« PreviousContinue »
(2) in the anterior quadrigemina a center exists which under pathological conditions elicits tonic cramps, and in the posterior quadrigemina an analogous centre induces clonic spasms; (3) in the anterior quadrigemina are reflex paths for respiration, the vagus and the vasomotor nerves, and in the posterior besides these a centre for co-ordination of reflex movements and a centre for the formation of sounds. Clinical observations show that in disease of the quadrigemina, disturbances in the movements of the eyes, inco-ordination of muscle groups in walking and standing, tremors, dilatation of the pupils, exophthalmos and disturbances of sight and hearing appear. All these symptoms are explainable by the results of the experiments conducted by Prus.
Transitory Spinal Paralysis.-(Zeit. f. klin. Med., Bd. 39, Hft. 1-2). A complete recovery from an acute myelitis if it ever occurs is exceedingly
One finds in the literature several such cases reported, but in most of these cases there appears to be some doubt as to the correctness of the diagnosis. Peripheral neuritis is especially apt to be mistaken for acute myelitis.
KREWER reports two cases of a sudden paralysis involving both legs, the bladder and the rectum with increased patellar reflexes and ankle clonus. In one case there was complete loss of sensation, while in the other sensory disturbances were but slight. There were also painless clonic contractions in the paralyzed parts in both cases, but no trophic disturbances. In neither case were there any etiological factors that could be discovered, nor was there any fever. In both cases recovery was complete after a few weeks. The writer believes that the pathological process in these cases may be a minute apoplexia spinalis, an occlusion of a small vessel or capillary, or a secondary acute parenchymatous swelling of the cord. In the two cases he reports he is inclined to assume an occlusion of a small vessel as the most probable cause. The rapid establishment of a collateral circu. lation would explain the transitory character of the paralysis. In the two cases he reports he can assign no cause for the occlusion of the vessel in the cord. He insists upon the necessity of separating these cases from acute myelitis, and for that purpose proposes the term transitory spinal paralysis. He believes that there exists a well defined group of paralysis, which clinically resemble acute myelitis, and are characterized by sudden onset in perfect health with no assignable cause, and with absolutely no signs or symptoms that would indicate an inflammatory process.
Paræsthesia, which is rarely absent at the beginning of myelitis does not occur, nor are there any trophic disturbances. Clonic contractions occur in the paralysed legs, a phenomenon but very rarely seen in acute myelitis, and the all important point is the course of the disease which differs markedly from myelitis. Recurrences appear to occur in certain cases apparently associated with pregnancy. Treatment is supporting and symptomatic.
The “Toe Phenomenon” of Babinski.—In the Gazette des Hopitaux for November 23, 1899, Cestan and Le Sourd discuss this interesting phenomenon and give the results of their examinations in a large number of cases in which they examined for this phenomenon. The phenomenon was originally described by Babinski in the following words: “On the healthy side the prick of the sole of the foot causes under normal circumstances a flexion of the thigh on the pelvis, of the leg upon the thigh, of the foot upon the leg and of the toes upon the metatarsus. On the paralyzed side a similar excitation gives rise also to a flexion of the thigh upon the pelvis, the leg upon the thigh and the foot upon the leg, but the toes instead of flexing execute a movement of extension upon the metatarsus." This phenomenon, observed first in cases of hemiplegia or of crural monoplegia, was observed later by Babinski in cases of meningoencepalitis, partial epilepsy, cerebro-spinal meningitis, strychnine poisoning, spasmodic spinal paraplegia, transverse myelitis and of Pott's disease.
Babinski indicates the existence of a clinical connection between the toe phenomenon, the exaggeration of the tendon reflexes and spinal epilepsy, and he thinks without absolutely asserting it that the toe phenomenon can be the first and only sign indicative of a change in the pyramidal system. The researches of Babinski have been partly confirmed, but rejected by some, and the writers think that in the latter instance the technique of the test may have been improperly carried out. They give the following as the principal points in making the test: “The muscles of the foot and leg must be relaxed as completely as possible, and in order to obtain this result it is necessary to leave the patient in ignorance of the fact that the test is to be made and to make him close his eyes. The leg must be slightly flexed upon the thigh, the foot lying on the bed on its external edge and completely deprived of support, the limb being held by the experimenter round the ankle. As soon as the muscles appear to be sufficiently relaxed one proceeds to make the test. By means of a needle or a pin one practices then along the external edge of the foot scratchings, at first light, then stronger until movements of the big toe occur. If the reflex is normal the toes, especially the three last ones, flex rapidly; if the reflex is abnormal the toes, above all the big toe, extend themselves upon the metatarsus by a slow movement. The intensity of the excitation is not an indifferent matter; it is necessary to avoid too great excitation, which in certain ticklish subjects causes a quick pulling away of the foot, accompanied by marked voluntary movement of the toes, which render all analysis impossible.
The authors in their own experiments investigated a number of normal individuals and also individuals of various types of nervous disease. They come to the following conclusion:
1. The toe phenomenon is always pathological; it is never observed in a healthy individual.
2. The toe phenomenon depends on disturbances of the pyramidal tract.
3. In organic hemiplegia the sign of Babinski is extremely frequent, and permits one to distinguish between organic and hysterical hemiplegia as in the latter the sign never occurs.
4. In recent organic hemiplegia the toe phenomenon, by its early appearance while the tendon reflexes are normal or diminished, acquires considerable diagnostic importance.
5. In spasmodic paraplegias of spinal origin the toe phenomenon is extremely frequent. It presents consequently a diagnostic value superior to that of epileptoid trepidation, since this last can occur without spinal alteration, as for example in patients with joint lesions.
6. Finally, in certain cord affections (tabes, Friedreich's ataxia) the toe phenomenon is the only sign which permits one to suspect the existence of a lesion of the pyramidal tract.
Localization of Intra - Cranial Tumors. (Brain, Autumn, 1898).— At a discussion of the Neurological Society of London on this subject, Gunn alluded first to the fact of the very great frequency of optic neuritis in tumor, pointing out that in order of such frequency tumors of the cerebellum come first, then of the basal ganglia, then of the occipital, frontal and temporo-sphenoidal lobes. He considers that the circumstances which chiefly contribute to its onset and severity are rapid growth, increase of cerebro-spinal fluid, and basal meningitis, these accounting for its particular disposition to occur in cases of cerebellar tumor. It is now well known that a certain type of neuritis, in which there is development of a stellate figure at the macula resembling that seen in albuminuric retinitis, is almost invariably a sign of cerebellar growth. He thinks it quite possible that unilateral neuritis or unilateral excess of neuritis may help in the localization, though the mere presence of neuritis is of no localizing value. Briefly put, his view is that the farther forward a new growth is, the greater probability is there that the neuritis may be either unilateral or at least worse on the same side. Thus there seems more likelihood that a tumor of the right frontal lobe may cause a right-sided neuritis than an occipital tumor, and certainly than a cerebellar one. As another possibility he suggests that minor anatomical differences in the orbit and its contents may predispose, and propounds the idea, also worthy of investigation, that differences in the refraction of the eyes may cause a difference, real or apparent, in the degree of ophthalmoscopic change.
Edited by C. M. Culver, M. D. Epidemic of Trachoma in Berlin.-Dr. Paul Schultz, (Berliner klinische Wochenschrift, 1 January, 1900.). The author refers to his former article, in the same periodical, concerning the same epidemic, which article considered the source of the contagion in a public bath institution. He had treated thirty patients having to do with this epidemic. They were from twelve to twenty-six years of age. Those considered, who were not infected directly from the bath, had become infected from association with those whose contagion did have its source at the bath. Twenty-four were directly infected at the bath, before it was sought to be disinfected, three after its disinfection had been attempted and three had caught it from some of the twenty-seven just mentioned. The use of the bath has now been abandoned. He discusses trachoma generally; then as to whether it was genuine trachoma that had affected the cases cited. As in the case of other infectious diseases, so in trachoma, we must depend exclusively on the clinical symptoms. They alone determine the diagnosis. Bacteriologic examination cannot here assure the diagnosis, because we are not acquainted with the exciting agent. There are infectious conjunctivitides in which it is very hard to say whether they are trachomatous. This fact is conceded by the ablest of the connoisseurs in trachoma and daily experience proves the necessity of the concession. In the earliest of the cases considered in this article, it was doubtful if it were a question of genuine trachoma. Later, the characteristic symptoms of trachoma were present and the disease was combated, with some success, by treatment usually adapted for cure of trachoma.
Schultz thinks the less characteristic cases shall also be considered trachoma. Fuchs, of Vienna, holds that there are three forms, papillary, granular and mixed. As to the course of the less characteristic forms, they are easily relieved but not easily cured. Schultz diagnosticated trachoma, in the cases in question, only when the diagnosis was pretty certainly justified by the facts. His professional conscience would not let him do otherwise.
He thinks it pretty serious to render anybody, who has not trachoma, subject to the suspicion of having had it. A case-record was carefully kept of twenty-four of the cases; six withdrew from clinical observation. Nineteen of the twenty-four had only one eye affected. In ten of these nineteen, the fellow eye was later affected. In five cases, the disease affected both eyes from the start. Seventeen of the twenty-four were mild cases, the other seven, hard ones. In two cases there was multiple infiltration of the cornea, in two cases, pannus. Ulcer and destruction of the cornea existed in none of the cases. In only two were scars formed. In one of these tho scar was in the upper cul de sac and the other scar was in the upper, palpebral conjunctiva. Thirteen of the twenty-four were cured, eleven were still under treatment at the time of writing. Nine of the thirteen who usually worked, were unfitted for work; the other four continued at work, of their own choice. The unfitness for work averaged a month and fourteen days. The patients who were pupils were kept out of school a month and twenty days, on the average. The decision as to when a patient was fit to resume work, is a part of the question as to when trachoma ceases to be contagious. As to this, opinions that have been empirically acquired, are all that are valid. The exact scientific proof, as to when trachoma ceases to be contagious, may first be realized when the exciter becomes known. Until then we must be content with the facts of experience and especially with the observation that by means of the secretion, and during the acute, inflammatory stage of the trachoma, the infection takes place.
All the patients under consideration were treated as out-patients. Prophylaxis consisted in ordering for each patient an entirely separate washing apparatus and towel, to sleep with nobody and especially to come daily for treatment and to act on the advice given. The treatment consisted, primarily, in squeezing out the granules. Except in a single case, in which the galvano-cautery was used successfully, to burn out the granules, the thumb nails were used for the expression.
Knapp's roller forceps and Kuhnt's expressor were not employed. The thumb nails have the advantage of being a living apparatus that one has always with him, the patient does not fear them as he does metal instruments, the pressure, with them, can be more readily modified and the granules that are almost concealed in the edges of the folds are more easily reached by them, while such granules may readily be missed with the forceps. When the principal part of the granules had thus been removed, wiping out of the conjunctiva with sublimat solutions and instillation of protargol followed. The author prefers the use of silver, in this connection, because he believes that the cauterization with copper sulphat causes scars. He used one-half per cent. of the sublimat, soaking in it a small bit of cotton and rubbing it over the lid's inner surface. The rubbing was made hard and continued, or weak and of short duration, according to the individual need. . To so individualize is essential to success. Generally, Schultz rubs the conjunctiva, after cocainizing it, until it bleeds slightly. The rubbing was painful only the first few times. Later, the pain from it was very slight. The pain lasted, for each session, only as long as the rubbing. With copper, the pain is as great one session as another and lasts long after the direct application. The rubbing was done alternate days. The days when it was not done, protargol was instilled. He used a twenty per cent, solution of protargol in cold water. Instillations of this, like the rubbings, were done by the doctor. For use at home the patients were given a one per cent. solution of the sulphat of zinc. They were further directed to make applications of compresses wet in cold, running water. In cases in which the corneæ were affected and pannus developed, the rubbing was not employed ; the protargol was instilled. The treatment resulted satisfactorily. The protargol was used to combat the inflammation and concomitant secretion, the sublimat to remove the granules and hypertrophic proliferations. A primary requisite is a serviceable solution of protargol.
In the cases here noted, the acute stage of inflammatory and secretory appearances was, for the most part, finished in a week or two. In no one of these cases did argyriasis appear, although we know that it may do so after the prolonged use of protargol.
Hæmorrhage into Eyeball.–DR. HOWARD F. HANSELL, (Ophthalmic Record, January, 1900.) On opening an eye, immediately after its enucleation, the author found its contents to be mainly a clot of blood. The patient was a man forty-eight years of age, whose left eye had been injured when he was thirteen years old and had been blind from that time. Within the last few months before enucleation, that eye had had a series of inflammatory attacks, with ocular pain and headache. At such times the right eye sympathized to the extent that he could not use it with comfort; it also became congested and painful. The last attack occurred a week before the enucleation. It was accompanied by severe neuralgia and pronounced signs of inflammation. He then applied for treatment at