DISCUSSION.

DR. HOPKINS-This brings out the interesting subject as to the localization of sensation and motion. This subject was thoroughly discussed in the American Neurological Association one year ago. Dr. C. K. Mills, of Philadelphia, is of the opinion that sensation is located in the parietal lobe and that the ascending frontal and ascending parietal are entirely devoid of sensory fibers. In a case of fracture of the skull over the motor area, which he and Dr. Spiller of Philadelphia studied, no disturbance in sensation was detected, therefore he is of the opinion as already stated. This view is contrary to that held by the majority of neurologists, as cases are reported where the motor area has been affected causing loss of motion and also disturbance in sensation. In all cases of monoplegia one must bear in mind the affection of the motor area of the brain, of the spinal nerves and also the functional diseases.

The case reported is undoubtedly due to cerebral injury and I will not take up the time of the Association in making a differential diagnosis of the other diseases which have to be taken into consideration.

DR. FREEMAN-I want to congratulate Dr. Kahn upon the completeness and accuracy with which he has reported this case. It is a subject of very great interest. We must be careful in considering these cases to exclude the possibility of traumatic neurosis, so-called. I am sure that it has been done in this case. Nevertheless I wish to emphasize the point. I saw a case some years ago with Dr. Eskridge. A man had been struck in the back by a piece of falling stone in a mine. His head was not injured. He was a big, strong man in whom no one would suspect neurosis of any kind. The accident was followed by paresis of the right leg; by hemi-anæsthesia, the anesthesia not following the course of the nerves, but going straight across the body; by troubles in vision, including the contraction of the visual field of the right eye; by headaches upon the right side of the head; by the passage of great quantities of blood in the urine, and by the bowel; by vomiting of much blood from the stomach; by coughing of blood from the lungs without any lesion discoverable in the lungs; by a rash which appeared at different times on the right side of the body following the course of the nerves;

and also by hemorrhages beneath the skin in the line of the nerves. There was also such difficulty in breathing and such differences in the heart's action that it was thought at times the man could not live. Through all this he retained a fair nutrition and remained alive. The last I saw of him he had recovered very much from his trouble, although the difficulty persisted for some months after the original injury, to my certain knowledge. Dr. Eskridge was sure that this was a case of traumatic neurosis without any particular injury to any nerves or to the spinal cord. In such a case as Dr. Kahn reports one would have to very carefully consider the possibility of a traumatic neurosis.

DR. COURTNEY—I was very much interested in Dr. Kahn's paper, and I think he has well brought out the point of differentiation in cerebral localization. I have recently seen two cases that have a bearing, possibly somewhat remote, one of them, on this question. One was a case that Dr. Freeman operated on to relieve bone pressure from the kick of a horse. This man received an injury in quite the same location as Dr. Kahn's. The man never had paralysis except a short general paralysis that he had from shock. He was delirious for some days, but there was no monoplegia. It has been several months now since his injury, and while there is no paralysis he has, on the side opposite the injury, which was on the right, over the right parietal region, occasionally a very annoying tingling. He has never had a spasm, he has never had an involuntary contraction of the muscles, but from his description a very circumscribed irritation is present. He says it is like "two wires striking together," that is, that he gets a slight shock in the left hand. The irritation is enough to prey upon his mind. It is not constant. It comes paroxysmally. Now, I think this has some bearing on the point showing that the man has a small subdural hemorrhage or a slight thickening of the dura at the point of injury. It is not sufficient to cause any motor paralysis. It is not sufficient to cause any spasm, but it is sufficient to irritate the sensory area and to cause that quite annoying tingling. The other case was not a cortical injury, but was an injury of the left internal capsule. A ranchman was riding and was thrown from his horse. He was alone and does not know accurately how long he was unconscious, but knows it was a short time. He knows that by the sun and by the time he got back home. He managed to walk home some half a mile. He

never had any motor paralysis, but he did have immediately and has had now for several months a right hemi-anesthesia, which is quite annoying and preys upon his mind. It can be demonstrated by the æsthesiometer. It is not profound but is considerable. Now, in that case I think there was a slight injury to the posterior part of the internal capsule, that is, as far as the sensory area is concerned, but not the motor area. This question of differentiating of these fibres is very interesting. Of course they gather as they descend to the large ganglia at the base of the brain, where they can be less readily injured without injuring more of the motor apparatus.

DR. HOPKINS-I would like to ask whether or not the field of vision was contracted?

DR. COURTNEY-The field of vision was not taken by the perimenter. I did take it by simply holding a small square piece of paper in the end of a stick between the man and myself, which compared his field of vision with my own. I thought that that was sufficiently accurate for the case.

DR. HOPKINS-Was it contracted?

DR. COURTNEY-No, it was not. His field of vision was almost normal.

DR. REED The paper is a very interesting one and brings to mind a case that I have in the hospital at the present time of a similar character. It is a miner who had been working at Rock Springs for quite a number of years and has been subject to epileptic convulsions, which have increased in the last year, so much so that he was obliged to be put in the hospital, and I think he has probably in the last six or eight months averaged from fifteen to twenty spasms a day; as these paroxysms increased the paralysis on the right side became more manifest. Between the spasms there would be partial paralysis of the right arm and right leg. First we tried medical treatment. Being led to believe it was due to some syphilitic trouble we put him on syphilitic treatment, and for a while he seemed to improve. But he became worse and his mind was becoming more or less affected, and we made up our mind that we would perform an operation, not that we had any signs of any injury of any kind or any history of any injury. We operated him three weeks ago, I believe it was, and, as the paralysis was on the right side, we took out a window on the left side on general principles. On taking out this

window, which was about the size of my three fingers, we found no attachment to the dura mater, no exostosis, and no gummata, but the dura mater was bulging and there was very little pulsation noticeable, a very little bit, it could be just barely noticed. I decided, notwithstanding everything looked healthy outside of this, with the exception of a general congestion of the circulation of the brain, so far as we could see, I opened up the dura mater and there was quite a large amount of brain liquid escaped. There was nothing abnormal about the appearance of the brain or about the appearance of the liquid which escaped, but all the blood vessels were intensely congested. Seeing nothing else to do in particular, we laid the bone back in its place, not pressing it down, just pushing it back so that it would come in contact again. This man got over the anaesthetic and found immediate relief. He was the happiest man that you could see anywhere. He had no headache, he had no paralysis that was noticeable at all, after a few days. He had no more epilepsy until about three or four days ago. The wound healed by first intention, in fact, we had no trouble with it at all. He was out around the ward in three or four days after he was operated on, and he got around nicely, feeling good. Now I think I made a mistake in not taking out that piece of bone and keeping it out; and as soon as I get my breath after getting home from this meeting I am going after that piece of bone and get it out. I have made up my mind, owing to the fact that there is such an intense congestion, that the brain seemed to be bulged out against the skull so tightly, and the relief that he found from the escape of the liquid warrants me in operating on the other side and I am going to take out another piece of bone, making it a bilateral opening in the head, and take out the bone also on that side, and if I live long enough to get to Denver next year I will have something to say on that subject then. He is now no earthly good to mankind or to himself, and is very anxious to have the operation at the present time. He was very well satisfied to have gone through with what he did for the two weeks' freedom from pain and epileptic attacks which he enjoyed for a fortnight.

Discussion closed by DR. KAHN-I have nothing further to say except to thank you gentlemen for the liberal discussion, and say to Dr. Freeman that if he would eliminate the possibility of traumatic neuritis the man might be suffering from, for this one

reason, that the paralysis was apparent to every one around the injured man previous to his becoming conscious, being knocked unconscious immediately; there hadn't any time elapsed in which he could get up anything of a neurotic or hysterical nature. So far as the neuritis due to injury is concerned, I do not think that was eliminated. The people when they picked him up (he was unconscious for two or three minutes or something of that kind) said he had a broken arm. They sent for me and said they had a man with a broken arm. It hung limp and he could not use it, so they concluded that it was broken. That was apparent to the people around him previous to his regaining consciousness. Then all reflexes were missing, showing that the injury was the sole cause of his paralysis, and no possibilty of its being hysterical.

RESUME OF X-RAY THERAPEUTICS.*

By G. H. STOVER, M.D.,
Denver, Colo.

Lecturer on Electro-Therapeutics and X-Rays, Denver and Gross Medical College; Radiologist to St. Joseph's Hospital, Denver.

This agent, at first made use of solely as a means of diagnosis of bone lesions, and for the location of opaque foreign bodies in the tissues, has now taken a prominent place in medical and surgical therapeutics.

It was quite natural that the earliest employment therapeutically should be in certain morbid conditions which were not curable by known or tried methods.

When it was found that it had curative powers in these conditions, it was given a trial in many others, which were already more or less under the control of medicine or surgery, with the result that every day sees new fields entered and conquered.

I shall give a brief resume of a small part of the already very large literature of the subject up to date, and shall then give some of my own conclusions, based upon reading and upon six years' experience.

*Read before the Rocky Mountain Interstate Medical Society, Cheyenne, Wyo., Sept. 9th, 1902.