3o8 Journal of Comparative Neurology. 



and intra-cerebral processes of the segmental afferent ele- 

 ments, and in rare cases the segmental motor elements, in still 

 rarer cases also the pyramidal tracts ('combined sclerosis'). 

 and finally going over into the preeminently-cerebral type, 

 general paralysis. 



IV. Unknown influence causing a chronic degeneration of 

 the terminations of the cerebral efferent motor system — lateral 

 sclerosis, sometimes involving also the segmental motor system: 

 amyotrophic lateral sclerosis. In H. Jackson's nomenclature, 

 this group would form the 'middle-level' lesions, occasionally 

 involving also the lowest level elements, my • segmental ' 

 neurones. 



V. Finally, the alienist may be allowed to add as highest- 

 level forms of acute intoxication or exhaustion those ' mental 

 diseases * which Kraepelin classifies as delirium of intoxication 

 or exhaustion, and also those cases of general paralysis which 

 run too rapid a course to have marked symptoms from the cere- 

 bral efferent and segmental mechanisms — ' typhomania or de- 

 lirium grave. '^ They are processes preeminently involving the 

 intracortical mechanisms. 



' The pathological anatomy of all these diseases seems somewhat unsatis- 

 factory for those who expect merely lesions of * neurones.' In end-stages the 

 lesions of the neurones may form the most striking part — as the absence of 

 large cells in the residuals from anterior poliomyelites. But the acute process 

 is a disease of the (issue, as the drawings of Goldscheider will show (Nothnagel's 

 Spezielle Pathologic und Therapie, Vol. X, pp. 418-422, figs. 20, 2ia, 21b and 

 32). Saying that a boy has an anterior poliomyelitis should indeed be distin- 

 guished from 'he has residuals from an anterior poliomyelitis.' 



Iht diagnosis must for these reasons always contain two factors: I. The 

 pathological entity —\.ht disease-process as such with the etiological side —for in- 

 stance nerve-degeneration on ground of chronic alcoholic intoxication ; or for 

 poliomyelitis: acute or chronic poliomyelitis (infectious — with fever — or 

 toxic ? etc.). 



2. The diagnosis of the scope : affections of which segments, total or partial, 

 coincident with the districts of which • peripheral nerves,' plexus roots or spinal 

 segments, involving which supra-segmental apparatus, etc. 



That such a diagnosis becomes a little lengthy, need not alarm us. It con- 

 tains the decision of the essential questions which arise when we proceed to the 

 prognosis and formulation of treatment. 



