HARVARD UNIVERSITY MEDICAL DEPARTMENT. BOSTON, MASS. ONE HUNDRED AND TENTH ANNUAL ANNOUNCEMENT (1892-1893). CHARLES W. ELIOT, LL.D., President. HENRY P. BOWDITCH, M.D., Dean, and Professor of Physiology. DAVID W. CHEEVER, M.D., Professor of Surgery. OLIVER F. WADSWORTH, M.D., Professor of Ophthalmology. FREDERICK I. KNIGHT, M.D., Clinical Professor of Laryngology. J. ORNE GREEN, M.D., Clinical Professor of Otology. AMOS L. MASON, M.D., Assistant Professor of Clinical Medicine. J. COLLINS WARREN, M.D., Associate Professor of Surgery. FACULTY. REGINALD. H FITZ, M.D., Hersey Professor of the Theory and Practice of WILLIAM L. RICHARDSON, M.D., Professor of Obstetrics. THOMAS DWIGHT, M.D., LL.D., Parkman Professor of Anatomy. OTHER INSTRUCTORS. THEODORE W. FISHER, M.D., Lecturer on Mental Diseases. JAMES J. PUTNAM, M.D., Instructor in Diseases of the Nervous System. JOHN W. ELLIOT, M.D., Assistant in Clinical Surgery. WILLIAM W. GANNETT, M.D., Instructor in Clinical Medicine. CHARLES M. GREEN, M.D., Instructor in Obstetrics. FRANKLIN H. HOOPER, M.D., Instructor in Laryngology. CHARLES F. WITHINGTON, M.D., Assistant in Clinical Medicine. GEORGE H. MONKS, M.D., Assistant in Clinical and Operative Surgery. The following gentlemen will JOHN HOMANS, M.D., in the Diagnosis and Treatment of Ovarian Tumors. FRANCIS B. GREENOUGH, M.D., and ABNER POST, M.D., in Syphilis. GEORGE W. GAY, M.D., in Surgery. HERMAN F. VICKERY, M.D., Instructor in Clinical Medicine. JOHN C. MUNRO, M.D., Assistant in Anatomy. EDWARD REYNOLDS, M.D., Assistant in Obstetrics. CHARLES W. TOWNSEND, M.D., Assistant in Obstetrics. ARTHUR K. STONE, M.D., Assistant in Bacteriology. CHARLES P. WORCESTER, M.D., Assistant in Chemistry, and Secretary CHARLES L. SCUDDER, M.D., Assistant in Clinical Surgery. JOHN C. CARDWELL, M.D., Instructor in Physiology. FRANKLIN DEXTER, M.D., Demonstrator of Histology and Embryology. give Special Clinical Instruction. GEORGE L. WALTON, M.D., and PHILIP COOMBS KNAPP, M.D., is ARTHUR T. CABOT, M.D., and FRANCIS S. WATSON, M.D., in Ge Every candidate for admission, not holding a degree of arts or science, must pass a written examination on entrance to this School, in English, I Physics and any one of the following subjects: French, German, Elements of Algebra, or Plane Geometry, Botany. General Chemistry will be a require for admission on and after June, 1893. The admission examination for the coming year will be held June 30, at Boston, Exeter, Andover, New York, Philadel Chicago, Cincinnati, St. Louis, and San Francisco; on September 26th at Boston, only. Instruction is given by lectures, recitations, clinical teaching and practical exercises, distributed throughout the academic year. In the subjects of Ar Histology, Chemistry and Pathological Anatomy, laboratory work is largely substituted for, or added to, the usual methods of instruction. The year i September 29, 1892, and ends on the last Wednesd y in June, 1893, and is divided into two equal terms. Students are divided into four classes, according to their time of study and proficiency, and during their last year will receive largely increased oporte for instruction in the special branches mentioned. Students who began their professional studies elsewhere may be admitted to advanced standing; but all who apply for admission to the advanced classes must pass an examination in the branches already pursued by the class to which they seek admission. Beginning with the academic year 1892-93, the required course of study in this School will be a graded course covering four y The degree of Doctor of Medicine cum laude will be given to candidates who have pursued a complete four years' course, and obtained an average of 15 p upon all the examinations of this course. In addition to the ordinary degree of Doctor of Medicine, as hitherto cbtained, a certificate of attendance on the of the fourth year will be given to such students desiring it as shall have attended the course, and have passed a satisfactory examination in the studies of the ORDER OF STUDIES. For the First Year.- Anatomy, Physiology, Histology and Embryology, General Chemistry, Hygiene, Bacteriology and Medical Chemistry during second half-year. For the Second Year. Anatomy, Pathology and Pathological Anatomy, Clinical Chemistry, Materia Medica and Therapeutics, Theory and Practice, CL Medicine, Surgery and Clinical urgery. For the Third Year.-Theory and Practice, Clinical Medicine, Surgery, Clinical Surgery, Obstetrics, Pediatrics, Dermatology, Neurology, Gynecolog For the Fourth Year-Required Studies: Clinical Medicine, Clinical Surgery, Clinical Microscopy, Genito-Urinary Surgery, Ovarian Tumors, Mental D Ophthalmology, Otology, Laryngology, Orthopaedics, Legal Medicine and Syphilis.' Elective Studies: Ophthalmology, Otology, Orthopedics, Gynecology, 1 tology, Neurology, Bacteriology, Physiology, Chemistry, Hygiene, Operative Surgery, Operative Obstetrics. Mental Diseases. COURSES FOR GRADUATES AND SUMMER COURSES. The Faculty has arranged a greatly enlarged and improved Plan of Instruction for Graduates, embracing all the branches of Practical and Se Medicine, in which graduates of medical schools may feel the need of advanced or special training. It is designed to supply those opportunities for clinic laboratory study which have hitherto been sought in Eurore, and by means of repeated short courses to limited numbers, to give the practitioner the adva to be derived from personal instruction in the following subjects: Anatomy, Physiology, Histology, Pathological Anatomy, Clinical Medicine, Surgery, Ofst Gynecology, Dermatology, Syphilis, Ophthalmology, Otology, Laryngology and Rhinology, Neurology, Mental Diseases, Diseases of Children, Legal Me Hygiene and Bacteriology. For full announcement of these courses, address Dr. C. P. WORCESTER, Secretary, Harvard Medical School, Boston, Mass. REQUIREMENTS FOR A DEGREE.-Every candidate must be twenty-one years of age, must have studied medicine four full years, have spent at les continuous year at this shool, have passed a written examination upon all the prescribed studies of the course taken. FEES.-Matriculation, $5; for the first three years, $200; for the fourth year, $100; for one term alone, $120; for Graduation, $30. For Graduates' C the fee for one year is $200; for one term, $120; and for single courses, such fees as are specified in the Catalogue. Payment in advance, or, if a bond is the end of the term. Students in regular' standing in any one department of Harvard University are admitted free to the lectures, recitations and examin of other departments. For further information, or Catalogue, address Dr. H. P. BOWDITCH, Dean, Harvard Medical School, BOSTON, M Press of S. J. Parkhill & Co., 226 Franklin St., Boston, Mass. Medical and Surgical XVII. JOURNAL. OCT 28 1892 LIBRARY Published Weekly by DAMRELL & UPHAM, corner School and Washington Streets. THURSDAY, OCTOBER 27, 1892. Five Dollars per Annum PAGE Mellin's Food For Infants and Invalids. 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Drug Co., St. Louis, Mo., Sole Agents. theories have but small value for you. the information live physicians and The Microscope surgeons require. It has the best We would like to send you a sample THE MERCK'S BULLETIN PUBLISHING CO., and Its Revelati The Seventh Edition of this most valuable just ready. It has been thoroughly reconsti much of it entirely rewritten by W. H. DALL eight hundred wood engravings it makes so co LL.D., F.R.S., and with its twenty-one plat a work of reference that the skilled Physi ian, be without it. one engaged in scientific research, cannot af For Sale at our Store, or sent postp on receipt of price, $6.50. DAMRELL & UPHÁ 283 Washington St., Boston, Ma 1 64 Original Articles. EYE-PARALYSES.* BY JOHN AMORY JEFFRIES, M.D. A FEW cases with autopsy have been reported in which conjugate paralysis of up or down, but not of lateral motion existed [Thomsen,i54 Nieden,98 Hoppe, 59 Henoch, Gee 2]. Of these I have collected a few cases and have been unable to procure the records of several others. Some are cases of pure paralysis of up or down motion, others are complicated by other pareses, but nevertheless this form of conjugate paralysis was the leading factor in the case. In all of these a lesion has been found at the level of the nuclei of the third pair, and in all but Thomsen's 154 case the disease has been central. As this case is of extreme interest it is given in detail. A man, forty-eight years old, slowly developed the following state: Viscera normal, mind feeble; pupils small, right larger than left, a trace of the light reaction in the left, but none in the right. Lids drop in rest, but can be well opened. Both eyes moved to a normal extent to the right, to the left, or down, but always with nystagmus. A marked paralysis on looking up, the eyes turning scarcely above the horizontal plane. Monocular vision the same, except that the right eye is less movable than the left. No changes in the state of the eyes to death one month later. The arms were weak and tremulous, the legs weak and slightly spastic with normal knee-jerks, but ankle clonus. The urine escaped at times, and the gait was unsteady and spastic. Autopsy revealed a moderate amount of chronic meningitis, thickening of the ependyma, a few sclerotic patches in the cord, and a partial degeneration of both the anterior and posterior roots. Also a gumma at the point of exit of the third nerves between the corpora mammillaria and the crura. In the left only a small portion of the crus and substantia nigra were affected, while on the right the growth involved the lower portion of the red nucleus, the median third of the substantia nigra, and less of the crus. The right third nerve was extensively degenerated, the left but slightly. The nuclei of the third nerve were normal. Thomsen classes the case as one of peripheral paralysis, which to my mind is a mistake. Though the lesion was peripheral to the nuclei, it was still in the brain. The substantia nigra and red nucleus can hardly be called peripheral structures. It seems clear that the lesion involved the nerve fibres destined for the superior and inferior recti. The only other associated motion of the eyes is that of convergence in near vision. In this motion the eyes both bring their axes to bear on the subject, and owing to its nearness the axes converge. Contraction of the pupil and accommodation are normally associated with it. Commonly the object looked at in near vision is in front of the face, and hence the contraction of the internal recti are approximately symmetrical; but even in running the eye across a page this symmetry is broken. The extent to which lateral near vision can be practiced appears to be very variable. In some cases as soon as the object is passed but a slight dis * Read before the Boston Medico-Psychological Society, March 17, 1892. 112 tance to either side of the nose, the pupil dilates, vision is poor, and the eyes become parallel, indicating the substitution of conjugate for convergent vision. In other cases the object can be carried so far to one side that one eye looks at the nose and the other is well turned out before the break comes. In all whom I have examined, even with the other eye covered, near vision does not occur when the object is far to one side. A good many cases of paralysis of near vision have been reported, but unfortunately as yet there are no autopsies. [Cases by Barel, Earles, 25 Parinau, 108, 110 Peters, Stölting,150 Gräfe, Pilz,119 De Watteville,2 and Binsler.7] Some of the cases are suggestive of an hysterical state, but the mass of them point to gross disease. A centre of convergence has been assumed to exist in the anterior part of the third nuclei, but as yet nothing definite has been shown. Hensen and Völckers' 55 experiments which do not tally with others- at the most do not demonstrate a centre: irritation at a point of crossing of fibres would produce the same effect. Thus, if, as suggested above, the fibres governing convergence come down to near the sixth nucleus ascend and cross to their nuclei, stimulation at this crossing would produce convergence. Whatever the mechanism this paralysis is just the obverse of lateral conjugate paralysis. With both eyes open, neither will turn in, but cover one and the other comes in at once, while the covered turns out to a parallel position. The case reported by Binsler may be taken as a typical example. A band-man, previously well, ran to an appointment, and while blowing on the horn, suddenly lost sight of the music and had to stop playing. Careful examination showed that distant vision was good, but near vision poor and accompanied by crossed diplopia. When one eye was covered, the other turned in well for near vision, the covered eye turning out at the same time. The right pupil reacted to light, but did not to accommodation. Sense of cold less distinct on the right side than on the left. No other symptoms, no change in six months. We have left to consider the great mass of eye paralyses, which simply affect one or more muscles and do not tend to select associated functions. In these cases we are deprived of a most valuable guide in localization, and are obliged to fall back on what other symptoms may be present, and a few isolated points of value. As is now well known, the nuclei of the fourth nerves lie just behind those of the third nerves, and practically form a unit with them. The nerves themselves, however, instead of passing down from the nuclei to the lower surface of the pons, go up and cross above the aqueduct before issuing from the brain. As a result, the crossing gives an occasion for double fourth nerve paralysis, without involvement of the other nerves; which the peripheral course of the nerves does not readily lend itself to. Though no cases of the isolated paralysis of the superior obliques have been reported, there are those of Christ's and others in which this symptom has been used with good success. There are few other factors of importance in the distribution of the paralysis. Mauthner 81 and others have held that a peripheral paralysis of the nerve trunk was complete or practically evenly distributed among the various muscles supplied by the nerve, while a paralysis due to disease in the base of the brain was commonly incomplete or irregularly distributed. Thus be affected or some of the muscles of the third and not the intrinsic or extrinsic muscles of the eye alone might the others; the reason being that while the nerve is Paralysis of the eye muscles is by no means rare in cases of multiple sclerosis. Uhthoff 157 found seventeen cases in a hundred. These cases are classed as follows: Two of double sixth paralysis, four of single sixth, three of third nerve, all partial; two of lateral conjugate, one of up conjugate, three of convergence, and two of ophthalmoplegia externa. It will be noticed that the paralyses are all limited, do not tend to include the whole of the third nerve, but only affect one or two muscles, or an associated motion. They tend to be more closely limited than in tabes. 84 Another symptom of value is the variableness of the paralysis. Most true peripheral paralyses tend to run a definite course, and do not change rapidly, indeed from minute to minute, as is not uncommon in central cases. This is naturally explained by the nerves being little more than conductors, acting when isolated from the body, while the centres discharge and generate force. As a result of this it is not rare to see a slight paresis grow during the course of an examination into a paralysis, and new paresis develop. From the same cause the paresis is apt to show itself at night or even ing and not in the morning. But the above characteristics are of use in only a small part of the cases: in the majority we must rely on the general symptoms and etiology for our diag nosis. There are a number of diseases which from their importance require consideration. In tabes, as has long been known, there is frequently a history of transitory diplopia during the prodromal period. A patient sees double on and off, just for a moment, particularly at night. The time is fixed partly by the causes already referred to, and partly by the fact that lamps afford a close test of the eyes. When the eyes are tested no signs of paralysis are detected. In another group, usually more advanced, a positive paralysis exists, an external rectus is weak, convergence is poor, or they see double in the upper stories of the houses as they pass along the street. These paralyses may in their turn pass off in a few days, give place to others, or remain fixed. The origin of these fugacious paralyses is not known, but their significance when combined with previous syphilitic infection is gravely suggestive of tabes to follow. The more fixed paralyses are apparently due to a mixture of causes, the most common being a thickening of the ependyma and an extension of the process into the nuclei and fibre tracts; another is syphilitic infiltration about the roots of the nerves before they are combined into a compact bundle. Endarteritis and its results do not apparently play an important part in these early paralyses. The latter and general paralyses of the eye occurring in tabes are usually classed as cases of ophthalmoplegia. These are characterized by their irregular distributions, extent and persistency. Tumors involving the corpora quadrigemina, the pineal or pituitary gland are very apt to cause paralysis in the branches of the third, together with a peculiar form of ataxia and impairment of sight, but there is nothing in the paralysis itself to indicate the nature of the lesion, except perhaps in cases of paralysis of up-and-down motion. The diagnosis of the nature of the lesion must be based on the general symptoms of tumor and the fact that other lesions are rare in this locality. In a summary of 29 cases Christ found paralysis of the third nerve in 22, of the fourth in six, The so-called cases of ophthalmoplegia externa require notice. In 1879 Hutchinson called attention to a group of cases in which a progressive fairly symmetrical paralysis of the muscles of the eye-balls formed a predominant symptom among a group of scattered bulbar paralyses and general cerebral symptoms. Since then the limits of this group have been extended so as to cover all general eye paralyses apparently of central origin and thus any value which may have attached to the name has been lost. To-day a diagnosis of ophthalmoplegia is about as significant as one of stomach-ache. The twenty odd cases in which there are fairly good autopsy reports, some being monuments of labor, skill and knowledge, show a great variety of processes. A few groups, however, can be separated out, with a fair degree of accuracy: 155 40 First, there are the cases of polio-encephalitis of Wernicke, represented by Gayet's case, Wernicke's 17 three cases, and Thomsen's two cases. In these cases there was but little paralysis except of the eyes, but in all mental disturbance, active delirium or somnolence, a staggering ataxic gait, tremor and the general signs of severe brain disease. At the autopsy a marked injection of the vessels, and numerous miliary hæmorrhages throughout the central gray matter of the third ventricle, aqueduct, and fourth ventricle have been the principal trouble. The process has also in some cases been diffused through the whole of this region. In others, more or less extensive degeneration of the nuclei has also been present. In Hutchinson's case 64 the process is given as a nuclear degeneration, the same as in muscular atrophy, a pathology with which the symptoms well accorded. Some of the cases of diphtheritic paralysis also appear to partake of the same nature though peripheral trouble is present. These cases are slower than those of Wernicke's group, and lack the high degree of vascu lar change and acute symptoms, but seem to be allied to them by a certain amount of vascular change and the nuclear degeneration. 29 A second class is represented by the cases of Dubois,28 Eisenlohr, and Bristowe, 12 in which careful microscopic examination gave negative results. character they all differ: the first was a recurrent In |