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broncho-pneumonia, with very scattered foci, or a simple congestion in the course of a pneumococcus infection. The inves

tigations showed, moreover, that so-called central pneumonia is of very rare, practically exceptional, occurrence.

NERVOUS AND MENTAL DISEASES.

UNDER THE CHARGE OF

WILLIAM B. NOYES, M.D.,

Attending Neurologist, Demilt Dispensary.

In connection with Huntington's Chorea. the current issue of Neurographs, a special "Huntington" number, devoted "partly to honoring him and partly to what is believed to be a useful clearing up of the record," the interests of many will be served by a review of the features of a nervous disease so rare as to come under the observation of a small minority only. In all his wide experience Professor Strümpell of Germany met with no more than half a dozen cases or so scattered over a number of years, most of these patients being men, whereas the two sexes are usually regarded as equally susceptible to the disease. The material for the following paragraphs has been derived in part from the theses of Esser (1891) and Mattheis (1897), as well as the original contribution of Lannois and Paviot, on the nature of the histological lesion in Huntington's chorea in the Huntington number of Neurographs. Enriched by contributions from American authorities, as well as famous European investigators and clinicians, this number is rendered still more valuable through the addition of an excellent bibliography.

This rare form of chorea is characterized by the following four cardinal fea

tures:

1. Heredity, combined with the peculiarity that as soon as one generation has been skipped its descendants remain free. from the disease.

F. R.

3. Age, between 30 and 40 years, rarely older.

4. Frequent terminal combination with. mental impairment.

With special reference to the hereditary character of the disease, Huntington first described entire families as affected with chorea, and further distinguished (according to the observations of his father and grandfather, both physicians) by the addition of a nervous element to every other kind of disturbance. After once a generation has been skipped the charm is broken, as it were, and the disease is then never transmitted to the third generation like other hereditary affections. The chorea begins in the usual manner, gradually increasing to the severest degrees, leading, as a rule, to mental disturbance, often with a tendency to suicide, and at last terminates in death. Recovery has never been noted. The disease never attacks youthful individuals. but appears, as a rule, between the third and fourth decade; rarely later. Men and women are attacked with equal frequency (?).

The distinctive features of Huntington's chorea as compared to ordinary chorea are as follows: The disease is characterized by its constant hereditary transmission, often through several generations; the late onset, not before the thirtieth year, in the majority of the cases; the gradually increasing severity of the choreic movements; the progres

2. Chronic progressive course, with- sive functional disturbance of constantly out cure or improvement.

added groups of muscles, including the

tongue and the larynx, and its incurability. The abnormal movements are intensified by emotional influences, etc., whereas, in contradiction to ordinary chorea, they can be more or less completely suppresed by purposeful movements; during sleep they are entirely absent. There are no sensory disturbances, and the mechanical and electrical irritability are unchanged. The reflexes are normal, rafely increased. Mild psychical disturbances are of very common occurrence, especially after prolonged duration of the disease, and may progress to melancholia, with a tendency to suicide. General progressive paretic dementia is not so very uncommon in these cases. Those members of an affected family who remain free from the hereditary chorea often present mental disturbances, or at some peculiarities and general "crankiness." After one generation has been spared the later descendants may be regarded as immune.

The designation of the disease as chronic progressive chorea was proposed by Hoffmann, who does not assign the same importance to the heredity, but ranks it no higher than in the remaining nervous diseases. The heredity, according to him, should not be interpreted as a characteristic feature, but the chronic progressive course is conclusive.

Concerning the pathologico-anatomical findings in hereditary chorea, a unanimous verdict has not yet been rendered, and the opinions of authors vary in rather wide limits. A case studied by Greppin in 1892 furnished the following findings at the autopsy: There was pachy-meningitis and lepo-meningitis; the roof of the skull was sclerotic. Macroscopically the brain presented no distinct changes, but the microscope showed in the white as well as the gray substance of the entire organ a well-marked accummulation of

cellular elements, always arranged in foci, which had proliferated into the healthy tissue, entirely filling innumerable pericellular and perivascular spaces, and causing atrophy of the ganglion cells and nerve fibres. These elements are derived from the fixed tissue cells of the neuroglia, according to Greppin, who regards this progressive focal proliferation as the fundamental process of chronic progressive chorea. The lesion described. by Greppin has been confirmed as constantly present in all their cases by Lannois and Paviot (1908). Similar granulations in the cortex and the central gray nuclei were likewise found in certain. kindred affections, as regards the symptomatology. An almost identical infiltration of small bluish granules into the cortex and the white center of the convolutions was recently demonstrated by these observers in a case of symptomatic chorea, presumably connected with alcoholism; and also in a case of myoclonia. They are inclined to assume, with certain recent Italian writers, the existence of a true histological relationship, besides the clinical resemblance, between the choreas, the myoclonias, certain true tics, and some cases of double athetosis. The uniting link between these variable symptomatic manifestations would be supplied by a genuine encephalitis, determining a progressive change, irritative rather than destructive, of the cortical layer of the brain, especially the Rolandian zone. Huntington's chorea, in their opinion, might well be grouped under this heading, despite the hereditary factor. What is transmitted is the soil favoring the appearance of nervous disease. If a menber of a family having Huntington's chorea in its ascendants or collaterals is exposed to infection or intoxication, his predisposition is apt to play a part; his nervous system and especially his brain

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cm. Microscopically, the tumor could be regarded partly as a lipoma and partly as a fibro-myoma. Careful microscopical examination, however, showed the growth to consist exclusively of ganglion cells and nerve fibres. The nerve fibres were matted in various directions, and ganglion cells were arranged between them, either separately or in smaller or larger groups. The rest of the findings consisted merely of scantly cellular tissue and blood vessels. The point of origin of the tumor was undoubtedly the cervical sympathetic, as indicated by the location as well as the microscopical findings. The growth presumably originated during intra-uterine existence, for the patient's mother had noticed a nodule at the neck, which slowly increased in size, before the child had reached the age of 7 months.

DERMATOLOGY.

IN CHARGE OF

HOWARD FOX, M.D.,

Clinical Assistant in Dermatology, New York Skin and Cancer Hospital, and the College of Physicians and Surgeons.

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making a comparison of the inhalation with other methods of administering mercury, the writer quotes. from a former communication and describes the Merkalator mask. This consists of a framework of light wire covered with cloth and impregnated with mercury. Each mask contains eight grains of mercury. The mask is fitted to the shape of the nose and chin, fastened by bands and worn during the night, or during both day and night. The average time during which each mask can be used is about ten days. The masks have an advantage in being convenient. Furthermore, when symptoms of mercurialism occur the in

gestion of the drug is immediately stopped by removing the mask. This is not the case with insoluble injections. From one year's observation of 160 cases the writer concludes that the action of the mask treatment occupies a position between injections and inunctions, its action being slower than the former, but quicker than the latter.

In judging of the value of methods of mercurial treatment, in addition to clinical observation, valuable information can be obtained from quantitative examination of mercury excreted in the urine, for we are justified in assuming that the quantity of mercury in the urine depends upon the amount in the body or blood. Patients were treated with inunctions, intramuscular injections and by the Merkalator mask, and a daily quantitative examina

tion of urine made. From a study of his results the writer draws the following conclusions:

1. The amount of mercury excreted in the urine depends not alone on the amount actually absorbed, but also on the rapidity of absorption.

2. A more rapid absorption of mercury results ceteris paribus in a more rapid excretion.

3. Methods of treatment with rapid absorption and rapid excretion are ceteris paribus of less worth than those with gradual absorption and slow excretion.

4. Methods with gradual absorption and slow excretion allow, ceteris paribus, the mercury to remain in the system a longer time.

5. The intravenous sublimate injections of Bacelli should not be considered practically on account of their danger, and theoretically on account of the rapid excretion of mercury.

6. Large salicylate of mercury injections at several days' intervals are less productive of results than daily small injections of the same drug.

7. Inunctions have the advantage of slow absorption, gradual excretion and the longer remaining in the tissues of the mercury as opposed to salicylate of mercury injections.

8. The Merkalator treatment combines the advantages of the inunctions with the rapid action of the salicylate injections.

Sequeira, London Lupus-Carcinoma. (Brit. Jour. Dermatol., February, 1908. Lupus vulgaris is complicated in about 2 per cent. of the cases by epithelioma. During the past seven years the writer has seen 964 cases of lupus, among which were 14 cases of epithelioma. In 12 per cent, of these 14 cases there were ten males and four females, an unusual proportion, as lupus is much more frequent in women than in men. The average age of the patients at the beginning of the malignant new growth was 36 years for men and 46 for women. The previous treatment seemed to have had little influence in the production of the growth. Three cases had been treated by X-rays. In six cases the epithelioma appeared in cases of "red lupus," in others the new growth arose in scar tissue. The cheek was affected in seven cases. In no case was the mucous membrane primarily affected. Treatment consisted in excision, followed by X-ray. Two of the cases have remained three years and one of the cases one and a half years without relapse, seven have died, two are still under treatment and three have disappeared from observation.

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with 2 deaths; 9 emergency operations place. The procedure followed was unon traumatic lesions, with I death; 15 doubtedly an error of judgment on my nephrorrhaphies and 9 operations on the part. lower ureter without mortality.

"The following are the pathological lesions found, many of the cases presenting two or more lesions: In the 48 nephrectomies there were 6 cases of new growth, 7 cases of tuberculosis, 18 cases of pyonephrosis, 17 cases of calculus, 3 cases of traumatic rupture, 8 cases of acute septic infarcts, 3 cases of hydronephrosis, 2 cases of ureterovaginal fistula following hysterectomy, I case of septic pyelonephritis, I case of severe hæmorrhage following nephrotomy and I case of necrosis of the organ from a twisted pedicle.

"Fatal Cases.-In the 48 nephrectomies there were two deaths. The first of these occurred in a middle-aged man upon whom nephrotomy was performed for . the removal of multiple calculi of the pel vis. There was considerable laceration of the renal tissue in the removal of the four stones, giving rise to a severe hæmorrhage, which was only controlled by generous gauze packing. Four hours later the hæmorrhage recurred. I was summoned and performed a hasty nephrectomy on a moribund patient. Although the removal of the kidney was accomplished without more than a trifling loss of blood, and although the patient received a large intravenous infusion of normal salt solution and was otherwise stimulated, he never rallied, and died at the end of four days from suppression of urine and oedema of the lungs. Autopsy revealed chronic left-sided pyelonephritis and several calculi that had not been revealed by the X-rays. While the case was an unfavorable one, had the nephrectomy been performed at the primary operation while the condition of the patient was still good, recovery might have taken

"The other death occurred in a feeble and profoundly prostrated girl who had been suffering for weeks from pain, vomiting and septic intoxication. She had a movable tuberculous kidney, which had become adherent in the pelvic cavity and had acquired a mixed infection. The operation was an exceedingly difficult one, and was accompanied and followed by profound shock, which did not respond to active stimulating measures. I cannot blame myself for this fatality, as the difficulty in the operation consisted in exposing the kidney. It would scarcely have been less if only drainage had been employed, and it is exceedingly doubtful if simple drainage would have sufficiently relieved the grave toxæmia to allow a secondary nephrectomy had she survived the primary operation.

"Of the eight deaths which occurred. in the nephrotomy cases, I can severely blame my judgment in but one instance. This was the case of a man, aged 71 years, in poor general condition, who for four years had suffered symptoms suggesting stone in the right kidney. There were frequently recurring attacks of renal neuralgia, with the passage of dark-colored urine. There was marked tenderness in the right costovertebral angle. Cystoscopy showed urine from both ureteral orifices. The urine at the time of examination did not contain blood. No X-ray examination was made. The kidney was explored by the lumbar route, its cortex incised, and no lesion found. Infection followed, and the patient succumbed five weeks later to general sepsis. There were four fatal cases of acute septic infarcts, which were treated by nephrotomy and drainage. These were among my earlier cases, when I believed

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