Recent Progress in Neurology

PHILIP COOMBS KNAPP
1909 Boston Medical and Surgical Journal  
expect some trouble in the speech center, but were unable to make any positive diagnosis. Absolute quiet was ordered and light diet advised. Two days later the whole right side became paralyzed. Dr. Bottomly was called to see the patient and suggested edema of the brain as a possible cause for his condition. The symptoms suggested trouble on the left side and not on the side of the suppurative process. For about a week there was no noticeable change in patient's condition. Then there was a
more » ... en there was a gradual improvement and by March he came to my office. At this time there were no signs of paralysis and except for slight loss of ocular motion on the right side physical examination was negative. The restricted motion in eye was apparently due to adhesions. I did not see patient again until Dec. 6, when, accompanied by his father, he visited me at my office and gave me the following history: Beginning last April there were attacks of unconsciousness accompanied by spasm and followed by periods of drowsiness. These attacks have almost invariably come in the morning. They came at first only about every ten days, but have increased in frequency and at present there are sometimes two in a day. Usually there are two or three a week. Almost always before an attack there is momentarily twitching of the right hand and fingers and after this warning there is usually time to grasp some support and prevent falling. A short time before an attack the boy is liable to stammer. After the attack there is usually a short sleep. After awaking there is no memory of the period during the attack. The father says the boy is full of fun and ready for any kind of sport, that he is bright and able to attend to all of his work at school and, except during these attacks, that he seems fully as well as he was before his illness. At this examination the boy seemed mentally bright and physically the average boy. The temperature was 98.8. The pulse was normal, in volume perfectly regular and the rate was 84 beats per minute. The reflexes were all normal. There were no areas of anesthesia. The muscles of both sides were apparently of equal strength. The muscle sense of space was normal. The sensation to heat and cold was normal. I could find no defect in speech. The right eye was slightly turned as you now see it. Some of the unusual appearance of this eye is due to the slight epicanthus caused by the drawing of the cicatrix. Dr. Inglis examined the boy's eyes and found a slight astigmatism. The vision was normal and there was a normal muscular balance. This boy has attacks of epilepsy with an aura suggesting a certain local irritation. This area is the same which could, if diseased, have given the aphasia and paralysis a year ago, and although it is on the opposite side of the head from the naso-orbital abscess, this is the only etiological factor we could find for the brain lesion. The all-important consideration in this case is what is the best treatment, operative or other, and what is the prognosis with or without such treatment. I think there is little doubt but that we have a case of Jacksonian epilepsy and very likely have as a causative factor some lesion in or about the motor centers in the second temporal lobe of the left side of the brain. This lesion seems to be limited in area to the speech center and the motor center controlling the arm. The boy shows no signs or symptoms of trouble other than those of epilepsy, and these are not severe. Since treatment there have been but two attacks in four weeks and these so slight as to be hardly noticeable, where before he was having one or sometimes two a day. This improvement has been brought about by simple hygienic measures and small doses of bromide of strontium. We do not know whether we have a local meningitis, a cieatricial thickening, a small abscess, a changed local blood supply or some other pathological condition in the brain. All of. these have been found to produce a similar group of symptoms. Although there have been many permanent cures of epilepsy by surgical interference, the great majority of the operations upon the brain for the relief of its condition have been failures. We propose to observe this patient and try the general indicated treatment, but if the attacks become more severe or very frequent we may have to consider surgical interference. In 1901 Babinski ' attempted to give a definition of hysteria at a meeting of the Société de Neurologie in Paris. Having first pointed out that hysteria is not the only disturbance capable of being provoked by psychical causes, or the only trouble which may be manifested in different forms in the same subject, or yet the only trouble which may not be associated with grave disturbances of the general nutrition or of the mental state, he maintained that the characteristic of all hysterical symptoms was that they could be reproduced in certain subjects by suggestion and could be made to disappear under the exclusive influence of persuasion. By suggestion he understands the action by which we make another person accept or realize an idea that is manifestly unreasonable; by persuasion he means the acceptance of a reasonable idea. To the whole state, therefore, he would apply the term pithiatism (from iretOd), persuade). This conception of hysteria has been further elaborated in an address2 before the Société de l'internat, des hôpitaux of Paris. In that he states that hysteria is manifested by two sorts of symptoms,-the permanent stigmata and the transitory troubles. The stigmata develop unknown to the patient and consist of anesthesia of the fauces, hemi-anesthesia, involvement of the special senses on one side, particularly of the visual sense, with concentric limitation of the visual field, monocular polyopia, dyschromatopsia and painful points. The transitory symptoms include attacks, paraly-1 Rev. Neurol-, ix, 1074, Nov. 15, 1901
doi:10.1056/nejm190904221601607 fatcat:xq2up6qe7nfgtdadnxlpltb3mm