Paradoxical Pseudohypertrophy in Infantile Cerebral Hemiplegia.-CASE III-C. W., male, ten years old, family history of epilepsy, insanity and alcoholism, rheumatism and tuberculosis. Personal history always good. Smallpox at five, and while in the convalescent stage he had a relapse, septicemia set in and multiple abscesses formed. After a prolonged convalescence from the relapse infantile cerebral hemiplegia developed. The convulsions were, however, general and continued for many not come all dast week because I had a very lad cold and FIG. 1. Patient had been under the influence of sedative treatment (bromide and chloral) for a week when this specimen was written. No loss of control is shown, except in a slight degree in the word "last."' hours. The next day after the convulsions a left hemiplegia was noticed. The convalescence from this lesion was prolonged, and three months after the initial stroke he had status hemiplegicus unilateralis (left) attended by high fever. There were forty-seven grand mal fits in four hours; they all occurred with an order of muscular march, beginning in the left hand, the side paralyzed, as is usual in such cases. He has now grand mal, petit mal, and psychic attacks of epilepsy every two or three. months two, three, and five times daily. The is not yet at hand. Morbid agitation of the hypertrophic parts cannot be the cause, as in this case as well as in several others no athetosis has ever been present. Probably the slight nature of the cortical affection (all the other cases have been epileptic) and the slight spasticity in the involved parts may account for the hypertrophy. We, however, still await an exact pathological description of the nature and character of the lesion present in any single case. During the low last night When the wind had a velocity of seventy five miles an hour the french bark Olivily de Clesson as soon as I got home bount to this City But feel a little FIG. 2. The amount of sedative had been reduced one-half that given at the time Fig. I was written. hypertrophy of the left calf on the paralyzed side was first noticed three years ago. The remainder of the left side, however, remains moderately atrophic, true to the usual type or law of infantile cerebral palsy cases. The fits are always followed by a more or less marked exhaustive paralysis in the side most participating in the spasm; the hypertrophy of the left calf is probably not true fiber hypertrophy, as the muscle action of the left leg is not so strong as the right. The boy is right-handed. The amount of hypertrophy is a half inch. The ankle is also with a cargo FIG. 4. In addition to the entire withdrawal of sedatives, the specime was taken on one of the "bad days." Myoclonic interruptions are fre quent and severe. The letters are all quite well formed. The muscles of the arm and shoulder cause the myoclonic movements. The bast writing is similar to that seen when one's arm or shoulder is struct violently in the act of writing. The x-ray photographs (Fig. 5) show an easy clinical method of demonstrating volumetric hypertrophy in bone, muscle, and fat in parts which undergo true or false hypertrophy. It obviate the necessity of excising tissue which is a painful, and inexact means of determining these alterations although the latter method must be resorted to in mother to carry it in sitting FIG. 3. The amount of sedative was reduced to one-fourth that given at the time of Fig. 1 a half inch longer on the paralyzed side, indicating thigh at gluteal fold. just above knee. 734 1434 1034 Right, 94; left, 9% Thirteen cases in all have been reported of this peculiar pathological condition in infantile cerebral hemiplegia.* An explanation for the condition. *Clark, Journal of Nervous and Mental Diseases, October 1, 1902, and Archives of Neurology and Psychopathology, Vol. 2, Nos. 3-4, 1899. order to determine whether the muscular increase is due to hyperplasia or fiber hypertrophy. I ar indebted to Dr. Holden for the excellent x-ray negative presented. Facial Hemiatrophy.-CASE IV-The patient is married and has two children; occupation that of clerk. As a boy of five or six he reports having received a severe burn on the right side of the face, which, however left no scar, and this mishap was so slight that its occurrence was not men tioned by the patient in the early examinations. Eighteen years ago, at the age of forty-four, the patient noticed a slight muscular contraction in the right angle of the jaw similar to that which is now present in the whole of the masseter and temporal muscles. Rubbing diminished the spasm for a time; the pain was not great, the patient felt discomfort principally, to which he soon accustomed himself. In three or four years he noticed the twitching or fibrillations as marked as now is present; now the tremor ceases at times but quickly returns on fatigue, exposure to cold, excitement, and any undue emotional stress. About six years ago he noticed a marked wasting in the right side of the face; three years ago the wasting became FIG. 5. was thought that the relative atrophy of the skin, fat, and bone could be shown by the x-ray. As mentioned before, there is no atrophy nor reaction of degeneration in the motor portion of the fifth nerve, the fibrillation being the only evidence of the involvement of the masseters and temporal. There is, however, shortening in the masseter muscles which apparently restrict the separation of the jaws for more than one inch; this limitation is decreased in the absence of fibrillation, and on good days he can separate them a little further than this, particularly in the morning after a full night's There is no lateral movement of the lower jaw, the pterygoids apparently do not functionate. rest. The amount of asymmetry in this case is, of course, not so great as in those cases occurring in earlier life when a hindrance of growth increases the effects of wasting. The atrophy has always been general, not especially marked in any one spot, as in the facial hemiatrophies of sclerodermal origin or morphoeal type. The hair and beard do not participate in the affection, although there is a rather marked thinning and whitening at the free border of the hair on the right side of the forehead. The lesion would. seem to be one that affects all divisions of the fifth nerve, which is not entirely confined to the right side. This case of facial hemiatrophy is shown as a probable bilateral involvement of the facial nerve in the lesion. The fibrillation present in the masseter and temporal of the right side, and to a slight extent in the left side, also proves the motor root is also. involved. The fibrillary tremor is quite analogous to that seen in progressive muscular atrophy, but, since muscular wasting and weakness are but little or not at all present, and in the absence of reaction of degeneration, the apparent analogy fails in anthological comparison. I am indebted to Dr. McEntee for the history of the case and the privilege of reporting the same in this clinicall study. Showing a method of differentiating true from false muscular hypertrophy. marked as to cause comment by all; the teeth cayed, loosened from the jaw, and were easily reoved by a dentist. The pain became so severe last nuary (right trigeminal neuralgia in all three disbutions of the nerve) that he sought relief at Dr. arr's nerve clinic. The physical examination owed that all the cranial nerves were free with the ception of the fifth; the sensory portion appeared act, except differential smell and taste were a le slow on the right side, possibly due to the actional defect expressed in the neuralgia. The ophy of the skin, subcutaneous fat, and bone re sharply confined to our supposed skin disbution of the fifth nerve (see Figs. 6 and 7). It is difficult to understand how exophthalmic: goiter has anything to do with facial hemiatrophy,. as some writers contend, but migraine or migrainous pains, hemicranial in type, may be more or less directly associated, inasmuch, as many of the hemiatrophic patients have complained of neuralgic pains sooner or later, in the course of the disease, as it is an affection of the fifth nerve (sensory). Our patient has had several periods of true trigeminal neuralgia; it is doubtful, however, that true migraine with classic eye and gastric symptoms have ever occurred. Gowers believes that the condition is due to an organic disease of the fifth nerve, with whi h we also concur. This view based upon the nature and distribution of the atrophy is further substantiated by the pathological investigation of Mendel, upon a case of Virchow's, in which Mendel FIG. 6. Facial he.nia trophy, Case IV. Compare Fig. 7. found interstitial neuritis in all parts of the nerve with degeneration and atrophy of many fibers in the upper root and of the cells of the locus cæruleus. It is necessary to call attention, however, to the atrophy may coincide clinically, as in Schwann's case, it is by no means proven that the lesions in the two affections are identical. Moreover, fa ial hemiatrophy is probably due to a particular form of disease of the fifth nerve, as lesions of the latter are infrequently followed by hemiatrophy. The etiology of the affection must be less patent than a trauma, which, when present (in only about one-half of all cases), has been singularly insufficient to cause so manifest a nutritional disturbance. The nutrition of all parts, except that of the muscles, appears to depend upon the posterior root fibers, to which the fifth nerve belongs for the most part. Slight trauma, therefore, might give rise to slow wasting in a chronic lesion, as in tabes, in contradistinction to a more acute affection produced by irritation. Intact sensibility does not militate against a lesion of the fifth nerve (posterior sensory root nerve), as wasting may occur in other parts of the body under analogous conditions. While, of course, the presence of trophic disturbance does not afford proof of trophic nerves, yet as Gowers suggests the rapid conduction of sensory impulses upward may be compatible with a slower cor veyance of a trophic influence downward, even in the same fibers, as the latter may be lost while the former is unchanged. The lesion of facia hemiatrophy is probably of the fifth nerve, but is not of that serious nature to impair its conduetibility. Cases are on record (Wolff, Muratow Sachs, and our own) in which disorders of motility are present in tonic and clonic spasm and muscula fibrillation, showing the motor part of the fifth nerve has also been involved, and as the twitching is the initial symptom, it argues primarily for a nuclear affection. I one case a tumor beside the po was found. Facial hemiatrophy t been produced in animals by section of the fifth nerve in the skull. We would, therefore, infer, from the variety of lesions found, that range of possible distribution of lesion may be quite extensive and, point of possibility, in any part of t fifth nerve, even to its extreme d origin, sensory or motor, or bet Finally, it must be said it may have a demonstrable pathology, depend upon certain nutrition changes in the nucleus or nerve fibe not discoverable by microscopical Myasthenia Gravis.-CASE V-H tie S., aged twenty-one; clerk; married. There is a family hist of insanity, hysteria, and tuberculoss the cause is unknown. The patients face "has always had a pecu look." She had infantile rickets a has always been rather anæmic. six years of age she had an hyster attack, and at thirteen years of a true epileptic fit, tongue biting, voluntary passage of urine, froth at the mouth, etc. Syphilis and a holism, congenital or acquired, f peared to play no rôle in causation The myasthenia came on gradua Six months before its appearance patient had frequent typical atta of angiospasm (digiti momortui). These attas still persist and occur most frequently posure to cold, fright, and after great fatigu they always appear in the bad days or perices Motor weakness first appeared in the left leg; FIG. 7. Showing on the right side contour of soft parts conforming more to the bony prominences, giving an angular outline; atrophy of subcutaneous fat; marked atrophy of muscles; right ramus and angle of mandible smaller; osteoporosis of right superior maxilla; transverse distance from the shadow of the vomer to that of the outer bony wall of the nostril is diminished as compared with the left side. Compare fig. 6. fact, that Virchow's case was probably one of scleroderma which happened to have a hemi-facial distribution in connection with the shoulder and arm involvement. In point of fact, while the atrophy seen in morphoea or scleroderma and in facial hemi years ago the leg gave away after a slight amount of walking and she fell down. In six months the right leg also became equally affected. For the past year both arms (left most) have also been affected. The symptoms probably first appeared in the face, but did not seriously incapacitate the patient, it was not complained of at first. Bilateral ptosis is marked, being most on the left side and most prominent in the evening. At times diplopia has been present for a short time. There has been an alteration of the relative position of the two images at different times. There is persistent irregular nystagmoid movements, similar to those seen in conditions of general asthenia. The movements are lateral and brought out on extreme position of conjugate lateral deviation of the eyes, most marked to the left. Patient complains that words become easily blurred and indistinct while reading on bad days. Difficulty in mastication and deglutition have not been very marked. The facial expression is quite characteristic, and reminds one of a mild type of Landouzy-Déjerine form of myopathy. There is marked inability to wrinkle the forehead, raise the eyebrows, or to frown. The sphincters of the orbit are so weak that the patient is unable to keep the eyes closed against much resistance. A very poor attempt is made to show the teeth. The patient cannot pout the lips well nor empty a spoon with the upper lip, whistle or blow out a candle. Bilateral slight atrophy of tongue is to be noted. Blood examination in this case made by Dr. Prout, is as follows: There is nothing unusual in this blood examiation-in fact, it is quite normal. The high red lood cells might be noted. Although Erb differentiated myasthenia gravis wenty-five years ago, but 114 cases have been ecorded since, which shows it is still to be regarded very rare affection. The nature of the disease ppears to be fairly well outlined as a clinical entity om the symptoms: (1) myasthenic reaction (Jolly, 895), consisting in rapid exhaustibility of the uscles by faradism, (2) rapid exhaustion of uscle by voluntary effort, (3) a state of more · less persistent paresis in the face and the exemities, (4) remarkable variability in intensity symptoms forming "good and bad periods d (5) facial expression, ptosis, partly obliterated cial folds, "sleepy look," etc. Its etiopathology is still uncertain and unsatisetory, although there is a record of fifty fatal cases, d an autopsy has been performed in thirty-one ses. The autopsies, as far as the nervous sysn was concerned, were negative in seventeen. eigert and Hun have shown that a sarcomatous perplasia of the thymus gland was present in eir cases which was not inflammatory but malignt in character; the muscles showed infiltrating I of lymphoid cells which resembled round nonuclear cells of the thymus gland. The nges in the thymus was similar to the hypersia associated with status lymphaticus, but phoid metastases do not occur in the latter lition. Hun believes that the muscle paresis ne due to a substance which lies in the liquor sanguinis or lymph, and which constantly bathes and surrounds the muscle fibers, and in this manner brings about nutritional disease of the motor end plates. 62 WEST FIFTY-EIGHTH STREET. THE MODERN TUBERCULOSIS DIS PENSARY.* BY S. A. KNOPF, M.D., NEW YORK. ASSOCIATE DIRECTOR OF THE CLINIC FOR PULMONARY DISEASES OF THE HEALTH DEPARTMENT; VISITING PHYSICIAN TO THE RIVERSIDE SANATORIUM FOR CONSUMPTIVES OF THE CITY OF NEW YORK; CONSULTING PHYSICIAN TO SANATORIUM GABRIELS, GABRIELS, N. Y.; THE CONSUMPTION HOSPITAL OF WEST MOUNTAIN, SCRANTON, PA., ETC. AMONG the multiple means of fighting tuberculosis as a disease of the masses, in large and even in smaller cities, there the tuberculosis dispensary stands out preeminently. What this relatively new institution is requires some explanation. It is a dispensary created, built, equipped, and managed for the exclusive treatment of indigent persons afflicted with pulmonary or laryngeal tuberculosis. The modern conception of the treatment and management of ambulatory tuberculous cases demands the creation of such institutions. Those of us who began our medical career fifteen or twenty years ago will remember the almost universal indifference of our teachers as well as ourselves when in our dispensary practice we came across a tuberculous case. The sooner we could dispose of it, the better we thought we did our duty. Some cough mixture and some cod liver oil was the routine treatment. There was no time, nor did we think it necessary, to teach the patient to take any precaution with his infectious sputum, or to give him any other hygienic instructions. The value of breathing exercises in such cases was thought of by but few. How different is it to-day! To avoid as far as practicable the contact of the tuberculous patient with other patients, separate classes are created in many of our general dispensaries; but the ideal, of course, must always be the entirely separate and especially constructed tuberculosis dispensary. The institution I have the honor to be connected with is, to the best of my knowledge, the first municipal tuberculosis dispensary especially built for that purpose in the United States. For obvious reasons it is not called a dispensary, but has for its official name Clinic for Pulmonary Communicable Diseases of the Health Department of the City of New York." While neither my distinguished chief, Prof. Hermann M. Biggs, nor my colleague, Dr. John S. Billings, Jr., nor myself, consider the building ideal, there are many features connected with its construction which may serve, in a measure, as a model for the establishment of similar institutions. The building is centrally located, adjoining the Health Department's building, on Fifty-fifth Street and Sixth Avenue. It is a one-story structure, and is composed of a registration room, a drug room, waiting room for women, a waiting room for men, two dressing rooms for patients, two examination rooms, an x-ray room, a laryngological room, one small dressing room for nurses and one for doctors, also toilet facilities for patients and employees. There are tiled floors throughout the building, all corners are rounded off, all rooms are light and well ventilated. A special treatment room for the operation of the pneumatic cabinet is in course of construction, and I hope an appropriation for the establishment of a little hydrotherapeutic installation will soon be forthcoming. All the furniture, as a *Opening address for the Symposium on Tuberculosis Dispensaries, delivered before the Section on Medicine of the New York Academy of Medicine, May 17, 1904. desks, tables, benches, chairs, stools, closets in the drugroom, etc., are made of white enameled iron, easily cleaned and disinfected. The desks and tables are covered with plate glass. The nurses wear the regulation white dress, and to each physician in attendance the Health Department furnishes three suits of white washable material, which these gentlemen wear during their work. Everything is done to reduce the danger from infection and reinfection. When during auscultation it is desirable to have the patient cough, Fränkel's mouth-mask is made use of to avoid drop infection. For the benefit of those who may not be familiar with this useful appliance, I beg leave to describe it briefly and illustrate it by the accompanying drawing. Fränkel's mouth-mask is composed of a metal ring, large enough and bent to fit the external contour of the mouth, a apporter, saddle and rings -the latter for the attachment of a band to pass around the patient's head to hold the mask in place. A fresh piece of gauze is placed between the supporter and the saddle every time the instrument is used. It goes without saying that those who have gone to the trouble to examine the deposits on these pieces of gauze, have not infrequently found the tubercle bacilli and other pathogenic microorganisms. To show the aims and objects of our clinic, permit me to quote briefly from the circular of in Care. These fall under three heads: (a) advanced or bedridden cases, with profuse expectoration, who will not or cannot take the necessary precautions against spreading the disease, and whose presence at home is a menace to others in a family; (b) cases able to get about who are unable to work and entirely dependent upon their earnings for their livelihood; (c) incipient cases, who stand a fair chance of recovery if removed to sanatoria outside of the city. 5. The Provision of a Municipal Institution to Which All Cases of Tuberculosis May Be Referred.-(a) By physicians (charity patients, etc.); (b) on their discharge from hospitals or sanatoria; (c) by the various charitable organizations throughout the city; (d) by persons doing individual charitable work who come in contact with such cases. 6. Extension and strengthening of the sanitary control of tuberculosis among the poor by the Department of Health. 7. Care of Laryngeal Cases.-The involvement of the larynx is one of the saddest complications of pulmonary tuberculosis, and the pain, distress, and discomfort of the patients are exceedingly great. While the prognosis in these cases is extremely grave, yet under proper treatment recovery takes place in some instances, and in every case the distress of the patient can be relieved and be made more comfortable. A special throat clinic has been fitted up, and special attention will be paid to such cases. To illustrate the general management of such a dispensary, will you permit me to give you here the rules and regulations for the physicians, nurses, and employees of our clinic, which were worked cut by my colleague Dr. Billings and myself, and formation issued by the Board of Health previous to the opening of the institution: 1. The Early Recognition and Accurate Diagnosis of Cases of Pulmonary Tuberculosis.—It is now generally admitted that tuberculosis is a curable disease, and that incipient tuberculosis, under favorable conditions, tends to recovery. But to insure such recovery, the diagnosis must be made at the earliest possible moment. Not only will careful physical examination of the patients be made, together with repeated sputum examinations, as required, but also in some cases x-ray examinations will furnish assistance in arriving at an early and correct diagnosis. 2. The Care of Patients Applying for Treatment.-This will include not only medical treatment, but also the furnishing of circulars of information in various languages (English, German, Yiddish, Italian, Chinese, Ruthenian, Polish, Hungarian, and Russian), careful instructions as to the nature of the disease, and the necessary personal and hygienic precautions to be taken to prevent the infection of others. Paper sputum cups will be supplied to indigent and needy cases, and also proper food (milk and eggs). 3. The Continued Observation at Their Homes of Indigent Needy and Ambulatory Cases, Including All Those Discharged from the Public Institutions of the City.-A special staff of trained nurses will visit the patients at their homes to see that the instructions given will be observed, that the sanitary surroundings are satisfactory, and that such assistance as is required is afforded. Suitable cases will be referred to the various charitable organizations for food fuel, ice, etc. Special attention will be paid to the children in the family and every effort made to prevent their infection. 4. The Removal to a Hospital of Cases Requiring Such were approved of by Dr. Darlington, Commissione of Health, and Dr. Hermann M. Biggs, the Media Director: The clinic is open every day, except Sundays and leg holidays, from 9 A.M. to 4 P.M. The morning classes are from 10 to 12; the aftern classes from 2 to 4 o'clock. On Monday, Wednesday, and Friday evenings clinic is open from 8 to 9 o'clock. The attending physicians are expected to arrive puncte ally and enter their names in the book kept for that p pose in the office. In case any physician is prevented from attending his class, he will notify one of the associate direct (Dr. Billings or Dr. Knopf) and arrange with one c other physicians to substitute for the time of his abses The general history of new patients coming to “2 dispensary having been taken by the nurse in charge ch registration room, the history card is carried by the tending nurse to the physician. A jar for the collection of sample sputum for bacter logical examination is then given to the patient, and bes assigned a seat in the waiting room. The examining physician may dictate to the attr nurse the results of his physical examination. It s however, desirable that the signs indicating chest defere tion, dulness, flatness, râles, etc., be marked by the 5 amining physician himself on the diagrams printed for the purpose on the examination card. (This should be don with red ink). Each patient is to be given a leaflet of instructio |