both phenomena obscure each other.
The exceedingly rare phenomenon of autoagglutination may be
briefly mentioned as a source of error. It is observed only at low
temperature and easily ruled out if a control of the red cell emulsion
in saline solution, or better, with a drop of the patient’s own serum
is made.
Blood intended for the preparation of the group serum should
preferably be taken under sterile precautions. After the serum
is tested for potency it may be transferred in quantities of 3-5 c.c.
into small ampules and sealed. To prevent clotting of the blood to be
tested the addition of 1 per cent sodium citrate to the group serum
is advisable. The increased salt concentration seems to act as an
accelerator for the agglutination. We have never observed a non-
specific agglutination caused by the addition of the 1 per cent.
sodium citrate.
Blood Groups in Psychoses—Statistical Study *
All patients in the Agnews State Hospital t for the insane were
grouped. This included 1,525 cases. Following this, selected cases
were grouped at various times at Agnew and other state hospitals.t
These selections always included the psychoses of dementia precox,
progressive paralysis, depressive mania and epilepsy, though the
females of some of these groups were occasionally omitted. These
four psychoses furnish the bulk (5/6) of the patients and of our
statistics. The original group, however, in which all cases were
examined, permits the formulation of ratios involving the rarer
* The reader is cautioned that group numbers in this article follow the
Jansky and not the Moss system. Groups I and IV are interchanged in these
two systems, Group I being the universal donor group in the Jansky
nomenclature.
+ The authors take the opportunity to thank these institutions for their
cooperation.
~ We are in debt to Mr. Wilbur Bailey who grouped the majority of the
patients in the Agnew State Hospital.
BLOOD GROUPS IN MENTAL DISEASES 577
diseases. It is felt that percentages based upon the few individuals
in the rarer psychoses would be misleading. These are therefore
omitted in what follows. It is unfortunate that all cases at all of the
hospitals visited could not be examined, though the results appear
convincing. Whenever possible the figures for all cases recorded
have been used, though the restrictions and limitations imposed by
the facts noted above should be remembered. Two thousand, one
hundred and four cases in all were examined and assigned blood
groups.
Before attempting a consideration of blood groups it seems desir-
able to know approximately how the various psychoses are distri-
buted among the list of patients. These values, based on the 2,104
cases plus a proportionate amount for rare types as derived from the
original group, are given in Table IV.
RATIO OF PSYCHOSIS TO TOTAL INSANITY
TABLE 1V
MEN WOMEN MEN & WOMEN
DP 65.5 DP64.2
The close correspondence in findings for male and female
patients will be noted here. This is true throughout and leads to the
conclusion that such differences as exist are within the laws of chance,
and that the laws of incidence of insanity, whatever they may be,
apply equally to each sex (except for relative susceptibility between
males and females which is not indicated by our data). In future
tables separation of the sexes will therefore be omitted.
In order to discover what peculiarities in distribution of blood
types occur in mental diseases, it becomes necessary to establish a
978 PREDERICK PROBSCHER Ain D4 to an hee
normal distribution. To do this, averages have been taken from the
first type (European) as given by Ottenberg in his classification.
This type was selected as it probably represents most accurately the
people of the state of California. Such a percentage distribution
of blood groups for normal individuals is shown in Table V in which
is also placed for comparison the percentage distribution for insane
persons as determined from our data.
DISTRIBUTION OF BLOOD GROUPSIN NORMAL & INSANE INDIVIDUALS
TABLE V.
505 CASES
GROUPS! Uw
Gruendel has recently compiled figures similar to these based on
normal individuals and persons visiting a clinic for organic nervous
diseases (not psychotic). A table similar to Table V and prepared
from his statistics follows:
BLOOD GROUPS IN MENTAL DISEASES 979
TABLE FROM GRUENDEL’S STATISTICS
TABLE VI.
—
_
i]
PATIENTS
670 CASES
oo @& = Cc «co
— en — en — er |
OMTATCTatAUOTTHUATUCVUOTTOTTIONTNTTTUTTIVONTTTTHTATITTTTTNTATTTTTTaTTaMnTTTTTTTTITIATTPOaTTT
Such figures as these, while indicating qualitative changes, do not
readily convey the practical facts because the change should be con-
sidered in proportion to the original value. Thus the shift in Group
I distribution of 13.8 per cent is, not more, but exactly the same as
the Group III change of only 4.2 per cent.
PERCENTAGE CHANGE IN BLOODGROUPS
BETWEEN NORMAL & INSANE EINDWIDUALS
TABLE Vil.
$45 (3a
Fmt beedore uh
580 FREDERICK PROESCHER AND A. S. ARKUSH
From Table VII we see that, in psychoses, the increase in Group
I by percentage is exactly the same as that in Group III and each is
equal to the decrease in Group II and to % the decrease in Group IV.
Expressed in another way we may say that the chances for normal
individuals of blood groups I, II, III, and IV to develop a psychosis
is in the ratio 4:2::4:1 respectively. This we interpret to mean
that the chances or liability for normal members of blood groups I
and III to develop a psychosis is equal and twice as great as for mem-
bers of Group II and four times as great as for members of Group
IV. The susceptibility of the members of the various blood groups
to insanity differs and is in definite ratio.*
DISTRIBUTION OF BLOOD GROUPSIN THE INDIVIDUAL PSYCHOSES
TABLE. Vill
545 54.1 99.9 59,4
liom tector)
MiSaTTTTTTTianiTivvan
—
=
30
1 90
1a
1E 10
En 13 2.4 1.
GROUP DI Ly: IDM LW 100 WW
DISEASE pp EPI
This Table (VIII) includes all of the data taken. A striking
similarity between each of the groups is at once noted. This leads to
the following conclusion: Distribution of blood groups is constant
in mental diseases regardless of the psychosis. Comparison with
Table V shows that the distribution of blood groups in each disease is
* This may be more readily understood mathematically if we derive
our relative liability values. for the blood groups from Table VII figures,
as follows: ;
For Group I 53.8/40 equals 1.345
For Group) Uy 28 .2/43 equals .656
For Group ITI lors /i255 equals 1.341
For Group IV 155/457 equals .319
Summarizing: 1.345 : .656>:: 1.341 =319 “equals 4 92 aoe eels
BLOOD GROUPS IN MENTAL DISEASES 581
the same as that for insanity in general which, in turn, has been
shown to differ from normal distribution only in susceptibility to
insanity in general.
One of the main objectives of this study has been the establish-
ment of a relationship of blood groups to mental diseases as the basis
for a chart of liabilities or susceptibilities, this chart to be used in
the diagnosis of prospective patients. Thus we discovered above
that the liability of the normal individual to mental diseases varies
with the blood group. We may further ask: (1) What is the relative
susceptibility of normal individuals to mental diseases, and (2) What
is the relative liability of insane individuals of the respective blood
groups to these psychoses? If a peculiar distribution exists within
each group, such a liability chart may be constructed to good advan-
tage. It was with this end in view that Table IX was constructed.
DISTRIBUTION OF MENTAL DISEASESWITHIN THE BLOOD GROUPS
TABLE IX.
: fi
DISE tee DPMD.CR EPI. OTHERS DPMD.GP.EPL OTHERS DPMD.CREPI.OTHERS DP MD. REPL. OTHERS
GROUP { 1 tH ly
Such a table (IX) is discouraging in so far as the objective just
named is concerned for it shows that within each blood group there
is practically a constant distribution of patients among the various
psychoses. Group IV comprises so few cases (about 1.5 per cent)
as to readily account for its deviation.
In spite of what has been said concerning sex there seems to be a
general tendency on the part of females to even the distribution in
Groups I and II. It has been thought best to show this separately
in Table X and to leave the question open as to whether or not sex
582 FREDERICK, PROESCHERVAND VARS
factor is concerned in the incidence through heritage or susceptibility
to insanity. It must be appreciated that, to some extent, social and
‘economic factors will further tend to distort these relationships, but
the delineation of such factors is beyond the author’s scope and
probably would not influence the essential conclusions.
DISTRIBUTION OF BLOOD GROUPS WITHIN THE SEXES IN INSANITY
TABLE X.
1.3
GROUPS 1 0m
It will be marked that any value which may lie in these statistics
or conclusions drawn from them will depend to a very considerable
extent upon the accuracy of diagnosis in the various institutions. It
is therefore desirable to attempt a correlation of results obtained from
individual hospitals. If close correlation ‘exists it will be assumed
that their diagnoses are similar and accurate. Table XI gives such
a comparison. Only tables involving considerable numbers of
patients are used.
TABIshe X14
> Correlation of Institutions
Group Te Led ae Lye JOEL red Va lL. UL elie
Agnew S, Hi 54.928 051 ae BZ moon Lise 67> 1p See
StOCKLON 5s eee eo ieee 46 AZo) Bae? 6b 6
Napa, Sab iano? i ee ee Ry eee ee Fel 58) eek
Patton 5. 6H. ao One Se ane S14 ee Ou iad. 5G La ae 3
Ratio: A B os
* Ratio A is No. in blood group/Total insanity (similar to Table V).
Ratio B is same, but for dementia precox only.
Ratio C is No. in psychoses/Total insanity (similar to Table IX).
Initials stand for State Hospital.
Blank spaces in the table are due to incomplete statistics.
BLOOD GROUPS IN MENTAL DISEASES 583
Results from this table (XI) are fairly conclusive. In judging
them it must be considered that of over 2,100 cases examined, only
312 were at Patton, 173 at Napa, 252 at Stockton, and all the re
mainder at Agnew. The correlation in Table IX therefore seems
quite close.
Several general aspects of this subject occur to the authors as
being worthy of notice. If we return to our evolutionary hypothesis
of the development of blood groups we may picture a time long ago
when no separation into races had occurred and all individuals were
universal donors. The fetus passes through this stage to-day, just
as in other respects it repeats, in rough form, its phylogenetic de-
velopment. With this picture of the primitive universal donor in
mind it would seem that the crudest and least highly developed of
nervous systems might belong in general to Group I members. ‘This
more simple system with its more undifferentiated parts might be
expected to be less susceptible to injury to those higher factors loss
of which stigmatizes one as insane. In other words, Group I mem-
bers should be least susceptible to insanity and this is actually the
case. In this regard a comparison between psychologic rating (as
reflecting racial development) and blood grouping (also reflecting
racial development) would be of interest. The same might be said
of blood groups and immunity in general.
There are a large number of persons who believe that insanity
has no organic basis. Exactly how these individuals picture or
explain the conditions in their own minds is difficult for the authors
to understand. The latter submit, however, that such findings as
these added to such facts as inherited insanity (or “ susceptibility ”’
to it) are strong indications for such an organic basis.
No conclusion as to the basis of insanity is possible from such
data as given. There is a very definite suggestion, however, that it is
fundamental and not ephemeral; it is a matter of race and structure
and not of infection, caprice, or environment (though the power of
environment to demonstrate or precipitate insanity is well known).
The authors believe that the negative results obtained, while dis-
appointing from the point of view of their original purpose, obtain-
ment of a diagnostic aid, are of considerable value. It should be noted
that the findings given herein are in line with those of the Hirszfelds
and Ljachometzky as noted above.
Summary of Indications from Data Collected
The character of a psychosis is neither determined nor indicated
by the blood group, though the susceptibility is so indicated. Distri-
584 FREDERICK PROZESCHEK CAND TAL se elie soie
bution of blood groups in psychoses and in a specific psychosis is con-
stant, as is also’ the distribution of the specific psychosis within
the blood groups. Susceptibility of the four blood groups shows a
constant ratio which differs from that of population and which may
be expressed for Groups I, II, III, and IV as 4:2::4:1 respec-
tively. These conclusions are drawn from the grouping of 2,104 cases
from California State Hospitals for the Insane.
BIBLIOGRAPHY -OF@PRINCIPAL GREP ak Ee Nei
Landsteiner. Wien klin. Wochenschr., 1901, p. 1132.
Moss. Bullof Johns Hopkins Hosp, 2), 902, 14tu),
Von Dungern und Hirszfeld. Muen. med. Wochenschr., 1910, p. 741.
. Ottenberg. Journ. of immunol., 6, 363, 1921.
ae Die Individualitet des Blutes, etc. Berlin, Julius Springer,
1925)
6. Hirszfeld und Brokman. Klin. Wochenschr., 1924, Nr. 29, p. 1308.
7. Johannses. Cpt. rend. des seances de la soc. de biol., 92, 112, 1925.
8. Dolter. Med. Klinik No. 36, Sept. 4, 1925.
9. Jansky. Kiliniky Sbornik, 1906. Nr. 2, Folia Serol’ 3/316.” 190s:
10. Von Dungern und Hirszfeld. Zeitschr. f. Immunitatsforsch. u. exp.
Therapie, Orig. 6, 284, 1910.
11. Decastello und Sturli. Muen. med. Wochenschr., 1902, p. 1090.
12. Happ... Journ. of expt med. Zh slic
13. Eden. Dtsch. med. Wochenschr., 1922, p. 85.
14. Diemer. Mitt. a. d. Grenzgeb. d. Med. u. Chirurg., 35, 464, 1922.
15. Nather. Wien. klin. Wochenschr., 37, 203, 1924.
16. Meyer und Ziskoven. Med. Klinik, 19, 91, 1923.
17. Jervell. Journ. of the Amer. Med. Assoc., 77, 1668, 1921.
18. Mino. Rif. med., 1923, p. 386.
19. Hoche und Mortisch. Mitt. a. d. Grenzegeb. d. Med. u. Chirurg.,
V 61 38,7 1925
20. Hirszfeld, L: and Hi banecety2 16758101)
21. Halber and Mydlarski. Cpt. rend. des seances de la soc. de biol., 89,
1376, 1923.
22. Verzar und Weszeczky. Biochem. Zeitschr., 126, 33, 1921.
23. Liu Heng and Wang. Nat. med. journ., China, 6, 118, 1920.
24. Fukamachi. Journ. of immunol., 8, 291, 1923.
25. Terbut' and Connel. Med. Journ. of Australia, 2, 201, 1922.
26. Coca and Deibert. Journ. of immunol., 8, 487, 1923.
27. Pirie: Med. Journ. of South Airicas165100. 192i
28. Schuetz und Woehlisch. Klin. Wochenschr., 1924, Nr. 36, p. 1614.
29. Ottenberg. Journ. of Amer. Med. Assoc., May 9, 1925, pp. 1393-1395.
30. Alexander: Brits)Jourri. cof Pixpeebathola ze oonio ss
31. Cavalieri.. Arch: di patol.e cline med, yo. 1 022.
32. Dossena and Lanzara. Ann. di osteter. e ginecol., 47, 163, 1925.
33. Buchanan and Higley. Brit. Journ. of Exp. Pathol., 2, 247, 1921.
34. Hoche and Mortisch. 1. c., No. 19.
35. Ljachometzky. Dtsch. med: Wochenschr., 1924, Nral7ap. 558:
Stor se ee Halber. Zeitschr. f. Immunitatsforsch. u. exp. Therapie,
ROAD aes
37. Vincent. Journ. of Amer. Med. Assoc., 70, 1219, 1918.
ARON
ENDOCRIN AND BIOCHEMICAL STUDIES IN
SHI ZOPEHREN TA
By Kart M. Bowman, M.D.
ASSISTANT PROFESSOR IN PSYCHIATRY, HARVARD MEDICAL SCHOOL; CHIEF MEDICAL
OFFICER OF THE BOSTON PSYCHOPATHIC HOSPITAL, BOSTON, MASSACHUSETTS
(Continued from page 483)
CONCLUSIONS
A study of twenty-four cases of schizophrenia was made, using
tests which would have a special relationship to endocrin function.
The following studies were made: A complete X-ray study, basal
metabolism, blood sugar curve, galactose tolerance test, chemical and
microscopic examination of the blood, Kottman test, spinal fluid
examination, gastric analysis, renal function test, and cardioocular
reflex.
The following findings appear to be of significance: Abnormally
low basal metabolism was found in half of the cases with a tendency
towards low or minus readings in nearly all the other cases. Nearly
one-half of the cases showed an abnormal blood sugar curve, all but
one being of the “sustained ” type. Over one-third showed a positive
galactose test. X-ray examinations and gastric analyses showed a
definite functional disorder of the gastro-intestinal tract in about
half of the cases and questionable functional disorders in all but
two of the other cases. X-ray examinations further revealed infected
teeth in 40 per cent of the cases with questionable infection in 10
per cent more. X-ray examinations also revealed “ dropped” hearts
in 30 per cent of the cases, questionable pulmonary tuberculosis in
13 per cent and healed pulmonary tuberculosis in 4 per cent (one
case).
The findings are not consistent with the constant presence of any
definite endocrin disorder and do not suggest that a simple glandular
disfunction of a constant type is an etiological factor in schizophrenia.
Rather they suggest that many functional disorders, closely linked
up with the endocrin system, are frequently found and that schizo-
phrenia is not a specific endocrin disease but may arise on a number
of different bases. The one constant finding appears to be that a
metabolic disorder of varying degree is nearly always present as
manifested in functional gastro-intestinal disorders and a tendency
[585]
586 kK. M. BOWMAN
towards low basal metabolism which are present in the majority of
cases. |
Credit is due to Dr. Jacob Kasanin for the work on the Kottman
reaction, to Dr. Julia Deming for the studies on the cardiodcular
reflex, to Miss Emily Knapp for the different chemical analyses and
to the staff of the Boston Psychopathic Hospital in general for
cooperation and assistance in this study.
CASE HISTORIES IN ABSTRACT
Case 1. A white female, twenty-two years old, single. Admitted
October 9, 1924.
Family History: Mother is said to be nervous and excitable. Other-
wise negative.
Personal History: Birth and early development were normal. She
had measles when five years old. Was operated on for appendicitis when
twelve. She finished high school at sixteen. Studied the piano with
private teachers up until the time of admission. She taught music since
she was sixteen but had few pupils as she was too independent and did
not fit in with things. She has been self-supporting since nineteen.
Personality: Very sensitive, did not mix well with others, felt su-
perior to her family. She would often sit alone day dreaming. Was
of high intelligence. She was completely wrapped up in her music.
Onset of Present Illness: Her sickness has come on slowly and
insidiously and no exact date can be given for its commencement. In
the fall of 1922, two years prior to admission, she weighed over 130
pounds and went on a diet to reduce. She became very much attached
to a poet and started fussing a great deal about her personal appearance.
She commenced to complain of stomach trouble. She did not menstruate
for five months preceding admission. Became greatly interested in
religious matters. She assumed attitudes and talked in a queer way
about having found God.
Mental Status: The patient laughed, sang, wept or was very quiet
without apparent cause. She assumed dramatic poses. Her speech was
frequently incoherent and she constantly brought up the topics of religion
and sex. Her mood was variable. She had many vaguely formulated
delusions. She said that she was the devil, that she had to save souls,
etc. She had visual hallucinations in which she saw Christ throwing
confetti about. Orientation and memory were impaired and she had
little insight.
Physical Status: Sixteen pounds under ideal weight. Otherwise no
noteworthy findings.
Progress: The patient became progressively worse while in the hos-
pital. She would go into a stupor at times when she would wet and
soil herself and have to be tube fed. At other times she would show
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 587 ,
odd and impulsive behavior. She expressed a great many delusions of a
religious and erotic nature. She was discharged on July 1, 1925, to the
Danvers State Hospital as unimproved.
Case 2. A white female, thirty-six years old, single. Admitted
February 7, 1925.
Family History: A number of members of the family are said to be
rather high strung and sensitive but there have never been any definite
mental or nervous diseases.
Personal History: Birth and early development were normal. She
had measles, mumps and scarlet fever when a small child. She had a
few convulsions when a baby. She was always considered somewhat
sensitive and high strung. She bit her nails. During adolescence she
had temper tantrums and crying spells. She finished three years work
in college but developed pulmonary tuberculosis in 1913 and spent a year
in Colorado. Four years later, when twenty-seven years old, she had
an operation for appendicitis. She worked and studied irregularly as
a social worker.
Personality: Was always extremely sensitive, high strung, and ambi-
tious, chiefly interested in her studies.
Onset of Present Illness: No exact date can be given for the onset.
Since the age of fourteen she had frequent spells of depression and
tension. She had numerous physical complaints. She was a patient at
Bloomingdale Hospital for two years, from June, 1919, to July, 1921,
where she was diagnosed as psychoneurosis-neurasthenia and considered
improved at the time of her discharge. In 1922 she was psychoanalyzed
for three months and fell in love with the analyst. She commenced to feel
that he was influencing her in a peculiar way. Several times she felt
that an influence was suggesting that she marry some man. She felt that
people imitated her on the street and this was caused by the analyst.
Mental Status: The patient was quiet and cooperative. She had
spells of laughter which she, herself, felt had no cause. She had numerous
ideas of influence and felt that peculiar forces were influencing her.
She was correctly oriented, her memory and general information were
satisfactory. She had practically no insight.
Physical Status: The patient was fifty pounds underweight and a
few fine crepitant rales were heard at the right apex. Other findings were
megative.
Progress: The patient’s condition continued unchanged and she was
discharged on June 5, 1925, as unimproved.
Case 3. A white female, seventeen years old, single. Admitted June
292 1923;
Family History: Maternal grandmother had a psychosis coming on
at the involutional period. She was very suspicious. Her psychosis
588 K. M. BOWMAN
continued until her death thirty years later. The father is alcoholic
and does not support his family.
Personal History: Birth and early development were normal. She
finished the second year of high school when sixteen years old. She
had measles and whooping cough as a child. On leaving school she
worked in several clerical positions.
Personality: The patient has always been rather stubborn and irri-
table. Appeared to be quite self-satisfied.
Onset of Present Illness: Patient was always fat but took on a great
deal of weight in the past few years. For six months or so preceding
admission she became progressively irritable and showed a personality
change. There is a vague history of some sort of fainting attack follow-
ing an argument at about the time this personality change commenced.
Patient would go to the movies clad only in underclothes, shoes and
stockings and an overcoat. She neglected her personal appearance. One
day she started to work in her nightgown.
Mental Status: Patient was quiet and well behaved. She admitted
having had auditory hallucinations and explained that she went out with
little clothing because the voices told her to do so. Her menstruation
had started im the fifteenth year, was irregular and she had not menstru-
ated for sixteen months. She said this made her feel as if she were of a
different sex. There were some compulsive phenomena. She was cor-
rectly oriented. Memory and general information were satisfactory.
There was little insight.
Physical Status:, Height 5 ft. 2 inches. Weight 187 pounds. Com-
plained of frontal headache, pains in abdomen and vomiting spells.
Progress: The patient was discharged from the hospital on visit
October 13, 1924. She had been given thyroid extract and claimed
that she felt better while taking it. She purchased thyroid extract and
took fifteen grains a day for some time because she felt it would make
her thin. She ate less. She had an attack of acute appendicitis and
was operated on at the City Hospital. She commenced to have attacks
of a peculiar nature. She would often vomit at the beginning of the
attack, scream, and then lie as if unconscious. There was no biting
of the tongue. There were no involuntary movements. She would
eat little and often vomited immediately after a meal. She returned
to the hospital on December 2, 1924, at which time she showed very
much the same picture as at her first admission. She was a little more
frank and acknowledged more abnormal ideas than previously. Following
pituitary feeding in January, 1925, she started menstruating. She was
later put on thyroid medication. Her weight at this time was 145 pounds.
The patient would eat very little in a studied attempt to reduce her
weight which dropped to 126 pounds after three months of five grains
of thyroid daily. She was again discharged on visit on June 10, 1925.
BIOCHEMICAL STUDIES IN’ SCHIZOPHKENIA 589
She returned home and after a while secured a clerical position at which
she is still working. She gets along poorly with her family.
Case 4. A white female, thirty-nine years old, single. Admitted
January 26, 1925.
Family History: Mother is sixty-six, has diabetes. No history of
any nervous or mental disease or defect obtainable.
Personal History: Birth and early development were normal. She
had measles twice and jaundice when nine years old. She has always
been subject to colds and had her adenoids removed when twelve. When
a child she was struck on the left side of the head by a refrigerator
cover. She finished high school when twenty. She took piano lessons
from her eighth year and also studied the pipe organ. She gave piano
lessons until June, 1922, being quite successful in her work. She was
never given any sex information, never appeared interested in the
opposite sex.
Personality: Very shy and modest, never mixed well with others,
was fond of reading, especially history and travel. Her main interest
was in her music.
Onset of Present Illness: There was probably an insidious personality
change, starting about five years ago. The patient felt people were
looking in at the windows, were talking about her and trying to injure
her in her work. She fainted several times in church.
Mental Status: The patient was quiet and seclusive. Her delusions
were quite well systematized. She felt that people were jealous of her,
that they were trying to reveal her marriage, that white slavery was
going on in the town, that people stole things from her and that poison
was being put in her food. Auditory hallucinations were present. Her
intellectual functions were well preserved.
Physical Status: Essentially negative.
Progress: The patient gradually became more antagonistic and more
insistent in stating her delusions. She was discharged on July 15, 1925,
to Foxboro State Hospital as unimproved.
Case No. 5. A white male, thirty-three years old, single. Admitted
October 25, 1924.
Family History: The father was a heavy drinker, quick tempered
and a_ spendthrift.
Personal History: Birth and early development normal. Has never
had any serious illness. He graduated from grammar school and then
started to work as a clerk in a drug store. After this he held several
positions driving delivery teams.and continued this up until the time of
admission.
Personality: Devoted to his mother, very few friends, extremely
religious, no bad habits.
590 Kk. M. BOWMAN
Onset of Present Illness: There was a vague history of some sort
of fall three years before admission but nothing to show that the patient
sustained any injury. However, he stopped work at this time, started
to worry about his mother and became very religious. He would allow
no one to cut his hair and refused to shave. He prayed a great deal and
fasted.
Mental Status: The patient was quiet, cooperative and in fair con-
tact with his environment. He stated that he was Christ and the
Incarnation of thirty-two Popes. He had visual and auditory hallucina-
tions of a religious nature. He would not cooperate enough for tests
of his intellectual functions.
Physical Status: The patient was quite thin and emaciated as a
result of lack of food. There was a fine tremor of the tongue and
extended fingers and he appeared to be a little weak.
Progress: The patient’s condition continued essentially unchanged
and he was discharged on June 10, 1925, to the Boston State Hospital as
unimproved.
Case No. 6: A white female, eighteen years old, single. Admitted
March 16, 1925.
Family History: Negative.
Personal History: Is a twin. Birth and early development normal
and she was possibly a little more precocious than her twin brother.
The patient was in the last year of high school at the time of her
admission. During infancy she suffered from indigestion. She had
measles, scarlet fever, whooping cough and chickenpox during childhood.-
When five years old she had a paracentesis. She had influenza when
fourteen.
Personality: Always bright, cheerful, a good mixer with plenty of
friends, a leader in social and athletic activities at school, very conscien-
tious but not bashful or sensitive. 7
Onset of Present Illness: Six months before admission the patient
seemed a little different. She did not speak to certain people for days,
was rather fault finding. Two months before admission she became less
cheerful. On February 21, 1925, she broke down at school and cried.
She appeared confused. She was tube fed and was incontinent. She
complained of abdominal pain and there was some rigidity of the right
side. She was operated on February 25. Her appendix and two ovarian
cysts were removed. After the operation she appeared greatly confused,
she inserted articles up her vagina, seemed afraid that people knew things
about her and talked constantly of a young man of her acquaintance.
Mental Status: The patient was usually underactive but occasionally
became somewhat overactive. She often assumed rigid attitudes of a
symbolic or dramatic nature. Her talk was fragmentary.- She occasion-
ally wept and occasionally appeared ecstatic. She talked in a self-
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 591
accusatory manner about love. She apparently had auditory hallucina-
tions. She said that she was in Heaven.
Physical Status: Recently healed scar over the right rectus. Other-
wise negative.
Progress: The patient gradually cleared up. She stated that she
had felt that some mysterious force had been controlling her actions
and that she had been having auditory hallucinations. She was dis-
charged from the hospital June 17, 1925, and has apparently done well
since then.
Case No.7: A white female, thirty-four years old, single. Admitted
April 18, 1925.
Family History: Unknown.
Personal History: Little known of her birth and early development
but she was thought to have been normal as a small child and not to have
had any severe sicknesses. She finished grammar school when about
fifteen. She has been doing housework ever since leaving school.
Personality: Very quiet, sensitive, has no friends and is not sociable,
is fond of reading books about beautiful homes and rich people, prayed a
good deal, took religion very seriously.
Onset of Present Illness: Four days before admission the patient
called up her cousin and said that people were following her and that
something very peculiar was going on. She said that people were trying
to poison the doctor at the home where she worked.
Mental Status: The patient was underactive, appeared cheerful, had
numerous delusions which were rather ill defined and vague that trouble
was going on and that people were watching her. No hallucinations
were elicited. She was correctly oriented. Memory and general in-
formation were satisfactory. There was slight insight.
Physical Status: About ten pounds underweight. Fine tremor of
fingers. Knee jerks hyperactive.
Progress: The patient became more underactive and had to be tube
fed at times. She often appeared rather dazed. She was discharged
on October 27, 1925, to Danvers State Hospital as unimproved.
Case No. 8. A white female, thirty-two years old, married. Ad-
mitted July 30, 1924.
Family History: Negative as far as could be ascertained.
Personal History: Birth and early development were normal. Diph-
theria when a small child is the only severe illness she has ever had.
Her mother died when she was eleven and she lived in private families
until nineteen, getting along very well. She finished the second year of
high school when sixteen. - She was married when twenty and has two
sons, ten and six years. Her husband developed pulmonary tuberculosis
three years after marriage and has spent much of his time in sanatoriums.
592 K. M. BOWMAN
Her early sex life was negative. She had adequate sex knowledge before
marriage and sex relations were satisfactory until after the birth of the
second child.
Personality: Very sensitive, conscientious and extremely religious,
fairly energetic and industrious, rather a good mixer with a fair number
of friends and of good intelligence.
Onset of Present Illness: Her symptoms started six years ago, fol-
lowing the birth of her second child. She no longer had any sex desire
towards her husband and relations were infrequent. She got sex satis-
faction from hot douches. She no longer felt happy. She commenced
to feel that her husband was sapping her strength and that he was
unfaithful to her. Her symptoms developed gradually and became much
more marked during the six months preceding admission. She became
very religious. At times she was excited and noisy.
Mental Status: The patient was quiet and seclusive. She talked
relevantly and coherently. There were numerous delusions present. She
accused her husband of infidelity and felt he exerted some mysterious
power over her and sapped her strength. She admitted auditory and
visual hallucinations about six months prior to admission in which she
saw her dead mother and heard voices singing but denied hallucinations
at the time of the examination. There was some confusion and the
intellectual faculties seemed impaired. Insight was lacking.
Physical Status: She has lost fifty pounds in the last six months.
Her pupils were somewhat sluggish to light. The white blood count was
21,000 on admission but dropped to 9,800 in four days.
Progress: The patient improved considerably, both physically and
mentally, and was discharged on visit in September, 1924. She soon
broke down again and was returned May, 1925. Her mental symptoms
had increased, the delusions of persecution were more numerous. There
was no change in the physical condition. On July 18. 1925, she was dis-
charged to the Boston State Hospital as unimproved.
Case No. 9. A white male, thirty-three years old, single. Admitted
April 8;-1925;
Family History: Negative.
Personal History: Birth and early development were normal. Has
never had any serious illnesses, accidents or operations. He finished
the ninth grade when sixteen years old, repeating the second grade. He
then worked at odd jobs and attended evening high school. Graduated in
1912 when twenty. He continued to work in daytimes and study
evenings. He spent two years in the Navy during the war and worked
as an electrician and finally as a book agent.
Personality: Always interested in mechanical things, quiet, reserved,
somewhat seclusive but got along well with others.
Onset of Present Illness: Exact date cannot be given. Has always
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 593
appeared unstable and shown less efficiency siince his discharge from the
Navy in 1919. Several months before admission he became more seclu-
sive and preoccupied. Spoke of hearing voices and felt that he was
being persecuted.
Mental Status: Patient was rather apathetic and indifferent. Kept
to himself. He explained many ideas of reference and persecution and
admitted having both auditory and visual hallucinations. Orientation was’
correct. Memory and grasp of general information were satisfactory.
Had no insight.
Physical Status: Pupils a little slow reacting to light and excursion
was slightly diminished. Deep reflexes were hyperactive. Tonsils were
slightly enlarged and ragged.
Progress: The patient has shown no essential change in his con-
dition while in the hospital. He has been fairly communicative and gone
over his symptoms in considerable detail.
Case No. 10: A white female, twenty-six years old, single. Ad-
mitted June 6, 1925.
Family History: Negative as far as could be ascertained.
Personal History: Birth and early development were normal. She
had measles, scarlet fever and whooping cough during childhood and
also had her tonsils and adenoids removed. When about nine years old
she had an abscess in the axilla and when about twenty-one had influenza
but recovered with no apparent residuals. She finished high school when
about sixteen. Was a very good student but could not go to college as she
had to help support the family. She worked steadily as a bookkeeper in
three different places. Nothing is known of her sex life.
Personality: Always quiet, a poor mixer having very few friends,
bashful but not especially sensitive, very conscientious, few amusements,
enjoyed reading good literature.
Onset of Present Illness: About three and one-half years before
admission the patient had a love affair of two weeks with a cousin. Her
family did not approve and he left. The patient then became depressed
and lost interest in things. She was unable to work for one and one-half
years, was preoccupied with her love affair and had vague ideas of
persecution. She once attempted suicide by cutting her arm with a
razor. She improved gradually, went back to work for a year and then
broke down again about a year before admission. She became depressed
again, had hallucinations of hearing and thought people were plotting
against her. Her condition became progressively worse up until her
admission.
Mental Status: The patient was underactive and restless. She
talked but little but was coherent and relevant in what she said. She
felt that she was unable to control her thoughts. There were vague
somatic complaints which were referred to outside influence and vague
594 K. M. BOWMAN
ideas of persecution. She had auditory and visual hallucinations. She
was fairly well oriented, her memory was good and she had a fair grasp
of general information. She had partial insight into her condition.
Physical Status: There were no noteworthy findings.
Progress: The patient’s condition continued unchanged and she-was
discharged on November 5, 1925, to the Boston State Hospital as unim-
proved.
Case No. 11. A white male, twenty-one years old, single. Admitted
June 1, 1925.
Family History: Negative.
Personal History: The mother had a fall two months before delivery
and was confined to bed until the time of delivery which was slightly
premature. Birth was instrumental and the patient was a “blue baby.”
His early development was normal. He had whooping cough at two
years, chickenpox at six years, measles at six years and swollen glands of
the neck when twenty years old. He finished the third year of high
school when seventeen years old. He started work on leaving school and
has worked in unskilled positions.
Personality: Always somewhat seclusive, not at all aggressive, very
fond of music in which he had considerable talent, reserved and considered
different from other boys.
Onset of Present Illness: In 1922 the patient seemed listless, had
crying spells and felt that he was being imposed upon at his work. In
October, 1922, he remained in bed for several days and became stuporous.
He was admitted to the Worcester State Hospital where he remained until
May 13, 1924, when he was discharged with a diagnosis of dementia
precox—catatonic type, condition improved. He then returned home
and tried to work but seemed weak and listless. He was finally arrested _
wandering about the street at 4 a.m. clad only in a shirt, talking inco-
herently.
Mental Status: The patient was listless and preoccupied. He was
largely indifferent to his surroundings. He was undertalkative, occasion-
ally spoke in a flat, colorless voice. His speech was quite incoherent.
He wrote out mathematical problems with a fair degree of accuracy but
did not respond to other tests of intellectual functions. It could not be
determined whether delusions or hallucinations were present.
Physical Status: Patient was poorly nourished and poorly developed.
There was some dullness of the apices of both lungs. Blood pressure
was 100 systolic, 65 diastolic. Pupils widely dilated. Hands and feet
were cold.
Progress: The patient has continued seclusive and evasive. He does
good work in occupational therapy. He shows little interest in his
surroundings. At times he has stated that he was Christ. In general
he has continued uncommunicative and little could be obtained from him
about what was going on in his mind.
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 595
Case No. 12. A white male, twenty-seven years old, married. Ad-
mitted June 22, 1925.
Family History: One brother is alcoholic. One sister had convul-
sions during infancy and has been crippled ever since.
Personal History: Little is known of his early life but he is thought
to have been an average sort of boy. No severe illnesses or accidents are
known. He finished the ninth grade in school and is said to have been
bright in his studies. Since leaving school he has worked steadily. For
the past nine years he has worked as a painter for one employer and has
given satisfaction. He was married when twenty-one and his married
life is said to be quite happy. There is one child, a girl of two.
Personality: Inclined to be irritable and fly off the handle but easy
to get along with. Made friends easily, was popular among his asso-
ciates.
Onset of Present Illness: For six weeks prior to admission the
patient became more and more preoccupied. He seemed to be brooding
over matters which he would not discuss with his wife. He seemed
afraid that someone was going to harm him. Three days before admis-
sion he would stiffen out in bed in a peculiar way and stare about him
but would not say what it was that was bothering him.
Mental Status: The patient was stuporous. There was waxy flexi-
bility. He occasionally spoke a word or two and was apparently in good
contact with his surroundings. When pricked with a pin he nodded an
affirmative when asked if it hurt but did not make any movement to get
away from it. When told to put out his tongue so that a pin might be
stuck in it he drew back slightly and said, ‘“ Stick pin,’ and refused to
protrude it. His eyes were open and he followed what was going on
about him.
Physical Status: No abnormal findings were made out.
Progress: The patient gradually came out of his stupor, remained
underactive and would only talk after much coaxing. At times he would
wet and soil himself. He was rather impulsive in his behavior. Some-
times he would not eat well and at other times he would demand a great
deal of food. Occasionally he would become combative and fight with
the attendants or other patients. He swallowed a number of objects
such a safety pins, pieces of metal, parts of spoons, etc. He pulled out
one tooth and inserted objects into the socket. He inserted the stopper
of a hot water bottle up his rectum. Later he became rather overactive
and overtalkative, showing a great deal of symbolism. At the time of
discharge he was found to have inserted the metal portion of a shoe lace
in the meatus of the penis and several pieces of paper into his ears. He
was discharged to the Grafton State Hospital on November 5, 1925, as
unimproved.
Case No. 13. A white male, thirty-two years old, single. Admitted
August 26, 1924.
596 K. M. BOWMAN
Family History: The father was very alcoholic. One paternal aunt
is insane and is now at the Medfield State Hospital.
Personal History: Birth and early development were normal except
for appendicitis with operation at the age of 12. He has had no severe
illnesses or accidents. He entered school when six and left at fifteen,
having completed the eighth grade. He was considered an average
student. After leaving school he worked on a farm and drove a milk
wagon for approximately ten years. He then ran a stationary engine,
securing a second-class fireman’s license and two months before admission
to the hospital he secured an engineer’s license. He was always a steady
worker and fairly thrifty and had no bad habits.
Personality: Quiet, good natured, unaggressive, interested in ma-
chinery but few external interests. Never much interested in religion.
Fairly sociable.
Onset of Present Illness: His symptoms started about five months
prior to admission. He had been trying to secure an engineer’s license
for five years and when given one at this time refused to use it saying
that the inspectors were persecuting him. He felt that Protestants and
the Ku Klux. Klan were after him. Three weeks prior to admission he
quit his work and wandered about the country with insufficient food,
finally telegraphing his brother for money. f
Mental Status: The patient was quiet and seclusive. He seldom
spoke unless spoken to but once started would discuss his ideas quite
freely. He felt that he was a self-ordained priest, that he mysteriously
influenced a woman in a theatre to fall in love with him, said that the
Ku Klux Klan were after him and will eventually get his life. He said
that he had frequently heard people talking about him in automobiles as
they pass him. They would make such remarks as, “ We'll get him,” “ The
Klan will get him.” The patient’s memory, orientation and grasp of
general information appeared quite satisfactory.
Physical Status: The deep reflexes were sluggish and there was a
tremor to the fingers. Otherwise the findings were negative.
Progress: The patient improved slightly and was discharged on
visit April 21, 1925. He took a job as a fireman for three and one-half
months,.working steadily but was forced to return to the hospital August
15, 1925, because he felt girls were making advances to him and he
asked them to confess to him because he was a priest. The patient is
still in the Boston Psychopathic Hospital. His condition has remained
unchanged.
Case No. 14. A white female, twenty-four years old, single—
Admitted September 5, 1925.
Family History: Two paternal and one maternal cousins have had
mental disease.
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 597
Personal History: Birth and early development normal. She had
double pneumonia’ when three years old, diptheria when eight and
measles at some unknown period during childhood. She finished grammer
school when fourteen years of age with a good record. She has worked
as a dressmaker until her present illness.
Personality: Always active, a good deal of a leader, fond of danc-
ing, swimming and other sports, sociable.
Onset of Present Illness: About February, 1925, the patient seemed
to be irritable and to keep to herself. She stopped her work but wrote
to numerous hotels for a position as a waitress in June, 1925. She
secured a position as a waitress but soon left it and took a number of
different positions which only lasted for a few days. She felt that people
were talking about her.
Mental Status: The patient was rather quiet. She often laughed in
a silly way without any apparent cause. She denied hallucinations but
would sit with her eyes closed and have the appearance of one either hal-
lucinating or living in some fantasy. She felt that people had looked at
her in a peculiar way and had a number of misinterpretations. She was
correctly oriented, her memory was satisfactory but she did very poorly
in tests of general information. For example, she did not know the name
of any President of the United States. She had some insight.
Physical Status: Negative.
Progress: The patient has shown much impulsive and peculiar be-
havior and is apparently deteriorating.
Case No. 15. A white female, fourteen years old, single. Admitted
September 11, 1925.
Family History: Negative.
Personal History: Birth and early development normal. Measles,
whooping cough and mumps as a child. Has gone to school continuously,
skipping one grade and is now a junior in high school.
Personality: Even-tempered, tractable and studious, affectionate, am-
bitious and capable, fond of outdoor sports but takes too little recreation.
Onset of Present Illness: In the fall of 1924 the patient complained
that her school work was hard. She became irritable, did not sleep well
and lost her appetite and became less affectionate toward her parents.
Said that the children at school made fun of her. Heard imaginary
voices. One day she went into the bathroom, locked the door and turned
on the gas. Told her father he looked like a Chinaman. Laughed with-
out cause.
Mental Status: The patient tended to keep by herself. She laughed
a great deal without apparent cause. One time she admitted that she
heard voices saying funny things. She usually talked in a very vague
and irrelevant manner. She thought people talked about her. Said she
had been unable to sleep well or study during the past year because of
598 Kk. M. BOWMAN
the voices that she heard. She was well oriented, her memory appeared
intact and she had a fair grasp of general information. She had con-
siderable insight.
Physical Status: Negative.
Progress: Patient’s condition has continued unchanged.
Case No. 16. A white female, twenty-six years old, married. Ad-
mitted September 19, 1925.
Family History: Father and mother are somewhat irritable and un-
stable.
Personal History: Birth and early development normal. As a child
she had whooping cough and scarlet fever followed by Bright’s disease.
Later she had a tonsillectomy. She finished the ninth grade when fifteen
years of age. Was considered an average pupil. Worked at odd jobs
until she married. There are two children, aged four and two.
Personality: Fond of dancing for entertainment. Read fiction and
the newspapers. Liked music. Always of a somewhat unstable disposi-
tion. Found it hard to settle down after marriage.
Onset of Present Illness: The patient has never been well since the
birth of her two children, both of whom were instrumental deliveries.
She complained that her housework was too much for her and that she
could not stand the strain of housework and the children. Her mother
constantly sided with her and told her that her husband did not appreciate
her. Her physical complaints increased gradually until the time of ad-
mission.
Mental Status: Patient was quite underactive. She complained a
great deal of various physical ailments. There was some looseness of
thought. She spoke of seeing and tasting blood. There are probably
auditory hallucinations. The intellectual functions were somewhat
impaired.
Physical Status: Twenty pounds under weight, some unsteadiness of
gait, possibly due to weakness. Otherwise negative.
Progress: The patient has been kept in bed and fed liberally. She
has increased about twenty pounds in weight but her physical complaints
have increased rather than decreased and she appears to be weak and
restless. There has been no improvement aside from the gain in weight.
Case No. 17. A white female, thirty-eight years old, single.
Admitted September 30, 1925.
Family History: Negative.
Personal History: Birth and early development normal. She finished
the sixth grade of school when about thirteen years of age showing aver-
age ability. She then went to work. She has worked in millinery stores
ever since. She had influenza in 1918. Her thyroid has been enlarged
fifteen or sixteen years.
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA _ 599
Personality: Somewhat seclusive but pleasant and entertaining in
the presence of others. Not oversensitive. Fairly capable.
Onset of Present Illness: About two years ago it was noticed that the
patient had lost approximately forty-five pounds in weight and that she
looked “run down.” Gradually she became more seclusive. She would
sit in one position for hours at a time without making a movement or say-
ing a word. She thought that people were putting chloroform into her
room. Said she had worms and bugs inside her. She felt that people
were after her and were trying to put her in prison.
Mental Status: Patient was quiet and showed no peculiar behavior.
She stated that she felt a little lonesome and worried because people were
talking about her. She expressed numerous delusions of persecution.
It was impossible to say whether there were hallucinations of hearing or
not. Orientation was correct and memory seemed good. Her grasp of
general information was rather poor. She had no insight.
Physical Status: Forty-eight pounds underweight. Thyroid enlarged
and soft. Eyes slightly prominent.
Progress: Patient’s condition has continued unchanged.
Case No. 18. A white male, thirty-eight years old, single. Admitted
September 21, 1925. |
Family History: Nothing known.
Personal History: Nothing known about his early life. For the past
five years he has worked as a pin boy in a bowling alley.
Personality: Nothing known.
Onset of Present Illness: The exact date of the onset is not clear.
It is known that for the past two or three years he has acted very pecu-
liarly. He would order persons out of the bowling alley if he did not
like their appearance. He would often disappear for a few days. He
was considered odd by his associates.
Mental Status: The patient was quiet, pleasant and cooperative.
There was considerable language difficulty but even then he appeared
undertalkative and not to grasp the meaning of many simple questions.
He seemed indifferent to his surroundings. He said that he was going to
die and that people were going to kill him. He admitted that he heard
voices telling him these things. He also admitted visual hallucinations.
His orientation was impaired for time and place and possibly for person.
There was considerable impairment of the intellectual functions. It was
difficult to say how much was deterioration and how much was due to a
constitutional intellectual defect.
Physical Status: The physical. examination showed that the patient
was slightly undernourished. His pupils reacted sluggishly to light.
The knee jerks were greatly diminished. There was moderate tremor of
the outstretched hands.
600 k. M. BOWMAN
Progress: The patient has shown no change in his condition while in
the hospital.
Case No. 19. A white female, twenty-one years old, single. Admitted
September 29, 1925.
Family History: Negative.
Personal History: Birth and early development normal. Measles,
whooping cough and mumps as a child. Cholera infantum at nine months.
Pneumonia at four years of age. Started school at five and finished two
years of high school when fifteen after which she studied stenography
for two years in business college. Was always bright and capable in
her studies. Since the age of seventeen she has been working as a ste-
nographer. It is said that she is not a good worker, that she is careless
and not’ prompt. She has had a number of different positions, often
leaving positions for no particular reason.
Personality: Quiet, shy, not much of a mixer, had few friends, very
conscientious, never interested in her work, inclined to day dream.
Onset of Present Illness: For the past year the patient has stated that
the girls at work were laughing at her. One day she stuffed absorbent
cotton into her ears because she said she did not wish to hear so much
noise. She lost interest and ambition and remained at home for six
months preceding admission during which time she has been hearing
VOICes.
Mental Status: The patient was overactive, apathetic and indifferent.
Her speech was coherent. She stated that people were laughing at her
and that people around her would have “dark and jealous faces.” There
were auditory and visual hallucinations. She was correctly oriented.
Her memory was good and she had a good grasp of general information.
She had poor insight.
Physical Status: Weakness of the external rectus of the right eye,
present since early childhood. Otherwise negative.
Progress: The patient’s condition has continued unchanged.
Case No. 20. A white male, nineteen years old, single. Admitted
October 6, 1925.
Family History: Mother, father and one brother are unstable and
are given to fits of temper. ,
Personal History: Birth and early development normal. He had
measles, mumps, whooping cough, scarlet fever and chickenpox as a
child. He finished the ninth grade, after skipping one full grade, at the
age of fourteen. About this time he seemed to have difficulty in grasp-
ing things in school and it was advised that he leave school and take a
rest. On leaving school he went to work and has been a printer’s appren-
tice most of the time.
Personality: Always shy and retiring, inclined to be seclusive, fond
of reading, subject to violent fits of temper, never frank and open.
—e
BIOCHEMICAL SLUDIES IN-SCHIZOPHRENIA 601
Onset of Present Illness: About January, 1925, the patient complained
of inability to concentrate and feeling “heavy.” A little later he desired
a change of work. The patient then had a number of visions and felt
that a young lady he saw was someone else. He demanded her name
and when she laughed at him he fell over in a dazed state. Shortly after
this he heard a voice telling him he was the Messiah.
Mental Status: Patient was quiet and well behaved. He saw peculiar
meanings in trivial happenings, he believed that people were talking about
him and had delusions of persecution. He believed that he was the Mes-
siah, had auditory and visual hallucinations. He was correctly oriented
and memory was unimpaired and he had a good grasp of general infor-
mation and there was practically no insight.
Progress: The patient’s condition has continued essentially unchanged.
Case No. 21. A white female, twenty-seven years old, single.
Admitted June 25, 1925.
Family History: The mother is alcoholic and she and the father do
not get along well together. One brother was a patient at the Boston
Psychopathic Hospital in 1923.
Personal History: The mother was not very well during the preg-
nancy and the patient nearly died at birth. She had measles, mumps
and whooping cough as a child. She was said to have always been nerv-
ous but definite data is lacking. She did not play well with other chil-
dren but kept to herself and was interested in her books and her school.
She graduated from the business course in high school at eighteen years
of age. She then went to work as a stenographer and has worked stead-
ily ever since. When ten years of age she was taught masturbation by
an older girl.
Personality: Always sensitive, very tractable and obedient, very fussy
and particular, extremely religious, fond of reading “perfectly clean
novels’ and religious books.
Onset of Present Illness: In November, 1924, the patient developed
a fear of men. She felt that a man came into her room at night and had
sex relations with her and that she was pregnant. Her condition grew
progressively worse until her admission.
Mental Status: The patient was quiet and very cooperative. She
cried frequently, appeared worried and said that she had a great many
fears. She talked in a coherent and logical way concerning all matters.
She stated that she feels in the morning that a man has been with her
during the night and that she has been violated by this man. She had
numerous fears. She was afraid of men, of everything that she ate, of
toilets, of taking a bath. “She once went a month without taking a
bath.” There were no hallucinations. Her orientation, memory and
general information were excellent and she had a good deal of insight.
Physical Status: Essentially negative. There was slight tenderness
602 Kk. M. BOWMAN
in the right lower quadrant of the abdomen and a fine tremor of the
fingers.
Progress: The patient gradually improved while in the hospital. She
‘became less bothered by the ideas that were upsetting her and after a
great many interviews with the physicians she professed to understand
how her condition had come about. She still continued to be somewhat
unstable emotionally. She was discharged September 30, 1925, as im-
proved and took up work outside as a stenographer.
Case No. 22. A white female, sixteen years old, single. Admitted
March 25, 1925.
Family History: One maternal uncle was psychotic and committed
suicide.
Personal History: Birth and early development normal. Was quite
sick at one time when teething. She finished the eighth grade in school
when fourteen years old.
Personality: Quiet, usually happy, enjoyed the company of other
girls.
Onset of Present Illness: Her sickness probably started about two
years ago, during her last year of school. She would complain of pains
in her head, her hands and her body. She would scream out at times.
She was unable to sleep well. Would strike persons in a fit of temper.
Would keep to herself. Spoke of getting messages from God and of
imagining “bad” about herself and other people.
Mental Status: Fairly cheerful and quiet. Occasionally a little de-
pressed. At first she stated that she received messages from God, that
she heard His voice ‘“‘as if coming from far.” At night she would see
devils. She felt that people looked at her on the street and were talking
about her. Later she spoke as if the hallucinatory experiences were not
as she had first represented them to be and called the voices vivid
thoughts. There were numerous obsessions and compulsions. She was
correctly oriented and her memory and general information were good.
She had considerable insight.
Physical Status: Question of slight ptosis of right upper eyelid. Fine
tremor of fingers.
Progress: The obsessive and compulsive behavior has become more
marked and the patient denies any actual hallucinatory experiences. It -
is difficult-to determine what is the correct view concerning this.
Case No. 23. A white female, fourteen years old, single. Admitted
January 21, 1925.
Family History: The mother had a psychotic episode at the time of
the pregnancy before the patient was born. Later she committed suicide
in another spell of depression.
Personal History: The patient was always sensitive and high strung
as a child. She had terrifying dreams which have continued up to the
BIOCHEMICAL STUDIES IN SCHIZOPHRENIA 603
present time. There is still some enuresis present. She has always bitten
her fingernails. She finished the eighth grade at fourteen years-of age.
Personality: The patient has.always been quick-tempered, stubborn.
She has never gotten along well with her step-mother and her family
and has been very irritable. She has not been sociable. Has read a
great deal. Has not had many friends.
Onset of Present Illness: During the past year the patient has had a
number of fainting spells, following which she seemed somewhat con-
fused. She said that she worried about her mother and that she was
afraid of insanity.
Mental Status: The patient was inclined to be somewhat seclusive.
She had a number of mannerisms. She appeared somewhat depressed
and unhappy. She would often sit for long periods at a time gazing into
space and would not answer any questions the physician asked her. She
stated that on two occasions she had actually heard her mother’s voice
calling to her. She was correctly oriented. Her memory and grasp of
general information were good. She had some insight.
Physical Status: Over a period of a number of months her urine
showed sugar present a considerable part of the time. At one time there
was as much as ¥% of 1 per cent. Occasionally there were hyalin and
fine granular casts with some albumin. The blood sugar was always
normal. Careful physical and neurological study, including electrocardio-
gram, was negative.
Progress: The patient improved slightly while in the hospital and
was discharged August 13, 1925, as improved. She has apparently made
a fair adjustment at home.
Case No. 24. A white female, twenty-seven years old, single. Ad-
mitted October 17, 1922.
Family History: Maternal grandfather alcoholic and later became
insane. Mother had Huntington’s chorea. One maternal uncle was
alcoholic.
Personal History: Birth and early development were normal except
that enuresis persisted until fourteen years of age. Strong and healthy
as a child. Tonsils and adenoids were removed sixteen months before
admission. For the past ten years she has had fainting attacks, particu-
larly during her menstrual periods. She finished grammar school at
fourteen and has worked ever since in clerical positions with only a mod-
erate degree of efficiency.
Personality: Always shy and sensitive she made friends with
difficulty.
Onset of Present Illness: The patient has shown a decrease in indus-
trial efficiency during the past few years, being constantly discharged
from positions. She refused to see her mother and aunt. She was much
disturbed over a love affair.
604 K. M. BOWMAN
Mental Status: The patient was quiet and cooperative. She seemed
to show lack of emotion and to be entirely unconcerned about matters.
She would frequently smile when discussing matters which should have
been serious to her. She admitted a great deal of day dreaming and
fantasy with regard to the young man who had jilted her and claimed
that she felt he would some time come back to her.
Physical Status: There were no noteworthy findings.
Progress: ‘The patient was discharged from the hospital on December
8, 1922. She went to live with her aunt and worked at odd jobs at dif-
ferent times. She seemed quite uninterested and indifferent and made
little effort to secure work and was content to allow her aunt to support
her. She was readmitted to the hospital on June 17, 1925. She showed
essentially the same sort of behavior as on her previous admission. She
talked more freely about her love affair and explained that she felt a cer-
tain man intended to marry her because she once heard him whistling
“Until We Meet Again.” Although this man is now married and the
patient has been informed of it she still insists that the man is in love
with her and that he will some day come to her. Her condition has con-
tinued essentially unchanged although she has done some work about
the hospital and shown a little interest in things.
BIBLIOGRAPHY
1. Kraepelin, E. Dementia Praecox. E. & S. Livingstone, Edinburgh,
1919,
. DuBois, D., and DuBois, E. F. Clinical Calorimetry. Arch. Int. Med.,
17:863, June, 1916.
. Janney, N. W., and Isaacson, V. T. The Blood Sugar in Thyroid and
Other Endocrine Diseases. Arch. Int. Med., 22:160, August, 1918.
. Rowe, A. W. The Metabolism of Galactose. Arch. Int. Med., 34:388,
September, 1924.
. Benedict, S. R. The Determination of Uric Acid in Blood. J. B. C.,
51518751922.
. Kramer, B., and Tisdall, F. F. The Direct Quantitative Determination
of Sodium, Potassium, Calcium and Magnesium in Small Amounts
of Blood. we -be 24/ aca el
7. Bell, R. D., and Doisy, E. A. Rapid Colorimetric Methods for the
Determination of Phosphorus in Urine and Blood. J. B. C., 44:55,
1920.
8. Austin, J. H., and Van Slyke, D. D. Determination of Chlorides in
Whole Blood. .J. B. C., 41:345; 1920.
9. Kottman, K. Kollidochemische Untersuchungen tber Schilddrtsen-
probleme. Schweiz. med. Wochenschrift, 1-644, 1920.
10. Denis, W., and Ayer, J. B. A Method for the Quantitative Deter-
mination of Protein in Cerebrospinal Fluid. Arch. Int. Med., 26-436,
October, 1920.
11. Kasanin, J.. and Knapp, E. A Study of External Factors Causing
Meee Results in the Kottman Reaction. Submitted to Arch. Int.
Led.
Nn wm SF W Pb
SOCIETY PROCEEDINGS
NEW SORKIN UROEROGICAL SOCIETY
THE Four HuNprReED AND THIRTY-SECOND REGULAR MEETING,
January 4, 1927. THe Presipent, Dr. I. ABRAHAMSON,
PRESIDING
BACH ie PER AUS sPARALY SES
[AUTHOR’S ABSTRACT |
Dr. VINCENT GILIBERTI
Brachial plexus paralyses form the second largest group of birth
palsies. ‘They occur most frequently in cases requiring artificial aid
for birth of child and are more frequent in head than in breech,
shoulder or foot presentations. ‘Traction upon the brachial plexus,
and abduction, elevation and backward movement of the right arm
at the same time that the head is bent towards the opposite side, are
responsible. Compression or stretching of the brachial plexus in
attempted to free an arm or deliver a shoulder or after-coming head
will also produce similar injuries. Introduction of a finger or hook
into the axilla when the shoulder is delayed may lead to compression
either by direct pressure on the plexus or indirectly by pressure of
the clavicle when shoulder and clavicle are pushed backward and
upward. Forceps blades rarely may reach the cervical region and
damage the plexus. More often this form of paralysis is due to
pressure or traction exerted on the shoulders in attempting to acceler-
ate the birth of the head by such methods as the Prague, Smellie-Veit,
or Mauriceau, or the combined methods. Complications of obstetri-
cal paralysis may be fracture of humerus or clavicle, dislocation of a
shoulder, hematoma of sternocleido-mastoid, and separation of epiph-
yses. These complications are no longer looked upon as the actual
cause of the paralysis.
The nerve fibers and bundles of the plexus are usually torn
asunder or ripped apart and not just simply crushed or cut in one
place as in most traumatic nerve lesions. Overstretching breaks the
funiculi at any point from the spinal cord origin of the roots, to the
most distal point of trauma, causing irregular injury. Examination
of cross section of resulting scar discloses incomplete interruption
of continuity.
It is difficult for a neurosurgeon to determine exactly at what
level excision of the scar will give him intact funiculi, for there may
be interruption in a number of places. Lesions of compression, trac-
[605 ]
606 NEW. YORK NEUROLOGICAL SOCIETY
tion, or laceration vary only in degree. After slight compression
restoration of function is usually rapid and complete. If greater
compression over a comparatively long period of time there may be
radical organic changes, resulting in disintegration of the medulla
and axis cylinders extending the entire length of the nerves distal to
the site of injury. If traction has been the cause of paralysis the
disturbance may be transient or permanent, depending upon the
degree of trauma. In cases of avulsion of the root from the cord,
the cord has been found smaller and flattened in its anterior portions
at the level of the injury and the anterior horn area is inyolved in a
sclerotic process. Gray matter is deformed on both sides, the cells
completely absent on the affected side and on the opposite side only
a few darkly stained elongated forms remaining. Most common
types of brachial plexus paralysis are the upper arm type (Duchenne-
Erb), due to injury of the 5 and 6 C. roots or the upper primary
cord of the plexus which originates from these roots. ‘This is the
most common type and everything else being equal, offers the most
favorable prognosis. The lower arm type of brachial plexus paral-
ysis (Klumke-Dejerine type) is caused by a lesion chiefly involving
the 7 and 8 C. and 1 T. roots. This form is often the residtaijos
combined type, sensory symptoms are usually present, but as in the
cases of Erb’s palsy, are difficult to elicit in infants.
The combined type of brachial plexus paralysis partakes of the
nature of both types previously described, and is due to a lesion
involving the entire plexus or most of it. The prognosis of brachial
plexus obstetrical paralysis is much less favorable than that of ordi-
nary peripheral nerve lesions. Mild compression traction paralysis
may be recovered from in a few days or weeks. If severe, it may
take as long as two or three years. If actual laceration with sever-
ance of continuity, separation and displacement has taken place, we
can only expect recovery by resorting to neurosurgery. From the
standpoint of clinical types, upper arm type offers the most favorable
prognosis, lower arm type next, and finally the combined type.
One of the grave dangers of a long-existent obstetrical paralysis
is that a habit palsy may replace the organic one when nerve conduc-_
tion is finally restored. The various complications need to be treated
surgically as described in various books on surgery. Paralysis proper
is taken care of by immediately immobilizing the affected extremity
to prevent additional hemorrhage and further separation of nerve
segments. <A splint of aluminum lined with soft felt, extending from
hip to axilla, holding arm elevated in abduction at an angle slightly
more than 90 degrees, will help to approximate the torn nerve ends.
The hand and forearm should be kept in full supination to overcome
the tendency to pronation. The general nutrition of the involved
parts can be favorably influenced by electrical stimulation, massage,
heat, hydrotherapy, and exercises. All the forms of treatment should
be so conducted as not to interfere with the postural treatment. If
signs of regeneration have appeared within one year the mechanical
and physical treatments should be continued. If there are positive
evidences of interrupted regeneration or no regeneration at all after
NEW YORK NEUROLOGICAL SOCIETY 607
a year, one is justified in resorting to neurosurgery. Contractures
are best overcome by the method of gradual correction.
Discussion: - Dr. T. P. Prout said: About twenty years ago,
Taylor, L. P. Clark, and myself presented some work on this subject.
The paper described about six cases which concerned themselves
mainly with the type of palsy that is induced by the rupture of the
outer cord of the brachial plexus and eventuating in the upper arm
type of palsy. In several of these the lesion was in such a position
that its excision accomplished a fair result: in some others the lesion
was more complicated and the result was less favorable but some
improvement was shown. In all, the condition had existed for a
long time so that any improvement was a gain. There were no very
early lesions in that series. Subsequently I saw several very early
cases in the course of my service at the Vanderbilt Clinic; some did
well on a simple regime of massage. ‘The lesion is easy to palpate
in the newborn infant and the younger children. I would call atten-
tion to the fact that even the neglected cases are not absolutely hope-
less. Excision of the lesion and resection of the nerve ends accom-
plishes something. Of course, where there is evulsion of the nerve
at the cord, one cannot expect to accomplish much. However, these
cases presenting a lesion of the outer cord of the brachial plexus
eventuating in the upper arm type of palsy do respond to treatment,
and where neglected and conservative means fail, surgical intervention
should be considered.
Dr. John Hugh Nolan said: The sooner the cases are treated, the
easier it is to get results. As Dr. Giliberti said, it is a matter of
degree of injury that counts. Having been connected with a mater-
nity hospital for a number of years, I found that sometimes it is
necessary to exert great traction, so much so in fact that at times you
can actually hear the nerve trunk snap. I have followed many of
these palsies in newborn babies, and any improvement usually occurs
within the first six months. I have seen a few get well, but these had
minor injuries. In the severe types the chances of a good recovery
are very poor. These cases as regards early operation are in the
same category as the newborn with cerebral hemorrhage.
Dr. Michael Osnato said: Dr. Giliberti did not have the oppor-
tunity to say something about the clinical side of his case, which illus-
trated several points he made in his paper. I have seen the girl
several times. The story was that she did not improve perceptibly
for a long period, and then rather suddenly; in the short space of a
very few months, following an infection, she made what appeared
to the family to be an almost miraculous recovery. When seen at
the New York Post-Graduate Clinic, it was found that she did not
have an R.D., and in spite of some wasting in the shoulder girdle
group her reflexes were quite negative. There were no, or very few,
residual sensory disturbances, and apparently what had happened in
608 NEW YORK NEUROLOGICAL SOCIZATY
her case was the thing Dr. Giliberti has called attention to in his
paper, namely, that she had developed a habit paralysis, and when the
habit disappeared, recovery, which had unquestionably taken place a
number of years before, was then allowed to make itself manifest
ina very short time. I think it might be well to stress again the point
that surgery is not the method of choice, so far as routine treatment
is concerned, in these cases. The postural treatment, with patient and
persevering physiotherapy over a long period of time, is the regimen
which offers the best results.
Dr. Charles Rosenheck said: A considerable number of these
cases drift to the institution I am associated with, an orthopedic insti-
tution, and we see quite a number of these children with both upper
and lower arm palsy. They come in soon after the birth of the
baby, or some time after. Of course Dr. Giliberti will bear me out
in this, that it is a very difficult matter to take electrical reactions in
children. They cry a great deal, and nothing will be gained by that
sort of thing, but we do try to determine the amount of palsy by the
position of the baby’s arm and the amount of functional disuse. Our
orthopedists put the child up in what they call the “aeroplane ”
position, t.e., abduction of arm to a horizontal and externally rotated
position. It is rather awkward. ‘The babies obviously do not object
to it, but the mothers do, because it entails a considerable amount of
work on the part of the mother in dressing and undressing the child,
but after it is explained to them, we get good cooperation. The
results are good in those in which there is no nerve avulsion or tear-
ing; 4.€., in the ordinary stretching of the nerve roots we get a
considerable functional recovery. We use that treatment for a period
of four to six months. The baby is then brought in for massage, and
electrical treatment. This treatment is kept up for six months to
two years, and 1f there is no recovery the orthopedist takes the stand
that nothing further can be done for the case. Operative procedures
are then instituted (devised by Dever of Boston) which are intended
to divide those muscles which keep the arm fixed in an adducted and
inward rotated position. After this operation is performed, the
child is again put up in the so-called “aeroplane” position, but just
the reverse of what the original position was, that is, external rota-
tion, and the child is kept in that position for possibly a period of two
or three months, and the electricity, exercises and massage are kept
up. It is purely an operation not intended to correct the entire func-
tional use of the arm, but it prevents that awkward inward rotation
and offers a fair amount of functional recovery.
Dr. I. Abrahamson said: I wish to stress two things in examin-
ing these children: In the first place, we must keep a record of the
movements that are preserved. From time to time all the movements
should be noted in the record of the case, and they should not be left
to the memory of the examiner. In order to discover the movements
possible, watching the child will be found to be a long and tedious
task; we must test them by noting their resistance to passive move-
NEW SYORK, NEUROLOGIC ALS OCIETY 609
ments. The child will resent passive movements and we can test one
group after another.
Dr. Giliberti (closing the discussion) said: I might dilate on what
Dr. Osnato said about the patient who was to have been presented
this evening. She was fourteen years of age when she came to the
hospital, and she had absolutely no use of the right upper extremity.
There was atrophy of disuse which was generalized over the entire
extremity. She was not able to write with the right hand. She had
become accustomed to writing with the left, and at the same time she
had a peculiar sensory disturbance over the radial side of the lower
half of the right forearm on the anterior surface which one might
think had something to do with the brachial paralysis. She had a
definite history of a brachial paralysis, but there was a patch of
atrophied skin which prompted us to send her to the skin men for
diagnosis. They made a diagnosis of morphoea, a form of circum-
scribed scleroderma, and they considered the anesthesia and other
sensory disturbances as being caused by the morphoea. Under
arsenic treatment the skin lesion improved, and as it improved the
sensory disturbances also improved. In about two and a half months
she could use that extremity perfectly well and normally. Within
six months her handwriting was legible, and when I last saw her,
about a year after treatment was begun, she wrote better with the
right hand than with the left. I believe this was really a case of
habit paralysis.
ADHESIVE SPINAL ARACHNOIDITIS SIMULATING
SPINAL CORD TUMOR. OPERATION AND
COMPLETE RECOVERY.
Byron STOoKEy, M.D.
[AuTHOR’s ABSTRACT |
This patient, a painter, appeared at the Post-Graduate Hospital
on the service of Dr. Osnato in March, 1925, with complete paralysis
below the arms; unable to move the legs, having a spastic paraplegia
with incontinence. He had been treated for some time previously
for lead intoxication, principally because he was a painter. Dr.
Osnato’s diagnosis was spinal cord tumor, with which I concurred,
and laminectomy for spinal cord tumor was done. Complete
obstruction of the subarachnoid space was shown by manometric
study.
A definite sensory level was established. The neurologic signs
and progressive evolution of the symptoms led us to believe that a
spinal cord tumor would be found. There was nothing atypical for
spinal cord tumor in his history, or in the progression of his symp-
toms. At operation no tumor was found, but a very definite circum-
scribed adhesive arachnoiditis was exposed. The adhesions were
freed without bleeding and the dura closed. An uneventful recovery
610 NEW YORK NEUROLOGICAL SOCIETY
occurred with gradual return of function, both of the extremities and
bladder, so that he was able to return to his home. Since discharge
he has been following his occupation, that of a painter. ‘The patient
is now subjectively well, except he has some urinary urgency.
This case is presented to show that circumscribed adhesive
arachnoiditis can be cured by operation, providing it is limited.
Unfortunately, most of the cases of so-called arachnoiditis are not
circumscribed. It is usually a diffuse process, and consequently one
not amenable to operative approach. If the adhesions can be broken
a fairly good operative result follows. The interesting point in this
man’s history is the gradual progression of symptoms almost atypi-
cally that met with in spinal cord tumors. In most of the cases which
I reviewed some time ago in a paper read before the American
Neurological Association the preoperative diagnosis was spinal cord
tumor. In only the last two cases of the series were we able to make
a preoperative diagnosis of adhesive arachnoiditis. There are two
main differential points which, if present, aid in establishing the
diagnosis. The history shows a long and gradual evolution. How-
ever, this man’s history was short. he other point which permits of
a diagnosis beforehand is that in the presence of a total block of the
subarachnoid space usually no increase in the total protein content 1s
found. This is an extremely valuable point because when a tumor
obstructs the subarachnoid space venous circulation of the spinal cord
is interfered with-and diapedesis results. In adhesive arachnoiditis
an ideal set of conditions causing obstruction of the subarachnoid
space, without interference with the venous circulation, is established,
permitting one to prove the role engorged veins with diapedesis plays
in producing an increase in the protein content. In adhesive arach-
noiditis no increase in the total protein content takes place.
Where the diagnosis can be made before operation, these two
points are of value, viz.: first, a long progressive history; second,
subarachnoid obstruction without increase of protein content in the
cerebrospinal fluid. |
Occasionally in the history a note of some previous general infec-
tious disease is related. The etiological factor is obscure. We know
that many infectious processes are associated for a time during their
course with a mild degree of meningitis. It is possible that such
previous infectious processes may be the etiological factor.
The progressive story is extremely interesting. The explanation
offered is but a theory, namely, that adhesions of the pia arachnoid
and dura fix the cord to the dura, gradually interfering with the free
back and forth movements of the spinal cord. The spinal cord under-
goes constant back and forth rhythmic movements during each respi-
ration. After years of continuing slight traumatism produced when
these movements are interfered with by fixation of the cord at any
given segment gradual interruption of condition of the long fiber
tracts of the segment occurs. Interruption of conduction once estab-
lished, it continues: once the symptoms appear a gradual evolution
takes place. In this respect adhesive arachnoiditis simulates spinal
cord tumors.
NEW YORK NEUROLOGICAL SOCIETY 611
A simple laminectomy was done and the circumscribed adhesions
broken. JI am demonstrating this man not to show a brilliant result,
but to show that circumscribed adhesive arachnoiditis is amenable to
surgical treatment and that essentially a cure can be obtained.
Discussion: Dr. Abrahamson said: Does one see, in these cases,
an acute exacerbation of symptoms following lumbar puncture, such
as one occasionally sees in tumors of the cord?
Dr. S. P. Goodhart said: We are all familiar with Dr. Stookey’s
contributions on this subject. The clinical forms which he has
described are becoming more familiar to us as we recognize the
symptoms and associate them with this particular form of lesion of
the spinal meninges. This particular case differs from most of the
cases heretofore described, as I recall them, in that it presents a more
acute symptomatology; the case doubtless belongs in the category of
those cases he has previously described, but differs from them in that
this case presents a much longer duration. This presentation brings
to my mind a case of arachnoiditis seen at the Bronx Hospital and
which ran a very acute course. Having seen several cases of this
group, I was able definitely to make the diagnosis—I say definitely,
yet of course with that degree of reservation which is demanded in
such intricate cases. Dr. Joyner, at my suggestion, operated upon
the case and at once recognized the involvement of the pia arachnoid ;
there was a very manifest inflammatory arachnoiditis with adhesions
and pressure upon the cord. A diagnostician from the Board of
Health had seen the case previously and made the diagnosis of
encephalitis. With this I could in no sense agree. The patient had
what was regarded as a mild “flu” lasting a few days; she com-
plained of severe pains in her chest which, upon careful investigation,
I regarded as root pains. The patient was brought into the hospital,
however, as a case of pneumonia. When I first saw her there was a
definite hyperalgesia at a level of the third and fourth thoracic derma-
tones; definite Kernig, rigidity of the neck, and nystagmus. The
spinal fluid was at first under great pressure and the fluid contained
only a few cells, with slight increase in globulin. In the course of
the following few days, that is, about ten days after the acute onset,
there occurred mild tonic fits with periods of unconsciousness, sudden
general rigidity, and dilatation of the pupils. Subsequent spinal
punctures showed a gradual diminution of pressure and within a few
days a definite xanthochromia, some three hundred polymorpho-
nuclears with marked increase in globulin. The area of hyper-
algesia remained definite. There were no sensory changes and no
definite pyramidal tract signs. Sugar disappeared from the fluid.
The picture strongly suggested to me that type of localized lesion, in
this case of rather acute onset, that Dr. Stookey has described; it is
of interest to note that the fluid gradually was so reduced in pressure
as to essentially disappear. There were no organisms in the field. I
felt that we had definite evidence of a localized lesion, inflammatory
rather than neoplastic. The operation confirmed the suspected con-
612 NEW- YORK NEUROLOGICAL SOCIETY
dition. I feel that some of the cases which simulate cranial neo-
plasms, especially of the base, and in which operation fails to reveal
a growth, are really of the character described by Dr. Stookey.
Dr. E. D. Friedman asked: Was there evidence of arachnoid
cyst formation in this case?
Dr. Henry A. Riley said: I have been very much interested in
this condition. At the Neurological Institute we have seen three or
four instances, and the matter has come up at our conferences. There
are two conflicting points of view which particularly struck us during
their consideration. Most of the cases presented rather a long course
leading up to the picture which simulated a spinal cord neoplasm.
There usually is a definite interference with the long conducting
tracts, both those coming toward and going from the brain, with
pyramidal tract signs, and with more or less indefinite sensory level
symptoms with sphincteric disturbances and a certain amount of pain.
When a lumbar puncture was done, they presented the classical
appearance of a spinal cord tumor. On the one hand, there was the
incomplete picture of a spinal cord tumor on the clinical side, and
from the special investigative viewpoint there was the classical picture
of a tumor, and it is the balancing of the two features which is
important in determining whether the case is one of arachnoiditis
adhesiva spinalis or a spinal cord tumor. I think this is a very
instructive case demonstration for us to see. It shows that all patients
who have even indistinct evidence of a level lesion with interference
with the cerebrospinal fluid circulation should be operated on, and if
this condition is found they can often look forward to an amelioration
of their disease, if not to complete recovery.
Dr. Wilder Penfield said: It is of utmost importance to bear in
mind the point that Dr. Stookey has made with regard to these
cases—that you may have a complete block with no xanthochromia
and no increase in protein content. This case is atypical in several
respects: the presence of xanthochromia; the rapid development of
symptoms, and a well localized and well circumscribed arachnoiditis.
This might bear out the point of view that the increase in protein
below the block is due, not to exudation from the vessels of a tumor,
but to localized constriction of the vessels in the spinal cord. That
is also borne out by the fact that xanthochromia develops even when
the tumor is a chondroma where there is almost no blood supply, and
when the tumor is outside the dura, and in cases where the compres-
sion is from a cold abscess. It seems to me that this type of well
circumscribed arachnoiditis which Dr. Stookey has pointed out here,
with rapidly developing symptoms, may well compress the veins in
the cord itself and thus give rise to increase in the protein; whereas
he has pointed out in the other cases, where the adhesions are more
diffuse, there is no increase.
bie Rosenheck said: Can Dr. Stookey explain the absence of
spinal arachnoiditis in cases of meningitis that occur in childhood,
NEW YORK NEUROLOGICAL SOCIETY 613
that are followed for a great many years, and are not followed by
spinal block? Possibly the explanation he gave for the ordinary
infectious processes that produced circumscribed serous meningitis
may not apply to the meningitis of the meningococcus variety.
Dr. Stookey (closing the discussion) said: In answer to the
chairman’s question as to whether the symptoms were increased after
lumbar punctures, I do not recall that I ever saw a case in which they
were. I have seen one or two cases in which they were improved
after lumbar puncture. I would not be willing to say offhand
whether any were made worse after it, because I do not recall
definitely.
As to Dr. Goodhart’s comment, I would recall to him those cases
described by Dr. Horax of adhesive arachnoiditis of the posterior
fossa which simulated cerebellar tumors so that apparently a clinical
picture of cerebellar tumors may occur by adhesive arachnoiditis
within the cranial cavity.
Dr. Riley has emphasized a point that I am very much in sympa-
thy with, mainly, that if a level lesion is found with subarachnoid
obstruction I think exploration should be done. A level lesion with
subarachnoid obstruction should always be explored.
As to Dr. Penfield’s comment concerning the source of the
xanthochromia and increased protein, I meant to imply that the
source of both was from the congested veins of the spinal cord, and
that it occurs whether the tumor be extradural, a chondroma, or a
cold abscess; or from any condition which obstructs the circulation
of the veins of the spinal cord. It is generally accepted that obstruc-
tion of these veins gives rise to increased protein and xanthochromia.
Concerning Dr. Rosenheck’s question, why in so-called meningitis
of childhood of the meningococcus type we do not have adhesive
arachnoiditis afterwards, I have no explanation. We do know that
various organisms give rise to various types of tissue reaction, wit-
ness the type of membrane formed by the diphtheria bacillus, and
certain types of streptococcus. We know that tissue reactions differ
in various processes. I think he should ask that question of Dr.
Globus and not of me. I would be glad if Dr. Globus would tell me,
for I have no explanation to offer.
I do not want anyone to think that this good result is what is
usually obtained. We have operated on some cases with no improve-
ment. To the extensive processes we can do little or nothing. Un-
less the adhesions can be freed no good is likely to come of the
operation whether or not it is an extensive process or a limited one.
Exploration should be done when the diagnosis is established.
614 ' NEW VORK-NEURGLOGICALPSOCInGY
SPINAL CORD COMPRESSION IN HODGKIN’S DISEASE
REpoRT OF A CASE IN HODGKIN’S DISEASE OF THIRTEEN YEARS’
DURATION
GeEorRGE A. BLAKESLEE, M.D.
[ AUTHOR’S ABSTRACT |
Compression of the spinal cord from disease of the peridural
tissles such as has been known to occur in the lymphoplasias of the
peridural lymphoid tissue in Hodgkin’s disease is rare. In a review
of the literature a few cases are described in which paraplegia is
associated with Hodgkin’s disease, some with clinical symptoms with-
out a post-mortem examination, and others with clinical symptoms
and corroborative -post-mortem findings. The following case of
Hodgkin’s disease of about thirteen years’ duration, with a complicat-
ing paraplegia developing after ten years, was reported, and the case
presented.
When the patient was fourteen years of age, lymph node enlarge-
ment was first noticed in the right supraclavicular region, and on
biopsy was diagnosed as Hodgkin’s disease. Following X-ray therapy
the cervical lymph nodes disappeared. A remission of eight years
followed, during which time the patient enjoyed excellent health.
Then there started a constant, dull, aching pain in the abdomen, and
physical signs revealed a large mass in the epigastric region and a few
lymph nodes in the neck. A second biopsy diagnosed the case as
Hodgkin’s disease. Following X-ray therapy the mass in the abdo-
men disappeared and the symptoms were relieved.
About eight months later sharp shooting pains radiated from the
shoulder blades to the anterior thoracic region. Six weeks later there
was complete paraplegia with sensory change from the fifth thoracic
level downward, and bilateral pyramidal tract signs in the lower
extremities. Following X-ray treatments the patient was able to
take a few steps in about three months, and in nine months got about
with the assistance of a cane.
Two years later he entered the Post-Graduate Hospital with a
fever, increased difficulty in walking, weakness, loss of weight, and
large glandular masses in the left and right axillary and pectoral
regions. Histological examination of a gland from the right axillary
region diagnosed Hodgkin’s disease. The neurological examination
revealed some spasticity in gait, bilateral pyramidal tract signs, and
posterior column sense impairment in the lower extremities.
The axillary, pectoral, and cervical regions of the body were given
X-ray treatments and the glands disappeared. The patient was
advised to live in the country, and gained twenty pounds in weight,
strength increased, and his locomotion improved.
It is felt that the difficulty in locomotion at the time of his entrance
to the Post-Graduate Hospital might have been due to the general
weakness as a result of the general adenopathy, but the presence of
localizing spinal cord signs speaks for local involvement of the spinal
cord.
NEW YORK NEUROLOGICAL SOCIETY 615
The patient showed very definite signs of spinal cord compression
which receded under X-ray therapy along with the general signs of
Hodgkin's disease. Reports of necropsies in the literature prove that
the lymphogranuloma of Hodgkin’s disease can occur in the peridural
space as a localized process. It seems fair to assume that this case
of localized spinal cord compression in Hodgkin’s disease can be
explained in this way.
Discussion: Dr. Ward H. Cook (by invitation) said (demon-
strating lantern slides): Cases of Hodgkin’s disease typically exhibit
a somewhat symmetrical enlargement of the cervical nodes on both
sides of the neck, with dyspnoea and moderate emaciation. The
illustration will recall to your mind the essential features of this
disease. ‘This picture shows the dissection of the enlarged lymph
nodes of both sides of the neck and mediastinum from a case of
Hodgkin’s disease. Note the discrete nodes. That is one of the
characteristic features of the enlarged nodes in this disease. The
nodes may become fused by fibrosis due to secondary infection or as
the result of X-ray therapy. The latter fact is of interest in connec-
tion with Dr. Blakeslee’s case because it has been observed at necropsy
in the retroperitoneal nodes in cases which have received X-ray
treatment.
This slide is the low power appearance shown by the sections
removed in 1923. It presents a fairly characteristic appearance of
Hodgkin’s disease. The deeply stained nuclei are those of the
lymphocytes of the invaded lymph nodes. ‘The paler cells are for
the most part mononuclear cells, variously interpreted as of endo-
thelial or reticular origin. A few of the giant cells so often described
as characteristic of this disease are shown.
The next slide is a high power photomicrograph which brings out
the characteristic lobulated nuclear cells more clearly. Also there are
lymphoblasts and mononuclear cells of large size associated with
reticular hyperplasia.
Next is a photograph of the last biopsy specimen taken last spring,
showing essentially the same features.
With regard to the nature of the pathological changes, they present
typical histology, easily recognizable, which has been understood for
a long time by pathologists, yet the etiology of the process remains
a source of discussion and of more or less acrimonious combat.
‘Opinions are at the present time held distinctly in abeyance by the
more conservative pathologists as to whether this is an infectious
process and deserving the name of lymphogranulomatosis, or whether
it is essentially a neoplasm. I will not go into the arguments on the
two sides, but suffice it to say that with regard to the involvement of
the nervous system, occasional cases have been described in the litera-
ture of such extension, chiefly from the retroperitoneal masses. A
recent case is described by the late Eugene Fraenkel of Germany, in
which the patient came to operation with the preoperative diagnosis
of spinal cord tumor. The ordinary signs of Hodgkin’s disease were
not observed, because it was one of those cases in which the glandular
616 NEW YORK NEUROLOGICAL SOCIETY
involvement was retroperitoneal rather than cervical. Fraenkel
reviews the involvement of bone in this disease, and observes that the
vertebrae as well as the long bones are occasionally invaded. The
involvement of the ectodural tissues occurs by direct extension, either
through the vertebrae or around the vertebrae. Following X-ray
treatment the condition is one of fibrosis with disappearance of the
hyperplastic cells which constitute the essential features of the disease.
Recurrence in the same location is a variable matter, and recurrences
following radiation are more apt to be in some other location, rather
than in the one in which post-radiation fibrosis has taken place.
Dr. J. H. Globus said: The case we have before us to-night is
an extremely unusual one. Cases of Hodgkin’s disease resulting in
spinal cord changes are rare, and when a case is presented to you
with the clinical course of gradual improvement with the almost
return to the normal, it warrants consideration of the case as being
extremely uncommon. My experience, as the experience of others, is
limited to but a few cases of Hodgkin’s disease with involvement of
the lymphoid tissue of the epidural space, but a degenerative process
in the cord, which occurs in other instances of long and protracted
illness. That 1s, a disease characterized by systemic involvement of
the spinal cord. In two cases I have autopsied there was no evidence
of increased lymphoid tissue in the epidural space. I recall a case
where the entire posterior column was involved and the clinical pic-
ture was that of tabes. Of course, at no time was there a question
of operative interference, as there was no evidence of local pressure,
and it was clinically recognized that one was dealing with a system
disease, a degenerative process, secondary to a constitutional disturb-
ance. I am familiar with the case reported by Eugene Fraenkel of
Hamburg, and there are other instances of the same character where
there was actual involvement or increase in the epidural lymphoid
tissue simulating tumor formation. Such tumors of course are not
a common accompaniment of Hodgkin’s disease. They usually occur
in a multiplicity of sites, and for that reason present disseminated
signs. They therefore do not present the sensory level shown in the
case presented to-night. This is another reason for considering the
case as an unique and very instructive one.
Dr. Riley: I should like to ask (it must have come up for con-
sideration) whether this patient should have been operated on rather
than treated by X-ray. I should like to know why the decision was
reached not to remove the tissue. I imagine it could be done, rather
than to try the slower and possibly not so complete means of therapy
by X-ray.
Dr. Abrahamson said: I recently had a case of Hodgkin’s disease,
verified by the microscopical examination of a gland. He later devel-
oped jaundice, abdominal pains, headaches, and then a progressive
hemiplegia with aphasia. All agreed that we were dealing with a
Hodgkin’s deposit within the brain. An autopsy was refused.
NEW YORK NEUROLOGICAL SOCIETY 617
Dr. Blakeslee (closing the discussion) said: In answer to Dr.
Riley, as to the method of treatment, it seems to me that the treat-
ment of Hodgkin’s disease has been going through certain phases for
a great many years. Several years ago vaccine treatment was tried,
then salvarsan was used, and this has been followed by X-ray and
radium therapy. Surgery seems to have been practiced less fre-
quently in recent years.
The decision to use X-ray treatment in this case I think was a
good one because of the excellent results in the treatment of the
adenopathy prior to the onset of the compression myelitis.
Po ON ais vey el Or EPILEPTICS
TeyNoTKin, M.D.
[| AUTHOR’s ABSTRACT]
In 1919, in a paper presented at the convention of the American
Psychopathological Association, L. Pierce Clark put the question:
“Ts Essential Epilepsy a Life Reaction Disorder?” and answered it
in the affirmative. He went into the details of the personality
make-up of epileptics and tried to show that it is a specific one. He
enumerated the well known traits of egocentricity, supersensitive-
ness, noted the emotional poverty and the stiffness of mentation.
He further asserted that the character faults of the epileptics are
present even before manifestation of seizures; he spoke of increasing
slowness and diminished capacity for any kind of activity long before
the epileptic disorder manifested itself. In recent years he formu-
lated the conception that epilepsy should be looked at more from a
psychobiological aspect, and regarded it as an outflow from a homo-
sexual component which is not sublimated or accepted. He consid-
ered the epileptic make-up as being deep rooted in narcism which
results from poorly repressed homosexuality. He claims that the
extraverted sexual life of epileptics ceases somewhere between
twenty-five and thirty years of age and the whole libido is then
focussed upon the ego, making larger and larger the innate narcism.
MacCurdy, who made an extensive study of epileptic deterioration,
concurs generally with the early conceptions of Clark. In Europe,
Franziska Minkowska, in an article contributed in the Festschrift on
the occasion of the twenty-fifth anniversary of the professorship of
Eugene Bleuler, advocated, alongside with the schizoid and syntoid
type of personality, a third one which she called the epileptoid. How-
ever, making a study of epileptic heredity rather than of the epileptic
make-up, she never went into details of the character traits and gen-
erally spoke of already full fledged epileptics. Otherwise, there is
very little in the literature in regard to this problem except for Fischer
and Kretschmer, who both casually remarked on the occurrence of
the benign type of personality, and the schizoid make-up in epileptics.
We have had an opportunity to go into the make-up of non-
psychotic epileptics in a general hospital (New York Post-Graduate
618 NEW YORK NEUROLOGICAL SOCIETY
Neurological Clinic) and we were surprised to find in a great majority
of cases nothing or very little of the so-called epileptic make-up.
We then decided to review the epileptic material at the Manhattan
State Hospital, and we selected a group of 150 cases—seventy-five
men and seventy-five women—where a more or less reliable life his-
tory was available. Here again we were impressed with the frequent
occurrence of benign type of personality in epileptics. We attempted
then to tabulate various factors in each case and see if there was any
correlation between them and the personality make-up, and as we
progressed we were surprised to find that the age of onset of the first
convulsive seizure has apparently a direct bearing on the type of per-
sonality. When ever the convulsive seizure appeared in infancy or
early childhood the make-up was decidedly an epileptoid one, and the
more remote from infancy is the first manifestation of epilepsy, the
more benign the make-up. So we had pure epileptoid traits in 16.6
per cent of the cases with the onset of convulsive seizures up to the
age of twelve. And even in this group we had a small number with
an admixture of a few benign traits and a few with a pure syntonic
personality make-up—usually cases in which the convulsive seizures
were very infrequent or with intervals of many years’ duration.
With the onset above the age of twelve, and in single cases below that
age, we found in 19.3 per cent of the epileptics a normal make-up up
to the first manifestation of the epileptic disorder and then a change
to an epileptoid, and in 8 per cent a change to a schizoid type of per-
sonality. Then followed a small group with a syntonic type of per-
sonality with a slight admixture of epileptoid or schizoid traits (4.6
per cent). The majority in this group had their onset after the age
of twelve, and a few below that age, the latter with infrequent
seizures—a fact to which we have already referred above. Finally,
we have the largest group, making 37.3 per cent out of the total
number with a pure syntonic type of personality, all of them except
three cases, with the onset of convulsive seizures after the age of
thirteen. It is interesting to point out the definite alcoholic history
ina good number of these cases. Not uninteresting also is the occur-
rence in about 8.0 per cent of pure schizoid types where the epileptic
manifestation appeared between the ages of eleven and fifty-four,
and of a small number (4.0 per cent) with pure traits of psychopathic
personality. It would be idle to draw any conclusion; but one per-
haps may be justified to look for an explanation in the occurrence of
these various types of personality in epileptics in the fact that in
those cases which developed epilepsy in early infancy or childhood
there was very little time left for the epileptic to develop a person-
ality, and what we really have then is the epileptic mental reaction.
This may be substantiated by the striking similarity of these traits in
all cases and the more striking resemblance of this reaction with the
psychotic traits where irritability, ezocentricity, and supersensitiveness
reached their limits.
In the cases with the schizoid type of personality we look for the
tendency for these individuals to withdraw from the outside world
because they are conscious of their affliction. The pure schizoid types
—
NEN YORK NEUROLOGICAL SOCIETY 619
of personality will then easily develop with the onset of convulsive
seizures in puberty and later. One must, however, think of the pos-
sibility of a primordial schizoid personality which has been awakened
and brought to the surface by the epileptic reaction. It is interesting
to note that their psychotic reactions are characterized by epileptic
traits and an admixture of hallucinatory and delusional elements.
With the onset of convulsive manifestations in later years we see an
admixture of epileptoid or schizoid traits; the first then would be
considered as the result of an epileptic reaction, the second one of
the awakening of the latent schizoid tendencies. (The tables have
been shown in projection. The paper will appear in extenso.)
Discussion: Dr. Osnato said: I think this paper is extremely
important. Under the leadership of Dr. Clark there has been a very
definite tendency to explain idiopathic epilepsy on the basis of a life
reaction, and the tendency has been extended to the point of treating
these cases through the psychotherapeutic method of approach on
the theory that epileptic seizures constitute simply one portion of the
general life reaction based on certain psychopathological situations
which have been dilated upon ad nbitum and sometimes ad nauseam.
It seems rather clear from Dr. Notkin’s paper that the cart has been
put before the horse, that they started first with a false premise. If
Dr. Notkin’s work proves anything, it seems fair to say that his con-
clusions are two: first, that the so-called epileptic make-up is the
result of epileptic seizures, and is therefore the protective reaction of
an individual which results in the development of hypersensitiveness
and irritability and egocentricity, and not that the epileptic seizures
come because the individual is possessed of these personality traits.
The second point which Dr. Notkin brought out is that the so-called
epileptoid make-up does not make itself manifest in patients who have
developed seizures rather late in life, that these show the rather
ordinary run of personality make-up, either schizoid, or syntonic, or
the normal. It is hard to exaggerate the importance of this work. It
brings us rather sharply back again to the more materialistic method
of investigation of epilepsy and brings us more in line with the type
of work which I think will be fruitful of results.
Dr. S. P. Goodhart said: In your observation of 150 patients,
all of whom were subject to institutional treatment and in whom I
presume there was a psychosis for which they were brought to the
Manhattan State Hospital, was there any common psychic factor
which stood out in the cases? For example, would the patient with
paranoidal trends or the manic or depressed types show definite varia-
tions from the direction of the psychosis, and was there any special
feature that appeared to characterize all the groups?
Dr. Notkin will recall a case which I sent to him from Bellevue
and now under his direction, where the reaction of the patient was
typically hypomanic, though the psychotic state appeared within a
very short time following a mild convulsive seizure. The psychotic
reaction was not that of the epileptoid equivalent, nor was it of the
620 NEW YORK NEUROLOGICAL SCOCIEs
post-epileptic state. There was no amnesia, no confusion, but the
distinctive flight of ideas and typical manic behavior which brought
her to the psychopathic ward at Bellevue Hospital. It would be of
interest to us to know if in psychotic episodes the epileptic person-
ality, so-called, really has any distinguishing characteristics. I
believe I share the very general opinion among the majority of psy-
chiatrists that this epileptic “ personality ” is a term to conjure with.
‘
Dr. Joseph Smith said: These personality studies are always
interesting. J well remember the late Dr. Hoch presenting years ago
a paper before the Neurological Society dealing with studies in manic-
depressive conditions and dementia precox, and he came to the con-
clusion that the make-up of certain persons tends toward the dementia
precox type; of others, toward the manic-depressive type of reaction.
It was quite absorbing but I do not believe that later observations
have tended to substantiate that view or that in all cases it is typically
so. The traits here observed should be in reality regarded as symp-
toms of the disease which does not manifest itself clearly until years
after. If you have a manic make-up it is only discovered after the
symptoms have become so pronounced that a differentiation from
dementia precox is easy. Then you discover in the patient’s previous
history certain traits which you name constitutional manic or schizoid
traits. These things are interesting but they throw little light on the
subject. A more fundamental question is, To what earlier “ consti-
tution ’’ do these later traits owe their existence? In many cases of
epilepsy we would consider that reactions have a great deal to do
with situation in life, with environment, and educational niveau.
Since these vary markedly, the personality make-up will vary likewise
tremendously, and one cannot in an off-hand manner divide the
epilepsies into two great groups, the manic and schizoid. The char-
acteristics of individuals go far beyond any limits set up by
classifications.
Dr. Philip R. Lehrman said: I should like to know if Dr. Notkin
has made individual studies of these patients. How did he arrive at
the conclusions? Were they made by mass studies, or did he go
into personal studies, after the manner of Dr. Clark?
Dr. Charles Bernstein said: I was greatly interested in this paper.
About two or three months ago in Syracuse we had an admirable
paper, asreview by Dr. Duren of the Syracuse State School on the
subject of epilepsy, which greatly interested us. Some of the men
insisted that we must get back to some sort of organic and physiologic
basis for the epileptics, and I am sure it would be worth your time to
read this paper by Dr. Duren. Our interest in epilepsy is not so
great at the Rome State School as we have only twenty to thirty at
any one time, but I have been interested in this attempt to hitch on to
the epileptic an epileptic personality. Wherever we see these epilep-
tics handled young and trained individually in an interest in life
(and not allowed to deteriorate as so many of them do when they are
NEW YORK NEUROLOGICAL SOCIETY 621
held in large numbers in institutions) and given vocational training
and an opportunity for natural human activity, we do not see this
so-called epileptic personality or irritability and all sorts of excessive
sensitiveness develop. If they have the opportunity to be active
along normal lines, as normal children are, and if you can keep them
active, they do not show these definite personality traits.
Dr. Notkin (closing the discussion) said: I think I should have
to refer to the tables to answer Dr. Goodhart. In the cases where
the seizures were infrequent or came on later in life, we see very
little or practically none of the epileptic make-up. On the other
hand, as it was pointed out, we see these traits in cases with the onset
of epileptic manifestation in infancy. I know the particular case
which Dr. Goodhart referred to, and I must say that she shows a few
traits of the epileptic make-up, or perhaps what would be called the
epileptic mental reaction. She is always insisting on certain things;
making all kinds of demands of the physician. However, I have not
had much of an opportunity to make a detailed study of her so far.
In answer to Dr. Lehrman’s question, I must say that the study
was based on the life histories and observation and examination of
Cac mneividuaimcace me catinoteco.into the “details in this paper
because it would take up too much time. We did not analyze each
single case but we tried to go into details into their adjustment in life.
Where the history seemed to be insufficient the Social Service Depart-
ment of the hospital helped us in securing further additional data.
Relatives or friends of the patients have been invited to the hospital
for the same purpose; and this, together with the study of the patient,
made the material for this paper.
MEDULLARY AND PON PINE SYNDROMES
Rusin A. GERBER, M.D.
(by invitation )
[AuTHOR’s ABSTRACT |
This paper, essentially clinical in character, correlates the symp-
tomatology and clinical findings in several cases of medullary and
pontine lesions with the anatomico-physiological characteristics of
the brain stem. A brief review of the anatomy and physiology of the
chief motor and sensory fiber tracts and the origin and course of the
cranial nuclei and their interrelationship is utilized to point out the
diagnostic criteria available in interruption of physiological function
of these parts; also a few embryological considerations to point out
the teleological mechanism which resulted in the localization of
important nerve centers in the pons and medulla.
The first case described shows the syndrome of the nucleus
ambiguus and the nucleus hypoglossus (syndrome of Tabia—syn-
drome of Horner). A man, fifty-four, complained of inability to
swallow and a drooping of the right eyelid, which came on suddenly.
622 NEW VORK, NEUROLOGICAL SOCIETY
Subsequently, his tongue became thick and he was unable to speak or
swallow. Speech returned, but swallowing of liquids was very diffi- -
cult, with regurgitation through the nose. The important neurolog-
ical findings were limited to the cranial nerve disturbances of the
10th and 12th and reflexes, motor and sensory examination of the
extremities being essentially negative. The right palate and right
side of the tongue were affected. There was the additional com-
plicating factor of right enophthalmos, myosis, and ptosis.
The fundi showed some senile perimacular changes and some
angiosclerosis. Cocaine dilated the left eye widely, the right much
less. The left vocal chord was involved. Fluoroscopic examination
of the esophagus showed an apparently partial obstruction in the
upper esophagus, with moderate dilation above this point. Blood
pressure was 100/78; laboratory tests negative. Patient became
progressively worse and died of some pulmonary complication early
in January, 1926:
Comment: The lesion in this case was probably one of throm-
bosis, affecting the medulla. The involvement of the hypoglossal and
vagus nerves explains the tongue and palate symptoms; and with the
lesion extending dorsally to include the pupillary center of the
medulla gives us the syndrome of Horner—the ipsilateral enophthal-
mos, myosis, and sympathetic ptosis. The X-ray findings are readily
interpreted as the result of slight failure in the action of the muscu-
lature of the upper portion of the esophagus, inervated, as the larynx,
by the vagus. Thus the entire symptom complex is explainable. In
the absence of all sensory or other motor symptoms, the absence of
any peripheral lesion of the 12th and 10th in their peripheral course
at the cervical level and the fact of the simultaneous involvement of
the 10th and 12th, point to the localization as occurring in the medulla
oblongata.
Case of syndrome of the nucleus ambiguus and spinal fillet com-
plicated by syndrome of Horner (the syndrome of Avellis). This
patient, a man, fifty-six, noted a closing of the left eye, and the
following day difficulty in swallowing, with regurgitation of fluids
through the nose. His voice changed to a whisper. On March 18th
he noticed that the wind blowing in through the window of his room
felt differently on the right side of his face than on the left; on the
right side, a warm sensation; and when bathing, cold water felt warm
on the right side of his face and the right upper and lower extremities.
A few days following the onset of his symptoms fluids ceased to
regurgitate through the nose and he swallowed with less difficulty.
The essential findings were limited to the sensory and cranial nerve
status. ‘These showed the classical loss of pain and temperature sense
in the right arm, and diminution of pains and temperature sense over
the right trigeminal area. The fundi showed some angiosclerosis.
There was the additional complicating Horner’s syndrome, on the
left. The uvula pointed to the right. There was a paresis of the
left palate, with an impairment of the left pharyngeal reflex.
Laryngoscopic examination showed almost total immobility of the
left side of the larynx with impairment of swallowing. There was
NEW YORK NEUROLOGICAL SOCIETY 623
an increased secretion of tears of the left eye. Perspiration follow-
ing a hot bath showed very profusely on the right side of the face
and very little on the left. A 4 per cent solution of cocaine produced
very marked dilation of the right pupil with exophthalmos and widen-
ing of the palpebral fissure, and no change in the left eye. The heart
rate ranged between 80 and 108. Blood pressure was 180/100.
Laboratory tests were all normal.
Comment: The lesion in this case was probably one of hemor-
rhage in the radicular branches supplying the medulla oblongata.
This is definitely borne out by the fact of the simultaneous involve-
ment of the nucleus ambiguus, the supply of the larynx and palate
and the spinothalamic tract (spinal fillet) which lie close together in
the lateral white column and are susceptible to the damage caused by
a small lesion. So we have the loss of pain and temperature sensi-
bility in the entire opposite half of the body, including the skin over
the scalp to the interauricular line. This constitutes the syndrome of
Avellis, in the case complicated by the syndrome of Horner, produced
by a slight dorsal extension of the hemorrhage to include the pupillary
Genter.
Case of syndrome of nucleus ambiguus, pyramid and spinal fillet:
The patient, a man, forty-eight, complained of difficulty in swallow-
ing, hoarseness, pain in the right side of the larynx, pain in the right
pectoral region, and emaciation. The first symptom noted by the
patient was pain in the right side of the larynx six months ago. The
onset was gradual. ‘The patient believed he was constantly getting
better. Additional data showed that there was no difficulty in swal-
lowing and the pain in the right pectoral region was present at the
same time as the pain in the right side of the larynx; gradually, also,
hoarseness of voice and some difficulty in talking were noted.
Examination: The voluntary motor system showed a definite
weakness of the right arm and leg; right greater than left reflexes
and a transient clonus both right and left, the right more enduring.
Sensory examination showed no objective changes, except that the
left pain sense was slightly less than the right; temperature sense
was normal; other modalities normal. Pupils reacted to light and
accommodation promptly. There was an old left external strabis-
mus. Uvula pointed to the left. There were no marked differences
in the motion of the palate, though there was greater elevation on the
left than on the right. Also the muscles going from the palate to the
fauces on the left showed greater contractile power than those on
the right. All other cranial nerves were normal. The fundi were
normal; blood pressure 138/90. Subsequent examination disclosed
practically the same finding in the palate and vocal chord, motor and
sensory examination. At a later date the temperature seemed to be
better interpreted on the right than on the left, but no distinct loss
was present. X-ray and laboratory tests done at other institutions
were all said to be negative. A special laryngeal examination showed
a left-sided vocal chord paralysis present.
Comment: The above case does not clearly indicate the etiological
factor responsible for the condition. There is some likelihood of
624 NEW YORK NEUROLOGICAL SSCOCIEg
thrombosis, as there was no marked disturbance in consciousness and
as the lesion seemed to come on gradually. Apparently, the involve-
ment of the spinal fillet is not of a very grave character. The find-
ings though distinct were not the typical complete loss of pain and
temperature that follow in lesions of the spinal fillet. That of the
palate and vocal chord was permanent and decisive. ‘The affection of
the nucleus ambiguus and the spinothalamic easily occur conjointly
when it is recalled that they lie close together in the lateral white
column of the medulla. We have a complicating factor in this case
in the involvement also of the pyramidal tract. The lesion is prob-
ably in one of the radicular arteries supplying the medulla, which may
easily cause the picture given above as regards the syndrome of
Avellis—characterized by the laryngoplegia and palatoplegia asso-
ciated with a contralateral pain and temperature disturbance. Per-
haps an additional lesion must account for the pyramidal tract finding.
Case of syndrome of the vestibular nucleus. The patient, a man,
aged forty-nine, complained of attacks of vertigo which began about
a week ago after an interval of five years during which there were
none. He also complained of “ noises in the right ear” during attack.
He had similar attack about five years ago. Previous to his first
attack, he had had an attack of pneumonia which leit, as a sequer
cardiac disease. He subsequently suffered attacks of vertigo on and
off for two years. His general neurological status was completely
negative with the exception of beginning vertigo when he was about
to le down. A few nystagmoid jerks were noted. His disks were
noted as being very pale. Bone conduction was greater than air
conduction equally on right and left. There was no middle ear
condition. The blood pressure was 110/60. The pulse 82, occa-
sionally intermittent, the irregularity occurring about every six to
ten beats. The history and description of acute attacks were con-
firmed by a relative, who described the acute paroxysm minutely,
stating that the patient became very pale with moist, clammy per-
spiration on his forehead, and complained of being very dizzy, with
the bed turning round and round. Occasionally he would vomit.
It would take three or four days before he felt well enough to resume
his usual work.
Comment: From the acute paroxysmal nature of the disease,
one would infer a transitory lesion especially as there is complete
good health between the attacks. The etiological factor is probably
in the nature of an angiospasm in the region of the vestibular nucleus
in the medulla. Since the sense of hearing is implicated one would
think of Meniere’s disease but there is only the slight change in that
bone conduction seems to be greater than air conduction both on the
right and left. There is, however, no evidence of middle or internal
ear disease, though the symptoms are exactly similar in the latter
disease. The vestibular area of the medulla is abundantly supplied
by blood vessels, and one can easily think of a probable angiospasm
as the cause of the vertigo. There were no other special or neuro-
logical findings, except that of lost equilibratory control. This fact
in the absence of internal ear involvement argues for the diagnosis
Wir ey ORK NEGOKOLOGICAL, SOCIETY 625
of medullary involvement especially when the cardiac condition is
taken into consideration.
Case of abducent alternate hemiplegia. Pontine syndromes are
particularly charterized by the alternate character of the lesion. A
child, aged four years, presented a paralysis of the left external
rectus muscle coming on one week before, after an attack of measles.
This was apparently sudden in onset and no change was noticed
since the onset. There were no other illnesses or abnormalities.
Examination showed right reflexes uniformly increased over left;
right Babinski and right Chaddock.. Sensation was normal. Of the
cranial nerves only the presence of the left external paralysis was
noted. The fundi were normal. Dr. Reder’s report of the eye
condition confirmed the left external rectus palsy with diplopia which
increased as the patient looked outward to the left. Tested with
light the diplopia in a horizontal direction became wider and wider
apart in reference to images. ‘There was no error in refraction. The
paralysis was reported as a convergent squint due to paralysis of the
sixth nerve. The limitation of motion is to the midline only (in
refractive errors the eye goes outward).
Diagnosis: “ Non-refractive convergent squint due to paralysis
of the sixth nerve. Right eye normal in every particular.”
Comment: The etiological factor here is probably the toxemia
attendant on the measles. This toxemia probably produced a throm-
bosis in the caudal portion of the pons. A small lesion here would
involve both the emergent fibers of the sixth nerve and the pyramidal
tract giving us a syndrome of alternate abducent hemiplegia. (The
author here diverts to make some remarks about nomenclature, con-
cerning which there is a little confusion. He believes it were best if
no definite names were attached to the syndromes other than the ana-
tomical designation of the site of insult). Mullard-Gubler syndrome
is the name sometimes given to this condition. But Bing’ reserves
this name for the picture when it is further complicated by facial
paralysis on the same side as the abducent. Tilney speaks of several
variations of the abducent syndrome, one of which is with the involve-
ment of the facial. In contrast to Tilney, who reserves the title
Millard-Gubler syndrome for the pure hemiplegia alternans facialis,
Jelliffe and White delimit, the Millard-Gtbler syndrome to a contra-
lateral hemiplegia of the trunk and extremities without inferior
facial palsy, without hemianesthesia and without the syndrome of
Foville, with alternate paralysis of the 6th nerve alone, or 6th and
7th if the lesion extends laterally. The author further states that it
is also possible in reference to the facial form of alternate hemi-
plegia, to have a nondegenerative form both of the facial and
extremity paralysis. In such a case, though rare, it is true, the lesion
is so situated that neither the facial nucleus nor the issuing root 1s
involved; instead, the central tract shortly before its entry into the
nucleus, and this immediately after it has crossed the midline and
entered on the side of the lesion. Thus cases of supranuclear involve-
ment of the facial nerve associated with paralysis of the opposite
extremity are readily visualized.
626 NEW VORK NEUROLOGICAL 3 CCii in.
Cases of hemiplegia alternans hypoglossus et facialis. The fol-
lowing cases illustrate the variation of the alternate facial hemiplegias
and complicating factors. A man, fifty-five, complained of difficulty
in walking and weakness in the right leg. He had no difficulty in
swallowing, but some slight difficulty in talking clearly.
Examination: A definite left facial weakness, ataxic gait, with
dragging of the right foot; reduced associated movement of the right
arm in walking, were readily noted, and a right hemiplegia. No
R. D. was present in any of the muscles of either the right or left
extremity. Sensory examination was completely negative. There
were evidences of marked arteriosclerosis. Arcus senilis was present.
The facial showed the left nasolabial fold less marked than the right
and the angle of the mouth lower on the left than on the right. The
upper branch was apparently normal. There was an indefinite diminu-
tion of movement of the palate on the right during phonation. ‘The
hypoglossal nerve showed involvement. The tongue deviated to the
left, and showed some corrugations on the left, with the left half
smaller than the right. Blood pressure was 220/110. The various
laboratory tests were all negative; Barany tests, normal.
Comment: The lesion here was undoubtedly a hemorrhage, and
this is borne out by the arteriosclerotic changes in the vessels and
the high blood pressure. ‘The site of the lesion is in the medulla
on the left side involving the left pyramid and the left hypoglossal
nucleus. The pyramids subsequently decussating give the paralysis
on the right side while the left side of the tongue was affected. We
have here a further slight complication in the facial of the left side,
which is the lower two-third variety and which the patient has never
previously noted. Whether it is the residual of some old condition
it is hard to say as there was no R. D. It is more likely that there
may have been a progression of the symptoms with the lesion extend-
ing across the midline, or it may be an irritative or pressure phenom-
enon due to interference with the circulation in the region of
the facial.
Case of hemiplegia alternans facialis complicated by subsequent
ipsilateral hemiplegia. Another case which shows the continuity of
the etiological factors in producing ever extending lesions is cited: A
woman, fifty-four, complained of twitchings all over the body, gen-
eral nervousness, shooting pains in the head, hot flushes all the time,
though these latter first began five years ago and are worse now.
Particularly she complained of dizziness, saying she could not turn
in bed; everything would turn around her and she would feel
nauseated. When walking she would fall over to the right more
than to the left and had to be careful of her gait. Her first symptom
was dizziness which has been gradually getting worse.
Examination: She held her head rather stifly and though walking
normally, was guarded in her steps and walked slowly. Codrdina-
tion tests were normal. The reflexes showed an increase on left
over right. The abdominals could not be elicited because of patient’s
obesity. There was a questionable Babinski on the left, none on
the right, but fanning was present, both right and left. All confirma-
NEW YORK, NEUROLOGICAL SOCIETY 627
tory signs were absent. Hoffman was present both right and left.
Sensory examination was negative. The fundi showed evidences
of arteriosclerosis. Right palpebral fissure showed greater than the
left. The 7th showed a right lower facial paresis. (General systemic
examination noted the obesity, pulse rate of 84, blood pressure
180/80, hot flush over the face. At subsequent examination on
March 26, 1926, there were signs of slight hyperreflexia on the right,
greater than on the left. Hoffman was more actively elicited on the
right than on the left. Achilles jerk was more active on the right
than on the left. The blood pressure was 200/100. Patient com-
plained of the dizziness and said that she had to take a long time
to effect any change in posture as the slightest movement and par-
ticularly change in posture even to the side was accompanied by
severe pains in the head. Laboratory tests were negative with the
exception of the urine which showed some slight nephritic condition .
present.
Comment: In this case the patient undoubtedly had an incom-
plete facial paralysis on the right with left hemiplegic signs which
subsequently showed in addition an ipsilateral hemiplegia. One
should be wary of the presenting symptoms. Any organic lesion may
be masked by neurotic symptoms. In this case the patient undoubt-
edly had some of the neurotic symptoms associated with the meno-
pause, such as the hot flushes, nervousness, irritability, etc., but also
had grave organic symptoms and findings. ‘The lesion here was
hemorrhagic, in the caudal half of the pons, right side, involving the
facial fibers and the pyramidal tract. This tract subsequently decus-
sating gave the appearance of paresis on the left side of the body.
The sixth nerve is very frequently involved in these lesions but
apparently escaped here. However, subsequently another vascular
insult was suffered and increasing signs of involvement of the right
side were found. There was apparently no nuclear or infranuclear
involvement of the facial here. |
In his discussion, the writer reviews other interesting syndromes
of the pons and medulla, seen in patients who are no longer ambula-
tory. He discusses hemiplegia cruciata and tetraplegia, pointing out
the anatomical basis for these lesions. He makes some remarks con-
cerning the syndrome of the vago accessory and the syndrome of
the 10th, 11th and 12th cranial nerves, and the syndrome of the
post-inferior cerebellar artery. Of the pontine syndromes, he men-
tions briefly some lesions of the oculogyric and cephalogyric fibers.
After some remarks on extracranial disease, affecting cranial nerves
and simulating pontine and medullary syndromes, he reviews some
etiological factors present in these conditions and concludes his paper
with an outline of some of the important points in differential diag-
nosis. Finally, he makes a plea for a more definite delimitation of
syndromes—a standardized nomenclature, utilizing anatomical desig-
nations and the interpretation of not only signs but also symptoms
on an anatomico-physiological basis.
Discussion: Dr. Abrahamson said: It is not fair to discuss a
paper of which the author has only read fragments. We should
628 NEW YORK NECKOLOGICAL SCOCGIETY
wait and see the paper in full and go over the cases in detail, and
examine the description of the clinical syndromes. I think Dr.
Gerber has an unusual group of cases.
Dr. Osnato said: It is difficult to make this material interesting
or to make a presentation of it attractive, especially when one is
pressed for time. The paper is extremely well and carefully written,
and will be very much worth while reading. Just one practical point:
the organic neurologist is useful to the otologist and laryngologist in
just this type of case. In the case where the esophagus was involved
as part of the syndrome, a provisional diagnosis of carcinoma of the
esophagus had been made, and it was only after the patient had been
studied from the neurological standpoint that the real condition was
understood. When Dr. Blakeslee sent over to the nose and throat
men a diagnosis of syndrome of Avellis they came over in droves;
they did not know what it meant, and they were extremely interested.
In that particular case the diagnosis of tuberculosis of the larynx
was the provisional diagnosis, so that the organic neurologist plays a
very important role in aiding the men in other specialties in the
diagnosis of these conditions.
CURRENT LITERATURE
I. VEGETATIVE NEUROLOGY.
1. VEGETATIVE NERVOUS SYSTEM.
Martini, T. INTERMITTENT GASTROPTOSIS. [Semana Méd., Vol. XX XI,
ew o me peas VL AY]
Martini describes here the symtoms and treatment of what he calls
orthodigestive dolichogastria. The stomach sags and stretches with
otherwise normal digestion. There is no actual pain with this inter-
mittent form, but the sensations of oppression and weight, the drowsiness,
dyspnea and eructations from the muscular atony may be accompanied
by secretory disturbances and lack of appetite. The prognosis grows
graver with every day that treatment is postponed, as the intermittent
gastroptosis soon becomes chronic. Treatment must combat the various
factors involved, the asthenia, inherited taints, etc.; mechanical supports
are useful, and measures to strengthen the abdominal and gastric walls,
fatten the patient and give tone to the nervous system. He advises also
fractioning the meals, reclining afterward with the pelvis raised, and
refraining from fluids at meals. Psychotherapy must not be forgotten.
Santenoise, D. THE SoLaR REFLex. [C. R. Soc. Biol. 88, 1142. ]
The solar reflex first studied by Laignel-Lavastine, Thomas, and
Claude, which consists in a diminution of the amplitude of the pulse
during and after compression of the region of the solar plexus is here
reported upon. ‘The reflex indicates increased tenus of the sympathetic,
and is of clinical value especially in the absence of the oculocardiac reflex.
The stomach should be empty when the test is made.
Santenoise, D,, and Codet, H. Tue So_ar Rerrex. [Progrés Meédical,
Glee UN vlayeal. o): A, Ml. A.
Santenoise and Codet advise testing the tonus of the sympathetic by
means of the solar reflex. The fasting subject lies on his back with open
mouth, breathing freely but without forced movements. A sphygmoma-
nometer (preferably with recording attachment) is applied to his arm. The
physician compresses with both hands the middle epigastric region, push-
ing it toward the diaphragm. The reflex is positive if the oscillations
of the pulse diminish. This sign of increased sympathetic tonus occurs
in persons with vasomotor instabilitv, paroxysmal secretory disturbances,
[629]
630 CURRENT LITERATURE
and palpitations, such as are most marked in exophthalmic goiter and in
the menopause.
Philippsthal. Epicastric Neuratcia. [Deutsche med. Woch., Sept. 21,
Vol ers
A clinical study of ten patients with epigastric pains resembling those
of gastric ordnodenal ulcer, Injection of procain into the painful spot
gave relief and is held to be a differential indication of a nonsomatic
process. Addition of alcohol cured two, while five were refractory to all
measures until relieved by excision of the painful spot, the seat of the
neuralgia. In two of the cases, asthma accompanied the attacks and
subsided at the same time (after operation in one case, conservative treat-
ment in the other).
Soupault, R. Druc Dissociation oF V1iTAL CENTERS. [Presse Méd.,
Vol. XXXL, April 25.552 Ag vA
Soupault reports a case in which intraspinal anesthetization with
procain arrested completely the functioning of the respiratory center.
The blood pressure and circulation were only very slightly modified. -
Under artificial respiration the drug was eliminated enough so that the
paralysis of the respiratory center was finally overcome, and natural
respiration began anew the forty-fifth minute. This confirms on man the
dissociation of the bulbar centers realized in dogs by injection of
chloralose into the region. In the animals and in this clinical case,
consciousness was unimpaired. The man complained that the pressure
on the ribs hurt him, and the dogs dodged when threatened with a blow.
As the patient resumed spontaneous but sluggish respiration, a brief
convulsion occurred, and recurred six or eight times in the following
four hours. Soupault interprets the convulsions as indicating that
respiration was not adequate at first. The whole experience teaches the
importance of artificial respiration in mishaps with anesthetics. Instead
of wasting time on other measures, artificial respiration should be started
at once, and kept up regularly as long as needed.
Shawe, R. C. CoMMUNICATION BETWEEN VAGUS AND CERVICAL SYMPA-
THETIC. [Lancet, March 29, 1924. J. A. M. A.]
Shawe describes some connections which pass between the inferior
and middle cervical sympathetic ganglia and the vagus nerve with its
branch, the recurrent laryngeal—including their detailed distribution,
which appear to have hitherto escaped particular notice—and draws
attention to the clinical aspects of these associations. From the clinical
side it appears that the importance of these vagosympathetic fibers depends
on their two main spheres of distribution: (1) to the cardioaortic region,
and (2) to the thyroid gland. In the former association they mediate,
at least in some cases, as shown by the success of Jonnesco’s operation,
the critical nervous impulses of angina pectoris, transmitting the afferent
VEGETATIVE NEUROLOGY 631
stimuli from the heart and aorta, and very probably transmitting efferent
stimuli to that region. These nerves form a concentration point for the
sympathetic cardiac fibers from the upper dorsal segments, and as such
present a readily accessible isthmus at which to attack the vicious cycle of
irritation by surgical methods. In the latter association these same
communicating nerves probably mediate secreting fibers to the thyroid,
and it is the pathologic hyperexcitability of such fibers which may form
a most important etiologic factor in the production of exophthalmic
goiter; consequently, in suitable cases, in association with the other
cervical sympathetic ganglia, their extirpation would appear to be justified
in this disease as judged by the results of Jonnesco’s work.
Daniélopolu, D., and Carniol, A. OcuLocastric Rerrex. [Arch. Mal.
VApp. Digestif, Feb., 1924. ]
These authors find that like the oculocardiac syndrome there is also
a gastric motor inhibition brought on by light pressure upon the eyeballs.
Both signs can therefore be brought out at the same time.
Schroeder, C. B. Brockinc Nerve 1N WHOOPING CoucH. [KI. Woch.,
Wool lie Aug 137 J. An M.A: |
Schroeder had bad results with injection of alcohol into the superior
laryngeal nerve in children suffering from whooping cough.
Hustinx. BLocKING THE SPLANCHNIC Nerve. [Ned. Tijd. v. Gen.,
rere Oo sels VE. A :
Hustinx adds 119 cases to those on record which brings to 1,375 the
number of operations done under anesthesia of the splanchnic nerves in
the last two or three years. Four deaths have been recorded. The Braun
technic is more certain, but the Kappis technic anesthetizes all viscera
above the pelvis. A combination of the two seems to be preferable.
Complications on the part of the respiratory organs are reduced to the
minimum, but are not entirely done away with. The needle must be fully
14 cm. long, and it is a great improvement to introduce it in a sheath,
pushing the tip beyond the sheath only at the deepest point.
Westphal, K. Nervous INFLUENCE oF THE Motor PROCESSES OF THE
GAtIeDUCT. +} Zscnr. tek) Med,,. Vol. XCVI, Nos. 1-3. ]
Westphal first presents a review of all that has been written in regard
to the anatomy and physiology of the gall duct. He then describes his
method of investigation by which he is able directly to observe the entire
gall canal system in cats, rabbits and guinea pigs. He describes in detail
his various experiments and subjects them to criticism. They include
electrical and pharmacological stimulation of the vagus and sympathicus.
The phenomena observed in the gall duct are facilitation of the gall
discharge induced by a slight stimulus of the vagus by electricity or
pilocarpin which causes a lively peristalsis; checking of the discharge
632 CURRENT LITERATURE
even to complete retention of the gall as a result of a strong stimulus
which produces spasms chiefly in the region of the portio duodenalis
choledochi. Decrease in tonus is caused by paralysis of the vagus by
atropin. Stimulus of the splanchnic causes a closing of the sphincter in
Vater’s papilla and with it relaxation of the duodenal portion of the
ductus choledochus as well as of the gall bladder. The strengthened
muscular apparatus in the wall of the lower choledochus may be compared
functionally with the pylorus portion of the stomach.
Westphal, K. Pain oF THE GALL Duct ANp Its RADIATING REFLEXES.
[Zschr. -f£. kl. Med., Vol. XCVI, Nos. 1-3.]
Westphal reports his findings in 25 cases of disease of the gall duct
which received a contrast meal in the attack of pain. A marked increase
of motility of the stomach and intestinal musculature was observed in the
larger number of cases. The stomach showed widespread spastic states
of the entire canalis egestorius, increased contraction of the antrum,
pylorus spasm with failure of peristalsis, sometimes even a total gastro-
spasm. The small intestine gave the picture of hypermotility, the large
intestine a spastic collapse. These motor disturbances are brought about
through reflexes which originate in the nerve plexa of the gall bladder
and of the ductus choledochus. Atropin has a farreaching effect upon
these disturbances. Beside the peritoneal tension in the right upper
abdomen the stopping of the right dome of the diaphragm frequently
observed at the umbilicus is looked upon as a visceromotor reflex. An
important differential diagnostic sign for all sorts of diseases of the gall
bladder is the latent viscerosensory phrenic reflex, 1.e., sensitivity to
pressure of the right phrenic nerve at the neck.
Westphal, K. Motor Neurosis oF THE GALL Duct AND Its RELATION
TO THE PATHOLOGY OF THE LATTER, TO STOPPAGE, INFLAMMATION,
STONE ForMATION, ETc. [Zschr. f. kl. Med., Vol. XCVI, Nos. 1-3.]
Westphal by sounding the duodenum confirms in man the results
obtained in experiments with animals in regard to the emptying of the
gall duct under varying conditions. Aside from pronounced disease of
the gall duct there may be heightened stimulability of its musculature in
pregnancy, during menstruation and in vegetative neurotics. In investiga-
tion with pilocarpin this heightened stimulability manifests itself in an
increased initial checking of the discharge of gall. The author finds in
these observations more satisfactory explanation of the special disposition
of the female sex to diseases of the gall duct than in pressure of corsets
or pressure of the enlarging uterus. He considers functional nervous
disturbance as the basis for the genesis of stoppage of the gall bladder in
its hypertonic or its hypotonic form and as the ground for the result,
that is the formation of stones. The latter as well as the muscular
hypertrophy of the bladder is considered as due to stoppage which results
from incomplete discharge, hypermotor neurosis of the gall duct. This
VEGETATIVE NEUROLOGY 633
would probably have its origin, as e.g., in pregnancy, in disturbances of
internal secretion and it is probably further determined by a hyper-
cholesteremia such as is found in pregnancy and in arteriosclerotics. The
pains in gall colic are due to convulsive peristalsis of the gall duct and
reflex contractions in stomach and intestine. Atropin freely administered
recommends itself as the best means for combating these, together with
hot cataplasms and medication with olive oil.
‘Peritz, G., and Fleischer, F. SpasmMopuHit1a 1n Gastric Utcer. [Arch.
f. Verdauungs, Vol. XXXII, p. 243.]
The interrelationships between spasmophilia and gastric ulcer are
here emphasized and their fundamental pathology sought for.
Henderson, J. E. Stupres 1n Peristattic Faticue. [Am. J. Physiol.,
LXVI, p. 380.]
If one employs the Trendelenburg method of studying peristalsis in
isolated intestinal strips of the guinea pig one finds that on increasing
the internal pressure to a certain critical point the strips begin to show
peristaltic movements. These waves die out after a longer or shorter
time. In many cases, however, the activity is resumed and waves occur
in short groups. In these contractions both longitudinal and circular
muscles take part. During a quiescent period between the groups, local
pinching or other stimulation of the gut sets up a local contraction of
circular and longitudinal muscles and is not propagated as a peristaltic
wave. Evidently the musculature is contractile and irritable. The lack
of propagation must be due to a deficiency in some other structure. Some
evidence was presented to show that the mechanism had suffered from
fatigue of the ganglionic plexus, and the work of Cannon and Trendelen-
burg is discussed in the light of these results showing that this too could
be explained on this same basis. It was pointed out that the state of
tonus did not necessarily determine the presence or absence of the waves.
It was further pointed out that the frequency of the peristaltic waves
did not depend on the length of the strips as suggested by Trendelenburg,
but was due to some other factor. [Author’s abstract. ]
Morison, J. M. W. ELEVATION oF THE DIAPHRAGM: UNILATERAL PHRENIC
Paratysis. [Arch. Radiol. and Elec., Vol. XXVII, 353; Vol.
XXVIII, 72. B. M. J.]
The author discusses the differential diagnosis of elevation of the
diaphragm. A temporary elevation, he explains, is frequently caused by
gaseous distension of the stomach, and is often seen in carcinoma of that
organ. It differs from the permanent variety in that the movements of
the affected leaflet are never reversed—that is to say, there is no paralysis.
Permanent elevation may be congenital or acquired. Loss of movement
of the chest wall at the base and apex of the lung suggests that there is
congenital unilateral paralysis of the diaphragm, whereas increase of
movement on one side suggests an acquired corresponding condition.
634 CURRENT LITERATURE
That movements are not lost on the affected side in the acquired type is
due to expansion of normal lung and to the use of extraordinary muscles
of respiration. The causal condition may be injury or disease. The
author points out that Petit’s eventration and unilateral phrenic paralysis
are indistinguishable apart from a definite lesion of the phrenic nerve.
Permanent elevation of the diaphragm is to be differentiated from (a)
herniz, (b) localized hydro- and pyo-pneumothorax, (c) subphrenic or
subhepatic abscess. In herniz the X-rays show an elevated irregular
broken line extending across the hemithorax; underneath this line lung
tissue may or may not be seen. The stomach contents may reach above
the line of the cardia, palpation of the abdomen producing a rippling of
the surface. In small herniz reversed movements during respiration are
seen, but movements may be absent in large herniz. The author does not
lay much diagnostic stress on the presence or absence of the colon in the
pciture: it may be present or absent in both herniz and eventration. Of
the utmost importance is examination of the stomach by the bismuth
meal, which should settle the diagnosis. Hydro- or pyo-pneumothorax
and subphrenic or subphepatic abscess should cause little difficulty. In
all of them the X-ray picture will easily reveal the condition present, the
differential diagnosis from Petit’s eventration resting on the presence in
the latter of an unbroken bow line extending high into the thorax with
reversed movements unless adhesions have formed. In eventration, also,
the level of free fluid in the stomach is that of the cardia, and the bismuth
meal will reveal the gastric deformities so frequently present in the
condition.
Santenoise, D. PErRIopICITY IN VEGETATIVE NERvouS SysTEM. [Presse
Méd., Vol. XX XI, April 25.]
This author has followed some of the newer work on the vegetative
nervous systems and finds certain close interrelationships between the
oculocardiac reflex, the hemoclastic crisis, the solar reflex and certain
drug tests. He suggests that in periodic psychoses the balance in the
vegetative nervous system is seriously upset. Symptoms of vagotonia
accompanied paroxysms of acute. mania or psychoses of dread.
Bachlechner, K. Bitockinc THE SPLANCHNIC Nerve. [Zeit. f. Chir.,
Vol. CLXXXVY Feb.°98 ieAw vies
Bachlechner reports his experience in 600 cases of splanchnicus
anesthesia (Braun). He found the method harmless. Operations on the
upper abdomen (stomach, gallbladder) are entirely painless. No acci-
dents occurred. He observed no cases of collapse even in the most difficult
operations. He has never observed that the method caused any con-
siderable lowering of the blood pressure, as has been reported by some.
Failures are due in many cases to the inadequate anesthesia brought about
in the abdominal walls.
VEGETATIVE NECROLOGY 635
Balan, N, P. So-caLLep PyLorospAsM 1N InFants. [Archiv f. Kinder-
heilkunde, Vol. LX XIV, April 5, p. 81.]
This observer finds that in pylorospasm of infants, based on seven
cases, that the whole of the pylorus canal except the actual pylorus ring
itself is involved. Both musculature and elastic tissue were much hyper-
trophied, and the hypertrophy increased with the duration of the spasm.
Hypertrophy, therefore, is the consequence, not the cause, of the spasm.
Changes in the mucosa in the pylorus region accompanied the reflex spasm
in a few cases; in the others, innervation factors alone were analyzable.
Hannemann, K. Spastic Constipation. [Munch. med. Woch., April 4,
Vole x cl ale As MM; A. |
Hannemann presents arguments to show that a neurotic overexcitability
is the primary factor in spastic constipation. Psychotherapy is the
rational treatment, and has proved astonishingly successful in his hands.
He has returned to the method of simple suggestion as published by
Bernheim in 1892 and Forel in 1911, and only exceptionally resorts to
hypnosis, catharsis or psychanalysis methods. In case of doubt as to the
exact nature of the constipation, whether atony or spasm is the pre-
dominating factor, an adductor sign he describes turns the scale. He
lifts with both hands one leg of the reclining patient, flexes the leg, and
tries to abduct it, telling the patient to relax his muscles. There is no
resistance in normal subjects, but almost invariably in the spastic constipa-
tion cases the adductors are contracted so that abduction is almost
impossible. In some cases the foot of the other, the horizontal leg,
spontaneously twists inward at the same time. This adductor sign indi-
cates extreme motor excitability which includes the intestines, readily
explaining the spastic constipation, and the benefit from treatment of the
neurotic predisposition. The same method of treatment has proved
remarkedly successful in other conditions in which neurotic-functional
influences are at work, as for instance, Heyer’s success in curing gastro-
ptosis with psychotherapy. He describes a few typical cases, saying that
spastic constipation is encountered in men almost as often as in women.
The intensity of the adductor sign is a gage of the severity of the spastic
condition in the bowels, and it subsides parallel to the subsidence of the
clinical and roentgen-ray findings typical of spastic constipation.
Pipping, W. INTESTINAL INFANTILISM. [Finska Lak. Hand., Oct.,
Mollak te passe. jc ACM. A.
Pipping describes the clinical picture of the severe chronic insufficiency
of the digestive apparatus, in children past babyhood, which Herter calls
intestinal infantilism. Pipping has encountered five cases in the last
five years, and one was in the children’s hospital for three years. Nothing
suggesting inflammation was found in the intestines at necropsy, in one
typical case. The pathologic findings were dilatation of the ventricles and
636 CURRENT UIT ERALURE
fatty degeneration of the liver, with anemia of all the organs, and acute
pneumonia. The extremely chronic course of the intestinal symptoms;
the fluctuations in the weight, independent of external causes; the develop-
ment of edema of neither cardiac nor renal origin; the lack of any
influence from dietetic measures—all testify to a constitutional endogenous
factor. Two of the six children had severe attacks of tetany—which is
rare in Finland—with other signs of an intense spasmophilic diathesis;
instability of the nervous system was evident in all. One of the children
had pains in the hands and feet, insomnia, edema, micturition every half
hour, lack of appetite, vomiting and loss of weight and strength, long
before the intestinal symptoms became pronounced, and a younger sister
presented a similar clinical picture. Only one of the six belonged to the
laboring classes, and all were girls, between the ages of two and five.
Three have died, from inanition cachexia; they were “ unnourishable.”
Two seem to be improving slightly at present as regards the nervous
symptoms, but they will probably be stunted in growth. One of them
seems to have nearly recovered; the symptoms had all been milder in this
case. She improved on a diet of skimmed milk and meat juice at first, but
the hemoglobin percentage was 40 (Sahli) on leaving the hospital after:
a year’s stay.
Livingston, Edward M. StupiEs oF VISCEROSENSORY PHENOMENA. [J.
A. M. A., May 10, Vol. LXXXIII.]
This study is based on fifty cases diagnosed clinically as acute
cholelithiasis or acute cholecystitis. Thirty-one of these came to opera-
tion. Twenty of the thirty-one patients that were operated on had positive
skin signs, two had negative skin signs, and nine had no sensory tests.
In other words, with but two exceptions all tested patients had positive
cutaneous hyperesthesia. The first negative patient was a woman having
both gallstones and kidney stones as concomitant findings, the skin signs
being negative for cholelithiasis and positive for nephrolithiasis. The
other negative patient was a woman who entered the hospital without
acute colic but on account of a gradually deepening jaundice of three
weeks’ duration. A preoperative diagnosis was made of carcinoma of
the head of the pancreas or impacted common duct stone. Operation
disclosed the latter. Skin signs would not be expected in such a case on
account of the long duration of the complaint, the lack of an acute colic,
and the operative findings. An analysis of the thirty-one operative cases
of acute biliary disease shows further that localized skin signs are as
constant and valuable as any other signs or symptoms of this disease.
Characteristic pain was noted in nineteen cases, eructations of gas in nine,
vomiting in twenty-four, constipation in seven, jaundice in thirteen,
hematamesis in none, typical tenderness in thirteen, abdominal rigidity
in nineteen, a mass in eight, positive skin signs in twenty, and positive
roentgen-ray findings in nine. If these data are reliable it would seem
VEGETATIVE NEUROLOGY 637
that a dictum might be made concerning the most uniform of these signs
and symptoms. It may ordinarily be concluded that a history of
acute pain in the right upper abdominal quadrant associated with vomiting
and abdominal rigidity constitutes a combination of symptoms pointing
definitely to acute biliary disease, but that if localized cutaneous hyper-
esthesia is superimposed, the diagnosis is almost certain. In biliary colic,
it may be concluded that: In acute cholelithiasis and acute cholecystitis,
localized skin signs uniformly develop during the attack. In cases with
negative skin signs or with skin signs present elsewhere, the condition
is not a simple acute disease of the gallbladder. In renal colic it is con-
cluded that: The viscerosensory phenomena may be produced at will for
study or demonstration by a sufficient distention of the ureter and kidney
pelvis. A triangular area of skin on the inner and upper portion of the
thigh is here suggested as being of value, from a clinical standpoint, in
determining cases of intraureteral tension. A few isolated cases of acute
nephrolithiasis are reported. It is emphasized, 1n conclusion, that acute
distention within the appendix, biliary ducts and ureter uniformly produces
localized cutaneous hyperesthesia. Tests for this hyperesthesia should be
made with the grosser forms of stimuli, and a vigorous twisting pinch is
the most reliable method of examination. Localized hyperesthesia, when
properly correlated with the other clinical data present, is of great impor-
tance in the differential diagnosis of diseased states of these tubular
structures. No physical examination for the diagnosis of acute diseases
of the appendix, biliary ducts or ureter is complete without tests for
localized cutaneous hyperesthesia.
Bickel, A,, and Watanabe, T. Action or Drucs on Bite. [Deutsche
med. Woch., Vol. XLIX, June 29.]
Drugs which act on the sympathetic and parasympathetic systems have
little influence on bile secretion according to this report. They have a
pronounced influence on the musculature of the ducts however.
Meller, E. Mertazorrism IN Nervous Anorexia. [Uge. f. Laeger.,
Weta Vleet epaai4ep 130; J AseM: A]
Mller gives figures showing the basal metabolism in four cases of
nervous anorexia. With the extreme undernourishment and loss of
flesh, bradycardia, chilliness, amenorrhea, constipation and low metabolic
rate were pronounced; also low sugar content of the blood, increasing
only slightly and very slowly after intake of glucose; with hypotonia, and
only slight increase in the blood pressure under epinephrin. One of the
patients presented cyanosis of the hands, and one had periods of profuse
diuresis. He discusses which of these symptoms can be ascribed to the
undernourishment, accepting the amenorrhea as due to this. Nothing to
suggest myxedema was observed in any of the cases. His observations
justify the conclusion that undernourishment has an influence on the
functioning of the endocrine system in whole or in part.
Book REVIEWS
Alfvén, Johannes. Das ProBLEM DER ERMUDUNG. EINE PSy-
CHOLOGISCHE STuUDIE. [Verlag von Ferdinand Enke, Stuttgart. |
This small monograph (78 pp.) constitutes Vol. 6 of Mboll’s
‘“Abhandlungen ”’ dealing with psychotherapy and medical psychology.
We have dealt, in these pages, with some of its predecessors and turn
to the present work with the anticipation of pleasure which its fore-
runners have already prepared.
Nor are we altogether disappointed. First, because it is not a
series of kymograph tracings of tired muscles—as if muscles were
all there was of man. For this relief much thanks; for reviewers are
always tired. Fortunately the material before us contains much to
intrigue, not a little to stimulate, and perhaps somewhat to combat.
The author announces that he will deal with conditions of psycho-
logical fatigue, concerning which he notes some dearth of study.
He thus comes first to the fiction of “ Neurasthenia.” Thumb
sketches of the definitions of Westphal, Ziehen, Binswanger, Beard,
Oppenheim, Dubois and Dejerine prepare the way to a formulation
of the condition of “ irritable weakness ”’ which is “ psychical’ above
all things. What is called “ physiological fatigue’ must first be stud-
ied as his next step in the consideration of which unpleasant and
goalless work is considered; their fatigue as a protection against
monoideal and stereotyped performance. This leads to fatigue and
exhaustion.
Nervous fatigue is then discussed as “ overinnervation,” “ te-
nacity ’* of work, “ repulsion,’ adaptation and avoidance, and finally
negativisms to work, and so on. Unfortunately the author floats
on the descriptive surface of his subject and never gets down to
grips with the “affectivity ’ situations in their dynamic setting.
In this respect we find nothing that really helps us although the
general discussion has been entertainingly set forth.
Muskens, L. J. J. Epirepste. VERGLEICHENDE PATHOGENESE,
ERSCHEINUNGEN. BEHANDLUNG., Mir 52 ABBILDUNGEN.
[Julius Springer, Berlin. ]
This is a monograph of approximately 400 pages chiefly dealing
with the researches of the author upon a variety of phases of the
epileptic phenomena. It is a very serious and valuable work, the
which to adequately review would involve much more time and space
than can be spared. This is to be regretted since any investigator
who has spent so many years in painstaking study, as here set forth,
should receive a just modicum of praise for his efforts. This we
would frankly grant him and say this is the most important con-
[638]
BOOK REVIEWS 639
tribution to the general subject that has appeared within the past
twenty years. The problems are so many, however, so intricate,
complex and involved that even this monumental effort falls short of
completion. And yet here are certain definite attainments; valid
solutions of certain aspects, and foundations for future research.
In the main the emphasis is perceived as dealing with the physio-
logical aspects of the convulsive phenomena. The author’s experi-
mental work affords certain platforms, some conclusions which need
not be further inquired into and from which future research can
proceed.
As a record of over twenty years of continuous preoccupation
with the problems much praise is to be accorded. To attempt to
recapitulate what the author offers would be a task far beyond the
reviewer's capacity.
We can only state that this work is one that every worker in this
field will find indispensable. Our own conviction is that twenty
such volumes will be needed to completely set forth all of the many-
sided intricacies of the epilepsies. This is a sound beginning. Its
chief deficiencies as an effort to encompass the whole field, as we
see it, lies in the inadequate portrayal of the psychical side of the
problems involved. This is not a criticism. Some day, maybe, a
supergenius can encompass the total situation. This may be in a
decade, a century, or a millenium. We vote for the last, but at all
events here is a most sincere and praiseworthy effort, at least, to
outline the difficulties, if not offering a solution of them. As a final
word we cannot resist offering our thanks for the publisher who
eives us this contribution. The least that can be done by neuro-
psychiaters is to buy the book in recognition of such bravery.
Ferenczi, S., and Rank, Otto. THE DEVELOPMENT oF PsyCHo-
ANALYSIS. [Nervous and Mental Disease Publishing Co., New
York and Washington. |
This is a short and fascinating monograph (No. 40) which details
some of the advances that have been made in psychoanalytic theory
and practice in the past thirty years, since Freud in 1893 first pub-
lished, with Breuer some new ideas about the psychoneuroses.
As with all other aspects of medical science psychoanalysis was
not content to rest upon its earlier formulations. In this span of
time it has grown by leaps and bounds as have other special medical
studies. Freud has already written upon the psychoanalytic move-
ment but the present work would, in a sense, continue this general
story, both from the medical therapeutic earlier interests to the
scientific theoretical principles which have spread over into vastly
larger fields.
This spread has become so great that an inevitable confusion has
become manifest. One is not now alluding to the many pseudo-
analytical or wild analytical contributions, which seem to be the spe-
cial camping ground of misinformed critics, but to the difficulties
which sincere workers have met with the deeper the investigations
have gone into unconscious processes in man and their resultant
640 BOOK REVIEWS
symptomatology. The practical and therapeutic gains have seemed
to outrun the more important theoretical foundations and a thorough
investigation of the whole situation has seemed advisable. This is
the main thesis of the present study.
In 1914 Freud contributed an important study upon ‘“ Remember-
ing, Repeating and Working Through.” From this point on new
issues came into psychoanalytic technique and new theoretical con-
siderations grew out of the material. Older technical rules needed
revision, as with all scientific techniques, and new insight was gained,
which this monograph very clearly sets forth.
The first situation discussed is that of the “unwinding of the
libido.” A situation which in a less consciously understandable form
is that already seen in every medical situation, where the “ doctor ”’
quietly and patiently serves his patients. Here the “ transference,”
which is an universal phenomenon, and necessary in all sincere medi-
cal practice, is more carefully analyzed in view of psychoanalytic
principles, and the factors of resistance subjected to more pains-
taking scrutiny.
This leads to a critical historical retrospect of what has been
gained and a revision of many of the older points of view especially
with reference to the significance of free associations and interpreta-
tion of dream material. This is a very illuminating chapter and
should be read by the superficial critics who have thought to make
much material out of what they call “faulty methods” of
psychoanalysis.
It was a common observation among many physicians using psycho-
analytic methods that the ease of early cures gradually ceased and
many disappointments arose. It almost seemed that the “ laiety ”
becoming acquainted with the general principles, cured their own
minor psychoneurotic difficulties, and only brought more difficult
situations to the psychoanalyst, or that “cures” were not so often
“cures ’ as substituted activities requiring more intensive application.
These and other problems are all reviewed in this very valuable
monograph which marks a definite milestone in the advancing com-
plexities of the new science of psychoanalysis.
Lange, Carl Georg, and James, William. Tne Emotions. [Wil-
liams and Wilkins Company, Baltimore. |
It was a happy idea this—to reprint under the caption of “ Psy-
chological Classics ’—a translation of Lange’s The Emotions, and
James’ essays What Is an Emotion? and The Emotion, the combina-
tion having been current for years under the idea—the James-Lange
Theory of the Emotions.
Dr. Dunlap of Johns Hopkins sponsors the effort and we look
forward to other. fundamental conceptions which have been current
in psychological circles. Whereas the work of James has been
available in English for many years the work of his Danish precursor
has heretofore been available only in French and in German. It is
a valuable addition to all students of the mental sciences and what
BOOK REVIEWS 641
educated man can think of himself as such without some compre-
lension of the mental life of man? We congratulate Dr. Dunlap
upon his performance and hope to see other classics appear under
his guidance. This is an indispensable work for the library of every
worker in neuropsychiatry.
White, William A. THe Meantinc or Disease. [The Williams
& Wilkins Company, Baltimore. |
Dr. White. has termed this work in his subtitle, An Inquiry in
the Field of Medical Philosophy. This is a comparatively unexplored
field, 1.e., by those competent to investigate. In practical literature
there is no dearth of pseudophilosophies about medicine. To quote
even a moiety would overrun our pages. Pliny vented his spleen
upon doctors; Moliére in his “ Malades Imaginéres”’ held up the
medicine of his day to ridicule; with much humor not unmixed with
malignancy Bernard Shaw took a shot at modern conceptions of
immunology, and coupled with his more recent swat at the clericals
Sinclair Lewis in his “Arrowsmith ” screeches a modern preachment
at certain trends in medicine.
The present work, however, 1s no Arrowsmithian portrayal of the
mendacity of practical medicine. Had Lewis but a scintilla of the
knowledge of the field as Dr. White portrays it he could never have
shown his myopic perspective.
Here is a real and honest effort to show how broad and wide must
one’s conceptions be to even understand what medicine and disease
signify. Cheap and filthy criticism are easy—understanding is diff-
cult, as Hippocrates had long ago spoken in his memorable statement
“Ars longa, vita brevis est”’—-the whole quotation, running as a
legend along the facade of the new and beautiful New York Acad-
emy oi Medicine at 103d Street and Fifth Avenue, serving as a
reminder to a posterity of the dignity and sincerity of the medical
discipline.
Dr. White has caught the spirit of this Hippocratic conception and
offered a work upon the significance of disease, which is both timely
and salutary. He has here set forth in language that any one can
understand what disease, in its larger frame is, at the same time
most lucidly setting forth its complexities and intricacies.
One might wish that more efforts of this type might be offered
to the new gigantic developments that are taking place in American
medical activities. Had we more thinkers as sincere and as clear
in setting forth the general principles that underly a philosophic
understanding of the meaning of disease one could prophesy great
things for American medicine.
Storfer, A. J. AtmanacH 1927. [Internationaler Psychoanaly-
tischer Verlag. Wein.|]
It was a happy idea that prompted the issuing of the Almanach of
1926 and so the issue for 1927 follows: Those in touch with the most
intimate features of the psychoanalytic movement know what it is
642 BOOK REVIEWS
all about. Here may be found some extremely interesting short
articles upon psychoanalytic subjects. There is an excellent repro-
duction of Schmutzer’s etching of Freud and a photograph of
Abraham. Among the articles are reproduced the birthday addresses
of Andreas-Salomé, Bleuler, Zwerg and Doblin on the occasion of
Freud’s 70th anniversary. Then follow three short papers by Freud,
one on Psychoanalysis and Quackery being most readable; it is taken
from his latest work on “ Lay Analysis.”
Then follow short studies by Pfister, Eder, Reik, Abraham,
Levine, Wyneken, Binswanger, Kelsen, Kohn, Gomperz, Rank,
v. Sydon, Jekels, Alexander, Horney, Simmel and Groddeck.
Some of these have appeared in other periodicals; others are new.
The collection is noteworthy and the Almanach should be in the
hands of all interested in the practical or theoretical aspects of
psychoanalysis.
Seelert, Hans. ANLEITUNG zU PSYCHIATRISCHEN UNTERSUCH-
UNGEN. [George Thieme. Verlag. Leipzig.]
A short, concise and clear little handbook of methods of psychi-
atric examination. Psychiatry is here conceived of in the orthodox
behavioristic and descriptive sense. No mention is made of the inner
significance of any of the “ facts” to be observed, without which no
psychiatry is vital. As one who once having looked at the minute
structure of things with a microscope is not content to rest with
macroscopic observation, so once having really tasted on the methods
for the study of the unconscious, the older regimes seem insipid.
Monrad-Krohn, G. H. THE CLINICAL EXAMINATION OF THE
Nervous SystEM. [Third Edition. Paul B. Hoeber, Inc., New
York. |
We have had occasion to commend this little volume highly on
the appearance of both previous editions. It is not complete but it is
clear and serviceable. The new edition has had added to it some notes
upon the pharmacological testing of certain functions of the vegeta-
tive nervous system and also some descriptions of Thomas’ work
upon the pilomotor reflexes and Magnus-Kleijns postural reflex
activities. It is even better than the previous editions.
Léri, Andre. Eruprs sur LES AFFECTIONS DE LA COLONNE VERTE-
BRALE, [Masson et Cie., Paris. ]
Professor Léri, Agregé to the Faculty of Medicine in Paris, has
for many years devoted much of his attention to neurology. At the
same time, as is consistent with the best French traditions, he has
made extensive and valuable surveys in other domains, one notably
in studies on the bones and articulations other than those of the
spinal column.
It is then quite consistent that the neurological interest should
come nearer to the footlights in this study of diseases of the vertebral
column, for here naturally the spinal cord and the various nerve
plexuses become subjects of intimate interest.
BOOK REVIEW'S 643
Protessor Pierre Marie has written a preface in his usual graceful
style and called attention to certain features of the work. These are
the studies on Spina Bifida, upon Sacralization of the Lumbar Verte-
brae, upon Fracture of the Spinal Column, and a number of other:
vertebral diseases which, implicating the nervous system, constitute
extremely important chapters in that frame, that Professor Marie,
calling attention to Bouchard’s vision, would designate the “ chronic
disorders of mankind,” and the which he emphasizes should by
all means be represented by a “Chair” in the Faculty of Medicine
of every university.
When one realizes with what patience and indomitable energy
one has to combat this vast horde of “incurables,”’ the prey of every
type of despicable parasitic exploiter in the realm of quackery, one
can but echo an earnest “Amen ” to Professor Marie’s plea.
This work is therefore doubly welcome. It is not only sincere,
but beautifully documented. The use of X-ray investigation is quite
brilliantly set forth. Every neurologist meets with numerous
instances of mdst annoying chronic illnesses in which disease of the
spinal column plays a major role. Here is a most illuminating help
to an understanding of these difficult problems.
Delgado, Honorio. SicMuUND FrREup. [C. F. Southwell, Lima,
Peru] :
It is not many years ago when the opponents of psychoanalysis
used to muster up a list of the old guard professors of neuropsychiatry
who were antagonistic to the newer principles as evidence of its
untrustworthiness or what not. But in the past ten years there has
arisen a volume of adherents in nearly all the faculties of the entire
world keenly alive to Freud’s genius and to the fruitfulness of his
conceptions in psychopathology. The old guard opponents now stand
out as “islands ” like the deserted castles of the Danube in compari-
son with the living younger members of the neuropsychiatric
Eraternity.~ 7
Here is found an appreciation from Lima, Peru, in the volume
under consideration, which was prepared in honor of Freud’s 70th
birthday and given before the National Academy of Medicine in
Lima, Peru.
It is a delightful review of the psychoanalytic movement in all its
phases and is an excellent orientation as to the attitude of the grow-
ing body of the newer generations in South America.
Rivers, W. H. R. PsycHotocy anp EtHNoLocy. Edited with
Preface and Introduction by G. Ettiot Smitu. [ Harcourt, Brace
& Company, New York. |
Genetic psychology has become dominant, for the most part at
least, in cultural circles. That the past has had much to do with the
present no one doubts, and the acceptance of a general principle of
recapitulation is fairly on its way, so long as one is not too meticulous
in the straining of analogies.
644 BOOK REVIEWS
In matters of antomical structure of the nervous system the con-
ception is fully adhered to; in social structure it is highly probable,
although as yet a complete genetic sociological platform has hardly
more than begun to be erected.
Dr. Rivers has done much to follow such a viewpoint, and it is
one of the great catastrophies of science, that he should have not
been able to complete his work. Dr. Elliot Smith has done admirably
with the unfinished fragments but one regrets that the author himself
could not have revised the individual papers he left behind him.
For the student of neuropsychiatry there are many excellent
chapters. It need not be insisted upon in these columns how much
ethnology belongs to the deeper understanding of man’s mnemic
inheritance of racial experience. We are inclined to be sententious
and point out that one doubting this general conception would be
best described as one with long ears and whose family crest is a bale
of hay.
At all events we feel convinced that the reading of the book
notwithstanding some juvenilities, would reduce the length of the
ears or the size of the fodder of any aforementioned doubting
Thomas.
Rouhier, A. Le Peyotit. [Gaston Doin et Cie., Paris. ]
A very complete and satisfactory monograph upon the “ Mescal ”
plant, now termed by the botanical systematists Echinocactus W1l-
hamsu, mostly known in American literature as Anhalonium Lewinit.
The author gives us a complete botanical, pharmacognostic,
chemical, pharmacological study; one of the most satisfactory with
which we are acquainted. We note in passing he has overlooked
Maloney’s careful psychological investigation, one of the best in the
literature.
Thévenard, André. Les Dystonies p’AtTTiTtuDE. [Gaston Doin,
Paris. |
This small but very delightful monograph is a direct outgrowth of
the encephalitis epidemic and of the work upon the extrapyramidal
systems, specially founded however, as he states in his introduction,
upon some dystonia patients of the Ziehen-Oppenheim type.
The monograph begins with a discussion of so-called normal
vertical standing, its bony and muscular correlates.
Elementary motor synergisms are then taken up, and the leg and
foot phenomena involved in maintaining equilibrium minutely
analyzed. The tonus of position then is discussed, to be followed by
pathological states, thus involving consideration of the Magnus
studies on labyrinthine and neck reflex phenomena.
This leads directly into pathological states, the first of which
taken up is dystonia musculorum, then decerebrate rigidity, athetosis,
torticollis, and a final chapter upon the anatomopathology of these
various anomalies of posture.
A delightful, clear and practical monograph.
NOTES AND NEWS
BRITISH-AMERICAN NEUROLOGICAL MEETING
A combined meeting of the Neurological Section of the Royal
Society of Medicine and the American Neurological Association will
be held in London, at the House of the Royal Society of Medicine,
1 Wimpole Street, W-!, on -July 26, 27 and 28, 1927.
TENTATIVE PROGRAM
Tuesday, July 26th:
O307a.m,: short papers,
2 p.m.: Short papers.
Wednesday, July 27th:
9.30 a.m.: Discussion on the Cerebellum:
Ope tee tedenches! imey and Fi. Jy.; Riley: “Comparative
Morphology.”
eco ies eonock,and las Davis: “ Physiology.”
(3) Or, Aubrey l. Mussen: “ Experimental Results.”
(4) Dr. Harvey Cushing: “ Surgery.”
to) Dri. He. Weisenburgs “Clinical.”
To be discussed by Dr. James Collier, Dr. Gordon Holmes, Dr. F.
M. R. Walshe and Mr. Wilfred Trotter.
2.30 p.m.: Special clinical meeting.
Thursday, July 28th:
9.30 a.m.: Discussion on Sensory Disorders in Organic Disease of
the Nervous System:
(1) Professor J. S. B. Stopford: “Sensory Disturbances Fol-
lowing Division and Suture of a Peripheral Nerve.”
(2) Dr. Gordon Holmes: “ Sensory Disturbances Due to Spinal
and Brain-Stem Lesions.”
(3) Dr. Wilfred Harris: The same.
(4) Dr. S. A. Kinnier-Wilson: ‘ Certain Dysaesthesiae and
her, Neurals Correlates.”
2 p.m.: Papers and Demonstrations on Pathological Subjects.
5 p.m.: Dr. Charles L. Dana will deliver the Hughlings-Jackson
Lecture.
[645]
646 NOTES AND NEWS
BRITISH MEDICAIZ ASSOCIATION
The annual meeting will be held in Edinburgh, Scotland, on July 19
‘to 22, 1927, inclusive. It will be the occasion of the centenary
celebration of the birth of Lister. Dr. Edwin Bramwell, 23 Drums-
heugh Gardens, Edinburgh, is the Chairman of the Neurological
Section. A very cordial invitation has been extended to American
neurologists to attend.
Two numbers of a new Archives of Psychoanalysis have been
received which are worthy of attention. Dr. L. Pierce Clark is the
directing editor. They contain important psychoanalytic material
which by reason of its bulk or minutiz is usually excluded from the
usual technical journals. The first number also contains the begin-
ning of the translation of Groddeck’s Das BucH Vom Es, an
extremely delightful work and one that all neuropsychiaters should
know, and Number 2 contains a translation of Freud’s HEMMUNG,
SYMPTOM AND ANGST, which is one of the latest and most com-
prehensive expressions of Freud’s views concerning the relationships
of these behavioristic responses. The Archives of Psychoanalysis
will appear quarterly. No. 2 is bound—250 pages each—and the
cost will be $5.00 per number.
NOTICE
A meeting of the Ligue Internationale Contre I’Epilepsie (The
International League Against Epilepsy) will be held in Zurich,
Switzerland, early in August. The exact dates will be published
soon. Those who wish to bring before the meeting any communica-
tions or read papers, are invited to communicate with Dr. L. J.
Muskens, Secretary, 136 Volden Straase, Amsterdam, Holland;
Dr. Ulrich, Canton Interspital, Zurich, Switzerland; Dr. G. Kirby
Collier, 80 East Avenue, Rochester, New York, or Dr. A. L. Shaw, -
The Olbiston, Utica, New York.
N. B.—All business communications should be made to Journal of
Nervous and Mental Disease, 64 West 56th St., New York.
All editorial communications should be made to Dr. Smith Ely Jelliffe,
Managing Editor, 64 West 56th St., New York.
INDEX TO VOLUME 65
Figures with asterisk (*) indicate original articles and are accompanied with
title.
SS AMG Bibs ofl end Mah ladles, SON Apart 76
Abstraction, psychology and
Pat lOr Vy Olireyer ee aon to: 220
ENOCH s lies. a. ates ans tee 193, 194
Achylia gastrica, etiologic relation
of to combined sclerosis of
SPW COIGS os cheers. bi eeces 191
Acidosis in hyperthyroidism..... 66
PACLAMTL GLI E, Seat sy ace ae tere we 430
POMEL ye eta eine eles eae ee 89
MCE ewe Clini cet ceke.s oe He ee 180
Pulsvotanineawki, eae. vs 4 dvieeiee. 191
Alcohol in relation to insanity... 211
Ler erinStirancCes:! sv. sualee Oat 211
IEF O PICS toa oe slere ore ek Zid
problem, social aspects of...... eA
Alcoholism, mental states in..... 92
MODAL Ole fe ak. Sse a de PA
PLLG SANUGE Ws. te GALE Seite oe eto 546
PB clotqinrad Oe hs hepmpg ot ate eae tA 97
WL Veta ONanVeS i .~ ea na ced Selo es 638
vata Nott OS ADR ee ae ae eG 537
PNMHAT A CINIIOL/ nnn Ata Gn, cs ors 641
PeINareZ aa ita Meas oof 4: 176
Amyotrophies, encephalitic ...... 59
i TO) GSN be 2 RS a a 412
Anaphylaxis, place of thyroid
DTATIC WIT Me Rhea kee ee Se,
Anemia, pernicious, mental
changes associated with.... 93
neurologic aspects of early di-
ACHOGIS® Gian ree i, ne 428
PathOgenesiss Of onan. se igs
Angina pectoris, resecting the left
cervicodorsal ganglion of
synipatietio tos is 624k 7 Mee. 180
Anhydraemia following destruc-
How or thalamius st Git ssc) 89
relation of cerebral puncture
ny pecuierniin thee Ae St 2 Ae 89
Anorexia, nervous, metabolism in 637
A Siertirclbtie aint Meet ces. 80
exmitnropology, social> <..24e0i0.. 449
Apes, reflexes in.......... ha See *457
Aphasia, intermittent, in right
sided hemichorea with right
Bemiplegiay 2.5) 520s sae 433
UT aaine ee okey. eRe. wlese bo 66
Arachnoiditis, adhesive spinal,
simulating spinal cord tumor. 609
AM PEM age 1 yi a cdi ae *569
Figures unaccentuated, accompanied with titie, indicate abstracts.
PLTOMOVItCH;. Gevl pice ene eee *457
Arsphenamin therapy, acute as-
cending meningo-myelitis pos-
Siply resultine’ -troir.. ae 195
Arteriosclerosis in children, ma-
lignant hypernephroma ...... *42
Arthritis, vertebral, and pyram-
FOAIMIESIONS Hee cs he oe ees 191
Association-system in cerebellum 78
EOS Ree Tee, utes oc oe cre 420
AMC CCHIUT obs sult oe ee 427
MinbecCaraiac® Teves’. ....6.<0) 183
and loss of vagus symphatetic
‘0ST EY OS Sa, 427
bromctial and climate... 0.25. 426
Ce te RATICE.” 6.8. Sa8 has 517
ileocecal delay and vagus re-
flex as etiologic factors in. 182
nature and pathogenesis of
and relation to hay fever
and other diseases..:..... 183
CORCT Ta ee PO AS Ok Si a 3 427
CEIOLOON eee pia ad aps hos 423, 425
hay tever, treatment of........ 426
MIRC MULGLCH Batok onl ek ees a: 426
treatment of
treatment of with combined pep-
LOHR ane VACCINE sei foie os 425
Asthmatics, studies on reactions
of and on passive transfer-
ence of hypersusceptibility.. 183
Athetosis, clinical and experi-
Mmicntalestuidy Ofe...- 224s: ec 434
Atropin, pilocarpin and _ gastric
MOCOt UIICtIONL ws 6. fnew ks 520
Auditory function in relation to
Caley LOU» INUSIC, 2. aa ee 536
Auricular fibrillation in hyper-
PEL VGOLAUSIT ereelci secs aor see 70
Automutilations in mental dis-
Ordetsr ts Migs 2 ho. Ae ee 99
Autophagia in mental disorders. 99
ACH LEGHNE RS Keyes 634
Backache, psychoneurotic .... 439
Badonnel.cMa ves oo eee eee 98
Baerwald. Ri see es 103
Batley 203k oe ee en ae 64
Bailéya,b erciva. wats. eee oe 508
Bailey, Pierce to, aman tee. *345
Bakker 1S 2 VP ngc.ce) pre oe he 78
[647]
648 INDEX TO VOLUME 65
Balan Ns.P/ cha ee eee 635
Baldi, “FO: fete oe eee 543
Barbour, “DING: wee eee 100
Barres Avnet eee ee 191, 199
Barrier:. Cy Wait ace eee eee 181
Basalizanglia®. 2 so ee eee 218
iractcanatomy1o1s. ee oe ee 534
metabolic rates in exophthalmic
goiter! (Parts ae Pacer eee 70
metabolism in cretinism....... 72
in shyperthyrotdism [2.2 40.. 67
Bassoé;., Peter iis senate ee 339
Bajtain: Miia eee ee ee 534
Bauer,..J) (see eee eee 186
Beating phantasies and day dreams 442
Behavior, erotic, of. idiots........ *407
Behaviorisit) aivao eee coe ee ee 450
Belgrano, Ratl Artceaneenee oe 519
Belloni; :.Gi Bs a ee eee 209
Berardinells. Woes oe ee 430
Beretervide, ip.) see 426
Bergamini, Ai eee Sect VAM 529
Beriberi: Gakic nee eee 187
glands of internal secretion in. 188
Bériel...2 92. seein ee ee 202
Berkeley, \W. iNi@r tae ee 217
Berlucchi,. Ga fa) eee 83
Bernard, dias Le ee eee 221
Bernifeld,:Siecintedan aes 106
Bertillon, Ko... es eee 81
Bickel, A. 4. 3c ae ee 637
Bickel, (Ga Shige eee eee 187
Bietipals.. 4 ee eee 426
Bigtand, A: jee eee 179
Bile, action Of dries ona eee 637
Biochemical and endocrin studies
in schizophrenia ....... *465, *585
Biology of the intersex.......... 327
of the, person... ae ee 447
Bircher; Eason eee 71
Birnbaum;uikarl, Sse eee 550
Blacklock). &.... te eee 430
Blakeslee, George Alla. -., ane 614
Blatherwick iN, oRsacancee see 188
Bleeding time in catatonic de-
mentia orecox (pn ee 207
Blind Goddess¥>.30..5. a see ae
Bloch, awanit.c2 epee eee 105
Blood, action of fight ones. ee 179
groups in mental diseases...... *569
pressure in dementia precox... 203
study: so ape on eee 176
test of liver functioning...... 76
Body posture and corpus striatum 534
Bogaert, Van vay fe sa eee 430
Bolk, LL. 2:4 eee 73
Book reviews:
Alexander, Gy) Marburs, 70>
and Brunner, H., Handbuch
der Neurologies des Ohres.
III Band
Book Reviews—C ontinued
Alivén, Johannes, Das Problem
der Ermudung. Eine psy-
chologische Studie". .] see 638
Baerwald, R., Zeitschrift ftir
Kritischen Okkultismus und
Grenzfragen des Seelenlebens.
Vol. Uy Hettel =. 5 cee 103
Barbour, D. N., Psycho-analysis
and -E.verymaii 92... . see 100
Bassoe, Peter, Nervous and
Mental Disease. Vol. VIII.
serres, 1925) 225.00 eee 339
Berkeley, W. N., The Principles
and Practice of Endocrine
Medicine
Rernard, LL. -L.. lustinctaaee
Study in Social Psychology. 221
Bernfeld, Siegfried, Sisyphos
oder die Grenzen der Erzie-
edbe ct aaa pa ey 106
Birnbaum, Karl, Die psychi-
schen Heilmethoden. Fur
aerztliches Studium und
Praxis von K. Birnbaum, H.
v. Hattinberg, G. R. Heyer,
E. Jolowicz, A. Kronfeld, E.
Wexberg
Bloch, Iwan and Lowenstein,
George, Die Prostitution.
Zweite Band. Erste Haelfte. 105
Borries, G. V. Th., Fixation and
Nystagmus> so. ba. ee 549
Bruck, Carl, Experimentelle
Telepathic \ 0s «<5. -5 eee 102
Brugsch, Th., and Lewy, F. H.,
Die Biologie der Person.
Band J) lieferune: 2 oe 447
Brugsch, Th., and Lewy, F. H.
Die Biologie der Person.
Lieferung 3, Band I, pp. 749-
1051. Name and Subject
Index
Bruni, Champy, Gley, Lugaro,
Thorek, e Voronoff, La Fun-
zione Endocrina delle Ghian-
dole: Sessualian. cette oe ee 548
Carus, C. Gustav, Symbolik der
menschlichen Gestalt. Neu
bearbeitet und erweitert von
Theodor Lessing, — Dritte
Auflage: <3.) eo se eee 101
Cornelius et. al., Bericht der
Sondertagung des Vereins
der Aerzte ftir Nervenmas-
Sages Ge Pe 547
Delgado, Honorio, Sigmund
Freud). fn foo ae ene
Dewey, John, Experience and
Nature jeaneni OF eee 100
INDEX, TO; ROLUM E65
Book Reviews—C ontinued
Dide, Maurice, Introduction a
Etude de la Psychogenese.. 448
Dorsey, George A., Why We
Behave Like Human Beings
Eldridge, Seba, Political Ac-
PLE t MCP UE BERS pons ep Sere
Eliasberg, Wladimir, Psycholo-
gie und Pathologie der Ab-
straction. Beiheft 35 zur
Zeitschrift fur angewandte
PSvcinopice Ft Wiles asain .doc meus
Ferenczi, S., and Rank, Otto,
The Development of Psycho-
CAL ihl Wes lS rae Re eo Seca 50) Suan 3
Foix, Ch. et Nicolesco, J., Les
Noyaux Gris Centraux et la
Region Mésencéphalo-sous-
optique. Suivi d’une appen-
dice sur l’anatomie patholo-
gique de la Maladie de Park-
inson
Freud, Sigm., Psychoanalytische
Studien an Werken der Dich-
tune, cand’, Koumst <5 coke <=.
Freud, Sigm., Studien zur
Psychoanalyse der Neurosen,
aus der Jahren 1913-1925....
Garcia-Diaz, Guillermo, Etude
analytique et synthetique de la
Sympathectomie Périarterielle
appliquée au traitment des
Ulcéres chroniques des Mem-
bres Inférieurs
Gerstmann, J., Die Malaria-be-
handlung der progressiven
Paral VGEn aeecee eS ee
Grosz, Karl, Klinische und
Liquourdiagnostik der Ruc-
kenmarkstuinoreis 35 23.5025 6<
Hamilton, G. V., An Introduc-
tion to Objective Psycho-
pathology
Heller, Theodor, Grundriss der
Pic padagogile jana: as eaena!
Helson, Harry, The Psychology
of Gestalt
Henning, Hans, Psychologische
Studien am Geruchsinn......
Hillyer, Jane, Reluctantly Told
Homburger, August, Vorlesun-
gen ueber Psychopathologie
des Kindesalters
Jacobi, Mary Putnam, A Path-
finder in Medicine. With Se-
lections from her Writings.
Edited by the Women’s Medi-
cal Association
Jaspers, Karl, Psychologie der
Weltanschauungen. Dritte
RET ENS Re oat Ro) ee: nn eee a
61.6: (6: © 10, 6, 6) 4 © (0) \0) 66 Lei@) <0, 0: 9) 0! 8) '@ Co
eel ens is) of ial wuet ie 6
Pe; ene 6 ele 6, 6 Je Le (Sie ea) ee
es) 9 0 oe 6.0 vine 6
Die ie 011-0 Mies wie: ce: "6" 16
445
217
220
639
218
446
546
223
106
452
451
104
Book Reviews—C ontinued
Kleist, Karl, Die gegenwartigen
Stromungen in der Psychi-
atrie
© 0 © 8) 00.6: 0:8 6. 6 © @: © 0 he @ [0 0:0) 0. ere
Kleist, K., Episodische Dam-
erzustandes <0. te et een ah eee
Krabbe, Knud, Les Maladies
des Glandes Endocrines.....
Kraepelin, Emil, Arbeiten aus
der Deutschen Forschungsan-
stalt fur Psychiatrie in
BVIECEIC TLC ates fies ts oie eee
Kraepelin, E., et al., Arbeiten
aus der Deutschen Forschung-
sanstalt fur Psychiatrie in
RAAITNCH le Tphenys ea tec See
Krutch, Joseph Wood, Edgar
Allan Poe. A Study in Genius
Lange, Carl Georg, and James,
William, The Emotions......
Léri, Andre, Etudes sur les
Affections de la Colonne
Vertébrale. .
Levine, Israel, Das Unbewitisste.
Authorized Translation by
Anna Freud
SiS) 6) 16) B10, #0) 6) en 1e|- 6 (eu 0 tel ,e
Liertz, Rh., Ludwig II. Konig
POM Ies AVET IG cere, codh 24 cate eah
Lipschtitz, Alexander, The
Internal Secretions of the Sex
(CET A Oe te ee ee ee
Maier, Hans W., Der Kokainis-
TERRES 5) Rr (Ue) Rane a
Masson-Oursel, Paul, Compara-
tive Philosophy. With an in-
troduction by F. G. Crook-
SAT hia Ey an rr
Monrad-Krohn, G. H., The
Clinical Examination of the
Wer youse SYStCMI.....4 5 6 sce
Muller-Freienfels, Richard, Das
Denken und die Phantasie.
Band II. Grundztige einer
Lebenspsychologie. Zweite
/ACBER EN 2 Ge Pac heh ee Fore
Muskens, L. J. J., Epilepsie.
Vergleichende Pathogenese,
Ercheinungen. Behandlung.
Mit 52 Abbildungen..>......
O’Brien-Moore, Ainsworth,
Madness in Ancient Litera-
[GB ha cnet somata ner cate OAS ine cir
Peters, W., Die Vererbung
geistiger Eigenschaften und
die psychische Konstitution.
Pfeifer, Richard Arwed, Myelo-
genetisch-anatomische Unter-
suchungen ueber den zentralen
Abschnitt der Sehleitung...
Platt, Charles, The Riddle of
Society
©} ere: 9:46) 10 Be Ol 8 el @ he: (eh es w..8) wi ie) 8)
649
pare)
106
216
102
650 INDEX" FO
Book Reviews—C ontinued
Pruette, Lorine, G. Stanley
Halle =k Biography Of pa
Mind’) 222) SiR eee
Riley, Woodbridge; Peabody,
Frederick W., and Humiston,
Charles E., The Faith, the
Falsity and the Failure of
Christian Science
Rivers, W. H. R., Psychology
and Ethnology. Edited with
Preface and Introduction by
G: Elliot Smith: <i eee
Roback, A. A., et al., Problems
of Personality. Studies Pre-
sented to Dr. Morton Prince,
Pioneer in American Psycho-
pathology. Edited by Drs. C.
Macfie Campbell, H. D. Lang-
feld, William McDougall, A.
A. Roback, and E. W. Taylor
Robitsek, Alfred, Der Kotillon.
Ein Beitrag zur Sexualsym-
bolik
Roffenstein, Gaston, Das Prob-
lem des __ psychologischen
Verstehens 43.5 oe eee 547
Roger, G. H., Widal, F., Teis-
sier, P., Nouveau - Traité
de Médecine. Fascicule XIX,
Pathologie du Cerveau et du
Cervelet .
Roheim, Géza, Social “‘Anthro-
pology. A Psychoanalytic
Study in Anthropology and a
History of Australian To-
teMIsti ..7. we eee ne eee
Rouhier, A. Le Peyote es
Sachs, (BL) and” Havsman oes
Nervous and Mental Dis-
orders from Birth Through
Adolescence) i, eta eee
Schaffer; Karl, Ueber - das
morphologische Wesen und
die Histopathologie der heredi-
taer systematischen Nerven-
krankheiten
Seelert, Hans,
Psychiatrischen
unigen 2s ne ee Sea:
Seeling, Otto, Die Psycho-
analyse in Padagoscher Be-
leuchtuna2 a. ee
Steiner, Max, Die Psychischen
Storungen der mannlichen
Potenz. Dritte Auflage......
Storfer, A. J., Almanach 1927..
Thévenard, André, Les Dys-
tonies: dA ttitude i900 nee
Thomson, Te Arthur, Concern-
ing Evolution i, ow See
448
103
@ 0 6 0 '¢ 6 6 os ¢ %
Ce
219
453
vg RS ae 337
Anleitung zu
Untersuch-
641
VOLUME 65
Book Reviews—C ontinued
Train, Arthur, The Blind God-
dessa ee 339
Turpin, R. A., La Tétanie In-
fantileow: ) sce eee eee 109
Ward, Stephen, Ethics. An
Historical Introduction ..... 100
Watson, John B., Behaviorism. 450
Weigeldt, Walther, Studien zur
Physiologie und Pathologie
des Liquor cerebrospinalis....
White, William A., Essays in
Psychopathology. Nervous
and Mental Disease Mono-
graph »peries| Nos 4342. . ae
White, William A., The Mean-
meg. ot Diseasé:.. ieee
Winterstein, H., Grund, G.,
Methoden zur Untersuchung
des ueberlebenden Zentral-
nervensystems. Methoden zur
Funktionsprufung von Muskel
und Nerven beim Menschen
mittels des galvanischen und
faradischenm Stromes., 2o.ncae
Boothby, WM ee te eee
Borries, Gi ¥.
Boston. Society of Psychiatry and
Neurology 398, 508
Boutttety sc onc ts cee eee ee eee
Bowen, Bo-D 2. a eee
Bowitian, Kari, © ee *465,
Brachial plexus, anomalies of
seventh cervical transverse
process and effects on........ 528
paralyses. eee
Brain, action on vasocontrictor
substances on arteries of.
and: cerebellum J: 27 te: eee
diseases, organic, and character
alteration” i. 285.200 se See
Brain-stem of man, columnar ar-
rangement of primary afferent
centers in..... *1, #149, *282 5 376
studiesion?. -.-atrche nse ae eee 89
tuberculosis in mental diseases 204
Brainweight, total, relation of
cerebellum weight in human
216
109
oe eee ee ww ee eee
*585
races and in some animals... .*113
Branche, jive etal ee eee 202
Breukink He? ee eee 96
Brights Rae Mies aera 179
Brall, Av rs tn 3 oie ae eee 412
Brock Samuels aan eee 77
Bronchial asthma and climate.... 426
dtie. to mice 2 Se See 517
Brousseat) AAs... eee 93
Brown: Earle:G.. — eee 429
BruckMGarlt. tee 102
Brugsehe Th: “to eee 447, 549
Brunt o.3 42 se ae ee eee 548
INDEX TO
rghit ton), ae be ta 7g ne 546
Bulbocapnin, effect of on tremor
in paralysis.agitans........% 532
poisoning, disorders of move-
TIBUEE IS Cae ee oe ra oe 8 52
poy i gies) Casey eee oe a 99, 210
BOsCAmO wire hy eee borin ae gta > 91
Bae eae eee bie ore Ne ee awe 8 se 541
ADWALADER, W.-B:..<2.. 530
Calcium: and asthma... .#0.%; 427
chloride, intravenous treatment
of some epileptics with........ ¥3/2
lactate, treatment of migraine
Dy an eS clos She wa pinion 179
freatmetitetor, edema: . cases... + 181
Cit alate, | Ae epee er oe 427
Camauer, CPR AE. cokes nem Sey aR 433
Cio) mete cee ee Sart os ky de os 435
ae tales crt s oes aos 200
Cardiac infantilism and endocrines 187
er ves ands asth Mas sn: 55 eee 183
Garniol ccc . ear ene Oaks OS
Carus, G. sGsiaye es siohson eis 101
Castration BOMIPLE Stele. eee neck 440
threats against children........ *21
Cations«and hormones :4-200. 33. ss. 184
Caudate nucleus, cyst of......... 432
Cerebellar artery, posterior infe-
PIGUEOCEINISION OFS She oe Fi 8 *125
haemorrhage in a boy....:.... 79
eMisyioroOmes. ta. one ecae ees 81
nucleic 3.25 80
PSELOL Gene ar eke aes Sar cae hale Ss 83
pylorospasm in case of...... 80
Perehe iis. 2s GaAs. tose B3
TTR he pee ee oe eee 219
SCOT airice LuNCHONSe a sen he. 85
association-system in ........ 78
Recent \€esSearciy On owids. os se es 80
weight, relation of to total
brainweight in human races
anid in some animals:. ...0s% Sti3
Cerevrale dyspnea 0. . cess etes 535
puncture hyperthermia, relation
of to an associated anhy-
CEES in gy ey ee ene oe
Cerebrospinal fluid and multiple
sclerosis . 193, 194
physiology ‘and. pathology of. 216
Cervical lesions, high, in guise of
combined system disease.... 307
sympathetic and vagus, com-
munication between ......... 630
CUSTER (Gv os oe NA peg | re gem ae 548
WBA Trice « Pave tc st. Ge Poe ss 536
Ghapmatiek MCG. oot. ve ales 545
Character alteration and organic
RI PeTIUMOACESOG Bh. 2,5, a 55 vie os 440
OL ORSSTUETS 2 Rn 428
RoE Iti BUA tees oc ie a x as acl 44]
Childhood, psychopathology of... 451
VOLUME 65 651
Chorea, classification of in relation
LOMITS) CAUISOSE. Coe a eee bt
experimerital study ol: sss sane 434
Huntington’s pathological anat-
OMmyiOt.. a. as Caer eee 533
Sydenham’s neuropathological
findings in a case of....... *273
symptomatology of ......... 433
with bilateral papillary edema. .
Christian science, faith, falsity and
TXUULC OE sfeuses. SOO 103
Cirietia NSeis Ves caves fae ee 197
Clare AS OU i FS ried «eee 523
ALIA G tn bL sh EN ee Ss eke 92, 93
Climatic psychoneurosis ........ 542
Clinical consideration of special
Eee Se sere re yea nate ee SZ
MODeee Stanley Arsen sta: ee eke 398
Cocaine Te aN Roc. Ho. did tre eae 338
MER Cen EL Ue et tee oem. Gece ee cv winee EOE 629
Colloidal gold reaction in acute
poliomyelitis sins ioe Mee eee 201
Colloidoclasis and endocrine
anaes Wr Wes 33 eds vee hee 76
Coma, pupils as aid to diagnosis
IMS ACS TOL es. AA kc ea eee #553
Consciousness, localization of.... 444
Constipation, spastic swe en 635
Contractures sand) tonus.. ...%0 04: 434
CEST R TENCE 5 ees a Re or te 547
Corpus striatum and body posture 534
syndrome of traumatic origin 535
Cortex cerebelli, connection with
pons, medulla, oblongata
and. intrinsic cerebellar
WiC. Ree 80
intrinsic connections of..... 80
structure of with some physio-
lOmical CONclEsIONS .. 2s 5s. 85
OUTENC Gel Se Vette ess. oe was 439
Courtseimedical expert in........ A ke
(Cemiecrah 1 Te Ret.) ja. 179
Cretinism and endemic goiter and
PML VUAKES ise) Siete e a he as 73
Dacalesimetapalisn? inv. o.ss We. fe:
respiratory exchange in....... 72
Grimmer ai UWENet oG2. 0. otk eee 210
Galisaleractors: Ole 2.0 ¢ dnc oeee 99
Crumpmalepsychopaths *.. ho. ee 210
Criminality and hystero-epilepsy. 438
Griceantie ds eis. deed eon ee 85
Gursehinanie Hs. 00dne eee 195
Cyst formation in spinal ganglia 190
Ole caudate snuclens ve) eee oe 432
ANCE. RI et 548
Daniélopolu, Daan Boi! 631
Darts RESAG coas eae rece ees 421
Death wish and vertigo: 2.4... 07. =131
de: Beschew: Aiwce sie een Skis 183
Decerebrate rigidity in man..... 433
ime thesopossimiere eae aoe. 85
652
Decorticated! cats: 98% 244... e ne ar 398
Deficiency diet, pluriglandular
atrophy {romi queen Bee
diseases and endocrine glands. 522
pathogenesis Ofte .c7u. eee 521
de ‘Gennés SU. sccmn. ee ere 70
De. Giacomots Ute. a eer 434
De®] of) Hee eee 532
Delgado) -Honorio pane ee 643
Dementia praécoxes-..0.0e% 91, 92, 97
and Syphilistyas..s- 2c 205
* blood ipressure..1--. eee 203
catatonic, platelet count and
bleeding time in........... 207
ductless } glands ative eee 206
histopatholog VE OE ee eae 96
nature Of: or eeeerne ees 93
type of hereditary degenera-
{10 gee 97
Depression, states of, ‘and neuras-
thenia® «fee eee 44]
Deutsch, Heleneme 22s se ane AG
Devic, “Axdtaie oes oe eee 202
Dewey, John s.54204 -o Gee 100
Diabetes from lesions in tuber
CINErellil «. sae oe ee 435
Diaphragm, elevation o0f......... 633
Dide,) Maurice... oe eee 448
Diencephalic centers controlling
associated locomotor move-
ments ..2 see eee 87
Dieterle, Robert Richard......... *42
Diplegia, facial, in multiple
neuritis’, 4. 1 tee eee OO
Disease, meaning Of Aner 641
Diuresis and anhydraemia follow-
ing destruction of thalamus. 89
Donath) Julius... 0) 3235 eee 539
Dorsey, George Ave eee 445
Dowman;C> E..4 33 193
Dreams, day, and beating phan-
taSies AR. 4 bu See ee 442
Dresél,: KK. Me aaibesa yt Geet ee 86
Drug dissociation of vital centers. 630
habits, treatmentsofs a eae wis
Drugs; action) ot onenile a5 eee 637
Duaney Ave eue® oe eee 177
Dduchone. ..4uks. ee eee eee 429
Ductless glands in dementia pre-
COX yoo pe bucspene ik ae ee 206
Dufour, Gee eee 429
Duke, (Wo Woio6 ie ee eee 426
Danlap; . Bits ee eee 97
Duralvepitheliomas. 4aean eee 203
Dyspnea, «cerebral 2a sae ee 535
Dystonia. . 77, 644
AR, neurology ofa. eee 546
Parl) Cx, J) «Gs s5. eee eee 79
Edema, bilateral papillary in
Chores: <ceiecato tea: eee 433
calcium treatment 4ores.s.2c4 181
INDEX TO VOLUME ‘65.
Eegenberger, H.9 oskeeae eee 524
Ehrstrom, Rave eee ee eee 185
Hider, )\W. . 2.08 ook Gee 543
Eldridge; ‘Seba’ oes2.5 us ane 217
Electrical exammations 42.0.0 cee ee
treatment of infantile paralysis. 199
Electrolytes in the organism..... 185
Eliasberg; “Wiadimir. ..2-. eee 220
Elsé; JE... eee ee 64
Emile= Weil Gea tees eee 423
Emotions. Tae 640
Encephalitic amyotrophies SOS 59
Encephalitis, epidemic, specific
diagnosis and treatment of... 171
Encephalopathies, congenital, stri-
ate Syndrome nck. 2a. cane 434
Enderleny. 2.0 J. es ta. eek ee 70
Endocrine and biochemical studies
in’ schizophrenia. /,.4..*°465 906s
clinic, diagnosticy5-ce . eee 187
function of sex gonads......... 548
elands (2. 448 oan eho ae 108
and ‘colloidoclasis.... “ance 76
and deficiency diseases....... 522
and individual constitution... 186
and vitaniitis! o2. ee eee 52z
constitution and surgery with
especial reference to....... 188
reciprocal relations between. 190
medicine, principles and prac-
tite. Of. 3. Get aoe. Pe eee ey
OF Pans ina. en ane eee 522
therapy, experimental basis of.. 523
Endocrines and cardiac infan-
tilist, .23545.40 Jeno e se ee 187
role of in growth and nutrition
of. children 244020 eeeee
Endocrinology, archives of...... 184
from physician’s point of view 186
of eat, nose and ‘throats... +. 422
Engelbach, “W. (35.30 ee eee eee 187
Epizastric: neuralgia sss eee 630
Epilepsy... . vcs TUS
and hysteria in.u.ee 0. sone eee 208
etiologyof: /..85 Sia ote eee 208
fasting in treatment O17. eee 208
laboratory studies ins) oes ee 209
traunratic, Vee oe oe oe 209 -
Epileptics, intravenous treatment
of with calcium chloride and
sluco-calcitims 2) ee ee
personality make-up of........ 617
Epithelioma,-dufal Sie..0. eee 203
Erotic behavior of idiots......... *497
Escomel> Hz i. ataee ce eee eee 542
Estable, Co. « wands uae eee 85
stapes J 73M ...4u:..Sane oer 192
Ethics, an historical introduction. 100
Ethnology and psychology....... 643
Etretine, Gauss few sp eee eee 200
Evolutions cacioec ces ee eee 339
Experience andinatures 10: fecee 100
INDEX TO
ARROW, E. Pickworth...... *21
Fatigues peristaltic 0.5.66. 6.0ek 633
psychological Stuy OPu aes: 638
Feeblemindedness . Rae ee DAG
PEGE CTIN) ASCP te. ws int gis 209
Ferraro, ENE ENAING OF Melee ciara are Fe *225
a Sigeaters © oo: (8 Sgn a oe eee 639
UEC pA Re dae Ae a a ne 196
Pixation, and nystagmus.......... 549
TUES ET) bee eh le A Since ea Oa Oa am 196
| PUY CTS ceil i eed Bee ae 0 Pea Re ne 633
Bileapittee ry oes coals oc oe esas 72
PUleUrV ee MVlLaUuriCce de ie. me. oils see 44]
Flexion, spastic paraplegia in.... 526
Plesiier SNe eer ces. ee oh aie e sts 203
Hee ae CO Se eee eae 218, 434
BoraeuneodoresG,) Cor ia eke ao8 *225
MOPOOhe PAIS enle! a4 24d. Ge hess *372
WRC Yee. © oi,5e ok oh ee ene 422
ReGSeY 4 ee els eecr WY Oe RNG Atle 527
Pocemam Valter Se 35.45% *1, 80,
*149, 171, +282, *379
Reretanate: tract Ces ok a ett 206
Berets ALA) Ao area lat ete oe 442
Freud, Sigmund ....412, 446, 546, 643
rey Hn user tes tates a ee eee 183
BRraedmaa th eD.2ko tea 6 BUM 197 307
Friedreich’s disease, necropsy find-
IESE ID Bi aack mee ice) Ue
Frontal lobes, significance of for
higher intellectual activities.. 539
ALL duct, motor neurosis of. 632
nervous influence of motor
DLOCESSOS OL) Go, ware ee 631
pain of and its radiating re-
Exe ste ark wer ee es Te O52
PeaNtipyy NG ets ee ek eee he no ore he 427
Ganglia, basal, tract anatomy Obama 534
Ganglion, superior cervical, after
pre- and post-ganglionic sec-
tions . ENE sey Drie’ cory ok 528
Ganglioneuroma of cervical and
thoracic sympathetic gan-
SPI LOHIS hee CA see fee eh ate ole nates 181
Gareia-Diaz, Guillermo .......2- ee
Gastric motor function and atropin
are paloCarpiti, cas au «se es - 520
Gastroptosis, intermittent ........ 629
heenins NSU y Ii) vane hse 2 oe are 452
Peer ipe mM RCTUDIT Ay Mio: tree hace cade « 621
PSE ST Ge 7 ed OR a Se Gig Soa ae 106
Gestale, psychology of.......... 451
PaleLti ay 1WiCent: os sede we bas eos 605
Melitta FIM REY Bets lec oo oe oes Ges elataie ¢- = 526
Gland disease, ductless, and mental
retardation . . re
Glands, ductless, in dementia
DECOR Meet pal Sate ahs ole aie #8: 206
sex, internal secretions of..... 105
RE PIZIMATIIN Ee ees ea ee os ov onee 522
VOLUME 65 653
Gleyi serge eee a eee 548
Gluco-calcium, intravenous treat-
ment of some epileptics
ANICTIS Ve eens Oo: ce oP tale ek ae *372
Goiter® death. tram: 3 ee 70
endemic, and cretinism and pro-
pivvlaxis #26 eee 73
exophthalmic, and involuntary
Nervousesystem aioe a ee ae 65
basal metabolic rates in...... 70
differential diagnosis of..... 66
pathogenesis ;Of; fee eee 65
history of iodin treatment of... 71
prevention of and its recur-
TENCE wt kh hes Wate eee 524
Recurrences OL vay: 2A eee 70
simple, prevention of in man... 68
toxic, roentgen treatment of... 68
Goldstein, Hyman 55, Vee 188
(OOS, ay ED eae ae En, Se is 186
(CORE ALRA 12% J Ig gd RES See RE ree oh ct 70
Greene, PeaTISOlil fA. wo ae ee 205
Greenfield, Jee RB Le eee eee. 91
Mer eenelaey ere een vo tee ae 536
AOS iih, 100 I oe een 3 75
CS TaNEeAS eR Gs de a a el ea boZ
Gorreces : CATAL eee panne Beer ee a 101
Growth within spinal canal..... 202
EPEC IES a's Ren err 222
Griine wee ee = AN cits chs ye one ee 192
CERI Sy 6 CE aay eo na Cand Serer Geryrae 191
Gurewitsch, EN ee a oe, ee ee ee 440
exible. Ernest Boe. oss. cs *131
Hahn, LRU Ue gh bt. 178
Halbertsma, fitch Ren one he Na tire Dope 207
ea en LATO Vie ate erecta aon aleve nes 448
Hamilton, (FoR Ve ee er ts eee 214
Pe ieMetty Lf 50. Settee. wea ores 68
HE lavy isl We, (USNR Amaia 2 Aca rm aba 176
Mannemann, Ki tsetae se. vce. ne 635
arene lvde: Lie etme. oo 6 ae rn 422
Hatcher, Ris Asean mers) Metlas 520
Pieistvia tye lay, ch tia ahion s,s asus ties 453
Hay- fever asthma, treatment of.. 426
relation of bronchial asthma to. ve
Headache, Causes Of. 2.5)... ams rif
Healing, spiritual RY Rn ae cee 5a7,
Heart in myxedema. ...:..25.. 20 72
rate, influence of vagus on..... 179
Heine-Medin’s disease, Ttibingen
epidemic Of Gey. fe eee eee 198
efelernaniee |e. ceed: a see oem tenes 425
Heller UPheodor tm, Manes were 548
Helson- Harry =i. oes ee 45]
Hemichorea, right sided, with
right hemiplegia and intermit-
feniteapiiasian st eee eee, 433
Hemilaminectomy. . Silk
Hemiplegia, right, sel ne
tent aphasia in right sided
hemichoréay ned sitar eae
654 INDEX TO VOLUME 65
Hemispheres and striatum, dog
without . 86
Hemoptysis and vagosympathetic
tonus. 71518
Hemorrhage, "birth, “into ‘spinal
Cordes er he ta Ree eOU
cerebellar, in a 1 boy iu cee ee eee 79
intraventricular . by ee Re
subarachnoid, from medico- legal
poirit (Of vieW lls eae eee eee *484
Henderson, Jl sis ce 2 ue eee 633
Henning, Hats.) sik ae eee bee
Henry, sAVAKRR hols eae ee 180
Hepato-lenticular degeneration... 536
pathogenesis or tse acer eee 435
Heredity and the psychical con-
stitution 2.2 s. Gee ees es eee
Heredo-degeneration ..........<. 337
Herman, E PTE fH! 433, 434
Hermanti, | es.0 60. ates eee
Hess, Lij.c.e othe ye eee ee 535
Heveroch, wA). 5, ni see eee ee 208
Hillyer,Jane 20. 0. Seu eee 452
Hirsch) 3322 eee 90
Hitzler.04 0 S424 3ae
Hodgkin’s_ disease, spinal cord
COMpression jh eae eee ee 614
Flotimann, HS) hae ees 91
Holler?) . os .3. 3.) eee eee
Holst; J ..24 2.28 6 eee 65
Homburger, August 2 451
Hormone function, derangement
in. <p onae be Loo
Hormones and. cations oe Gaeta 184
relativity of actionvol «eee 186
Wotz) Ge fan 20. eten ee ve
Huddleson... [). sane eee
Human beings, why we _ behave
iy solike them ©. 2... see ee 445
Famiston,\Charles i... ee eee 103
Huntington’s chorea, pathological
anatomy of |. ate ae 533
Hustinx. (2... ... 4° ee
Hutton, I. Ey ogee a 203
Hydrocephalus, spina bifida with. 532
Hygiene, mental 2.070. 544
PHyynan a ge ee eee 65
Hypernephroma, malignant, coin-
cident with arteriosclerosis in
childten toe eee PP ae
Hyperthermia, cerebral puncture,
relation to associated © an-
hydraemia..... eS SALOD
Hyperthyroidism, acidosis ins eae 66
auricular fibrillation in......... 70
basal. metabolism ‘imi, 6 v0. oe 67
causes of surgical failure in. 64
value of surgery and roentgen
fay in ‘treatiient.ot eee eee 69
Hypothyroidism, recognition and
treatment (Ot) tae eee 73
Hysteria’ atid epilepsyiaceee ae ee 208
Hystero-epilepsy and criminality. 438
Babette: ea Eee familial
amaurotic...... Se tee
mongolian, 11 COUSINS. 272.5 ee 91
respiratory exchange in...... of
mongoloid . ts. gl nee tel errs
Idiots, erotic behavior of........ “497
Immunity and the thyroid gland. 67
Impotency . ; i Ee
Inebriety, treatment of........... 213
Infantile tetany <>. 15 4..¢4e ee 109
Infantilism, cardiac, and endo-
erines’.e 25. ove ye bee
intestinal... .. 7... eee
psythid wo). . fe. 2
Ingvar So Use. oe eee 89
Insanity, alcohol in relation to... 211
physiologic conditions under
which. it occurs: 23.0). . ceeee 205
Instinct . : We a.
Instincts : and neuroses, . i. eee 543
Insulin, sources of error in or-
ganotherapy as illustrated by
ae and administration
of. O11 Y 4.43 ee
Interbrain, ‘tumor of. hh ae 87
Internal secretion, glands of in
beriberl... ..'... «2212.2
Intersex, biology of oh os Gee 327
Intestinal mfantilism :22 5. ee ee 635
Intracranial pressure, increased... 197
increased, and ae cen-
ters. ie eet
Intraspinai tumors ass eee 202
Intraventricular hemorrhage..... *360
lodin treatment) of, goiter... eee 71
Irvine; Hi: Sk ives hk Ce 64
JACOBL iar Putnam eee 104
Jacobi, Wi i.28ss): eee 92
James, William \.... 03. Sess cee 640
Jaming Er) ay hens. acne 92
jJarloy, Exo. Boe oe 192
Jarosthy, We es. 145 .e55ee eee 192
Jaspers; Karle 2) 25.40 42nne 341
Juarros, Gagsiee.<¢ one. ee 208
J AISCOT ese. ia 0s Shank Alpe
Juvenile.crime Tia acon 14 ee 210
catisal Tactors. Old..an= eee ee 99
AMIGA, Riketunneu see 187
Kappers, Co-UD Ariens Ree *113
Karpman, Ben ois eens. se eee 327
Kennedy, Foster: v.11 38 eee 315
Kessel, Leo! Gia ete Loe. eee 65
Kidney function in mental disease 98
malformations in mentally dis-
ordered...) kane ee eee
Kambath Gas Pv cctee ss, tera ee 68
Kingsbury. sbi > 20). 5 Seen ee 522
Kien, “Pimer-s2 Sheerness eee fe
Kleist Rar ke eee 103, 340
lettiriany Nig ot eene eee 542
Kochety Aw iaiets< see ek eee 188
INDEX TO
allie), (0.10 ho Sah 200
TCOreLIGRVEIU tact soa sends 188
CTAB DORE UG: pattie hes oes 108, 430
rae OOIy MEATT es. CA vue Z16, 219
eerie tts ts Ae ey ala Aviad a ae ok 185
Hroten, joseph. Wood... Moe..s. 452
ABBE, Wap eee Watters of Vuavess 66
— “Vandry’s. paralysis,” jena
logical anatomy of.. 192
PEATE WESC rhe eR ae okies diate peeing 70
TEAC att |. GreOER Milks 2 oteta tek. ace 640
Ranoworthy, Orthello Ry .. 2.26% 85
DRS Lee ea.nc ale BM ere, sono Soo 8 529
Laughing, spasmodic, and weep-
TEE Sete sini. ait oe Rivet whe DO4
REAM AIETS IK ns alin, > 405 0 loss Spas ® 412
eerewmriaes : fo00. i. eae *360
Peereonded Child) 2. lah,.qiss eas ot 543
WEERIIGN CHK OR Gt sock we Lad wee oe 76
Perenonliete Ps. isa, lst igre: 75
PGE AOULE, 2.5 as eee che earns = 642
eric ser.) IWEUITrayy,® aon se ake’ «te 199
PEM RASE AE] (3 L084 o tees mae 2s vives 338
Were rks, hean.n{ eteide ee ae 81
Lévy-Frankel . 423
Lewis, Nolan te Gr Peete hep Pa 204
Dewars foe Elta ea dude ae Re 447, 549
Pe Wako (oon seaciietanons Peers ere 3 65
Peter eden erie gkee 8 Ree ies Eee 101
Light action. of on blood)... 2: 179
PTZ VV eae Shee ea as 517
hapsehutz, Alexander, .. ..a0.00 105
racer Plek Pien Gon... Ste; ee 74, 98
Eatvas MAL eas see a Pauper ee aN ae 201
Liver functioning, blood test of.. 76
DIMOY. OLURG ee See ee 77
bavine ston, fdward, Nowy aise... 636
TOMER al <3 Avis orct tt ric amet ty
Lowenstein, Georg ody. MUN Mele er ne 105
FeO VL! sere aU RA ao ae oeeee 520
Ludlum, Seymour Dewitt........ 205
Pudwies LE kine of Bayernoiss «. 101
Puearo ws, fe. ie ahs SAO
Lumbar vertebra, ‘dislocation of
LGA Ceti Se spaces oa See ee 199
Luminal treatment of migraine... 180
PEST IAL coe Sire od Ae en hee aes 427
Lung diseases, nasofacial reflex in 423
Pevigiee PALAOLOP ICAL sis asa duc aan 211
Rie) DE Oo Hae nea 533
Macdonald, Maxwell E..... 509
Madness in ancient literature.... 106
WETS RA gt 182) Be ae enn ER ee poe
eee eh LatiS™ VW dibasic. wate as oe 3s) 338
IMs Sore gl SEA ps ce Be Gage ere a ane 66
Malaria treatment of general
paesie | oe. es, tat gate. + 106) *225
ICING RAC CARS. cee nee ks bia tia, 77
MAA PATS seas ota sboksscaidiot yon ss 68, 184
GENIE RG Mog nt ge me oh e396 fu5) 592 546
Bhariane Mae Dee Se ako h ves xs nes 78
VOLUME 65 655
Marie; Adio. cake ermal oe Gens 433
MartinrnAie dered oe seucseua ue 518
Martini i Teas Somes ae aee 629
Masson-Qursel, Paul 2.44. sees ee 446
McCarrisat. Ri ive du. neon ate 521
MeGConnell Jol w 2 aim oe eee ones 530
Medeher “|i Hatin 2 pean 544
Medical expert in the courts..... S15
Medicine, a pathfinder in........ 104
Medio-pubian reflex Jats) vat 191
Medullary and pontine syndromes 621
Mellast Pl seas 30. Sic see eee
Meningo-imyelitis, acute ascend-
ing, possibly resulting from
arsphenamin therapy ........ 195
Mrenminwers Warl- Al iisia2 5. ee 90
Menninger, William C.... e026 *553
Mental affections, treatment of... 96
ainlanemvous disease. s6 SOE 339
automatism, syndrome of and
its role in the formation of
chronic systematized psy-
CHOSE SH: «4! | Sel . *345
disease, kidney function ike tee 98
brain tuberculosis in......... 204
diseases, blood groups in...... *569
disorders, autophagia and auto-
SULT GV Ee CTS0 2 2 eM ea pn la 99
PRTC MRCS iiccid.o ae Galea a wot
retardation and ductless gland
disease. .... ORD Sete EG
states in alcoholism............ 92
Mentally disordered, kidney mal-
TeyT CATIONS EITI Arlo tn Flees Stl 204
DACA Dla ENN tay 2.0108 Saya a Souci 644
Mesencephalic automatic reflexes. 80
Metabolism in nervous anorexia.. 637
Mice, bronchial asthma due to.... 517
Midbrain, phylogenesis of with
special reference to _ optic
thalanins's Samant) eon LOo
RIGED: ATCAS: linham en Gas Fe oe ee 90
Migraine, ophthalmoplegic, and
recurrent paralyses of the eye
muse] as. ava eo SLL,
pathogenesis and therapy i ithe Geo
treatinent, OFF Vee. ees ae woman 176
by caltiumelactate. 5 eens 179
with ligiinale paved, eee 180
Millet JeeAl2 PSs, oils See es 73
Moller, | Rg PRO ebay ue © ES 5.) 637
Mongolian idiocy in cousins..... 91
respiratory exchange in...... 72
Mongolism, etiology of.......... 207
ink ONG OLet Wins sere shan 207
Mongoldidcidiocy: oases 73
Wionradek cohn, Guadl sy eee 642
Moriarty: Mi) iieiia es aes oie 72
Moriny’ Rast Nahe OR eer cures 80
WMorisaths: | ioe NV roc aa ore eit 633
WMorduio, Eth vacua met rire 79
656
Morphine habit
habituation, presence of toxic
substances in blood serum in. 91
Morse Mie Te qe palpee aee 206
Moses.... 177
Motility of stomach, “influence. of
sleep ‘Olt.c eats eee 521
Motor functioning of stomach in
fheuropaths claves ec neuen en
Mott, PW 2 ou 6 eee eee 203,°204
Mouriquand,G. oi Yaseen eee 522
Movement, disorders of in acute
bulbocapnin poisoning ....... 532
Mucinoid degeneration of oligo-
dendroglia. . 508
Miller®.C.- 2 eee eee 194
Muller-Freienfels, Richard ...... 221
Multiple sclerosis and cerebro-
spinal Huid fees eee 194
and syphilisceacy a. eee 429
cerebrospinal-fluid anzeer ee 193
diagnosis of in early stages.. 530
experimental: 2... Wenn ae oe
vaccine therapy ings eee 402
Munck, . Willy ce. eee *A84
Muscle, ossification of after spinal
COrd dijury esike ee eeee 194
Muskens,- ly. J. J... 420. eee eee 638
Myelitis, acute, serotherapy in.... 200
ascending, in acute poliomye-
litigate ee ey. Ey
Myerson, Abraham. see eee
Myxedema, adult and childhood.. 74
Congenital»... (ee 74
heartiin 3.0. vacise cee eee 12
ARCOLEPS Y 25.352) eos
Nasali neurosis’ /x., . ere 422
Nasofacial reflex in lung and
nervous diseases ........55). 423
Nature and experience........... 100
Navrac Paulo) «ee See 435
Neoplasms, multiple dural........ 50
Nerve, blocking of in whooping
Coughiee ck, sen ay Bee
massage 547
splanchnic, blocking | of. cecal 634
Nerves, cardiac, and asthma..... 183
Nervous and mental disease...... 339
disorders from birth ee
adolescence . m45o
diseases,~ nasofacial reflex itt... 425
system, ‘clinical examination of. 642
involuntary, and exophthalmic 65
vegetative, periodicity in..... 634
Neuralgia, €pigastricin.. ee eee 630
Neurasthenia and states of de-
Pression Fe sim eee ea
fiaiinatices ee 541°
Neuritis, pe fein dicots
a el 1 ties Ge Lemna OU
Nuraiony of ear
VOLUME 65
Neuropaths, motor functioning of
stomach tices cers 521
Neuropsychiatric disorders and
throid.dysiunction <i eee 64
problem of U. S. Veterans’
Bureau. ; 403
Neuroses and instincts. SA Ss eee 543
changing manifestations of..... 52
psychoanalysis Of \.’... 2.77asoaee 546
Neurosis, nasal 5-5... che ae 422
Newsholine, A.
New York Neurological Society,
50, 307, 605
Nicolesco,, J. sc. <b oc.4 et eee 218
Nitescty: Ls fee ....2.aly ee 435
Nixon, Chase He 3.5.4 ois 98
INétlein, (Feenien cl cs oe eee eee 617
Nystagmus. and fixation: >.2... 549
via alata 526
OES J.oM.
Obituaries :
Bianchi,, Leonardo Vis. ee ee 558
Clark, CharlesoHermasi). eee 343
Cole;iRobert’ Henry...) ee 454
Kraepelin, Emil $24. ..6 eee 110
O’Brien, J. Fecvak ook eee 208
O’Brien-Moore, Ainsworth ...... 106
Occlusion of posterior inferior
cetebellar-artery. .... Je ene *125
Ocular disturbances in respiratory
AH ECTIONS< whl & eee
Oculogastric' reflex... 425 eee 631
Oksala SH: jst to. eee 93
Oligodendroglia, mucinoid degen-
eration Ofvews « Beason. eee 508
Ophthalmoplegic migraine and
recurrent paralyses of the eye
muscles... 0.) Ag va.
Optic thalamus, phylogenesis of
midbrain with special refer-
ENCE 10. J yaa pe ae ae eee 89
tracts: giklrei ee eee ohOZ
Oratory) Vi ace eee ee 185
Organotherapy, sources of error. 188
Owerbosch; Ji. Be As*. 2. 5 eee 206
ACHYMENINGITIS hemor-
rhagica, experimental study
2) a em ee
Pack Gare es eee eee 518
Papadat05. Lis thiics opie eee 433
Papilians- Vein foie eee 85
Paral Jap ot ance k doe ee 529
Paralyses, brachial plexus.7- ee 605
recurrent, of eye muscles and
ophthalmoplegic migraine ... 177
Paralysis agitans, effect of bul-
bocapnin on tremor in.....
therapy, ifloes «ce crea eee
familial spastic spinal. 47a 195
general, malaria treatment of.. 106
INDEX
Paralysis agitans—C ontinued
infantile, electrical treatment of 199
recurrent. : Ae eee 4!)
surgical treatment of. OP Pay Maree 200
LAGE yes ness 192
of Pott’s disease, operation for
relief . Be ons 52/7
spastic, new “operative treatment
of. . Pe ee Brrr 6
unilateral phrenic aren ea retard 633
Paraplegia, spastic, in flexion.... 526
Paresis, general, malaria treat-
GN SRES EDT peer ke oe A ae e225
REO Sl Merely eres cate ayeis,t Fics do 8% 67
eee ey Pe nin rile cokes Been 213
ge Soh gh ie Aas a are ee be A
COIS i oa Or ee ee i 438
Bavev-omith, WA°(B. xdeens ae 177
Peabody, Frederick W.-.....:... 103
Pedagogy and psychoanalysis.106, 548
Beeire slave rie 2 Ake taut denne oe oe 81
Le UNE G YR! OA POT MOR Veen Ay <2 al
IE Et alls Gi $x. oto aot aera 2: 529
eristalticn 1Atigei mince sie os cette 633
erst ot Gri Gah. oe ceric: Oates 633
Personality make-up of epileptics. 617
problems Oi sew... 4. eee ane 108
Petersen Wis gies Coin. tee es 216
Pfeifer, Richard Arweds oo: 0-5-5 102
Phantasies, beating, and ee
dreams. tesa, . 442
Phantasy and thinking. TUG Fae 2k
Pharmacodynamic functional tests 185
PHUippstiiaien . wuss ce)
Philosophy, comparative ........ 446
Phlogetan, neurological experi-
EICey Withee anita cee te as 196
Physical needs of sick in hospitals “a
Pierce, B.
SS Rm (eel ee Oye \6' 0) 0) 6) a? aiie '6,.'0\ O26 10 2
Pilocarpin, atropin and = gastric
fHOLOreiiincriotiwe. came © pee 520
Pineal gland, extirpation of...... 75
PIU TOL) Cries ot cnc ae Sector ee 75
PMT VW a Ree ae ets we 635
Platelet count in catatonic de-
MCUia PreCCOX vou ee. voles, 207
Petar tar leSon( fy cae Fone be: 338
[Ea 5 Bee Re Ae ie a 196
Pleuropulmonary reflex ......... Bay
Plvriglandular atrophy from de-
moIeneydciietaca tat ed,.. ls 522
ISUIICTONGY.. asec. ite ere es LOO
Pe Sareork LATOR 4 eae ee nes 452
Perec siya. FL ak ities Ee, 91
Poisoning, acute bulbocapnin, dis-
orders of movement in...... Oey2
Poliomyelitis, acute anterior...... 430
early mechanical treatment
‘Saf Leip fi ee eee 196
dEDMAIUR Col Ue Gu oes ass 430)
ascending myelitis in........ 192
colloidal gold reaction in.... 201
VOLUME 65 657
Coniinued
epidenmict iim Lopelas, Utes. oe 429
treatiient Ol ae oe ae 529
infantile, spinal cord in........ 430
Political ‘actioneeaex. oe oe pare cA)
Pollate ce swat Pisa ipie Oe arn a Joa 535
Polymorph cells of dentate fascia
Oi; Old saniinalsnwse- 1 tone ee 83
Pontine and medullary syndromes 621
origin of sensory and_ trophic
syndromes. 0). ae. 79
Poreesy (Owen ah a eee eee 80
Posture, body, and corpus. stri-
atum . . : 534
Posture reflexes in man....-...-. 89
Fotenciys psychical Rae aa ee 340
Pottenger, Yo Mes a e.see 421, 423, 427
Potter, Howard Wore t eee *497
Potts disease, paralysis of 520) 527
POZO eran kcten sole as Bee eee 432
Loco rel bP CG BRR EN ee Lig Zed
Poynton, Tc Pe ee 536
Pe Vart OR RECS Gee Oe OPED Ee oe ge ota AL: 5 426
Ietesenile DPSVCHOSeS 14.400 ee ae 93
PTAA DISIUY sho ws ber whack renee Ok
Proescher, Frederick su. ahalnee *569
Prostitution . a eae bee ars areata: ocitt LU)
Pruette Isorinens2:). 9: se sae et 448
Psychiatric examination, methods
Ol. fs one Ode
interferometric studies ........ 92
ae VGA Vga tres See et ks ene US
BULUIV LOM ean Rue neat ie eet 90
studies from Deutschen For-
schungsanstalt fur Psychiatrie
ir steer a ean a0: le 216, 219
Peveric infantilistis tc 2 kscr aoe 92
Psychical constitution and heredity 216
potency . . ... 340
Psychoanalys SiS s and. everyman. 100
and pedacoayenyeew..) Soe: 106, 548
and GOetryrandsabiog + c+ se cee 446
devyelopment?or mets. . hte 639
oP they neurosessiae eae eee 546
Psychoanalytic study in anthro-
pology and history of Aus-
tralian botemisiires sere 449
Psychogenesis... . .... 448
Psychological understanding . se 547
Psychology and ethnology....... 643
ot abstractions <n 5 J..% #4 220
Of (westaltyic.imye Wonels arte eee ee 451
Psychoneuroses, treatment of.... 436
Psychoneurosis, climatic ........ 542
Psychoneurotic backache ........ 439
Psychopathology, essays in....... 109
ODIECLIVE acd 4 Ooms eR Rn ee ae
Of childhoods. ken .4 ere 451
Psychopaths; criminal >s....—e0- 210
Psychoses, chronic systematized,
role of mental automatism in
LOCiMaliONs Ol mie eae eee *345
presentleyaacds ae Ave eee OO
658 INDEX TO VOLUME 65
Psychotherapy . ietelaOU
Pupils as aid ito: ‘diagnosis in
states (OL COInd shee eee 555
Pithan, Irma. Kellersieeaa aaee *260
Putnam, Gracy, ackson=eee. en *260
Pylorospasm in case of cerebellar
LUDIOT Rie Warts ere araeue
so-called, in Antante sear 635
Pyramidal lesions and vertebral
arthritis a Cen ee ene
| ADIUM emanation, hemolytic
ACtION OT doe ce ae ae eee 179
Ramam Pease be eee 179
Ramirez: (MwA es en eee ee 425
Rank: “Ditto .:.chco Senter ne een 639
Ratner, (Joi: is cee aoe ae ee 87
Raynaud’s disease in children.... 176
Red nucleus)::4 06.4... 5-2 see 432
Redield,wA, Gan cae oe ee 179
Reflex, medio-pubian ............ 191
nasofacial, in lung and nervous
diseases. . EMM ete ens
oculogastric., \s.-. ee eee
pleuropulmonary (Asm eee
Solar ..5-. yc ee a eee
Reflexes, importance of knowl-
edge of in diagnosis of pul-
monary tuberculosis ........ 421
INL APES bis: e/seie sors baile eae *457
mesencephalic automatic ...... 80
posture, inv man; ee eee 89
Reean, feo es: wack oa ee eee 201
Rewans Gs 14 i-sieedie cee eee See 201
Renbein, <M. scat een ee 194
Rei ye). Po seas oo Re 176
Reiter, Tes eles oe sate 184
Reluctantly told: «ik eee eee 452
Respiratory affections, ocular dis-
turbancesim |. ise eee 518
centers.’ toe, seach a RRL:
exchange in cretinism and Mon-
politi AdiGCy : dg eee Te
Reticular tpenabon pala Moke ee 81
Riceiterls, gidcpcn . cee eee 422
Richard, Gite ike hole eee 67
Richardson, EdwardeRe <p eae 69
Riddelbs owes tile cope kee aero
Riese, Wess sold diieiiere nee 534
Rigidity, decerebrate, in the opos-
SUtth nis Wis nee es See ene
Riley, Woodbridge Vitis Dee 103
Rivar ola ji deat aaa eee seals Sn 526
Rervers,) Wi Eire cera 643
Roasendi, Ce ak eee oa oe 99
Roback, A yA WN Se eae ae 108
Robertse 10 feo a eee 178
Robrtsek; VA li red see ee eee 548
Reck wood shy oe hace a See 181
Roentgen ray, value of in treat-
ment of hyperthyroidism..... 69
treatment of toxic goiter....... 68
Rorensteit, | Gastony igen ee 547
Roger.Ge be wees eae eee 1g
Rogers, eile bes noe aes 89
Rovers i Ldae Sele eee 211
Roheim, Gézas.2.6 vee eee 449
Romer..G... 5G. fe ae ee ee 436
Rouhser; “A022 ee oa eee 644
Rats, Gay sais aavrs ele ore ae 81
Rowe, E: ey RT Ao aye cho) cee Sey 68
Royle, N. Des: ee 196
Rud; Eid sal os us See Tee 192
AGH S (BUAkGh vise eee 453
M4) Sachs,) Hoe). cies eee 432
Saito, Eien sb Gr pene cee ee 80
Sands, ikeving, Jo. 2.5 2. 2 eee *360
Sansui sn 75 es, sae eee i88
Santenolse; 1), peace eee 629, 634
Savignac, Ro AG ee 520
Sawicki, Bo. Jere eee eee 196
Schaffer, Karl abs Recs de eee aon
Schall Aye ee We ee 198
Schaller AW 20P Ss. odgw kala eee 526
Schaltenbrand, George. . .398, 508, ae
Schigks Ba vee. vais ao eke eae 522
Schizophrenia, endocrin and_ bio-
chemical studies in..... *465, *585
Schizophrenics, neurological re-
searches tipon™. ...'2 5 ss ee 91
Schizothymia-cyclothymia ....... 91
Schloffer, Fiasco 432
Schou hy baie ih oe 208
Schroeder, C. Biv ks ae 631
Schuster Hass bea ee eae 195
Schwenset,, (Cl 4.050), 2 70
Sclerosis, combined, of the spinal
cord, etiologic relation of
achylia gastficatto.:) see 19]
disseminated . 430
multiple, and cerebrospinal fluid 194
arid sy philiss.i. oe 429
cerebrospinal fluid in... 9.38 193
diagnosis of in nis stages.. 530
experimental . + lie ale alee
vaccine therapy i if. piel 402
multiplex and diffuse sclerosis. 195
Scoliosis, late injury of spinal
cord trom 32.5... 20.0 192
Seelert, cians) <wioek ox ee ee 642
Seeling, “Otto 4.0. ae ee 549
Séneque, UL pds lesen eee eee 528
Sensation, new conception of ele-
ments of: . 2 yee eee ee 439
OF CHITSE wy he es cee eee ee 518
Sensory and trophic syndrome of
pontine origin, 440.06 eee
Serdjukott:... 4.4468 ung oor eee
Serotherapy in acute myelitis.... 200
Séstininee rane: . Gade eee
Sex glands, eal HEN oe of 105
Shawe, Ret Gives Lea ee eee eta 630
Sicard, J Aus ss ee 529
INDEX TO VOLUME 65
SerriveHael lie laaastacd ic esc ee deta ee He 83
Sleep areas in midbrain......... 90
influence of on ay, of
stomach . G 2
localization of center fee aes ue 89
Sleeplessness, control of......... 545
prolonged, effects of in man... 542
Smell, psychological studies of... 223
PSITER SAT CNY els Gah ciel woe Cottle 4 533
SOCIEC Ve! BIC G Olet sie aa! ahi. sv 5 338
SOT Ti CHOY ene eee wel ercs eee 3 629
POH pale alate fe oh ree ae aes 2% 630
Spasmophilia in gastric ulcer.... 633
Semel on da wa. <8 va ab es 25's 534
Spinal bifida with hydrocephalus. . 532
Spinal canal, growth within, com-
pressing the cord and roots
localized . ; 202
cord, birth hemorrhage into. . 200
cervical . ; 197
complete transverse ‘lesion of
with retention of super-
Hheialcreflexesr:: site ce ee 193
compression in ere dis-
CASE 614
etiologic relation of “achylia
gastrica to combined scler-
Osis bes Veter tat wee ue 191
in infantile poliomyelitis..... 430
injury, ossification of muscle
ALOR aay . 194
late injury of from scoliosis. 192
pains with compression of... 199
TUINOE ee oe tee tie 526
adhesive spinal arachnoid-
Hise Similild tiller ys oes 609
ganglia, cyst formation in..... 190
paralysis, familial spastic...... 195
tumors. ERE es EE . 196
Spiritual healing CE eater eye Role ate Say,
Splanchnic nerve, blocking of..
631, 634
lero physiology and pathology
Starcke, Usain Vane iiae. uet: 440
Steck, (CRA ee So RS, 91
St STD a Ah Oe MRE 178
PPM La AI EN Cia e eae chee ds 340
PRTETIISCNENN, Wiad) Ue ees Feds oes se 528
SSLEM CLiGORN biel.) Caan tis so oe 7AM
TOON MED WAT LV Fak eros sdalearn hone 425
STC TRATIN) Exde Foiv tlds sites coe ok Si/
OS OSM Ue ea ae a es 67
Stomach, influence of sleep on
POUL Ve Obes heeds Cae se s 521
motor functioning of in neuro-
paths. . Rees 521
SMa y IS VICI ae ets Rash es sk 609
Diop Orgs Olle wesc wh eee Jes ss 439
SST LE ay ol Ce ge 8 507 641
Storim van Leeuwen, W. ........ 426
Noth 6 aN! 2 Bede, Sc eee ae 181
SG Sees ud Ce AR kaa 180
659
Striate syndrome in congenital en-
cephalopathies . : ... 434
Striatum and hemispheres, _ dog
without . Pe nlen a Sgr Aan
Stubbe, H. je cos. Nc a 208
Subarachnoid hemorrhage from
medico-legal point of view. . .*484
Sydenham’s chorea, neuropatho-
logical findings in a case
ae LR OL PAS
symptomatolog ry of RACE ee 433
Symbolism of human formation.. 101
Sympathectomy . 223
Sympathetic, resecting “the ‘left
cervico-dorsal ganglion of in
ANSI PECTOLIS a. te ee eee 180
tonic effect of on ocular blood
vesselsiic 7.4 : 180
Syphilis and dementia precox. VPA
and multiple sclerosis ......... 429
AL BO Abt Bese nena 72
Tarcowlay Kiski gy eee 98
haylora Al ttedeiouw sn asset eee 311
Pe CiSsier a PWS ae bho ae were 219
Telepathy, experimental... 102
OTE ESE an vee tun care fyi eee ae 541
Tendeloo, Napa Ue aa 444
Terrien, ee Keo eon 518
Tetany, tataitiet. woe. ale ase e 109
ARS AT (Sy0d ORM lc ae eae WLS Hi Goes 520
Thalamus, diuresis and anhy-
dramia following destruc-
ELON 30) be gst yee denen tre a faltarenc ee 89
Mhevenard) Andrews. eva 644
ser ssh LS) Ole we ERRATA so stad en 193
ihinking and: phantasy.) .....% 0+. fa
Minirst; SelisatiolninOLuee “esto e 518
PRTG tADSOIt.. Hoek CURIE. soahees saatans 339
PROPEL S sth Pte Gee, oe a ee 548
Perrys’ deaths sane ee. vane. 78
iPhyroid and psychiatry: 4.5... 90
apparatus, studies Of.) ..2.02. 68
diseases, differential diagnosis
OF Aa RY Ca eae ae le seen 524
dysfunction and neuropsychia-
tVic) \disordersa.g Mai oe 64
function on different diets..... 68
eland and immunity). 4 ee 67
place of in anaphylaxis..... 66
SISTIN OLE sha oe SA oe nai ee 67
Spots TEAS ese wee ceed eee ee 68
Diseases Ou a ie Aleta ae rey ee 176
einibal’’ ys Soa ee eee 521
(bonus and. contracturesuse. a. 434
VASOsSyTipathetiGusncs ease eee LOS
and. hemoptysis) ay cramer: 518
Totemism, Australian, history of 449
Toxic substances, presence of in
blood serum in morphin
habttistiont eye ae sare eo |
Trabaudt Cae cue wwe wens ong 428
rainy: Atta we eee ter oy 339
660
PPrAriCERStATESA, salen hs sees sie eae eh 340
Traumatic neurasthenia ........ 541
Tremor, effect of bulbocapnin on,
in “paralysis, sagitans’e.,.. ne 532
Trophic and sensory syndrome of
pontine (Grigin™ Siem ore 79
USCHET TING. Lea~haterter bik mit een 519
FY suiPiter aS. S.u0 ash pak eles Oe aeecueee 85
eS] £ NG pes NE See A Gee 68
Tuber cinereum, diabetes from
lesions “inte wessiheee eee 435
role of «ae. ifkee ae ee 435
Tuberculosis, brain, in mental dis-
CASCS ti) sd hot See cere ee 204
pulmonary, impor tance of
knowledge of reflexes in
diagnosis sOt een 4 eee 421
Tamor, cerebellar.) /o. eee 83
pylorospasm in case of...... 80
at Vititerbrainh 2s. eee 87
Ot spinal-cord eae ees 101, 526
adhesive spinal arachnoiditis
simulating ws wee
fPumors, intraspinal ©) paaeeeeee 202
Spinal’. 4 0 Pet. aie ee eee 196
Turpin, R. A. wh ata ated lege ee ene 109
Types, special, clinical considera-
tion OL Ye Sans, eee ee ene 512
eer A. Armand ae 74
Ulcer, chronic gastric and
duodenal, treatment of .. 519
gastric and duodenal”) 79..4 520
predisposition to 45 epee 519
spasmophilia in. basse eee 633
Dinconscious:, |... 2 kee ees oe
Wivechia, Cys \s...26 sta ee 73,6455
Wyematsu, “Shichi. 2... seen 207
ACCINE therapy in multiple
sclerosis. "<5 4) eee 402
Vagosympathetic tonus ......... 182
and: hemoptysis \).Sssue eee 518
Vagotonic vomiting, treatment of 519
Vagus and cervical sympathetic,
communication between
Mallery-Radots.<.s.vteate eee 182
WanuBeogaert, «Lind... 6) Ree eee 432
Nander Foot, Douglas’ 2 ae 191
at Rij Hpetk. » Gyo) i cee a 80
garekamp,/ Uh bess os es tee 426
Vasoconstrictor substances, action
of, on arteries of brain.... 178
AGCLICH« .) h. ni: he eR ek eae Pee 425
Vertebral column, study of dis-
Gases iol, Loa. Fa eee Bee 642
Vertigo and the death wish...... P13
INDEX TO VOLUME 65
VietsPenry: osc bere seen eee 195, 402
Viretite: 3 ee eee 202
“: Viscereal, ” misuse of term..... 421
Viscerosensory phenomena ...... 636
Vitamins and endocrine glands.. 522
Vivian; Ms: <3 a. ia). een ee 98
Vomiting, «studies On0s.2. “eee 520
vagotonic, treatment of ....... 519
von- Gordon, Les. a3 eee 183
Voronoff «2. 20 es eon 548
AGNER, (Rov ve)e2 Gee 522
Waldorp; CG. UP) aie 83
Walshe. FMS Ries oe See 433, 536
Ward, ) Stephen": . 2.) 100
Warschauer . bina eh ee 1a
Washington Society for Nervous
and Mental Diseases Ra A 171
Watanabe, “lasses eee 190, 637
Watson, John By Pysjae he 450
Wechsler, L.?3. a eee 52) aa
Weed, Lewis R. visu: 20) One 85
Weeping, spasmodic, ee) laughing 534
Weigeldt, Walther .).. 2st 216
Weil) 'P. Emile 73.2 90.26. eee 76
Weiss, Sica eens. tiie eae 520
Wertheimer, Po .4:.¢2) 5. 202
Westphal, Kin) 28) Ga eee 631, 632
White;/Wilhtan: A. 528 109, 641
Whooping ope blocking nerve
A 5 at ae See ee may et
Widal sFo-2ite 2 ee eee 76, 219
Wideroe,’ 3... 0544 199
Williams, Lom A... 2... eee 202
Wilson,. George’. 2). 3.22 eee *125
Wilson's | disease... . 10s cee 433
microscopical findings in..... 433
Wimmer, August’ io. heeohaeee 9, 434
Winkelman, N..W.. o03.2 eee *125
Winterstein, H. <.. 23) ee eee 222
Wittermann;.: Ei. ot) (tiene 210
Wolte, Jy Te sco. 5 182
Woltman, Henry W.........; 93, 428
se DETAON Albert Bo ees *30
"]T ANDRENs Sven...) ee 72
Zeitschrift flr Kritischen Ok-
kultismus und Grenzfragen
des Seelenlebens, Vol. I,
Helt ‘1. atc 103
Ziegler, Lloyd Hit si..5..eee *273
Zier gee, 4 ee ee 204
Zingerle, HY feac lee eee 89
Londek; Ely aan Se 184, 186, 190
Zylberlast-Zand, Madame Natalie 79
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TABLE OF CONTENTS
ORIGINAL ARTICLES
She Pupils as an Aid to the Diagnosis in States of Coma. By William C. Menninger, M.D. 553
Blood Groups in Mental Diseases. By Frederick Proescher, M.D., and A. 8. Arkush, A.B. 569
Endocrin ‘and Biochemical Studies in Schizophrenia. By Karl M. Bowman, M.D....... Piceim aiiet
SOCIETY PROCEEDINGS
New York Neurological, Society sc. cc. cs cles ool erecie ice tere cstcbe ry ce toRet One ore ele ete tee teat 605
Brachial Plexus Paralyses (Author’s Abstract); Adhesive Spinal Arachnoiditis Simulating
Spinal Cord Tumor. Operation and Complete Recovery (Author’s Abstract); Spinal Cord
Compression in Hodgkin’s Disease (Author’s Abstract); Personality Make-up of Epileptics
(Author’s Abstract); Medullary and Pontine Syndromes (Author’s Abstract).
CURRENT LITERATURE
I. VEGETATIVE NEUROLOGY
1. Vegetative Nervous System: Martini, T., Intermittent Gastroptosis (629) Santenoise, D.,
The Solar Reflex (629): Santenoise, D., and Codet, H., The Solar Reflex (629); Philippsthal,
Epigastric Neuralgia (630); Soupault, R., Drug Dissociation of Vital Centers (630); Shawe,
R. C., Communication Between Vagus and Cervical Sympathetic (680); Daniélopolu, D., and
Carniol, A., Oculogastric Reflex (631) : Schroeder, C. B., Blocking Nerve in Whooping Cough
(631) ; Hustinx, Blocking the Splanchnic Nerve (631) : Westphal, K., Nervous Influence of the
Motor Processes of the Gall Duct (631); Westphal, K., Pain of the Gall Duct and Its Radiating
Refiexes (632); Westphal, K., Motor Neurosis of the Gall Duct and Its Relation to the Path-
ology of the Latter, to Stoppage, Inflammation, Stone Formation, ete. (632); Peritz, G., and
Fleischer, F., Spasmophilia in Gastric Ulcer (633); Henderson, J. E., Studies in Peristaltic
Fatigue (638); Morison, J. M. W., Elevation of the Diaphragm: Unilateral Phrenic Paralysis
(633); Santenoise, D., Periodicity in Vegetative Nervous System (634): Bachlechner, fee
Blocking the Splanchnic Nerve (634); Balan, N. P., So-called Pylorospasm in Infants (635) :
Hanneman, K., Spastic Constipation (635) ; Pipping, W., Intestinal Infantilism (685) ;
Livingston, Edward M., Studies of Viscerosensory Phenomena (636) : Bickel, A., and Watanabe,
T., Action of Drugs on Bile (687); Moller, E., Metabolism in Nervous Anorexia (637).
BOOK REVIEWS
Alfvén, Johannes, Das Problem der Ermiidung. Hine Psychologische Studie (638); Muskens.
L. J. J., Epilepsie. Vergleichende Pathogenese, Erscheinungen. Behandlung. Mit 52
Abbildungen (6388): Ferenezi, S., and Rank, Otto. The Development of Psychoanalysis (689) ;
Lange, Carl Georg, and James, William, The Emotions (640).
II
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Tachycardia
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11 oz. bottles (liquid), and in tablet form 60 tablets to
each package.
Literature, samples and further information from
M. J. BREITENBACH CoO.
53 Warren Street New York City
‘Used from the Start’’
of a cold or any other ills, such as influenza, La Grippe,
bronchitis, tonsillitis, and respiratory affections generally,
supportive measures are urgently needed, and it is at this
time that
Gray's Glycerine Tonic Comp.
(Formula Dr. John P. Gray)
often demonstrates its greatest worth. Prescribed at the
first indication of a eold, it lifts a patient out of his state
of depression and increases the functional activity of vital
organs. As this takes place, the recuperative powers of the
body are given the aid necessary to enable them to relieve
distressing symptoms and assure an early recovery, free
from complications and after effects.
Colds lose their serious aspects to those physicians who use
Gray’s Glycerine Tonic Comp. from their onset.
THE PURDUE FREDERICK CO., 135 Christopher St., New York
OA
as
DYONWOPWOor
aK
ERGOAPIOL (Smith )
Its Utility in the Treatment of
Amenorrhea, Dysmenorrhea and
other Disturbances of
Menstruation
Despite the fact that Ergoapiol (Smith)
exerts a p onounced analgesic and sed-
ative effect upon the entire reproduc-
tive system, its use is notattended with
the objectionable by-effects associated
with anodyne or narcotic diugs.
The unvariable certainty, agree-
ableness and s:ngular promptness with
which Ergoapiol (Smith) relieves the
several varieties of amenorrhea and
dysmenorrhea has earned for it the un-
qualified endorsement of those mem-
bers of the pro‘ession who have sub-
jected it to exacting clinica.
Dosage: Ordinarily, one to two cap-
sules should be administered three or
four t:mes a day.
MARTIN H. SMITH CoO.
NEW YORK, U. S. A.
Female Ills
especially those due to
circulatory derangements and
nervous irritation, have
always been one of the prin-
cipal fields of use of
PEACOCK’S
BROMIDES
In these conditions the undue
excitement and irritability of
the nerve reflexes are allayed,
muscular spasm relaxed, and
pain promptly relieved — all
without depression or gastric
disturbance.
Thus many of the functional
diseases of women rapidly dis-
appear under the use of this
exceptional preparation.
ne
Peacock Chemical Company, 5. Louis, Mo.
MONOGRAPH NO. 35
THE CONSTITUTIONAL FACTORS
IN DEMENTIA PRECOX
WITH PARTICULAR ATTENTION TO
THE CIRCULATORY SYSTEM AND
TO SOME OF THE ENDOCRINE
GLANDS. An Anatomic Study.
By NOLAN D. C. LEWIS, M.D.,
Clinical Psychiatrist, Saint Elizabeths
Hospital, Washington, D.C.
25 full page illustrations Price $3.00
NERVOUS & MENTAL SDISEASE
PUBLISHING CO.
3617 Tenth St., N. W., Washington, D. C.
Intestinal
Toxemia
Because of its marked
stimulation of the liver and
substantial increase of the
flow of bile,
CHIONIA
has long been known to be a
remarkably effective means of
controlling and correcting putre-
factive processes in the colon.
In conjunction, therefore, with
eolonic irrigation, Chionia is
considered by many clinicians
an invaluable adjunct in the
corrective treatment of intes-
tinal toxemia,
MILWAUKEE SANITARIUM
° ° ‘hicago Office—1823 Marshall Field :
Wauwatosa, Wisconsin. (eee ae ee
Maintaining the highest standards over a Resident Staff :
period of forty-two years, the Milwaukee ; Rock eres ese Med. poe
Sanitarium stands for all that is best WittiaM V-) ReAO WEL ae
MERLE Q. Howarp, M.D.
in the care and treatment of nervous io See
ending
disorders. PAT Leto: H. Doucras SincerR, M.D.
and particulars sent on Artuur J. Patex, M.D.
request.
Consulting Staff
WitiiaM F. Lorenz, M.D.
Ricuarp Dewey, M.D. (Emeritus)
COLONIAL HALL—
One of the Eight Units
n “ Cottage Plan” /
THE BEACON SCHOOL
FOR PROBLEM CHILDREN
Situated in Summit, N. J., six hundred feet above sea level, THE BEACON
SCHOOL combines for PROBLEM children who are not able to keep the
pace of the robust types, a real ““ Home” and a “ School.”
School instruction according to mental development. Supervised play hours.
Tuition $1,200 a year.
Summer camp Bridgton, Maine.
Mrs. Elsa Y. Palmer, 45 Oakridge Ave., Summit, N. J.
CHANNING SANITARIUM, INC.
(Established in Brookline, 1879)
Has been transferred to Wellesley Avenue
3 WELLESLEY, MASS.
Seven new buildings on fifty acres of high woodland. Sleeping porch and private bath for
each patient. Large and small suite cottages. Separate buildings for men and women. Facilities
for occupation and diversion. Complete equipment for Vichy, Nauheim and Electric Baths
and other forms of Hydrotherapy.
Clifford G. Rounsefell, M.D. Resident Physician Donald Gregg, M.D. Superintendent
Belle Mead Farm Colony and Sanatorium Belle Mead, New Jersey
For insane, senile and nervous patients, alcoholic and drug addicts: also selected cases
of feeble minded and epilepsy. Country, 42 miles from New York City and Philadelphia.
Reasonable rates for excellent accommodations and scientific treatment.
For rates and
) detailed informa-
tion, address the
Resident Physi-
cian, or New
York City office,
666 Madison Ave.
Hours 3-4 daily.
Five Attractive}
Buildings
Under State
License
MONOGRAPH NO. 45
Postencephalitic Respiratory
Disorders
By
Smith Ely Jelliffe
Price $2.50
Nervous and Mental Disease Publishing Co.
3617 Tenth Street, N. W. Washington, D. C. |
MONOGRAPH No. 39 MONOGRAPH No. 40
The Emotions, Morality and The Development of Psycho-
the Brain analysis
By C. v. MONAKOW oF ZourIcH By S. FERENCZI ann O. RANK
PRICE $2.00 PRICE $2.00
NERVOUS & MENTAL DISEASE NERVOUS & MENTAL DISEASE
PUBLISHING CO., PUBLISHING CO.,
3617 Tenth Street, N. W. 3617 Tenth Street, N. W.
Washington, D. C. Washington, D. C.
VII
CHARLES B. TOWNS HOSPITAL
293 Central Park West New York, N. Y.
For Alcoholism and Drug Addiction
Provides a definite eliminative treatment which obliterates craving for alcohol and drugs,
including the various groups of hypnotics and sedatives.
Complete department of physical therapy. Well equipped gymnasium. Located directly
across from Central Park in one of New York’s best residential sections.
Any physician having an addict problem is invited to write for ‘‘ Hospital Treatment for
Aleohol and Drug Addiction
BOOKS RECEIVED FOR REVIEW
FURTHER CONTRIBUTIONS TO THE THEORY AND TECHNIQUE OF PsycCHOANALYSIs: S. Ferenczt,
Hogarth Press, London
CriinicaL Neuroutocy: FE. A. Strecker, M. K. Meyers, P. Blakiston’s Son & Co., Phila-
delphia
Tue Tirep Cuitp: M. Seham, G. Seham, J. B. Lippincott Co., Philadelphia
La PsycHOLOGIE ORGANIQUE: P. Jean, Felix Alcan, Paris
VINCENT VAN GOGH IN DER KrANKHEIT: W. Riese, J. F. Bergmann, Munchen
Diz MertTHoDIK DER ERFORSCHUNG DER BEDINGTEN REFLEXE: WN. A. Podkopaew, J. F.
Bergmann, Munchen
User ApuHasie: K. Goldstein, Orell Fussli Verlag, Zurich
Das ProBLEM DER Ermupunc: J. Alfven, Ferdinand Enke, Stuttgart
MINERAL WATERS OF THE UNITED STATES AND AMERICAN Spas: W. E. Fitch, Lea &
Febiger, Philadelphia
Dir PsyCHOKATHARTISCHE BEHANDLUNG NERVOSER STORUNGEN: L. Frank, Georg Thieme,
Leipzig
SEMIOLOGIE DES AFFECTIONS DU SysTEME NeERvEUXx: J. Dejerine, Masson & Cie., Paris
Les Novuvestes MetrHopes sur tes Reactions CoLitoipates pu LiguiprE CEPHALO-
Racuipien: EF, de Thurzo, N. Maloine, Paris 5
THERAPIE DER OGRANISCHEN NERVENKRANKHEITEN: M. Schacherl, J. Springer, Wien
INNERE SEKRETION IN DER ErstEN LesenszeItT: E. Thomas, G. Fischer, Jena
TASCHENBUCH DER PRAKTISCHEN UNTERSUCHUNGSMETHODEN DER KoORPERFLUSSIGKEITEN
BEI NERVEN UND GEISTESKRANKHEITEN: V’. Kafka, J. Springer, Berlin
Tue Mystic Rose: E. Crawley, Boni & Liveright, New York City
Way Reticion? H. Kallen, Boni & Liveright, New York City
PsycuopaTtHotocy: B. Hart, Macmillan Co., New York City
Vav Bertypa IsoNDRINGSORGANEN FOR VAR KropP ocH sjaAL? A. Josefson, H. Gebers,
Stockholm
PsycCHOANALYSE: R. Urbantschitsch, M. Perles, Wien
eek ea 2 UND AKUTE ERKRANKUNGEN DES NERVENSYSTEMS: S. Ficischmann, S. Karger,
erlin
Der Sensitive Bezienuncswaun: E. Kretschmer, J. Springer, Berlin
Your Nervous Cuirp: E. Werberg, A. & C. Boni, New York City
NEUVERE BEOBACHTUNGEN UBER DIE PSYCHOLOGIE DER ZU LEBENSLANGLiCHER ZUCHTHAUS-
puehl VERURTEILTEN ODER BEGNADIGTEN WVERBRECHER: H. Tobben, F. Deuticke,
4eipzig
VIII
““hendleepls Prevented By Lain’
LUMALGIN
TRADE MARK REGISTERED
c Analgesic — Sedative — Hypnotic
Not merely relieves pain, but reduces the high nervous tension which
interferes with restful slumber. Besides being efficient and safe,
Lumalgin is economical and therefore within the reach of every patient.
Supplied in tablets, tubes of 10 and bottles of 25
SAMPLE AND LITERATURE ON REQUEST
WINTHROP CHEMICAL CO., Inc., 117 Hudson St., New York, N. Y.
IMPORTANT NOTICE
Fifty Years of American Neurology
The first 50 volumes of the Journal of Nervous and
Mental Disease have been indexed for subjects.
A complete history of American Neurology can be
here obtained.
Limited number of copies printed
PRICE $10.00
Journal of Nervous and Mental Disease
64 West 56th Street New York City
A NEW JOURNAL OF PSYCHOANALYSIS
ARCHIVES OF PSYCHOANALYSIS, issued quarterly. L. Pierce Clark, editor.
Its purpose is to publish in detail analyses of cases (narcistic neuroses and psychoses
especially), showing psychoanalytic technic. $5.00 single copy. $20,00 per volume.
October issue—Abstracts from Freud Anniversary Number of Zeitschrift. Grod-
deck’s ‘Das Buch vom Es.’? January—Authorized translation. Inhibition, Symptom
and Fear, by Freud.
Monographs in Press: Inhibition, Symptom and Fear (Freud) $2.50. The objec-
tive and Subjective Development of the Ego (Clark) $1.00. A Psychological Study of
Mental Defect (Clark) $1.00.
Accompany order by checks to
ARCHIVES OF PSYCHOANALYSIS, 2 East 65th St., New York
VERLAG VON JULIUS SPRINGER IN BERLIN UND WIEN
Die Cytoarchitektonik der Hirnrinde des erwachsenen Menschen
Von
Constantin Freiherr von Economo
Dr. med., a. 0. Professor der Psychiatrie und Neurologie in Wien, und
Dr. Georg N. Koskinas
em. Assistent der Psychiatrischen und Neurologischen Universitatsklinik in Athen
Bearbeitet an der Psychiatrischen Klinik Hofrat J. Wagner v. Jauregg-Wien
Textband
852 Seiten mit 162 zum Teil farbigen Abbildungen im Text
Atlas
Mit 112 mikrophotographischen Tafeln in besonderer Mappe
1925. Preis 600 R.M.
JUST FROM PRESS
Monograph No. 43
ESSAYS IN PSYCHOPATHOLOGY
By Dr. William A. White
Price $2.50
Nervous and Mental Disease Publishing Co.
3617 Tenth Street, N. W. Washington, D. C.
fe THE
THE ££ , MA DENVER
PERFECT : CHEMICAL
POULTICE % TRADE MARK MFG. CO.
The LIVERMORE SANITARIUM, LIVERMORE, CAL.
FOR NERVOUS AND MENTAL DISEASES
Situated in a beautiful valley, forty miles from San Francisco, two hours ride on the
Southern Pacific Railroad. Blevation five hundred feet. Climate excellent with sunshine
almost every day.
Large resident medical staff: Well trained nursing service: Clinical Laboratory;
Hydrotherapy: Occupational Therapy: X-ray Departments; also Gymnasium, Bowling
Alleys, Swimming Pool, Tennis and Croquet Courts. Dietary Department insures an
excellent cuisine. .
Separate Department for the functional neuroses. Cottage system for mental patients.
Several Bungalows for individual patients, wishing home-like surroundings with absolute
privacy and the very best accommodations.
Rates, inclusive of routine examinations, general nursing and medical treatment, forty-
five dollars per week and upward. Circulars on application.
V. H. PODSTATA, M.D., Supt.
J. W. ROBERTSON, M.D., Consulting. Cc. W. MACK, M.D., Asst. Supt.
JEWEL FAY, M.D.
G. WILSE ROBINSON SANITARIUM COMPANY
G. WILSE ROBINSON, M.D.
Superintendent and Medical Director
Nervous and Mental Diseases
Sanitarium—8100 Independence Road.
Suite—814-817 Medical Arts Bldg., 34th & Broadway. \ Uses Re
THE CINCINNATI SANITARIUM
Established
more than
fifty years ago
A Private Hospital for Nervous and Mental Diseases
Secluded but easily accessible. Constant medical supervision. Registered charge nurses.
Complete laboratory and hydrotherapy equipment. Dental department for examination
and treatment. OUccupational therapy. Ample classification facilities. Thirty acres in
lawns and park.
F. W. LANGDON, M.D., and ROBERT INGRAM, M.D., Visiting Consultants
D. A. JOHNSTON, M.D., Resident Medical Director A. T. CHILDERS, M.D., Res. Physician
REST COTTAGE
This psychoneurotic unit is a complete and separate hospital building elaborate in
furnishings and fixtures.
For terms apply to The Cincinnati Sanitarium, College Hill, Cincinnati, Ohio
XI
DIRECTORY FOR PRIVATE INSTITUTIONS
DR. BARNES SANTPARIUNL Ginccticas
A Private Sanitarium for Mental and Nervous Diseases, also Cases of General Invalidism.
Cases of Alcoholism and Drug Addiction Accepted.
A modern institution of detached buildings situated in a beautiful park of fifty acres,
commanding superb views of Long Island Sound and surrounding hill country. Completely
equipped for scientific treatment and special attention needed in each individual case.
Fifty minutes from New York City. Frequent train service. For terms and booklet
address
F. H. BARNES, M.D., Med. Supt. Telephone 1867 Stamford, Conn.
FATR OAKS SUMMIT, N. J.
sanatorium well equipped with the means for physical therapeutics (baths, electricity. etc.)
and especially designed for the care and treatment of organic and functional nervous diseases,
exhaustion states and cases requiring rest, hygienic, dietetic and occupational therapy. Summit is
located in the beautiful hill country of New Jersey on the D. L. & W. Railroad, twenty miles
from New York City.
Insane and tuberculous cases are not accepted
Telephone 143 DR lee PROUT, Summit, N. J.
THE WALLACE SANITAR TUN
SUCCEEDING WALLACE-SOMERVILLE SANITARIUM, MEMPHIS, TENN.
MEMPHIS, TENN.
WALTER R. WALLACE, M.D.
HUGH W. PRIDDY, M.D.
FOR THE TREATMENT OF
DRUG ADDICTIONS,
ALCOHOLISM, MENTAL AND
NERVOUS DISEASES
LOCATED IN THE EASTERN SUBURBS OF THE CITY. SIXTEEN ACRES OF BEAUTIFUL GROUNDS. ALL
EQUIPMENT FOR CARE OF PATIENTS ADMITTED.
WESTBROOK SANATORIUM ftscim”
Rooms single, or en suite, with or without private baths. Hot water heat, electric lights
and artesiun water. Bowling, tennis, croquet, billiards and a gymnasium afford recreation.
Electrical and hydrotherapy equipment. Nurses and attendants trained for this special work.
Two of the physicians reside in the institution and devote their entire time to the patients.
The magnificent home of the late Major Ginter, by alterations and extensive additions, has
been transformed into a private institution for the treatment of nervous diseases, mild mental]
cases and select alcoholic and drug habitues.
The grounds are ample, quiet is assured, and a new building for men makes easy the separa-
tion of the sexes. A number of cottages makes possible satisfactory and congenial grouping.
James K. Hall, M.D. Paul V. Anderson, M.D. E. M. Gayle, M.D
HARTFORD RETREAT
Established 100 Years
A sanitarium for the treatment of nervous and mental disorders by the
most thoroughly approved methods—Dietotherapy, Hydro-
therapy, Pharmacotherapy and Psychotherapy.
Dr. W. N. Thompson, Superintendent, Washington St., Hartford, Conn.
DIRECTORY FOR PRIVATE INSTITUTIONS
KENILWORTH, ILLINOIS
(Established 1905)
(C. & N. W. Railway, 6 miles north of Chicago)
Built and equipped for the treatment of nervous and mental diseases. Approved
diagnostic and therapeutic methods. An adequate night nursing service maintained.
Sound-proofed rooms with forced ventilation. Elegant appointments. Bath rooms en
suite, steam heating, electric lighting, electric elevator.
Resident Medical Staff:
Sherman Brown, M.D. Mable Hoiland, M.D. Sanger Brown, M.D.
Consultation by appointment only
All correspondence should be addressed to KENILWORTH SANITARIUM, Kenilworth, Ill.
S SEGUIN SCHOOL “is
for Children who Deviate Mentally from the Normal
Limited to 25 educable pupils—little girls and boys and young women (no epi-
leptics—no insane) ; eleven experienced teachers; five governesses supervise play hours
Large grounds adjoining 50 acre park
Tuition and Board from Sept. 15 to June 15, $1800
Summer School in Mountains, June 15 to Sept. 15, $450
MRS. ELSIE M. SEGUIN, Director 500 South Centre St., Orange, N. J.
WESTWwWooD LODGE
A modern, private sanatorium within
fifteen miles of Boston, fully equipped
for the scientific treatment of nervous
and mild mental diseases, also for those
in need of rest under medical super-
vision. The building stands in the midst
of over one hundred acres Salus
woodlands, cultivated gardens, beautifu
pine groves and walks.
For further information, apply to
WILLIAM J. HAMMOND, M.D.
Resident Physician
Westwood Mass.
DIRECTORY FOR PRIVATE INSTITUTIONS
BOURNEWOOD
A Private Hospital for Mental Diseases
Number of patients limited to eighteen. Cases of alcohol or drug habituation
not received. Telephone ‘‘Parkway 300.’’ Nearest station, Bellevue on the
N. Y., N. H. & H. R. R. Boston office, 48 Beacon Street. By appointment.
GEORGE H. TORNEY, M.D.
THE VAN VALEN SANATORIUM
Yonkers, N. Y.
Psycho-Therapeutic treatment for mental, nervous, functional disorders and addic-
tions. Also receive patients needing care, with or without treatment.
Booklet Upon Request. , Phone Yonkers 5321
THE NORBURY SANATORIUM “<3
Incorporated and Licensed.
For the treatment of Nervous and Mental Disorders.
Dr. Frank P. Norbury, Medical Director.
Dr. Albert H. Dollear, Superintendent.
Dison Gale ua Associate Physicians
Dr. Samuel N. Clark, f | y
Address Communications
THE NORBURY SANATORIUM, Jacksonville, Illinois.
GLENMARY SANITARIUM Owego, Tioga Co.
a. Pe > te) a ans New York
For the care and treatment of a limited number of selected cases of Nervous and Mental Disease.
Voluntary cases admitted. Epileptics treated and cared for. Absolute privacy and special ethical
treatment for Alcohol and Drug Addictions. Close cooperation at all times with the family
physician.
ARTHUR J. CAPRON. M.D., Physician-in-Charge.
Oconomowoc Health Resort
OCONOMOWOC, WIS.
Absolutely Fireproof
Built and Equipped in 1907 for treating
NERVOUS AND MILD MENTAL DISEASES
Three Hours from Chicago on C. M. & S. P. Ry.
’ Location Unsurpassed—Readily Accessible
ARTHUR W. ROGERS, B.L., M.D.
Resident Physician in Charge
JAMES C. HASSALL, M.D., Med. Supt.
FRED. C. GESSNER, M.D., Asst. Physician
XIV
Consult this Directory for Private Institutions
DIRECTORY FOR PRIVATE INSTITUTIONS
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(Continued on page XVIT)
OXFORD RETREAT
New Fireproof Building Opened July, 1926
A private hospital for Nervous and Mild Mental Diseases. Incor-
porated 1883. Separate departments for men and women. .
Careful attention to proper classification, every convenience,
and any accommodation desired. Facilities unsurpassed. Site
elevated, retired and beautiful.
R. HARVEY COOK, Physician-in-Chief,
OXFORD, BUTLER COUNTY, OHIO
DIRECTORY FOR PRIVATE INSTITUTIONS
MORPHINE DRUG ADDICTIONS AND ALCOHOLISM
Treated by the “‘ Quayle Method.” A safe and
easy way. Results guaranteed. Treatment is pain-
less and supportive, rather than depressant. Ne
nervous period experienced. I also furnish a Home
Treatment for Physicians to use in treating addicts
at home, who for various reasons are unable to go to
a Sanitarium.
For full particulars address
DR. QUAYLE SANITARIUM
CHAS. H. QUAYLE, M.D., Medical Director
Dept. B MADISON, OHIO
RIVER CREST asroria, L. 1. N.Y. CITY
Home-like, well-equipped sanitarium for nervous and mild mental patients. Drug and
alcoholic habitués are also received. Twenty-five years under same management. The
physicians have unusually large experience. The site is exceptional. Nearest psychiatric
institute to centre of Manhattan. Rates reasonable. Reached by all subways via Grand
Central Station, Astoria car, Queensboro Tube. Located at Ditmars Avenue and Kindred
Street. Phone 0820. City office 666 Madison Ave. Cor. 61st St. 3-4 daily. Phone Regent 7140.
For Terms and Booklet address WM. ELLIOTT DOLD, Physician in Charge
4 SAN ANTONIO,
DR. MOODY’S SANITARIUM aaa
For Nervous and Mental Diseases, Drug and Alcohol Addictions, and Nervous Invalids Needing
Rest and Recuperation.
Hstablished 1903. Strictly ethical. Location delightful, summer and winter. Approved diag-
nostic and therapeutic methods. Modern clinical laboratory. 7 buildings, each with separate
lawns, each featuring a small separate sanitarium, affording wholesome restfulness and recreation,
indoors and outdoors, tactful nursing and homelike comforts. Bathrooms ensuite, 100 rooms, large
alleries, modern equipment. 15 acres, 350 shade trees, cement walks, playgrounds. Surrounded
y beautiful parks, Government Post grounds and Country Club.
G. H. MOODY, M.D., Supt.
T. L. MOODY. MD. a Piva J. A. McINTOSH, M.D., Res. Phys.
WAUKESHA SPRINGS SANITARIUM
WAUKESHA, WISCONSIN
For the Care and Treatment of
NERVOUS AND MENTAL
DISEASE
Building absolutely fireproof
BYRON M. CAPLES, M.D., Medical Directer
FLOYD W. APLIN, M.D. and
L. H. PRINCE, M.D.
GREEN GABLES
The Dr. Benj. F. Bailey Sanatorium
Lincoln, Nebraska
A scientifically equipped, homelike institution, housed in brick
end stone buildings. located in its own park of twenty-five acres
XVI
Directory for Private Institutions—Continued from Page XV
LAV ICARG IT TmING WE OUDIOIA TIVO IN ct cle cyetuc sists nveleS fico ciclo cle es ee sl tinie ties lores wisleiale, sieve eles fa Se BK NIe CCE Ree 20
ENCED MAG O SILe Tame N came tre stete tere tere eter cee tees cve.clareeer stereos s ara tavers “cia aRne ore cle ekoie cate cPiave © Ghé cin e/ele euace aie susue Sree 18
ello 2 we Lee me cle AVEC LC aN RY a seen tastes vate wtate ale ene eueietacsterars witatlens drone) slice Recs ar areie el elevelers ere 0'6.0. 6 ee
Kenilworth moubi tari wrrCenilwoOrti, a LI e".. «aes solos sc ster se ss aivicto eels eS erie e ie cede owe cise dieas ols 18
TC ae) te cee ererae OL ITI US ye Ooenctareiets 55's. dretald ecole ene ciieeate ee ake aie ce eee UE PP tanane aie ete eugeebnree ecg 18
Eiverwvoremsaitarilim malvermore) CalifOrnial mete 6 cicero ic oles cioce are eis)cls «lene ahevelovalele acevers cere sere stleleneretetels 11
LG y Came) ome ler I Vane Vote EU LVCTIC A LOSMPIN ci Vole sucvc altace c @o, sisnav o cNTScar ais 8 lene Mae oa ott aa oa ee ein usta ccue Grchonere 19
Era ome mS em CSD Oe Linon eavaic cae eeitis « ceathe ce ren eee puccaie Oe Migtine ciate shtate a fecu rately SiMe Con IOMIGIS Oeaeeee eeeveane 21
MUGICARIA YC aL eee eV a ROCDIS SIDATINIS.: COMMMM sr: ncvarsholesietets cis cres ate eseteas acotomer tens ton Remo cot ovenst ane reveeete Teverens a¥e,.6 20
NCU Siem OT eel Cee Ata GUI MALIN CO T1LO ve @ Kerra eueiewens se tranaucteh anes etek theta roku Rr He eee eee beled oraveratels slave 16
PL Mig Orme Setird bey UUme OLLTEN UES eed Ol neee reeetaeteh occ ns ttecorars taal crore Acts come oacarnte ote Meee file chae hei orien ae 18
Mal Wm McComeniirariuiitve Wai WatOsn,~ WAS: s%.6 dae deve Cdvan Sasiguts aroubs a3 ad oaeteacet chee eaves eave 6
MOO VEG Eee Die ood yi sasanitarium. joan sAntonio, “Dex... scat ns cee ca ort oe sien etc ie era lees 16
etree eee met Ata TET Ie DOK oe akg Ge ak Oia a re sie hie Bile Gen and © a Sk CNSR LON ah SEW ae RAD eine 16
Neuron iiurst,.- Dr. W. B. Mletcher’s: Sanatorium, Indianapolis; Ind... . 2 oc.s. esc seen scinsnese 20
MULE MS aurlarin ee DYreeh, oP. Norbury, | Jaeksonville:) Te 7.7.2 Sons. Concern stuns 14
COMO WwOcmetea fi tesOrt, VOCONOMOWOC!! © Wi8s 1s sies (ety cowl dabloleers ae ae bie we TR woiele ae laren 6 14
Soe eee SPUMIPEOT (Ee COL Tse ve veg. ce Oe 5 Ck Seve hn eRe bok wheel be wae HOE eke ek eee es bs peer 20
freer tm CECT eC) GL Oe CO OTIG ce age cee ak cat Sas vhs 8 Ca ORGS tT hbo be wa Rae Meee Oe aes 15
De aM ORE USSR eS ITT G A Nad ok os le © ects dake aSe Sk a oso ors acslelthue wich of uewadhupine wale iste ern ees ee
See ee PRC ee LAVCrINOre aC ALLOA aie as. « dec cereus oie coe wis Coke aetna uae ued nae aero’ 11
Seats een mE ee Ga CORN GI Nena «nds Seatone oem cie ohne cons ckeanesaugennecteceneas 18
Pe ee Pee eC MOT Da Peni ce es eve t Aakd alone ee cd Soe eucueswssgaceerees 12
ae th el Cr ea ENAINT | Lap NE Ah 2 oR WA re eee AE Stem ard ics een = o's va bin OW EWA wieceh tin eye atari Bias 12
PPE venOmmnvtre LUstiLwte, Stamfords: COUN cs it. ic vc je cc cces owes bajesie cca sa tee edie ere ege oe mees 20
Weave Olmcnas sr ; Dr Quayle Sanitarium, Madison, ‘Ohidw.s....<0c. «i .s oae% soo o% oes ens ole Os 16
PN Ce te A LOLI A Lio Lele NO Wr OL SCILY sieie cod hives s wedide sda bess ede nbale eVewseetacceeals 16
Pig ate Pa eV os FOR SG CILY «MOS ec init Sel core elds Lode Oe bila sn dcx Slelditlnam acne sacswee umesece 11
ee eee ee OOCONCIMOWOC, OVW ISS se he ee oe daw clo Ses Dds eis s ced ediee balls gacubescen 14
Beene ere meCiiirords Goan W llesleyn Mash, o Sako ooo a boule. ae saeco ane va Segoe tw pe eenen 6
ee ee ee Vest DOre mC ONTa ee ito. 2 Fe 2) oksmdss Ge Gods ca buldtea ede dawt owes esicce ara 18
ee ea ORT OTIS Ney eae ot hh) Sah yiiets oes os tise cel. i oh Daels Oey Oy Mase wien HE Oe SEOs 18
eee mer OO CGH Ih OC IN tS onae Toor feet Ss ye ee eh ted ae ee le wale ce ie chee be oe Cees e ae eee 18
Bee eri am COG DCIS ING ALY eae tats tee itt ee Ne oh mL Tn ee ee seal ahs at tenn ee 18
ee ere encom WAUWALOKA, CWVidcy ts) ou. oc Salil Gosus Gv Buk odie e | cdaius oss alheckonteseen tee 6
Spink, Dr. Mary A., Dara G a Dodie bn Gwen be Sk) te ea) el a dra ao dob isos Woe. 6 Getetee em ee el 8 20
BU Lice nme taucebinie on orl 1d somes Nom Ys. Acs oc acs uiow oO iS hese os cobs cd oe lbndalh oeeswaeleawe 19
ora orem en meV ee Ne ree Ll are lorie GO nti. +. atc 620 OSs hk ions San ndc eo Tab SR es Ya deve beak euess 12
(Continued on page XXT)
NERVOUS AND MENTAL DISEASE
MONOGRAPH NO. 82
Foundations of
Psychiatry
By WILLIAM A. WHITE, M.D., ef Washing-
ten, D. C.
An Examination of the Fundamental Con-
cepts which are Necessary to an Understand-
{ng of Mental Disease.
CONTENTS: Chap. I: Introduction; Chap.
II: The Unity of the Organism: The Biological
Point of View—Integration—Structuralization
—Individuation; Chap. III: The Dynamics of
the Organism: The Canon of Physiology (The
Conflict)—Ambivalency; Chap. IV: The Strati-
fication of the Organism: The Physiological
Level—The Psychological Level—The Socio-
logical Level; Chap. V: The Region of Psycho-
pathology; Chap. VI: The Nature of the
Neuroses and the Psychoses; Chap. VII:
Therapeutics: Action, Objectification—Trans-
ference—Resymbolization; Chap. VIII: The
Social Problem: Elevation—Rationalization—
Sublimation—The Socialization of Strivings:
Chap. IX: Conclusion.
Nervous and Mental Disease Pub. Co.,
3617 Tenth Street, N. W.
WASHINGTON, D. C.
XVII
SL TREE ESE ETE BT TO SIO TEESE EEN ANOS TRE LORENA
JUST PUBLISHED
Completely Revised Third Edition
BING’S
Compendium of Regional Diagnosis
In Affections of the Brain
and Spinal Cord
A concise Introduction to the Principles
of Clinical Localisation in Diseases and
Injuries of the Central Nervous System
————EEEE
By ROBERT BING, Professor in the Uni-
versity of Basle; Translated from_ the
Sixth German Edition by F. S. ARNOLD,
B.A., M.B., B.Ch. (Oxon.)
Third Edition, Revised and Enlarged
204 Pages, 6x9. 102 Illustrations, many in
Colors. Price, silk cloth, $6.00
Condensed Table of Contents
DIVISION I. Regional Diagnosis of
Lesions of the Spinal Cord: (a) ‘* Trans-
verse’’ or systemic diagnosis; (b) ** Longi-
tudinal” or segmental diagnosis. :
DIVISION II. Regional Diagnosis of
Brain Lesions: (a) Lesions in the region
of the cerebral axis or brain-stem ;
(b) Lesions of the cerebellum ; (c) Lesions
of the cerebrum, the basal ganglia, and the
hypophysis.
C. V. Mosby Co. - Publishers - St. Louis
DIRECTORY FOR PRIVATE INSTITUTIONS
“INTERPINES”’
Goshen, N. Y.
Phone 117
ETHICAL— RELIABLE— SCIENTIFIC
Disorders of the Nervous System
BEAUTIFUL — QUIET — HOMELIKE — WRITE FOR BOOKLET
DR. F. W.. SEWARD, Supt. DR. CoA. PODER DR. B.A] SCOLe
HIGHLAND HOSPITAL
Succeeding Dr. Carroll’s Sanitarium
An institution employing all rational methods for the treatment of
Nervous, Habit and Mild Mental cases; especially emphasizing the
natural curative agents—Rest, Climate, Water, Diet and Work.
In ASHEVILLE, winter’s rigor and summer’s heat are alike tem-
pered. An elevation of 2500 feet, remarkable scenery and a superb
climate have made Asheville famous. For booklet address
ROBT. S. CARROLL, Medical Director ASHEVILLE, N. C.a
McMILLEN SANITARIUM COLUMBUS, OHIO
For treatment of Nervous and
Mental Diseases, Alcohol and
Drug Addictions.
A Private Neuropsychiatric
Hospital, modern in all par-
ticulars. Specialists’ services,
laboratory facilities, ideal loca-
tion. Prices reasonable. For
booklet and particulars address
DR. ROBERT A. KIDD, Supt.
Corner Nelson Rd. & East Fifth Ave., Columbus, Ohio
THE WESTPORT SANITARIUM
WESTPORT, CONNECTICUT
For the care and treatment of nervous and mental diseases, with special attention to chronie
nervous cases. Modern appointments, home life, beautiful surroundings, large private
grounds. Private attendants and cottage care if desired. Committed or voluntary patients
received.
For information and terms, address
Tel. 4, Westport, Conn. DR. F. D. RULAND, Medical Superintendent.
TIRBT AND. THIRD WEDNESDAYS, 10:30 A. M. to 12:30 P. M.
40 East 4]st St. 6950 Murray Hill, New York Ciry WESTPORT, CONN.
AV ILLE
VIRGINIA HOT SPRINGS
America’s Greatest Health Resort
Take the Cure at VIRGINIA HOT SPRINGS for Rheumatism,
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WATERS, BATHS, HOTEL AND SCENERY
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Average Temperature, Aug. 770F.; Sept. 750F.; Oct. 640F.
PLAYGROUND OF AMERICA—Golf, Tennis, Swimming Pool, Riding. Driving and Walks
Unsurpassed. The New Homestead Hotel, Best in America. Broker’ s Office, Logan & Bryan,
with direct New York wire.
New York Booking Office: Ritz Carleton Hotel, 46th Street and Madison Avenue
For Booklets, etc., apply to
CHRISTIAN S. ANDERSON, Resident Manager. Hot Springs, Va., U. S. A.
NSED EASTON,
en THE EASTON SANITARIUM PRUNES CA ten
A PRIVATDH INSTITUTION for the care and treatment of nervous and mental disorders,
conditions of semi-invalidism, aged people and selected cases of drug addiction and
alcoholism. Homelike atmosphere; personal care; outdoor recreation and occupation year
round; delightfully located overlooking the Delaware River and the city of Easton; 2 hours
from New York City; 68 miles from Philadelphia. For booklet and particulars address
8. 8. P. WETMORE, M.D., Medical Director, or phone 166 Haston.
66 THE SPRUCES 39 2 URN AE Spe iz tone
Dr. V. V. Anderson announces the removal of “The Spruces,’—his Mental Hygiene
School for the treatment and training of nervous and unadjusted children, from Shrews-
bury, New Jersey, to Staatsburg-on-Hudson, New York.
The rapid growth of the school has necessitated larger quarters. The new school
consists of an estate of 125 acres, with ample buildings for increased therapeutic and
educational facilities.
Vv. V. ANDERSON, M.D., Medical Director W. M. CAVENDER, Executive Assistant
WEST HILL
HENRY W. LLOYD, M.D.
West 252nd St. and Fieldston Road
Riverdale, New York City
Harotp E. Hoyt, M.D., Res. Physician in Charge.
Located within the city limits it has all the advantages of a country sani-
tarium for those who are nervous or mentally ill. In addition to the main
building, there are several attractive cottages located on a ten acre plot.
Separate buildings for drug and alcoholic cases. Doctors may visit their
patients and direct the treatment.
Telephone: KINGSBRIDGE 3040
DIRECTORY FOR PRIVATE INSTITUTIONS
THE PSYCHOANALYTIC INSTITUTE, STAMFORD, CONN.
(THE ORCHARDS)
For the treatment and psychoanalytic study of neurotic and convulsive disorders. A sup-
portive background of a private home with individual interests. Resident staff of trained
analysts under direction of New York neuropsychiatrist. Course of training in psycho-
analytic technique open to one or two pupils.
T. E. UNIKER, Assistant in Charge, Box 345, Stamford, Conn.
Telephone Stamford 1630
IDYLEASE INN
40 miles from New York Newfoundland, N. J. 1000 feet above sea-level
A modern health resort treating mild functional disorders of the nervous system,
convalescents, and those needing a change of environment. Mental, tuberculous
and otherwise objectionable cases are not received. The atmosphere of a large
country home rather than that of a hospital is studiously maintained.
Booklet on request
DR. McFARLAND’S SANITARIUM
“ HALL-BROOKE ”
FOR MENTAL, NERVOUS, AND HABIT CASES
Beautifully situated on Long Island Sound. The grounds, consisting of over 100 acres
laid out in walks and drives, are inviting and retired.
Patients received from any location. Address
Telephone 140 D. W. McFARLAND, M.D.
WESTPORT, CONNECTICUT GREEN’S FARMS, CONNECTICUT
9 Under State License
Dr. K ellogg S House for the Care and Treatment of Nervous and Men-
tal Diseases. Select Cases and Limited Number
Modern appointments and Handsome surroundings. Committed or voluntary patients
received. Trains hourly to Riverdale Station, Hudson River Railroad, or Van Cortlandt
Station, Putnam Railroad, or by Broadway Subway to 242d street, and then Broadway
Trolley to 253d street, one block from the house. Address letters or telegrams to Dr.
Theodore H. Kellogg.
CORNER RIVERDALE LANE AND ALBANY POST ROAD
N. Y¥Y. City Telephone, 36 Kingsbridge RIVERDALE, NEW YORK CITY
DR. BROOKS’ HOUSE
RYHoN 7 a).
Post Office and R. R. Station, Harrison, N. Y.
Telephone Park 893
A Private Hospital, on the cottage plan, for the treatment of Nervous
and Mild Mental Diseases. Number limited to eleven. Situated on the
Boston Post Road just east of Park Avenue, 22 miles from Columbus
Cirele, New York. |
DR. SWEPSON J. BROOKS, Physician-in-Charge.
NEURONHURST
Dr. W. B. Fletcher’s Sanatorium
For Treatment of Mental and Nervous Diseases, Including Legally Committed and
Voluntary Cases
Well equipped with all facilities for the care and treatment of all forms of mental and
nervous diseases, inebriety, drug addiction and those requiring recuperation and rest. AIL
approved forms of Electro and Hydrotherapy. Massage, Swedish Movements, ete. A
strictly ethical institution. Correspondence with physicians invited. For particulars and
terms, address:
DR. MARY A. SPINK, President DR. URBANA SPINK, Vice-President
1140 E. Market St. INDIANAPOLIS
Directory for Private Institutions—Continued from Page XVII
POL Vem Lae Cremer em POO KLINC# WLAN icin aes le sicis «vee cialecs oe ciate ei ce wdc leusiais cle Gut eaeiits aeeauce Sets un elec cue 14
Towns, Charles B., Hospital, New York City..... Safe stars Skee ENTS ay fate ia lal eiaia's, + alee wie are Sal aes Meike er ee 8
MO ROC D) Ceme me mS CINE OL Gre OTN: Morrie: s5 ices so cNovsuarcrens. ole sre ietelorcie eters ais ie vuttdlate dan cig chen eee 20
WANS SULE DEAS A Tr ea LO r UIT NTO KOEN, c INGue Ys fe or cay rene: oc. hielusial wuts «aie eye tate oct ee ahead winctelaeie orca Gee afeiacls < cuemed 14
Virginia Hot Springs, Hot Springs, Va....... Sectere Pe MeRS Tate g SING ae ate aU LIOTS Re aeeee plage tei the Rodin erate hoe eee 19
WALA CGMES ANT CATL Ul NLT DHISM pe DeN Mes eh sore ve. fie cee. se se ct clone 6 Siete state creuimmien Uae wiv on vnn ens 12
Wallace, Dr. Walter ree N Lem DiS Me Dh Olitiene ta eer neets Gara see kee tae vc ccc es ote ee eee eee 12
MSURCHleaeONTINge oAnitari iin.» We Ukeshia<” VWiiGs. oc iwlniswbseedie Gear de bnel'es ehudhe eee cca oeecrel 16
VWeishe TITAN, TROGIR Tk Gage Eee oa ie ta tien See ee ee re en eet a, ee a lo een 19
Westbrook Sanitarium, CINIMNOT Comey Vee erates nent oes cates lacnhy 2, atpee shen eee ere rere Mae ne 12
Ree reer RL ead Ren OSLWOT Cem COMTI nes 0- ors. viele so areC tse cba sw eee ease ceWSes ie ceeks's pulece eee oat 18
NVCRLWOOCMAOUL CTV VACS WOO Cem MASS seetiae ccc cri ces Ficia s crice fant vi'entho:eleacesuehe audbec’s enel Qal ecu cuehd-orsben chee ween 13-
Wetmore, Dr. S. S. P., Easton, Pa
CHICAGO SANITARIUM
1919 PRAIRIE AVENUE
For Mental and Borderline Patients
Modern in the way of case study and therapeutic management ; newer methods
of therapy intelligently applied.
New separate building for borderline cases and facilities for occupational
therapy.
Spinal fluid analysis a special feature. Facilities for keeping serological
patients over night following puncture.
A. B. Magnus, M.D. Phone
Medical Director VICTORY 5600
Monograph No. 44
HYSTERIA
By ERNEST KRETSCHMER, M.D.
A. O. Professor of Neurology and Psychiatry
IN TUBINGEN
Authorized English Translation
By OSWALD H. BOLTZ, M.D.
CONTENTS
Part I. Hysteria, INSTINCT AND IMPULSE
Chapter I. The Violent-Motor-Reaction and the Sham-Death-Reflex.
Chapter II. Hysteria and the Impulsive Life.
Part II. THe PsycHopHysicaAL DyNAMIcS OF HYSTERIA
Chapter III. The Hysterical Habit-Formation.
Chapter IV. The Laws of Voluntary Reinforcement of a Reflex.
Chapter V. The Volitional Apparatuses of the Hysterical.
Chapter VI. The Transformations of Experience.
Price $2.50
XXI
Nervous and Mental Disease Monograph Series
Edited by
SMITH ELY JELLIFFE, M.D., WILLIAM A. WHITE, M.D.
No. 1. Outlines of Psychiatry. (Eleventh Edition, 1926.) By WM. A. WHITE, M.D.,
Price $4.00. A clearly written and concise presentation of psychiatry especially
adapted for use in teaching and in public institutions for mental diseases.
No. 4. Selected Papers on Hysteria and other Psychoneuroses. (Third Edition,
enlarged, 1920.) By S. FREUD. Price $3.00.
No. 5. Wassermann Serum Reaction in Psychiatry. By FELIX PLAUT, M.D., Price
$2.00. A most complete setting forth of the principles of the Wassermann
Reaction by one of the original investigators in‘ this field, especially adapted
for laboratories and for use in institutions.
No. 7. Three Contributions to Theory of Sex. (Third Edition, 1918.) By PROF.
SIGMUND FREUD, Price $2.00. A most important contribution to the psy-
‘chology of psycho-sexual development.
No. 12. Cerebellar Functions. By DR. ANDRE-THOMAS, Price $3.00. (Illustrated.)
Tr. by Dr. C. Herring. A complete exposition of the anatomy and physiology
of the cerebellum and their application to the problems of clinical medicine.
No. 18. History of the Prison Psychoses. By DRS. P. NITSCHE and K. WILMANNS,
Price $1.25. The only complete exposition in English of the history of the
prison psychoses and the present-day concept of this group of mental dis-
turbances.
No. 14. General Paresis. By PROF. E. KRAEPELIN, Price $3.00. (Illustrated.) A
masterly presentation of the subject of general paresis by the renowned
Nos. 2, 3, 6, 8, 9, 10, 11, 15, 17, 19, 21, 22, 23, 24, 25, 27, 30 out of Print
Munich professor.
No. 16. Poliomyelitis. By DR. I. WICKMANN, Price $3.00. (Illustrated.) Tr. by
Dr. W. J. M. A. Maloney. A complete exposition of the poliomyelitis situation.
No. 28. Autonomic Functions and the Personality. By EDW. J. KEMPF, M.D. Seconé
Edition. Price $3.00.
No. 31. Sleep-Walking and Moon-Walking. By J. SADGER, Price $2.00.
No. 82. Foundations of Psychiatry. By WM. A. WHITE. Price $3.00.
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No. 85. The Constitutional Factors in Dementia Precox with Particular Attention to
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No. 86. The Primitive Archaic Forms of Inner Experiences and Thought in Schizo-
phrenia. A Genetic and Clinical Study of Schizophrenia. By DR. ALFRED
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communications to Journal office.
Wanted: Bound or unbound copies of Vols. 1, 2, 3, 4; Vol. 47, Nos. 1 and
3; Vol. 57, No. 1. For following will pay $1.50 per copy, 1876, complete;
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Disease.
Wanted: Bound or unbound copies of January, 1917; January, 1918;
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Wanted: Bound or unbound copies of Alienist and Neurologist, Journal
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Wanted: Bound or unbound copies of ‘‘Imago’’ and ‘‘ Zentralblatt fiir
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Wanted: Bourneville et Geurard: Le Sclerose en plaques, 1869.
Wanted: Photographs of Valentiner; Ordenstein; J. Parkinson.
J OURNAL OF NERVOUS AND MENTAL DISEASE
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The Psychoanalytic Review
A Journal Devoted to an Understanding of Human Conduct
Edited and Published by
WILLIAM A. WHITE, M.D., and SMITH ELY JELLIFFE, M.D.
CONTENTS, APRIL, 1927
ORIGINAL ARTICLES
The Conception of Narcissism. H. ELuis.
A Psycho-Sexual Inventory. S. D. Houss.
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The Sexual Significance of Ancient Chemical Symbols. N. D. C. Lewis.
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