A Case of Chronic Trional Poisoning. In the issue for the 2d of October, 1899, of the Berliner klinische Wochenschrift, Dr. Karl Vogel reports the eighth case of trional poisoning, the first, of the seven previously reported, having been published by Koppers, in his inaugural dissertation, at Würzburg, in 1893. In 1890 Bauman and Kast published the reports of their experiments on animals with trional and tetronal, after sulfonal had been found to intoxicate in many cases, especially affecting the kidneys. The case reported in this article is that of a twenty-eight-year-old lady, unusually intelligent, given to literary pursuits; had traveled in South America and Dutch India; ten years earlier had suffered somewhat, for two months, from articular rheumatism. In the fall of 1897 had been troubled by insomnia; on the 15th of January, 1898, began taking trional, prescribed by a physician; by the third of the following June she had taken, at regular intervals, a total of 127 grams. It accomplished its purpose and was, at first, well borne. When received at the hospital she was very weak, felt as if about to faint, complained of severe, colicky pains in the trunk, especially in the left abdominal region. For the relief of these pains she had taken, during the last previous few days, subcutaneous injections of morphine and also some trional during the trip, lasting about eight hours, to Bonn, where is the hospital in which the author saw her. Pulse slight, weak, 120-130 per minute, but regular; respiration, normal; a tendency of the left leg to shirk duty. It is not as sensitive as the right leg; the region of the end of the sacrum is especially numb, deep needle pricks there not being felt. Eye and knee reflexes not changed. Patient can take only a few steps unaided. Previously there had been diarrhoea, followed by obstinate constipation. When received at the hospital the patient's bowels had not moved for several days. The Burgundy color of the urine was especially striking. It was slightly cloudy, acid; specific gravity. 1.022; amount for the first days, 300-500 cc. The cardiac symptoms were so marked during the night of the third day after reception at the hospital that camphor injection needed to be made. Because of the unusually severe colic, injections of morphine had to be made, also, in spite of the heart symptoms. The threatening heart weakness began to gradually disappear at the third week, the pulse slowly became stronger and its frequency lessened. The patient needed to be kept four months in the hospital; when dismissed she was almost entirely well. The remarkable features of this case were the anomalies of the bowel movements, the great weakness of the heart (which, for a time, caused anxiety for the patient's life), the appearance of nephritis, conjoined with the peculiarly colored urine, the severe visceral colic and the nervous symptoms. Dr. Vogel regrets that the patient's condition prevented the application of certain forms of examination, whose results he would like to be able to report. NEUROLOGY Edited by Henry Hun, M. D. Tumor of the Pituitary Body.— WALTON and CHENEY (Boston Medical and Surgical Journal, December 7, 1899) report the results of a study of a case of tumor of the hypophysis, and summarize the present state of knowledge as to the relations of this gland. Their conclusions are: 1. Congenital peculiarities in growth resembling those of acromegaly, but occurring in otherwise healthy individuals, may point to a structural defect of the pituitary gland, a defect sometimes furnishing a starting point for new growth later in life. 2. The occurrence of pituitary tumor without definite symptoms of acromegaly does not necessarily disprove a connection between this organ and this disease, for the persistence of even a small amount of healthy gland tissue is sufficient fairly to carry on the function of the pituitary body. 3. The combination of general symptoms of new growth with optic atrophy and loss of temporal field of vision makes the diagnosis of pituitary tumor almost certain. 4. Hemiachromatopsia is not necessarily of central origin. The Pathological Anatomy of Acromegaly. - L. J. MITCHELL and E. R. LE COUNT have contributed to the New York Medical Journal (April 15, 22 and 29, 1899) a Report of a Necropsy in a Case of Acromegaly, with a Critical Review of the Recorded Pathologic Anatomy." In concluding a résumé of their studies, the following propositions, which directly concern the elucidation of its pathogenesis, seem to have acquired prominence: 1. The cases of acromegaly associated with true tumor of the hypophysis are certainly not as numerous as has been heretofore supposed. 2. There is not as much constancy in the pathologic condition of the hypophysis as there is in an enlargement of the heart, the thyreoid gland or the sella turcica. 3. Acromegaly does not depend, at least solely, upon abolition of any function of the hypophysis. 4. A relationship between the thyreoid gland and the hypophysis has already been amply proved. 5. It is not at all improbable that proliferation of the histological elements of the hypophysis may be instituted in some cases by a primary enlargement of the sella turcica; in other cases, an oedema or hemorrhage ex vacuo. 6. We have no reason for supposing that enlargement of the sella turcica may not be as constant an occurrence in acromegaly as the changes in other bones, or that it might not take place from a similar cause or causes. Changes in the Peripheral Nerves in Chronic Diseases of the Blood Vessels of the Extremities.- LAPINSKI (Deutsche. Zeits. f. Nervenheilk., XIII., 5 u. 6) gives the result of investigations of cases of amputation in which the nerves of the removed members have been examined. In one class of cases no changes were found in the nerves; in another marked changes were found. The results are summarized as follows: 1. Degeneration of the vessels in the form of chronic endarteritis or arterio-sclerosis may produce disease of the nerve trunks supplied by the affected vessels. 2. Such disease may make itself known by continuous pains, that are generally increased by the warmth of the bed, at night, and upon movement. 3. The motor strength of the diseased nerves is either not changed or is slightly lessened. 4. Their sensory functions may be only diminished in regions of the skin afflicted by sloughing; in other areas, even those directly involved in the slough, sensibility may not only be not lessened, but may be even lightly increased. 5. The skin and tendon reflexes may be either normal or slightly increased. 6. The reaction of the affected nerves to the faradic and galvanic currents may remain normal (in moderately extended cases), or may be somewhat diminished (in old cases), and then there in greater response to the galvanic than to the faradic current. 7. With the causes which promote the changes in the nerves must be enumerated not only the insufficient blood supply, but in all probability the long-standing oedema. 8. The histological changes of the nerves must be grouped among the dystrophic-inflammatory scleroses. The individual parts of the connective tissue are unequally attacked. The perineurium, which has no individual blood-vessels, shows the fewest changes, the endoneurium and epineurium, which have an individual blood-supply, are more notably involved. Inasmuch as the thickened connective tissue of the nerve trunk is compressed and twisted, it becomes an effort for the nerve fibres to preserve their medullary sheath. The axis-cylinders, as indicated by the clinical manifestations, are able to preserve their integrity the longest. Changes in the Nerves During Acute Disturbances in the Circulation. LAPINSKI (Deutsch. Zeitsschr. f. Nervenheilk., XV., 5 u. 6) reports the result of a study of personal cases and the literature, from which he derives the following conclusions: Acute ischemia of an extremity existing for several days may induce disease of the peripheral nerves. Their motor functions are weakened and soon entirely lost. Their sensory functions, the sense of touch, pain, localization, heat and cold, are gradually diminished and finally entirely abolished. The skin and tendon reflexes are quickly weakened and very soon destroyed. The irritability of the nerves for both faradic and galvanic currents is gradually reduced and finally disappears. The anatomical changes in the nerves consist of a very slight swelling of the connective tissue elements, degeneration of the nuclei, frequently com plete disappearance of the myelin sheath, and a slightly increased number of its nuclei. The axis-cylinders are generally very cloudy, often destroyed, and completely disappear. If collateral circulation be rapidly established, a distinct improvement, or even complete restoration of all the nerve functions follows. Participation of the muscles is much less marked than is the affection of the nerves. Nothnagel's Convulsive Center in the Pons.- LUCE (Deutsch. Zeitsschr. f. Nervenheilk., XV., 5 u. 6) reports cases of hemorrhage into the pons Varolii which sustained Nothnagel's claim of a convulsive center in this region, and from review of the literature, both of the experimental and pathological evidence, deduces the following conclusions: 1. Hemorrhages into the pons may produce general epileptic convulsions. 2. Convulsions produced by a hemorrhage into the pons are due to irritation of its motor structures; irritation of the tegmental region of the pons does not cause general epileptic convulsions. 3. The ganglion cells of the pons have epileptogenous properties; they are the particular agents through which irritation of the motor area produces convulsions. 4. The discharge of energy of the ganglion cells of the pons is directed in the direction of the cerebellum by way of the crura cerebelli ad pontem, and from the cerebellum the impulse is further carried by way of the corpora restiformia into the spinal cord. 5. The ganglion cells of the pons are not to be regarded as pure convulsive centers. The nuclei of the pons represent high grade nerve centers for the transmission of complicated motor mechanisms from the cerebrum to the cerebellum, without the object of inducing convulsions; their anatomical arrangement in the motor system exclusively involves the production of general convulsions when a hemorrhage into the pons occurs. 6. In man the existence of such a sub-cortical origin of epilepsy is to be considered in addition to the cortical form. 7. It is also in all probability to be assumed that in genuine epilepsy the gray matter of the pons participates secondarily in the attack. 8. It is also possible that local pathological antecedents in the pons induce the epileptic changes in the gray matter of the pons, and thereby produce the foundation for a persistent or transitional manifestation of epilepsy of sub-cortical origin, without any participation of the cerebrum. 9. Clinically pons convulsions have these characteristics: that the seizures taken as a whole are less accentuated in intensity than the genuine epileptic seizures, and that the muscles of the trunk are much more strongly involved than the muscles of the extremities. "The Mental Symptoms of Fatigue" received special consideration by Ch. FÉRÉ in La Medecine of November 12, 1898. In this article the author, firstly, commences by insisting on the great influence of fatigue as a predisposing factor in the production of many varied deviations from the normal equilibrium. He has found that the mental symptoms of fatigue present striking similarities to those observed in neurasthenia. Their essential characteristic is the transitory nature of the phenomena observed. The physiognomy and attitude reflect the general depression and sadness, and expressions which exhibit a feeling of malaise soon make their appearance. The lowering of the emotional tone results in a modification of character- a pessimistic tendency and depreciation of the environment which may brusquely appear. The blunting of the sentiments belongs to fatigue in general irrespective of its causes. Its occurrence in the course of painful digestive derangements has frequently been observed. The physical conditions of the attention are profoundly altered; the subconscious as well as the the conscious are both diminished. Defects of perception on the part of all the senses become more or less grossly complicated by errors of comparison; the faculties of perception markedly refract the aberrant subjective impressions. The will, which is the resultant of psychologic operations, is itself weakened. A default of voluntary activity likewise becomes manifest. Fatigue favors the tendencies to imitation; in other words, the individuality of the patient vanishes to conform to its environment. Abandon to all manner of excesses is not an uncommon result of fatigue. Morose moral sensations manifest themselves at times, in some few cases going so far as suicide. Objectively viewed, certain conditions will frequently elucidate the problematic, symptomatology. Involuntary movements "a forme de tic," scratching, etc., are sometimes noted. In general, fatigue can give rise to perversions of conduct by perturbations of perceptions, volitions and the emotions, and special fatigue of the senses can in turn give rise to disturbances of a more or less specific nature. The absence of antecedents with the frequently slight objective manifestations of a physical nature will often make the recognition of the symptomatic picture difficult. The reality of the existence of these phenomena as a result of fatigue the author conclusively demonstrates by the reports of typically illustrative cases. - Post-Anæsthetic Paralyses. - By Dr. MALLY. (Revue de Chirurgie, July, 1899.) These are generally supposed to be the result of the anesthetic. The writer discusses four classes of so-called post-anesthetic paralyses: 1. Paralyses due to cerebral hemorrhage or central paralyses. 2. Hysterical paralyses. 3. Peripheral paralyses. 4. Reflex paralyses. Cases are reported from the literature and from the writer's experience illustrating each of these four classes. He concludes that among the paralytic accidents following anesthesia, two groups do not appear to have any connection with the anesthesia. These are the hysterical paralyses and the reflex paralyses. The central paralyses due to cerebral hemorrhage are rare accidents in which the anaesthetic seems to have caused a vascular rupture in a purely mechanical fashion. The peripheral paralyses are rather frequent |