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Horizontal section through brain showing tumor and area of softening.

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Section from the cervical region of the cord, showing diffuse sclerosis.

November 1st-Operation by Dr. Steinbach. The patient was partially anaesthetized and an incision about three inches long made over the right Rolandic area; excessive bleeding being noted. The skull The skull was next opened with a trephine, making a circular opening about 4 c. m. in diameter, this operation for surgical reasons being preferred by Dr. Steinbach to the removal of a large osteoplastic lap as advised by Dr.

During the evening the patient became conscious and was able to swallow, although with difficulty.

The following day he could answer questions, protrude his tongue, etc. His temperature which had been up since the operation, was now falling; the pulse, however, remaining high. From this time on he became steadily weaker, dying about noon the third day after the operation. There

were no convulsions or twitchings of any description subsequent to the operation.

The pathological findings at autopsy were as follows:--Edema of lungs; chronic adhesive pleurisy; fatty degeneration of the heart; slight fatty infiltration of the liver; cholelithiasis; tumor of right frontal lobe; softening of the brain involving the right motor area and part of adjacent frontal convolutions.

Gross examination of the brain:- The cortical tissue of the center of the right motor area beneath the perforated dura was absent and the surrounding brain substance softened for a distance of 2 c. m. anteriorly, superiorly and inferiorly, and for a distance of 1.5 c. m. posteriorly. Two c. m. above the destroyed brain tissue and 1.5 c. m. anterior to the fissure of Rolando, was a fairly resistant mass, extending to a point 4.5 c. m. from the anterior margin of the hemisphere. The mass was fairly circumscribed, adherent to the dura, irregularly oval in shape and encapsulated. The tumor measured 6.2 c. m. by 5.5 c. m.

MICROSCOPICAL EXAMINATION. Tumor:-Sections stained with hematoxylin and eosin and hematoxylin and Van Geisen. A myxo-sarcoma, one of the forms of the sarcoma group infrequently seen.

Optic Nerves and Chiasm:- Sections

stained by Weigert and Weigert-Pal and Weigert-Pal methods. Both nerves and chiasm presented complete degeneration, not a single fibre remaining intact.

Cord and Medulla:- Sections stained by Weigert and Weigert-Pal methods-A "diffuse," rather than a "combined" sclerosis, extending throughout the length of the cord, being most marked in the cervical region, less in the thoracic and least in the lumbar and sacral. tion was noted, not intense, but most dis

Peripheral degeneraPeripheral degenera

tinct in Gower's tracts. This peripheral ring extended to the medulla and was faintly observed in sections cut from the lower levels of this organ. Higher up in the bulb it entirely disappeared. The greatest change was found in the motor tracts, especially in the crossed pyramidal bundles. The columns of Goll were but slightly affected in the sacral and lumbar regions, distinctly in the thoracic and markedly in the cervical section of the cord.

Burdock's columns were affected only in the cervical region.

The cells of the gray matter presented slight granular changes, but were otherwise normal.

In the medulla, sclerosis was marked in the pyramids, and was present to a lesser degree in the fasciculus gracilis and Gower's

tract.

That degenerative changes in the posterior columns of the spinal cord may be associated with brain tumor was first observed by Mayer in 1894. Since that date there have been numerous contributions on the subject, an excellent article by Batten and Collier appearing in "Brain," 1899.

These authors examined 29 cases of cerebral tumor with reference to spinal cord changes and found posterior column degeneration in over half of the series. Besold in 1896 reported two cases of brain tumor with degeneration in Gower's tract as well as in the posterior columns, and since then, other observers have recorded changes in areas of the cord (chiefly pyramidal and direct cerebellar tracts) other than the posterior columns. By far the most frequent, however, have been the changes limited to the columns of Goll and Burdack. The posterior nerve roots have also been found degenerated by several ob

servers.

As pointed out by Batten, the cord. changes are not dependent upon either the location or character of the growth, as changes in the cord have accompanied tumors of varied character and distribution. It is true that sarcomata have constituted the majority of the tumors in the cases reported, but sarcoma is one of the forms of cerebral neoplasm most frequently met with.

The chief interest lies in the cause of the spinal degeneration, and many theories have been advanced. Hoche, Pick, Kirschgasser, Batten and Collier, believe the changes result from increased intra-cranial pressure with increased tension in the dural sheath. Ursini and Dinkler favor a toxic origin; Besold considers the degeneration due to anemia or cachexia, while Campbell advocates a retrograde degeneration.

Without repeating the various arguments that have been advanced by these writers, I will only refer to what I believe to be the two most probable theories-viz.: increased intra-cranial pressure and toxemia.

Regarding the former theory, cases have been reported with evidence of extreme intra-cranial pressure, yet having no degenerative cord changes, while other cases have been recorded without pressure symptoms yet showing distinct cord degeneration.

The theory of a toxic origin appeals to me as being the most reasonable, as analogous changes have been found in the cord in pernicious anemia, cachexia, lead poisoning, ergotism, pellagra, etc.

The possibility of cord changes with a cerebral growth suggests the advisability of always including a search for cord symptoms in the systematic study of brain tumor cases, and may sometimes be the explana

tion of symptoms apparently aberrant or irrelevent.

In the case I have reported, the interesting points are the size of the tumor, the extent of the cord changes, and the fact that an osteoplastic flap would have unquestionably revealed the presence of the tumor which as it was encapsulated and reached the surface superiorly and mesially, could have been enucleated.

The pyramidal tract changes may have been retrograde, but I believe the peripheral and sensory degeneration to have resulted from the action of a toxine through the blood vessels of the cord.

1700 Walnut Street.

A SANATORIUM SCHOOL FOR CONSUMPTIVES.1

BY

DAVID L. SOHN, M. D.,

New York City.

This occasion gives me an opportunity of discussing with you a subject so much deserving of consideration that I look upon it as an agreeable duty. I shall endeavor to take a road on which I hope to find an exit out of the labyrinth, a road whose ultimate end goes beyond the immediate visible and stated one. A fact presents itself: there exists a fallen race-victims of the Great White Plague, the numerous offspring of which grow up to become a plague-sore to society. Instead of a fallen race, we ought to foster a better and a healthier one. The question is: how is this evil to be attacked at the root?

More than twenty centuries ago Hippocrates, the father of medicine, spoke of

1Presented before the Bedford Alumnae Association at Bedford Sanatorium, July 30th, 1910.

consumption and recognized it as the greatest ill that human flesh is heir to and the one which is responsible for the greatest number of deaths. We know that ever since consumption has been the greatest devastator of mankind. It destroys the human race, from infancy to old age, furnishing its greatest number of victims between the ages of twenty and forty-five, when men and women should be strong and healthy and able to support their families or their aged parents. Instead, however, of fulfilling their duties to home and state, many become a burden to society and those depending upon them must of necessity be taken care of by the charitable organizations.

Think of a yearly mortality from consumption of one hundred and forty thousand, and a yearly cost of more than one thousand million dollars in the United States alone! These will soon be conditions of the past. The battle has been half won, and I feel certain that if the efforts in which we are now engaged gather more force as they progress the disease should, in from twentyfive to forty years, disappear from all civilized countries. It will not be very long before tuberculosis will have become as rare a disease as smallpox is today.

In studying the report of the National Association for the Prevention of Tuberculosis, we find that the average cost of one patient per day in thirty semi-charitable sanatoria scattered in all parts of the United States is about $1.70. Computing that there are in the United States at least 300,000 consumptives who are unable to obtain admission to any charitable institutions, it is estimated that the annual cost for the treatment of these persons would be fifty million dollars. The lowest figures show that the country loses at least two hundred million

dollars a year from the incapacity of its consumptives. It would mean a net saving to the United States of one hundred and fifty million dollars a year, if all cases too poor to afford proper treatment in expensive sanatoria were cared for at the expense of the state. And this annual gain does not include the enormous saving that would result from the lessened infection occasioned by the isolating of dangerous consumptives.

Today with our small number of sanatoria and our great army of consumptives it is impossible to combat the disease successfully. It is true that a new era dawned when Dr. Koch discovered the cause of consumption thereby establishing a positive basis for the extermination of the Great White Plague. As yet, however, we know of no specific cure, wherefor we must resort to ISOLATION and EDUCATION.

Let us isolate those whom we can and educate those whom we cannot. In order to accomplish the best results under the present trying circumstances, I advocate the establishment of schools for consumptives, in which the patient will in three weeks derive the benefit of a practical course of instruction at a sanatorium-school devoted solely to this purpose.

The sanatorium-school I have in mind can be built within the city limits or in the suburbs. It should be an institution built and equipped as a modern sanatorium for the cure of consumption, suited for open air, rest, hygienic and dietetic treatment and should be under the supervision of trained physicians and nurses who will carry out the most approved treatment of tuberculosis. There the patients will not only be kept and treated, but they will themselves be instructed in the various phases of sanatorium treatment. There they will be trained how to take care of themselves after

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