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Notes of Societies.
Report of the Proceedings of the Twenty-Second Annual Meeting of the American Neurological Association, Held at Philadelphia, June 3, 4 and 5, 1896.
BY JOHN PUNTON, M. D., KANSAS CITY, Mo.
The twenty-second annual meeting of the American Neurological Association took place in the hall of the College of Physicians of Philadelphia, on June 3, 4 and 5.
The president, Dr. F. X. Dercum of Philadelphia, in the chair.
After the secretary, Dr. G. M. Hammond, called the roll, the president delivered a very instructive address entitled: "The Functions of the Neuron."
It dwelt at length upon the various views advanced by Nansen, and quoted several abstracts from this well-known author's work. Speaking of naked axis-cylinders, Dr. Dercum stated that they are in all likelihood a physiological impossibility in the cerebrum, for were they numerous, we could suppose nothing but a constant overflow of stimuli from one cell to another, and the consequent inco-ordination, not only of thought, but also of action. This is the view advanced by Nansen. The speaker stated that the question had arisen in his mind, as to whether the neuron was not an absolutely fixed morphological element, and whether it did not possess a certain, though perhaps limited, power of movement. Continuing, he said:" Realizing the practical value and the wide application of this idea, I have examined the literature to see whether a similar interpretation of nervous phenomena has occurred to others, and to gather such facts, if any, as could be brought forward in its support. I found that this thought had occurred independently to three observers, one in Germany and two in France.
"Ramon Cajal, however, opposes the theory of the mobility of the neuron and maintains, on the other hand, that the neuroglia cells possess a great deal of mobility. He points out, for instance, that the neuroglia cells of the cortex are at times stellate, and at others much elongated. He also maintains, that the processes of the neuroglia cells in reality represent an insulating or non-conducting material, and that during the period of relaxation they
penetrate between the arborizations of the nerve cells, and their protoplasmic processes, and render difficult, or impossible, the passage of nerve currents. To me, however, it seems as though Ramon Cajal admits the very thing against which he contends.
"Turning our attention for the moment to the subject of hysteria, we will see what a flood of light may be cast upon this hitherto obscure and mysterious subject. Take the simple example of an hysterical paralysis and see how easily it may be explained. The neurons of a certain area of the cortex, for instance, retract the terminal branches of the neurons to such an extent that the latter are no longer in contact or sufficiently near to the neurons in the spinal cord, which supply the muscles of the paralyzed parts. When power is suddenly re-established in hysterically palsied limbs, it simply means that the terminal branches of the cortical neurons, previously retracted, are again extended, so as to re-establish the proper relations with the spinal neurons. It would be interesting, indeed, to follow out the ideas here brought forward in their application to the various phenomena presented by hysteria and other morbid neurotic conditions."
The address was well received, after which the regular programme was proceeded with. The first paper was read by Dr. James J. Putnam of Boston, on "Hemorrhagic Encephalitis," in which he maintained, that in spite of the serious nature of the disease, recoveries were not impossible; that it was frequently a sequel of la grippe and that the differential diagnosis between basilar encephatlitis and basilar meningitis was at times exceedingly difficult.
The next paper was a report of a case of Raynaud's Disease, with Autopsy, by Dr. William Osler of Baltimore. Among other things he stated that it was mostly complicated with hysteria, and that it rarely proved fatal; that out of seven cases which he had seen, the case reported was the only fatal one.
Dr. Walter Channing of Boston then read a paper on "Tumor of the Thalamus, with a Consideration of the Mental Symptoms." In tumors of this region of the brain, he said, mental disturbance always preceded the focal symptoms.
The case reported entered the hospital as
one of acute mania, which was the diagnosis of the attending physician, but the postmortem revealed the presence of a tumor. The patient had pursued her usual occupation as school teacher until within five weeks of her death. The paper led to a general discussion on the diagnosis of cerebral tumors, in which several of the speakers concurred in the opinion that tumors of the thalamus gave no special symptoms, and that it was common for them to be mistaken for acute mania; indeed, mental symptoms predominate for some time. in most forms of brain tumor in their incipient stage.
At this juncture Dr. Hobart Hare of Philadelphia presented a patient for diagnosis, a boy 16 years old, who, when 5 years old was struck with a baseball over the left eye. A few days later he developed a peculiar form of muscular twitching, confined largely to the face and shoulders, which closely resembled chorea, and which has increased in frequency and severity until the present time. Examination of the eyes was negative; knee jerks partially abolished, and a slight heart murmur.
Dr. L. C. Gray of New York declared at once that it was a clear case of spasmodic tic or palmus, its traumatic origin strongly suggesting this. He also advised having the patient put to bed with the use of hydrobromate of hyoscine to control the spasms.
Dr. Joseph Collins of New York said he disagreed with Dr. Gray in the treatment, but instead of having him put to bed he would advise the use of the bicycle as a therapeutic agent. (Laughter.)
Dr. Theodore Diller of Pittsburg said he believed it was a case of tic and advised hypnotism.
Dr. Graeme Hammond of New York said that four years ago he reported twelve cases, two of which were of traumatic origin, and he had had good results with the use of the Fld. Ext. conium in 20 drop doses, cautiously given.
Dr. Osler said he would like to know which kind of ycle Dr. Collins advised? (Laughter.)
Dr. W. Sinkler of Philadelphia claimed that he had examined the boy and diagnosed the case as one of habit chorea. "The origin," said he, "is like other choreas and the heart lesion allies it to it also."
Dr. Patrick of Chicago said he thought it was a case of tic and belonged to mental diseases.
Dr. B. Sachs said: "I am glad it was so promptly diagnosed by my friends. I think this is not a habit chorea, but tic. We certainly owe much to Dr. Osler for the work he has done in the line of differentiation of these cases. I don't think putting to bed or the use of the bicycle will cure this patient. The prognosis at best is exceedingly unfavorable."
Dr. Collins: "I rise in all seriousness to say that I still believe the bicycle will cure this form of habit spasm."
Dr. L. C. Gray: "There is no resemblance between the muscular movements of chorea and those of tic. The former are much more extensive, involving whole groups of muscles, while the latter is confined to single ones. Then again, they do not respond to the treatment of rest and arsenic like the choreas."
Dr. Hare: "I showed this patient to Dr. Sinkler, Dr. Weir Mitchell, Dr. Dercum and several others. None of them thought it was tic, nor did I think it was a case of paramyoclonus, but the diagnosis to me is now as obscure as ever."
As the morning hour for adjournment had arrived the society was invited to luncheon by the Philadelphia Neurological Association.
AFTERNOON SESSION-JUNE 3.
The first paper was read by Dr. Burt G. Wilder of Ithaca, N. Y., on "A Nearly Constant Difference Between the Right and Left Paroccipital Fissures," which was illustrated by specimens and photographs. It was a very scientific discussion of a very technical subject, and exhibited a great deal of original work on the part of the essayist.
Dr. Joseph Collins of New York then read a paper, "Does Antisyphilitic Treatment Prevent the Occurrence of the Diseases of the Nervous System which are Considered Syphilitic in Origin?-A statistical study." He said: "Many neurologists believe that syphilis is incurable when it produces nervous disease, and I belong to that class. I am one of those who believe also that locomotor ataxia presupposes syphilis. In 100 cases of my own, 75 of them had a syphilitic history. Nor does the active and prolonged use of antisyphilitic treatment preclude the development of locomotor ataxia,
and my conclusion is that syphilis is practically an incurable disease."
Dr. Gray: "There are certain defects in the doctor's deductions, which I think we must not lose sight of. The details of his cases and treatment are not sufficient to base any such conclusions upon, and we all know how extremely difficult the diagnosis of syphilis is at times."
Dr. Sachs: "On the whole I think we can agree with the paper; but to take the cases that present early manifestation of syphilis, and see how much the treatment benefits them, leads me to have some faith in the treatment, as the very worst cases of syphilis are seen in those persons who have had no treatment whatever."
Dr. Knapp of Boston: "So far as I am concerned I shall not give up treating a case of syphilis, especially in the early stages, when I can benefit my patient as much as I have often done."
Dr. Osler: "My experience teaches me that early, thorough and systematic treatment makes a syphilitic a pretty good citizen."
Dr. Collins: "I have advanced no theories or new ideas, I have simply reported 100 cases and drawn some conclusions based upon them. If we are not permitted to do this, of what use are histories to us? If I had a patient come to me with tabes or paresis, I would not give mercury or iodides, as these, I am sure, do no good but often do harm. It is only in the exudative stage of syphilis that iodides are useful."
Dr. Henry Steadman of Boston then read a paper on "Notes on the Prognosis and Duration of Attacks of Mental Disease." "Owing to our lamentable knowledge of its pathology, we are more often tempted to generalize than to specialize. It is different with general paralysis, because we know its pathology and can easily predict its progress and termination. In spite of the popular belief that inheritance to insanity renders the prognosis unfavorable, I contend that the stronger the inheritance to mental disease, the easier the cure, but greater the tendency to relapse." He then summarized many of the causes which modify the prognosis, such as the time of life, at which it occurs, physical condition, form of insanity, previous mental capacity, etc. The amount of sleep and improvement of body weight are the
surest signs of permanent convalescence. A quick onset means a quick recovery. In all cases there is left behind some slight change, such as a lowering of mental or moral tone, hence recovery is scarcely ever complete. In judging a case no clinical test is to be relied
Dr. W. Channing said: "There is an erroneous impression abroad concerning the incurability of insanity. As a matter of fact it is a much more curable disease than is commonly supposed. In the past 50 years the character of insanity in our country has completely changed. We have not to-day the violent forms which formerly existed, and we have fewer of the acquired forms."
Dr. Gray: "I fail to understand why we should place reliance on statistics on insanity as an entity. The prognosis in young, vigorous patients, suffering from melancholia, is not the same as old atheromatous cases. In fact, I have no faith in the asylum treatment, nor the statistics from them, hence we ought not to allow these figures to go forth to the world without our protest."
Dr. C. Eugene Riggs of St. Paul, Minn., read a paper entitled "Paraplegia arising from hemorrhage into the spinal cord, due to pernicious anæmia," which was illustrated by drawings. The society then adjourned.
By invitation of the Philadelphia Neurological Society the members were invited to take "high tea" at the Country Club, which was reached by a splendid drive through the best parts of the city. At 9 p. m. the society was entertained at a reception given by the members of the Philadelphia Medical Club, which was a very enjoyable affair, lasting until the "wee small hours."
THURSDAY, JUNE 4--MORNING SESSION. The first paper was read by Dr. Theodore Diller of Pittsburg, on "Progressive Muscular Atrophy of Sudden Onset," which was well received; after which Dr. William Browning of Brooklyn read a paper on "Pitting about the hair cups, a trophic change in the skin in certain nervous disorders of central origin.” The essayist claimed that in many nervous affections, especially organic, this peculiar change can be discovered, and exhibited photographs in support of his views.
The next paper was read by Dr. W. G. Spiller of Philadelphia, subject: "A Case of Sy
ringomyelia, Unilateral in the Cervical Region, with Anthropathy of the Shoulder-joint and Ascending Degeneration." The reading of this paper elicited a spirited discussion on the ability to diagnose the presence of syringomyelia, the consensus of opinion being that the condition could be diagnosed during life, and that it was not so rare a disease as is generally supposed. Dr. Allen Starr said he had seen three cases since last October. The coincidence of its association with acromegaly was also recognized.
Dr. Burt Wilder of Ithaca, New York, then delivered some remarks on "The Dorsal Sack, the Aulic and the Diencephalic Flexure," which was very interesting and instructive, after which Dr. George Preston of Baltimore. read a paper on "Brown-Sequard Paralysis," with report of a case, which elicited a merited discussion.
After the reading of this paper the society was invited to proceed to the University of Pennsylvania, where a lunch had been provided by Provost C. C. Harrison. After luncheon the afternoon session was called in the hall of the Houston Club.
The first paper was a report from Dr. Weir Mitchell of Philadelphia, on "The Effects of the Mescal Nut, a Species of the Cactus." The paper was read by Dr. Sinkler and embodied a series of experiments with the drug on Dr. Mitchell himself, which was very instructive.
This was followed by a paper by Dr. Whorton Sinkler on "Uncertainties of Cerebral Localization," with special reference to growths in silent regions, in which the doctor maintained that growths which give rise to the most serious trouble are those which occur in silent regions of the brain, such as the frontal lobe. This fact, however, should not militate against operation. In two cases of his own the symptoms pointed to a growth in the cortex, and Dr. Keen operated, but found no growth. He believes the time is not far distant when even these apparently silent regions will be fully understood and properly interpreted.
Dr. Charles K. Mills of Philadelphia then read a paper entitled: "A Case of Cerebral Abscess Situated at the Posterior Part of the External Capsule."
After which Dr. B. Sachs of New York read a paper on the “Surgical Treatment of Epilepsy. A critical review of the results in 19 cases." This paper and the one which followed, by Dr. Joseph Collins of New York, on "A Contribution to the Pathology of Epilepsy and a Resume of the Utility of Operations in Epilepsy," led to a more spirited and extended discussion than any other papers so far discussed.
Dr. Sachs claimed that out of his 19 cases three were cured by operation, two improved, three somewhat improved, the balance no improvement whatever. "If cases," said he, "were more carefully selected, cures would be more often effected. It is the lack of the analytical feature which renders statistics so useless. Return of the attacks a few days after operation does not mar the future success of the operation. No case can be pronounced cured, however, until attacks have ceased at least one year or even more. Alcoholic cases are, in my judgment, the hardest to cure. Excision of the cortex is to be reserved for the cases of short duration. Six cases were associated with cerebral palsy; while none of them were cured, they were all improved. In cases where the motor area is diseased and tissue removed, the resulting paralysis is only transient. The use of surgery, however, for suggestive purposes should be condemned."
Dr. Keen of Philadelphia and Dr. Gerster of New York, two of the ablest American surgeons, had been invited to discuss the surgical aspect of epilepsy.
Dr. Gerster: "That the methods in the past have been defective, all are agreed. The chisel has finally supplanted the old circular saw or trephine, more especially on account of its slowness. Flap operations have been devised, which are of great service, but Vshaped chisels, which have been in use, are undesirable. The greatest danger in every operation of this kind is hemorrhage, not arterial, but oozing, hence time is an all important factor. The instrument devised by Devilbis enables me to open the skull in a few minutes."
Dr. Keen: "I have listened to the papers with a great deal of interest, and I wish to say that I have never yet seen a case of epilepsy cured by operation. I am not willing to accept one, or even two years, for recurrence,
as this is too short a limit to base a cure upon. I have, however, seen great amelioration of epilepsy, hence I believe in operation for it. If I had epilepsy myself I would take the chance surgery offers. I would not be tempted, however, to operate in general idiopathic epilepsy, for when epilepsy has existed for four years, I should hesitate myself to operate. I believe it will take at least ten years more to settle this mooted question as to surgical efficacy in epilepsy. It takes 20 years' experience to settle such questions, and so far we have had but ten to base our conclusions upon. I believe in the flap method, and indorse all that Dr. Gerster has said with reference to quickness of operation."
Dr. Allen Starr: "When I published my book, I had 13 cases to report in which there was no cure. I have now 24 cases and in none of them has a cure been affected by operation. I have never been tempted to operate in idiopathic epilepsy, and never will be. It is my firm conviction that brain operations should not be done by general surgeons, but by special surgeons, men trained specially for the work. I have seen 12 cases of so-called abscess of the brain, eleven of which were operated upon, and none revealed the presence of abscess either at the operation or at the autopsy. Neither can I confirm McEwen's dictatorial statements in his reports of abscess. From the condition of the temperature or pulse you cannot tell much about abscess. The facts are that the data for abscess of the brain are at present very unsatisfactory. The day of the trephine is over and the flap operations are a great improvement. The last case Dr. McBirney operated for me by this method he was but fourteen and one-half minutes before he opened the skull and made a very large opening, using a thin, fine, narrow chisel. The indications for surgery in epilepsy, however, in my opinion, are extremely limited."
of the Eyelids in Grave's Disease. Thyroidectomy." Presentation of patient.
Dr. P. C. Knapp of Boston, "The Nature of Neurasthenia."
Dr. Henry Upson, Cleveland, "Nerve Disturbances from Indigestion."
Dr. Henry R. Steadman of Boston, "Report of the Committee on the After Care of the Insane."
Dr. E. C. Spitzka of New York, "On a form of Mental Disease Intermediate Between Paretic Dementia and Primary Mental Deterioration," etc.
On the evening of June 4 the annual banquet took place at the Art Club rooms. There was a large attendance, and the affair proved very enjoyable, speeches being made by Drs. Hare, Riggs, Sachs, Gray, Hammond, Osler, Sinkler, Keen, Starr, Dercum, Collins and others.
The election of officers resulted in the choice of Dr. Allen Starr of New York, for president; Dr. Henry S. Upson of Cleveland, vice-president; Dr. Graeme M. Hammond of New York, secretary and treasurer; Drs. Dercum and Collins, councillors. There were three additional members elected to the limited membership of 100, viz.: Dr. John Punton of Kansas City, Mo., Dr. Alfred Wiener of New York, and Dr. F. K. Halleck of Cromwell, Connecticut. This brings the present membership to 93.
The vote for the place of the next meeting resulted in the unanimous choice of Washington, D. C.
The society then adjourned sine die.
The Mississippi Valley Medical Association.
A meeting of the executive committee of the Mississippi Valley Medical Association was held at Atlanta on May 6 and the following gentlemen were appointed to deliver addresses:
In closing Dr. Sachs insisted that much depended upon the selection of cases as to the efficacy of surgery, while Dr. Collins, with Dr. Starr, thought that only in a very limited degree could much be expected from surgery for the relief of epilepsy.
The indications are that the meeting to be held at St. Paul on October 20, 21, 22 and 23 will be the largest and most successful in the
Among other papers read at the meeting history of the association. As all the railroads were the following:
Dr. A. Booth of New York, on "Edema
will offer reduced rates for the round trip, an opportunity will be given to visit St. Paul and
Dr. H. N. Moyer, Chicago, "Address on Medicine."
Dr. Horace H. Grant, Louisville, "Address on Surgery."