ee

CORNELL UNIVERSITY.
34! es
PE eel, ge ThE

He oy Rca
Roswell P. Flower Library
THE GIFT OF

ROSWELL P. FLOWER
FOR THE USE OF

THE N. Y. STATE VETERINARY COLLEGE.

1897

 

 
CORNELL UNIVERSITY LIBRARY

Niiuiiiiigg

1924
 

at liom

_ LIBRA! ay
LO rTUuURES a
ep

Nate « aa %

ON

NERVOUS DISEASES

FROM THE STANDPOINT OF CEREBRAL AND SPINAL LOCALIZATION,
AND THE LATER METHODS EMPLOYED IN THE DIAGNOSIS
AND TREATMENT OF THESE AFFECTIONS.

BY

AMBROSE L. RANNEY, A.M., M_D.,

Professor of the Anatomy and Physiology of the Nervous System in the New York Post-Graduate
Medical School and Hospital; Professor of Nervous and Mental Diseases in the Medical
Department of the University of Vermont ; Late Adjunct-Professor of Anatomy in the
Medical Department of the University of the City of New York; Member
of the Neurological Society of New York; Resident Fellow of the
New York Academy of Medicine; Member of the New
York County Medical Society; Author of «The
Applied Anatomy of the Nervous System,”

** Practical Medical Anatomy,”

«*Electricity in Med:
icine,”’ etc.

PROFUSELY ILLUSTRATED WITH ORIGINAL DIAGRAMS AND SKETCHES IN COLOR BY THE
AUTHOR; CAREFULLY SELECTED WOOD-CUTS, AND REPRODUCED
PHOTOGRAPHS OF TYPICAL CASES,

 

PHILADELPHIA:
F. A. DAVIS, PUBLISHER,
1888,
4b Qinrser, Luke,
Ne & 14

a PN,

~~

 

es

 

Entered according to Act of Congress, in the year 1888, by
F. A, DAVIS,

In the Office of the Librarian of Congress at Washington.
All rights reserved.

as
34 /

~ i ed

Stor oe

The Medical Bulletia Printing House,
No. 1231 Filbert Street,
Philadelphia.
I DEDICATE THIS VOLUME

TO MY FRIEND,

ERRATA.
Page ls. Fig. 6. Text. For shaded portions read gray and red masses.
Page 156, 25th line. For musculo-spinal, read museculo-spire’.
Page 166. 26th line. For hyprocephalus, read hydrocephalus,
Page 248. No. (5) occurs twice in the diagram. The lower (5) should be (6).
Page 350. Under the * FUNCTIONAL DISeAshs OF THE Corp,” read Thomsen's
Disease for Thomson's Disease.

B02 UA YU ee ee

“CAUSATION AND CURE OF FUNCTIONAL
NERVOUS DISEASES.
1 DEDICATE THIS VOLUME
TO MY FRIEND,
GEORGE TT. STEVENS, M:D., Pu.D.,
AS A TRIBUTE TO
HIS PERSONAL INTEGRITY AND GENERAL sce,

AND, ABOVE ALL, TO

HIS ORIGINAL INVESTIGATIONS RESPECTING THE
CAUSATION AND CURE OF FUNCTIONAL
NERVOUS DISEASES.
PEP Co.

WaHatever of merit or demerit this course of lectures
may possess in the opinion of its readers or erities, it must be
conceded that it differs radically in arrangement and plan
from others published upon this department of medicine.

The first section treats of those facts (anatomical, physio-
logical, aud pathological) upon which the science of cerebral
and spinal localization of to-day is, of necessity, based.

The second section discusses more completely than most
works in this field the various steps which should be taken
by an aspirant in neurology during the clinical examination
of a patient; and the deductions which may be drawn from
the faets thus elicited. In many instances, authors have
given avery incomplete résumé of this field or have omitted
it entirely.

The third and fourth sections treat of individual diseases
of the brain aud spinal cord. Each is discussed from the
clinical standpoint indicated in the first section, viz., the
localization of. the lesions described, as well as the recognition
of the type which is encountered.

The section which treats of “functional” nervous diseases
will, I trust, receive the careful attention it deserves. It
comprises a full résumé of the researches of Dr. George T.
Stevens respecting the bearings of ‘“eye-defect” and “ eye-

(v)
vi PREFACE.

strain” upon the causation and cure of these imperfectly
understood conditions. My own observations in this field
have been quite extensive. They lead me to fully indorse
all that has been claimed by this author. I can bear strong
testimony to the value of the new methods of examination
and treatment suggested by him for these distressing and
obstinate maladies. Like other delicate procedures, they can
only be intrusted to skillful hands, well versed in their
intricacies and careful in respect to minute details. No
other treatment has ever yielded me such satisfactory results
in severe forms of epilepsy, hysteria, chorea, neuralgia,
headache, insanity, and functional visceral derangements.
As no drugs were employed by me in many of these cases,
the relief obtained must be attributed solely to the method
of treatment referred to.

The final section treats of electricity,—an agent which
is to-day invaluable in neuro-therapeutics, but which is
seldom if ever discussed in neurological manuals. To this
subject the author has given much attention for some
years past.

A glossary of neurological terms has been added, in
order that the reader may not grope in the dark when
uncertain respecting the meaning of a word which is new
to him.

Much time has been devoted to the condensation of the
matter presented within reasonable limits. To deal with
an extremely difficult and somewhat new field in medicine
in such a way as to bring it within the grasp of those who

have devoted little or uo attention to it, and at the same
PREFACE. vii

time to avoid, from those more familiar with the field, the
eriticism of superficiality, has been no casy task. The
author does not expect that his attempt will prove acceptable
to all. An experience of fourteen years, however, in teaching
medicine has governed the author in the presentation of
this field as he deems most wise.

‘To those who have attended the author’s lectures, deliv-
ered from year to year before his classes (either in the
Medical Department of the University of the City of New
York, the New York Post-Graduate Medical School and
Hospital, or the Medical Department of the University of
Vermont), much of the matter here contained will certainly
be familiar, and he trusts acceptable.

The labor of preparing this volume from scattered
lecture-notes has been greater than might appear on a cursory
examination. Many of the illustrations are from the author’s
pencil, while others are from original photographs of his
eases. Most of the colored diagrams incorporated are
similar to those drawn by him upon the blackboard before
his classes. Colors are of great service in making a diagram
clear and easy of comprehension. ‘To the author’s mind,
diagrams in this special field of medicine are of greater
utility to the busy practitioner than microscopic sections,
because very intricate mechanisms are discussed and inter-
preted which cannot always be shown.

‘Portions of this work embody extracts from two chapters
upon Diseases of the Brain and Spinal Cord in the third
edition of the author’s treatise on “Surgical Diagnosis.”

Some other portions have appeared in print from time to
Vili PREFACE.

time, in the following journals: New York Medical Journal,
Medical Record, Archives of Medicine, Journal of Nervous and
Mental Diseases, Medical News, Harper’s Monthly, Medical
Bulletin, and Medical Register.

In elosing, the author would acknowledge his great
indebtedness to the original investigations of those who
by their researches have been the source of much valuable
information incorporated by him in this work. This ac-
knowledgment must act as a poor substitute for frequent
reference-notes, which are precluded on account of a want
of space. A bibliography of some of the more important
works and monographs on this field to which the author is
indebted is, however, appended for the benefit of the reader.
Special care has been exercised in selecting these, as far
as possible, from sources which are easily accessible to
American readers.

AMBROSE L. RANNEY, A.M., M.D.

156 Mapison AVENUE,
New Yor City, May, 1888.
TABLE OF CONTENTS.

SECTION I.
ANATOMICAL, PHYSIOLOGICAL, AND PATHOLOGICAL DEDUC-
TIONS RESPECTING THE NERVE-CENTRES OF MAN, . 2 1

SECTION IT.

THE CLINICAL EXAMINATION OF PATIENTS AFFLICTED WITH
NERVOUS DISEASES, AND THE STEPS EMPLOYED AS
AIDS IN DIAGNOSIS, é : , é : i . 107

SECTION IIL.
DISEASES OF THE BRAIN AND ITS ENVELOPES, . ; e 21F

SECTION IV.

DISEASES OF THE SPINAL CORD AND ITS ENVELOPES, . . 347
SECTION V.

FUNCTIONAL NERVOUS DISEASES, , : é : ‘ . 449
SECTION VI.

TOXIC AND UNCLASSIFIED NERVOUS DISEASES, : . ood

SECTION VII.

ELECTRICITY IN MEDICINE, . . ; ‘ i s . 605
GLOSSARY OF NEUROLOGICAL TERMS, . 5 i . . 745
BIBLIOGRAPHY, . ‘ ‘ ; ; 1 ‘ . . 7538
INDEX, . : ‘ 5 ‘ 2 Y 3 ‘ : . 163

(ix)
LIST OF ILLUSTRATIONS.

SOURCE OF ILLUSTRATIONS, PAGE

I pouiiey ‘am of Component parts of Brain,

2—- * Cortical Cell.

8. — a “ Cortical Centres, r

co “Cerebral Convolutions, . é wz
a oY * Cortical Areas,

6.— ob * Cerebral Fibres,

iL cd ss om + 5

8.— as “ Centres of Thalamus,

9.—Section of Cerebral Hemispheres,
w- « « “ “
11.—Diagram of the Crura Cerebri,
12.— He “ Fibre-Tracts of Brain and Gora:
13.—Section through the Pons, .
14,—Diagram of the Fibre-Tracts of Cer aniline,

15.— ne ee i “ Medulla,

16.— oe ue Nuclei of the Medulla,

17.— ne ae Fibre-Tracts of the Spinal Cord,
18,— fe se Pyramidal Fibres of Medulla,
19.— a ah Nerve-Tracts of Spinal Cord,
20.— oe ep Motor Centres of Cerebrum,

2h.— + ae Optic Fibres, .

on “ 4“ 4G a

“ “i “ “ce

24— ee ue Cerebral Mechanism of Speech,

‘© of Motor and Sensory Cerebral Tracts,
—Base of Cerebrum (partial), zi ‘ “ é %
27.—Diagram of a Cross-Section of the Medulla, .
28.—Base of Skull and Cranial Nerves,

29.—A Diagram of Fibre-Tracts of Spinal eu d,

30,—A Spinal Segment,

31.—Diagram of Relations of Spinal Segments to Ver ae e,

 

  

32.— aR “ Fibre-Tracts of Spinal Cord, i

33— st “ Spinal Gray Substance,

34.— ee * a Reflex Arc;

35,.— ne “ Cerebro-Spinal ‘Ae nitartaiee.

36.—Scheme of Cerebro-Spinal Nerve-Tracts,

37.— te “ “

38.—Diagram of Refractive Errors of Eye,

39.— ef “ Ciliary Action, S cat ©

40.—The Ophthalmoscope, . a a i ,
—Sketch of Facial Paralysis, ; ‘ é “ ‘

42,—Syphilitic Teeth, . . ; a C , : "
43.—The Claw-hand, . é s 2 é z : ‘ é
44.—Ulnar Paralysi fs ;
46.—Median Paralysis (two es . si .
46.—Musculo- Spiral Paralysis, :
47.—Athetosis, : z

 

48.—Paralysis ‘Agitans, ‘ . %
49.—Pseudo-hy per tenphie Paralysis, i é : ‘
50,.— te Fi : 7 . . é

Original.
Modified fram Luys.
eb “Ferrier,
we Datton.
Original.
“

“
Modified from Lays.

ce “ Flechsig.
Schucfer.

“ “

Original.

“

Modified from Erb.

Original

Medved es om Erb.
“ “

Original,

ed ified from Ierb.
“ Flechsig.
Original.

“

Modified from Seguin.

Original,

Modified from Spitzku,

Original ©

Morlified from Branwcll,

Original,

LOE ou Gowers.
Bramwell,

“ eh Er vb.

th “Bramwell.

ss Ter Mer,
Aeby.

“

Original
Modified from Fick.
Loring.
Original,

Hutchinson.

Original,

Modified from Bramwell,
Original,

+

Modified from Hammond.

me “Charcot,
pe “Duchenne,
es “Gowers.

eX)

5

97
102
103
125
127
14)
lal
154
156
157
Jas
15!)
161
168
164
167
LIST OF ILLUSTRATIONS.

73.—Miliary .Ancurism of the Cerebr: a Gor igs:
TA, —Diagram of Cerebral Sinuses in Profile,

73.— Hs ** the Venous Sinuses of the PueacMates at
76.— a an Embolic Infarction, .

TT a “ the Mechanism of the Speech Koaaraties

73.— ee “a Transverse Vertical Section of the Left

Cerebral Hemisphere, showing the Arterial
Distribution, . “+ 3

719: —Diagram of the Effects of c ‘ortical and X Von- Cortical
Lesions of the Cerebrum,

80.—Diagram of the Motor Tracts and the Etfects as
Lesions of the Crus Cerebri, Pons Varolii, and,
Medulla Oblongata upon Motility,

81.—Diagram of the Sensory Tracts and the Effects ae
Lesions involving the same within the Crus
Cerebri and the Medulla Oblongata,

82. ~Diagram of a Horizontal Section through the C erebral
TIemispheres and the Basal Ganglia, .

83.—One of the Attitudes of a Hand caused by Post-
Hemiplegic Contracture, ; 7 : : -

84.—Chronie Hydrocephalus, —. & s " % . -

85,—Softened Brain-Tissne, . i e ie

86.—The Fundus of the Normal Eye,

87.—The Appearance of the Fundus wt the pe in,

 

 

“Choked Disk,” 2 5 : . =
§8.—Cerebral Sclerosis, : ‘ ‘ 2 g 3 a o
89,—Cerebral Glioma, . a * 4 2 “ ‘ . ig
90.—Syphilis of the Brain, . ¥ 3

91,—Diagram of Nerve-Fibre Trac te in the Spinal € aid;

92,— “ the Secondary Effects of a Lesion of the
Entire Spinal Cord, :

93. —Diagram to show Distribution of Gusseatl Py aii
Fibres to Spinal Seyments,

94.—Diagram of the Secondary Sclerosis following a Lesiiine
of the Left Cerebral Hemisphere, . é -

95.—Diagram of Multiple Spinal Sclerosis,

96.—Case of Poliomyelitis Anterior, followed by TRtanesre
Atrophy of Right Side.

97.—Case of ** Wing-Scapula,” from Atrophy cue SRE

98.—Protile View of same case, showing Atrophy of Deltoid,

Van Schaick.
Original,

te
Modified from Weber.
Original.

Modifie@ rom Westbrook.

Original.

wWodificd from Starr.

Original,

a

Modified from Fox.
Loss.

“

. Modified from Far.

“ es te
“ wok
Be S Flechsig.
Erb,

Original.

Erb.

cr

Original,
“

be

SOURCE OF ILLUSTRATIONS, PAGE

- 51.—Pseudo- enypertrophie Paralysis, S ch w «gee Maiaes tr oe Gers: 167
a— eR Be ae 167
a3) il <3 ue oe ¥ ae ee “ee 167
54.—Attitude te om Atrophy of ‘sade Migselei, ‘ - _ & Duchenne. 168
55, ee “ Abdominal Muscles, th . _ 169
56. a casechaanes ; & ¥ & & & Fs Instrument-maker. 177
57.—Dynamograph, : “ = 178
58.—Curves of Polar Muscular Gantenction (three aivts), Erb. 188
59.—Author’s Spring Electrode, Original. 191
6O— “ Tinganshic Key-board, a a Hs 192
6— * i (inaction), . 2. . te 198
62,.—Electrode, Erb. 198
63.—Diesmeter, ‘ : 5 ‘ ‘ : . A di « Beard. 199
64.—yEsthesiometer, Hammond. 200
65,.— ee Carroll. 201
66,— nr . Ntevcking. 201
67.—Diagram of Effects ofa an Unilateral Aptnal fede, . Modified from Erb, 205
65.— uo “ Relations of Certain Cranial Nerves, Original au
ith ss te fs * Optic Nerves, Modified from Seguin, 209
70.—Surface Thermometer, Seguin, 210
71.—Ditferential Thermo-Electric Calorimeter, instrument-maker. 211
72.—Duchenne’s Trochar, “ 212

 

219

2a
313
318
822
Boe
332
339
340
351
Fic,

“

a

LIST OF ILLUSTRATIONS.

SOURCE OF ILLUSTRATIONS,

99.—Poliomyelitis Anterior Acuta, ‘
100.—F ull View of same case, showing the Atri sake of Faia,
101 and 102.—A Case of Infantile Paralysis, with Involve-
ment of the Medullary Nuclei,
1038.—Hand in Amyotrephic Lateral Sclerosis,
104.—Fibres from the Diaphragm in Tlealth,

_ 105.—Same taken from a Case of Progressive Musentte

a\trophy affecting the Diaphragm,
106.—Two Views of the Hand of a Patient suffering fron
Progressive Muscular Atrophy, 3
107.—Progressive Muscular Atrophy of all the Tanhe. ‘
108.—Expression due to Implication of the Nuclei of the
Medulla governing the Mouth, —e and

Throat,
109.—Profile of Patient ainiilanty: affected,
110.—Hemiatrophy of the Face, ‘ s c
liL— BS “ Tongue and Palate,

112.—Side View of Pseudo-Hyper o opine Par. alysis, a &
113.—Rear “ a
1l4.—A Diagram of the Lesion of the Sensitive Tracts i in an
Unilateral Lesion of the Right Side,
115.—A Transverse Section of the Spinal Cord of an Agate
Patient,
116.—A Diagram of the Pathological Lesion of ne Cord
observed in Locomotor Ataxia, . % i 4
117.—Extensive Joiht-Changes in Locomotor Ataxia, . .
118 and 119.—‘‘ Charcot’s Disease” of Left Knee-Joiut fol-
lowing Locomotor Ataxia, . s
Cavities within the Substance of the pina tara,
constituting the condition known as ‘Syringo-
myelia,” . . . < is . . 3
121.—Hystero-Epilepsy, . . . . . . és

120.—

 

12 Another Attitude of same case, * = 2 ei 5
123.—Third Ke ne a oe s) é a % a
124.—Convulsion of Hystero-Epilepsy, . 2 2 S

 

125.—Case of Catalepsy, &
126.—A Cataleptic Patient, eanner ted by Titi andl Feet,
127,—A Marked Paroxysm of Tetanus, . ‘ ie ‘ e
128.—Paralysis Agitans, or Shaking Palsy,
129.—Morbid Appearances presented in Hereditary Ataxia
130.—Photograph of Case of Ataxia, 3 7 é
131,—Second Photograph of Case of Ataxia, . ‘“ a ‘
132:—Section of Dorsal Region of epinal Cord op te fs
BB | wo “ “ : €
134.—One of the Many Forms of Faradaic Machines, a Ss
135.—Diagram of the Construction and Action of a Fara-

daic Machine, . . s % * =
136.—A Static Machine in Use, . A é x 3
137.—A Simple Galvanic Element, . ‘a s ‘ “ e
138.—A Compound Chain, . < ‘ .

139.—A Schematic Representation of the Intr duc tion of a
Human Body into the Circuit of Closure of a
Galvanic Chain, ‘ Si th val +G> “<
140,—Six Cells Connected for Latenaty, S = 2 &
141.— “ He me & Quality, .* 5 3 fs
142.—Smee's Cell, . 5 n 5 ‘ 7 * ‘ a é
143.—Leclanche’s Cell, . . a . s . . ’
144.—Grenet’s Cell, . o . - = q ‘
145.—Fuller’s Cell,. j . - 3 .
146.—Siemens and Halske’s Cell, A A 3 < A é
147.,—Hill’s Gravity Cell, . ‘ ni % as a é
148.—Grove’s Cell, . m . c #£ « . oe @

Original.

“

“

Chareot.
ue

Original,
Fricdreich,

Hanrmone,
a
Original.
‘“

Duchenne,

“
Erb,
Van Schaick,

Erb.
Charcot.

Original,

Original.
va

Bell,
Charcot.
Privdreich,
Smith,

“

“e

Instrument-maker.

Original.
Instrument-maker.
firb,

“a

“

De Watteville,

“

Instrwment-maker.

ae
Bo

Sil

611
612
614
619

620
621
21
625
624
624
625

625

626
X1V

LIST OF ILLUSTRATIONS.

SOURCE OF ILLUSTRATIONS. PAGE

 

Fig. 149.—Bunsen’s Cell, . 2. 2...) Instrument-maker. 627
“* 150.—A Galvanometer Dial, De Watteville. 628
“ 151.—A Diagram of the Method of Tangent Cotilinaiiiers, Original. 629
““ 152.—A Horizontal Milliampére-meter, .  .  .  . » Instrument-maker, 629
“  153,—"* Dead-beat”’ Milliampére-meter, .  . 2 we 2 se 630
“ 154.—A Fluid Rheostat, se » & e “ “ 631
*  155.—Rosebrugh's Fluid Rheostat, z 3 ei é Canada Pract. 632
“ 156.—Thermo-Electric Differential Calorimeter, Instrument-maker. 633
“ 157.—A New Form of Current Selector, “ “ 634
“ 158.—A Skeleton Drawing of the Pin eee of "Portable

Galvanic Battery, .  . . oe 8 « eh ee 635
“ 159.—Various Forms of Electrodes, .  .  .  ..s Erb. 637
“ 160.— se te ** Special Electrodes, Instrument-maker. 638
“ 161.—The Physician’s Handy Cabinet Battery, 5 » Original, 640
‘““ 162.—The Perfected Office Cabinet Battery, . .  . . AInstrument-maker. 642
“ 163.— " WallCabinet, .. » 4 4 Original. 6H
“ 164.—Hawksbee's Original Electrical Machine, Nollet. 647
“ 165.—Ramsden’s Electrical Machine, Appleton & Co. 648
“ 166.—Nairne’s bs as e @ % - Re 649
“* 167.—Nicholson’s “‘ Electric Doubler,” . A ‘ New Royal Encyclop. of
Arts and Sei. 650
“ 168.—Same machine, New Royal Encyclop. of
Arts und Sei. 650
“ 169.—An Apparatus for Generating Frictional Electricity
by Steam, % ‘ » Armstrong. 651
“ 170.—Old Model of Gpindeicdi Static Mativiae: és New Royul Encyclop, of
: Arts and Sci. 651
“ 171,—Holtz’s Induction Machine, . ® “ . . Appleton & Co. 632
“ 172.—Stationary Plate of the Original eralie 5 ee ee 653
“ 173.—Holtz’s Static Induction Machine, . z ee a 654
“ 174.—Imnproved Holtz Induction Machine, Original. 657
“ 175.—Electrodes Employed with an Induction } Ach ie dnstrument-maker, 662
“ 176.—The Indirect Spark, . é 5 4 s * < . Original. 666
“* 177,—The Direct Spark, eo. z . a - = CGS
“ 178.—Shock with Leyden-Jar Tisehared ‘ te 669
“* 179.—An Application of the Leyden-Jar Shock duri a the :
Highteenth Century, « . « + New Royal Encyclop. of
Arts and Sci. 669
** 180.—Static Insulation, 4 é - 8 is ; ‘i . Original. 670
“ 181,—The Indirect Static erect i ‘ a i @ re 671
“  182.—The Direct te Se 8 Se ee ee 671
“ 183.—The Electrical Head-Rath, z ‘ = “ é oR 672
“ 184.—The Static Induced Current, . 3 e é ' 673
** 185.—Morton’s Pistol- Electrode, : a é % Instrument-maker, 674
“  186.—Electrode for Electrolysis, a . . ‘ ‘ ce ee 694
“ 187.—An Electrode for Electrolysis, . ‘ 3 % a : as, ey 694
“* 188.—Piffard’s Cautery Battery,.  . iby, “ ™ 698
* 189.—Schemutie Representation of the Distribution of an
Electric Current applied eli to the
Head, . Erb. 714
* 190.—Schematic Repr aseniakiea: of the Caine se of Rieeric
Currents sent Transversely through the Head, * 714
* 191.—Schematic Representation of the Tistribution and
Density of Threads of Mlectric Currents during.
Applications to the Spinal Cord, 2 * ae 716

192. —Schematic Representation of the Density of the Cum
rent upon Application of the Electrodes to the

same Surface and in Close Relation to Each

Other, is ‘i i . “ : % . i
SEOlION 4

ANATOMICAL, PHYSIOLOGICAL, AND PATHOLOGI-
CAL DEDUCTIONS RESPECTING THE
CEREBRO-SPINAL AXIS
OF MAN.
SECTION I.

ANATOMICAL, PHYSIOLOGICAL, AND PATHOLOGICAL DEDUCTIONS
RESPECTING THE CEREBRO-SPINAL AXIS OF MAN.*

Some thirty-six years ago, by a premature explosion of gunpowder,
an iron bar three and a half feet long, one and a quarter inches in diameter,
and weighing thirteen and a quarter pounds, was shot completely through
a man’s head and perforated his brain. This man walked up a flight
of stairs after the accident, and gave his account of how it happened.
Although his life was naturally despaired of for some time, he developed
no paralysis, nor did marked impairment of his intellectual faculties
follow convalescence. Eventually he recovered his health. Twelve years
elapsed before his death; during which time he worked as a laborer on
a farm.

The “ American crowbar case” at once became famous, It startled
the minds of the reading public, and confounded the medical fraternity.
No satisfactory explanation of the remarkable features of the case could
be given. Some prominent medical men pronounced it ““an American
invention,” and laughed at the possibility of such an occurrence. The
skull was exhumed, however, after death, and is to-day in the medical
museum of Harvard University.

This case may be said to have been the starting-point of a new epoch
in medical science. It rendered untenable all previous hypotheses that
had been advanced regarding the organ of the mind. It proved con-
clusively that little, if anything, was known at that time respecting the
architecture of the brain of man, and the functions of its component
parts. F

Since then, a large number of observers have published the results
of various forms of experiments upon animals, made with a view of deter-
mining the physiology of the brain; but for some years the conclusions
drawn from such investigations were contradictory, and nothing was
definitely established.

We now are aware that serious defects existed in the early methods
of research. By great ingenuity these have been gradually eliminated.
We owe, however, to the discoveries of Turck, Fritsch and Hitzig,
Waller, Flechsig, and Gudden, most of our knowledge of new methods

*The first ten pages of this chapter are quoted (with many important modifications
and additions) from an article contributed by the author to Harper’s Monthly, March,

1885.
1
2 LECTURES ON NERVOUS DISEASES.

of research which have simplified the study of the nervous system during
life and after death. These methods of investigations have settled many
points in dispute. They have also made our knowledge more accurate,
and in accord with clinical observations.

The last decade has enabled us to bring many of the results obtained
by vivisection into perfect harmony with pathological data. Those who
have claimed that conclusions drawn from experiments upon animals are
not applicable to man are, to-day, confronted with certain unanswerable
facts to the contrary. Nature, through the agency of disease processes,
is constantly performing experiments upon human brains; and the symp-
toms so produced may be recorded during life, and compared with the
changes found in the brain after death. Physiology and pathology have
thus proven valuable lines of research in this field *

To-day, the “crowbar case” is no longer a mystery to specialists
in neurology. Bullets have been shot through the brain since then
without loss of motion, sensation, or intellect; and, in some cases, they
have been known to remain buried in the brain substance for months
without apparent ill effects. Five years ago a breech-pin of a gun, four
and three-quarter inches long, was forced into the brain of a boy nine-
teen years old, through the orbit, and its presence was not suspected
for some five months. It was discovered during a surgical attempt to
repair the facial deformity that resulted from the accident. Death fol-
lowed the removal of the foreign body from the brain in consequence of
inflammation created by the piece of iron, or possibly by its extraction.
This case is quite as remarkable as the crowbar case, but it excited less
interest in neurological circles because we are in possession of new facts.

We know, to-day, that if even a needle be thrust into one region of
the brain (the medulla oblongata, Fig. 1), immediate death may follow;
while a crowbar may traverse another portion of the organ, and recovery
be possible. The effects of injury to the brain depend rather upon its
situation than its severity.

In the light of our present knowledge the brain must be regarded
as a composite organ; whose parts have each some special function, and
are, to a certain extent, independent of each other.

* There are at the present time three distinct schools among the experimental phy-
siologists respecting the subject of cerebral localization. Ferrier and Munk represent a
faction which strenuously hold the view that the cortical gray substance can be mapped
out into areas whose limits, as well as their individual functions, are clearly defined.
Goltz stands at the head of a school which denies the accuracy of these views, and supports
the conclusion, originally advanced by Flourens, that the brain can only act as a whole.
Exner and Luciani (in common with their followers) occupy a ground which opposes very
sharply-defined boundaries to cortical areas, functionally associated with the various senses,
They believe that these areas overlap each other to a greater or less extent. At present,
the latter view seems to be most perfectly in accord with clinical and pathological data.
THE CEREBRO-SPINAL AXIS OF MAN» a.

One limited part is essential to vital processes; hence its destruction
causes death. Another part presides over the various movements of the
body ; hence paralysis of motion is the result of destruction of any
portion of this area. A third part enables us to appreciate touch, tem-
perature, and pain; and some disturbance of these functions will be
apparent when this region is injured or diseased. A fourth region pre-
sides over sight ; disturbances of vision may follow disease or destruction
of this area, in spite of the fact that the eyes escape. In the same way,
smell and hearing are governed by distinct portions of the brain, and also
the sense of taste. When a combined action of different parts is demanded
—as in the exercise of the reason, judgment, will, self-control, ete.—the
knowledge gained by means of the special senses can be contrasted and
become food for thought.

The skilled neurologist can determine to-day, in many cases, by the
symptoms exhibited during life, the situation'and extent of disease pro-
cesses that are interfering with the action of certain parts of the brain.
So positive is the information thus afforded, in some cases, that surgical
operations are now performed for the relief of the organ. A patient
who had lost the power of speech from an accumulation of pus within
the brain, was lately cured by the removal of a button of bone from the
skull over the seat of the pus, and its prompt evacuation. Epileptics
who suffer in consequence of brain-irritation may sometimes be cured of
their fits by the mechanical removal of the cause. Paralysis can occn-
sionally be alleviated by a removal of blood or pus from the surface of the
brain through a hole in the skull. Only a few months ago a bullet, which
had been shot into the head during an attempt at suicide, was removed
from the skull, in one of our hospitals, by means of a counter-opening.
The labors of such men as Meynert, Nothnagel, Ferrier, Flechsig, Wer-
nicke, Munk, Luciani, Exner, Charcot, and others, have made neurology
a science that would exceed the comprehension of its founders. Our
ability to localize disease within the substance of the spinal cord is even
more positive than in the case of the brain.

When we consider that it is by means of our nervous system that we
move, feel, see, hear, smell, taste, talk, and swallow; that in our brains
are stored all the memories of past events; that we digest and assimilate
our food partly by the aid of nerves; and that, in fact, we perform every
act of animal life by the same agency,—the utility of the latest infor-
mation regarding the brain becomes apparent at once.

he nerves are but telegraphic wires that put the brain and spinal
cord in direct communication with the muscles, the skin, and the various
organs and tissues of the body.

The nervous centres may therefore be compared to the main offices
of a telegraphic system, where messages are being constantly received
4 LECTURES ON NERVOUS DISEASES,

and dispatched. Every message sent out is more or less directly the
result of some message received. So it is with our nerve centres. We
are constantly in receipt of impressions of sight, smell, taste, hearing,
touch, and other conscious sensations. These are called afferent im-
pulses. As the result of the information so gained, we are constantly
sending out efferent or motor impulses to the muscles. These create
movements of different parts of the body. Respecting this view, Michael
Foster expresses himself as follows: “ All day long, and every day, mul-
titudinous afferent impulses, from eye, and ear, and skin, and muscle,
and other tissues and organs, are streaming into our nervous system ;
and did each afferent impulse issue as its correlative motor impulse,
our life would be a prolonged convulsion. As it is, by the checks
and counter-checks of cerebral and spinal activities, all these impulses
are drilled and marshaled and kept in hand in orderly array till a move-
ment is called for; and thus we are able to execute at will the most com-
plex bodily manceuvres, knowing only why, and unconscious or but dimly
conscious how, we carry them out.”

Sometimes, however, the motor impulses sent out by the brain in
response to sensory impressions take place in spite of our volition. Let
us cite an instance in the way of illustration: a timid person sees per-
chance some accident in which human life is possibly sacrificed, or the
sensibilities are otherwise shocked. His feelings overcome him, and he
faints. How are we to explain it? Let us see what takes place. The
impression upon the brain made by the organ of sight creates (through
the agency of special centres in the organ of the mind) an influence upon
the heart and (by means of vaso-motor nerve filaments) upon the blood-
vessels of the brain. This results in a decrease in the amount of blood
sent-to the brain, and causes a loss of consciousness. In the same way
persons become dizzy when looking at a water-fall, or from a height,
through the effects of the organs of sight upon the brain.

Again, if a frog be deprived of only the upper part of the cerebral
hemispheres, he is still capable of voluntary movement, breathing, swallow-
ing, croaking, and all the other manifestations of frog-life. But when we
observe such an animal with attention, we shall see that he is only a pure
automaton, and that he differs from the normal frog in his behavior when
left to himself and when disturbed. He will swim when placed in water,
but only until he reaches a spot where he can safely repose. Then he re-
lapses into quietude, evincing no desire to hop (as a normal frog would
do) or to escape from his tormentor. Everytime that his back is stroked
the frog will croak. The same irritation will produce the same result
over and over again. Such a frog, if placed upon a board which can be
tilted, will climb up the board (in case he perceives that his equilibrium
is endangered) in a direction necessary to render his position secure.
THE CEREBRO-SPINAL AXIS OF MAN.

Otherwise he remains motionless.

the normal attributes of that animal in health.
escape. He experiences no apparent alarm at surrounding objects.

movements can be predicted and repeated again and again at the will of
the experimenter. He has been transformed into a machine in which

every muscular movement can be traced directly to some stimulating
influence from without.*

 
  

   
     

WHITE SUBSTANCE
OF THE CERESRAL HEMISPHERE

(FORMER OF NERVE FIBRES)

Fic. 1.—A D1acramM DssIGNED BY THE AUTHOR TO ELUCIDATE THE CHIEF COMPONENT
Parts oF THE Human Brain.—The lettering upon the figure will be explained in the text.
-C. Q. the corpora quadrigemina. The lines within the white substance of the cerebrum or
in the ‘‘crus’’ are not intended to convey any impression to the reader of the actual arrange-
ment of the fibres; nor are the colors employed selected with special reference to the elucida-
tion of the functions of the component parts of the organ thus diagrammatically shown.

Before we go farther, let us examine in a cursory way the anatomi-
cal elements of which the brain is composed. These are practically the
same in all animals of the higher grades. We can then review the group-
ing of these elements, and study some of the structural details of that

organ in man. Many of these have baffled all attempts at investigation
until of late.

*The distinction between “ instinctive’? or automatic acts (which are governed by
the spinal and cerebral ganglia) and ‘‘ conscious volitional acts” (which are always of cor-
tical origin) is not properly recognized by some experimental physiologists. Dr. M. Allen
Starr has very happily shown in a late article on speech (Princeton Iteview) that this dis-

tinction helps materially to reconcile the antagonistic views now held by the opponents
and supporters of cerebral localization.

He is no longer a frog endowed with
He does not attempt to
His
6 LECTURES ON NERVOUS DISEASES.

We may start with the statement that the brain consists of two dis-
tinct anatomical elements,—brain cells and nerve fibres.

The number of brain cells in the cerebrum alone may be estimated
at many thousands. Hach cell, by means of its nerve fibres and the pro-
cesses that spring from it, may be considered as a central station of an
clectric system. It can receive messages from parts more or less distant.
It can dispatch messages in response to those received. Finally, it can
store up such information as may be carried to it from time to time for
future use, affording us, at the same time, memories of past events. It -
will simplify description if we consider each of the anatomical elements
of the brain separately.

THE BRAIN CELLS.

These are placed chiefly upon the exterior of the organ, which is
thrown into alternating ridges and depressions, somewhat like a fan when
half closed. The ridges are called the “ convolutions,” and the depres-
sions are termed “sulci;” or “ fissures,” in case they are deeper than the
rest. The gray matter upon the exterior of the brain is called the
“ cortex.”

_ The cerebral cortex is alone associated with consciousness and voli-
tion. Like gray matter found in other regions of the organ, the cortex
consists of brain cells and a cement (formed of connective-tissue elements)
that binds them together. This is called the “neuroglia.”

Masses of brain cells are found imbedded within the substance of
the organ; but their functions are less well determined than those of the
cortical gray matter. The corpus striatum* and the optic thalamus are
certainly the largest and perhaps the most important of these ganglionic
masses.

If we study the appearance of the brain cells under the micro-
scope, we find that different convolutions of the brain are peopled with
cells that have individual characteristics of form and construction;
hence we are justified (from an anatomical stand-point alone) in attrib-
uting different functions to individual areas of the cortex. This view is
sustained, furthermore, by physiological and pathological investigation.
We may consider each cell within the brain as possessing an individ-
uality. Each is intrusted with and controls some particular function.
Hach is in telegraphic communication with other cells, and participates
constantly in the growth and development of some special region of the
body, acting in harmony with its fellows. Luys, who has carefully in-
vestigated the structure of these minute bodies, says of them: “ Imagina-

*I apply the term “corpus striatum” throughout this work to its two halves (the

caudate and Icnticular nuclei, Fig. 6) collectively. Many of the German authorities em-
ploy it as synonymous with the caudate nucleus alone.
THE BRAIN CELLS. t

tion is confounded when we penetrate into this world of the infinitely
little, where we find the same infinite divisions of matter that so vividly
impress us in the study of the sidereal world; and when we thus behold
the mysterious details of the organization of an anatomical element, which
only reveal themselves when magnified seven hundred to eight hundred
diameters, and think that this same anatomical element repeats itself a
thousandfold throughout the whole thickness of the cerebral cortex, we
cannot help being seized with admiration, especially when we think that

 

Fic. 2.—Corticar Cait oF THE Deeper Zones AT ABOUT ErGHT HunDRED Diameters. (After .
Luys.) A section of the cell is made through its greater axis, its interior texture being thus
laid bare. A, represents the superior prolongation radiating from the mass of the nucleus

. itself. B, lateral and posterior prolongations. C, spongy areolar substance, into which the
structure of the cell itself is resolved. D, the nucleus itself, which seems only to be a thick-
ening of this areolar stroma; it sometimes has a radiated arrangement. E, the bright
nucleolus, which is itself decomposable into secondary filaments. The colors are only em-
ployed to aid in recognizing the various parts of the cell.

each of these little organs has its autonomy, its individuality, its minute
organic sensibility, that it is united with its fellows, that it participates
in the common life, and that, above all, it is a silent and indefatigable
worker, discreetly elaborating those nervous forces of the psychic
activity which are incessantly expended in all directions and in the most
8 LECTURES ON NERVOUS DISEASES.

varied manners, according to the different calls made upon it, and set it
vibrating.”

In the cortex of the brain we find the brain cells arranged in super-
imposed strata: The number of these strata varies in different areas of
the brain surface.

Each stratum is composed of cells that have identical shapes, and
whose structure is apparently the same. Delicate, hair-like processes
are given off from the body of each cell, many of which subdivide like
the branches of a tree, and become closely intermingled with those given
off from neighboring cells, Nome of these processes unquestionably
serve to connect the cells that compose the various strata of the cortex ;
others serve as a means of attachment of nerve fibres to the cells. By
means of these processes, molecular movements generated within any
individual cell can probably be transmitted to other cells in the same
stratum of the cortex, or to those composing other strata. Thus the
different layers of cells can probably act independently, or in conjunction
with others.

We may generalize respecting the purposes for which these minute
bodies have been constructed, as follows :—

1. Some cells are unquestionably capable of generating nerve force;
just as the electric battery, for example, generates electricity for the
purpose of telegraphy.

2. Some are designed to promote muscular contraction, and thus
to cause voluntary movements. They are enabled to do this by the
nerve fibres. These conduct the current from the cells to detinite
muscles of the body. When, therefore, from any cause the generating
power of motor cells, or the conducting power of motor fibres is inter-
fered with, we have a symptom produced known as * motor paralysis.”

Tumors, or inflammatory deposits sometimes press upon the motor
cells to such an extent as to impair their function; intlammatory con-
ditions may affect them directly, and cause their disintegration; blood
may escape into the brain substance and plough up the delicate fibres
that convey the impulses to the muscles (the condition known as ‘“ apo-
plexy”); and many other pathological conditions may derange or de-
stroy this elaborate system of wires and batteries. Let me impress upon
the reader that paralysis of motion is not a disease, as most people sup-
pose. It is but one of the manifestations of disease.

3. Some cells of the cerebral cortex serve as receptacles for nerv-
ous impressions.* Let us cite some examples. At birth the brain may
be likened to the sensitized photoeraphie plite before it has been ex-

* Disturbances of the memory may often prove a valuable aid in localizing the seat
of a cerebral lesion, This fact has only been utilized of late; as new facts in cerebral phy-
siology have been brought to light.
THE BRAIN CELLS. 9

posed to the action of the lenses of the camera. Nothing has yet
been recorded upon it. It may subsequently be beautified or disfigured
by the impressions that are to be made upon it from without. At first
the child stares stupidly about, unable to appreciate or properly interpret
the pictures that are constantly being formed upon the retina by light.
Loud noises frighten it, and softer sounds fail to attract its attention.
It has not yet learned to determine the direction from which a sound
comes. The appreciation of distance has not yet been acquired. The
tiny hands are stretched ont alike at remote and near objects.

Now mark the change that occurs when suflicient time has elapsed
to allow the brain cells to accumulate memories of past events in num-
bers sufficient to admit of comparison with each other, and to form the
basis of judgment.* ‘The child soon begins to recognize familiar faces.
It learns to discriminate between the voice and touch of the mother
or nurse and that of a stranger. When only a few weeks old it begins
to estimate distance, and to make voluntary efforts to grasp surrounding
objects. Gradually its brain learns the meaning of articulate sounds. and
by associating such sounds with definite objects it acquires a knowledge
of language. The power of speech is developed later than the knowl-
edge of language, because the complicated movements of the tongue,
lips, and palate are difficult to perform properly, and also because articu-
lation must of necessity be based upon a memory of the various sounds
employed. Thus for many months the brain of a child is simply re-
ceiving and storing up in these wonderful receptacles, the brain cells,
the impressions of the external world, that reach it chiefly by mcans of
the organs of sight, smell, hearing, taste, and touch.

These facts become even more mysterious than they might at first
appear to the reader when we reflect that the eve, for example, telegraphs
the outline, coloring, and other details of every picture (focused by its
lenses upon the retina) to the cells in the cortex of the occipital lobes of
the cerebral hemispheres; and that these cells retain these impressions
in such a manner that they can be recalled by a voluntary effort again
and again as memories of what we have seen. The eve can thus go on
taking photographs of external objects forever without fear of losing
what it so elaborately duplicates. We have positive evidence to prove
the accuracy of these statements. If the occipital lobes of both hemis-
pheres be destroyed in animals, the sense of sight is lost immediately,
in spite of the fact that the eyes have not been injured by the operation.
I have had under my care several patients who have been rendered

* Clinical observation, as well as pathological statistics go to show that in right-
handed subjects the left cerebral hemisphere is more intimately connected with the storage
of memories than the right hemisphere. This is well illustrated in the reported cases of
ataxic aphasia, paraphasia, word-blindnees, and word-deafness.
10 LECTURES ON NERVOUS DISEASES.

totally blind in a lateral half of each cye by brain-disease ; the other
half retaining its normal power of vision. It is equally well proven that
the memories of our conscious perceptions of odors, sounds, taste, and
touch, are stored within the cells of ditferent areas of the cerebral cortex,
whose limits are already determined with approximate accuracy. These
memories, as we all know, can be recalled at will with unimpaired vivid
ness, just as picture after picture can le struck off the same negative
when once made indelible upon a vlass plate.

 
  

F0

907 qwiain00 3

=

Fic. 3.—Sipgz View oF THE Brain oF MAN SHOWING THE AREAS OF THE CEREBRAL CON-
votutions, (Modified slightly from Ferrier.) R, Fissure of Rolando, §, Fissure of Syl-
vius, divided into its two branches. 1 (on the postero-parietal [superior parietal] lobule).
Advance of the opposite hind-limb as in walking. 2, 3, 4 (around the upper extremity of the
fissure of Rolando). Complex movements of the opposite leg and arm and of the trunk, as in
swimming; @, 4, c, d@ (on the ascending parietal [posterior central] convolution), individual
and combined movements of the fingers and wrist of the opposite hand; prehensile move-
ments. 5 (at the posterior extremity or the superior frontal convolution). Extension for-
ward of the opposite arm and hand. 6 (on the upper part of the antero-parietal or ascend-
ing frontal {anterior central] convolution). Supination and flexion of the opposite forearm.
7 (onthe median portion of the same convolution) Retraction and elevation of the oppo-
site angle of the mouth by means of the zygomatic muscles. 8 (lower down on the same con-
volution). Elevation of the ala nasi and upper lip with depression of the lower lip on the
opposite side. 9, 10 (at the inferior extremity of the same.convolution, Broca's convolution).

pening of the mouth with 9, protrusion; and 10, retraction of the tongue,—region of aphasia,
bi-lateral action, 11 (between 10 and the inferior extremity of the ascending parietal convo-
lution). Retraction of the opposite angle of the mouth, the head turned slightly to one side.
12 (on the posterior portions of the superior and middle frontal convolutions). The eyes
open widely, the pupils dilate, and the head and eyes turned toward the opposite side. 13,13
(centres of vision in the occipital lobes). 14 (of the infra-marginal, or superior [first] tem-
poro-sphenoidal ee nee Pricking of the opposite ear, the head and eyes turned to the
opposite side, and the pupils dilate largely (centre of hearing). Ferrier, moreover, places
the centres of taste and smell (15) at the extremity of the temporo-sphenoidal lobe, and that
of touch in the gyrus uncinatus and hippocampus major.

Professor Ferrier, of London, has mapped out, by means of a series
of experiments upon the monkey tribe (the nearest approach to the type
of man),a chart of the brain which shows the situation of certain groups
THE CEREBRAL CORTEX. 11

of cells or “centres” in the cortex that preside over particular functions.
The cut introduced (Fig. 3), and its descriptive text, will make some of
the conclusions of this author intelligible to the reader.*

Most of the conclusions of this investigator (excepting those relating
to the visual centres, in which I think he is in error) have been partially
verified upon man. It may interest the reader to know how these con-
clusions have been verified, since vivisection upon the human race is, of
course, impossible.

In the first place, a careful study has been made of cases where
Nature has performed the experiment of destroying or imperfectly de-
veloping portions of the brain, and where an opportunity of examining
that organ after death has been afforded.t The clinical records of such
cases have been collected from all reliable sources, and critically ana-
lyzed by competent medical men (Charcot, Ferrier, Nothnagel, Wernicke,
Broadbent, Luys, Exner, Spitzka, Starr, Seguin, and many others).

Again, a large number of subjects who have suffered amputation of
limbs, and who have survived the operation for some years, or who haye
manifested arrested development of limb, have been made to bear indirect
testimony to the accuracy of the facts gained by vivisection and patho-
logical research. When any part of the body is deprived of exercise,
it will waste gradually from disuse. On this basis of reasoning, Bourdon
and others have sought to determine the centres of motion of the limbs,
by examining the cortex of the cerebral hemispheres of such subjects
after death, with a view of determining the existence and exact seat of
atrophy of definite groups of brain cells.

A third line of investigation, which has yielded brilliant results,
consists in tracing the origin, course. and ultimate distribution of sepa-
rate bundles of nerve fibres within the brain and spinal cord (Meynert,
Flechsig, Gudden, Wernicke, Spitzka, Aeby, Roller, Starr, and many
others). Some important discoveries have been made of late, which
enable us to do this with accuracy,—-a feat that was impossible by the
older methods employed. A knowledge of the peripheral connections
of certain groups of brain cells has shed much light upon their probable
functions.

Finally, much has been learned by a microscopical study of the dif-
ferent layers of the cortex and the nerve-nuclei with reference to the

*The view upheld by Ferrier and Munk that the cortical areas have distinct lines of
demarcation has been opposed by Luciani and Exner, who believe that the edges of these
areas merge gradually into each other, and manifest less prominently than do their cen-
tral portions the individual peculiarities of each. :

} The study of microcephalic specimens, which bears somewhat upon this field, bids
fair to become a very important line of investigation respecting the relations of certain
parts of the brain to definitely recognized bundles of fibres within the crus, pons, medulla,
and spinal cord. It is as yet in its infancy.
12 LECTURES ON NERVOUS DISEASES.

character of cells that compose them. It has been proven that the form
and arrangement of the brain cells afford some elue to the special fune-
tions over which each preside (Luys, Arndt, Betz, Stephany, Spitzka,
and others). Comparative anatomy has aided in this line of research,

Now, when we find that all of these methods lead us to an identical
conclusion concerning any point in cerebral physiology, that conclusion
becomes a fact beyond the possibility of dispute. Unfortunately for
science, much still remains to be determined regarding this mysterious
mechanism; but, on the other hand, much has been positively proven.
Perhaps the day may never come when the human mind can fathom all
of its mysteries.

SAR Er ay

 

Fic. 4.—A Diacrammatic Figure, SHOWING THE CEREBRAL CoNnvoLutions. (Modified

. from Dalton.) S, Fissure of Sylvius, with its two branches, a, and 4, 6, 6. Kk, Fissure
of Rolando. P, Parieto-occipital fissure. 1,1, 1, ‘he first, or superior frontal convolution.
2, 2,2, 2, The second, or middle frontal convolution. 3, 3, 3, The third frontal convolution,
curving around the ascending limb of the fissure of Sylvius (centre of speech movements).
4,4, 4, Ascending frontal (anterior central) convolution. 5,5, 5, Ascending parietal (posterior
central) convolution. 6, 6, 6, Supra-Sylvian convolution, which is continuous with 7, %. 7%
the first or superior temporal convolution. 8, 8, 8, The angular convolution (or gyrus), which
becomes continuous with 9, 9, 9, the middle temporal convolution. 10, The third, or inferior
temporal convolution, 11,11, The superior parietal convolution. 12. 12, 12, The superior,
middle, and inferior occipital convolutions, called also the first, second, and third (the centres
of vision). It is to be remembered that the term ‘“gyrus’’ is synonymous with ‘* convolu-
tion,” and that both terms are often interchanged.

Before we pass to the consideration of the second anatomical clement
of nervous tissues—the nerve fibres—let me call the attention of the reader
to the general form of the brain, and to a classification of the convolutions
THE CEREBRAL CORTEX. 13

that is now generally adopted. This will enable him to gain a clear in-
sight into the functions of different ureas of the cerebral cortex. Fig. 4
should be compared with Fig 5, as each will help to interpret the other.

The lobes of the cerebrum are named respectively the frontal, parie-
tal, occipital, and temporal, from the bones with which they lie in con-
tact. They are demarcated from each other hy fissures or clefts that are
clearly defined and more definitely placed than the sulci.

The fissures of Rolando and of Sylvius and the parieto-occipital
fissure are of special importance. (Fig. 4.)

The diagram shows that the frontal and. parietal lobes have four
convolutions cach, and the occipital and temporal lobes three each.

It must be remembered that the cerebrum has two hemispheres—a
right and a left—only one of which is seen in profile. The right hemis-
phere is associated chiefly with the left lateral half of the body, and the
left hemisphere with the right lateral half. Disease of one hemisphere
of the brain may produce, therefore, a disturbance of some or all of the
functions of the opposite side of the body below the head. There are ex-
ceptions to this rule, but it is a safe one to follow in the majority of cases.

Another diagram (Fig. 5) will be introduced later to show certain
areas of the surface of the brain that are believed, in the light of our
present knowledge, to preside over special functions, as, for example,
those of speech, muscular movements of the extremities, sight, hearing,
smell, and touch.

In summary, we are justified in drawing the following conclusions
respecting the cells of the cerebral cortex from the results obtained by
experimentation, clinical experience, and pathological data :—

1. The surface of the brain is the seat of all conscious mental
action. It is the receptacle of all impressions made upon the organs of
smell, sight, taste, hearing, and the tactile organs of the skin. Here,
and only here, do such impressions become transformed into a conscious
appreciation of external objects.

2. The mental powers are the result of different combinations of
memories of past events stored in the cells connected with the special
senses, and the activity of other groups of cells that are probably situ-
ated in the frontal lobes. Although the integrity of the entire organ
is necessary to the unimpeded action of the higher mental faculties
(such as judgment, will, self-control, reason, ete.), the cells of that por-
tion of the frontal lobes that lies in front of the motor centres are per-
haps more closely associated with these faculties than those of any other
area. (Fig. 5.)

3. The central convolutions* of the brain (a part of the frontal and

* Chiefly the precentral gyrus. The post-central gyrus appears to be associated with
both motion and sensation to a greater extent than the precentral.
14 LECTURES ON NERVOUS DISEASES.

parietal lobes of each hemisphere) preside over motion and the mewory
of all motor acts of the limbs and body. The upper part governs the
legs chiefly, the middle part controls the upper extremity, while the
lower part presides over the complex movements of the tongue and lips
necessary to specch. The memories of muscular acts are probably stored
within the cells of the motor area. It is also probable that some forms
of sensation are appreciated by the smaller cells of this area (Moeli,
Tripier, and others).

Mo 7 AREA

SYVLVIAN
FISSURE

 

Fic. 6—A DiaGram Desicnep By THE AUTHOR TO ILLUSTRATE THE PROBABLE FUNCTIONS
or DirreRENT AREAS OF THE CEREBRAL CORTEX.

The limits of these areas must not be interpreted too literally by
the reader as a basis for diagnosis, Each area probably merges almost
imperceptibly into those which lie adjacent to it. The central portion
of cach are more clearly related to special functions than the peripheral
portions.

The so-called “motor area” is probably connected not only with
voluntary muscular contractions, but also with the conscious apprecia-
tion of all sensory impressions connected with the muscles. It might,
therefore, be more properly designated as the “muscular area.”
THE CEREBRAL CORTEX. 15

4. The occipital lobes* preside over the sense of sight and the memo-
ries of sight-pictures (Munk, Wernicke, and others). The recognition
of familiar objects by the eyes depends on the activity of the cells in the
cortex of these lobes. Hallucinations of vision point strongly toward a
disturbance of the function of these cells. .An inability to recognize
familiar objects, such as faces, letters, words, etc., is one of the promi-
nent symptoms of disease of the occipital region, provided the eyes are
capable of performing their norma! functions. Colored perceptions of
objects and other ocular spectra often accompany irritation of these
lobes. If the whole of the occipital lobe be not destroyed, the unim-
paired part may slowly accumulate new sight memories, and the sense
of vision may thus be slowly regained. This has been proven upon the
dog by Munk.

5. That part of the parietal lobes which is not occupied by special
centres of motion is probably associated with the conscious perceptions
of various tactile impressions and the associated memories of touch,
temperature, degrees of pressure, and pain.

6. The temporal lobes are the probable seat of our conscious appre-
ciation of sounds, odors, and taste (Ferrier, Kussmaul, Gudden, and
others). When these lobes are diseased, the memory of spoken words
may be obliterated, and hallucinations of hearing or deafness may be de-
veloped. I once encountered an interesting case where hallucinations of
sinell (imaginary odors) existed in consequence of disease involving the
apex of this lobe. Persons who have heen suddenly deprived of their
ability te appreciate a question when spoken, but who would reply
promptly to the same question if written before their eyes, have been
reported. In such the memories of sound have been obliterated by dis-
ease of the temporal lobe, but the memories of the form and meaning
of letters have remained intact, because the occipital lobes were not
involved. These patients can sometimes be made to repeat mechanically
word upon word, in a parrot-like way, but the memory of their meaning
has gone forever.

1. The power of speech (when regarded as a merely mechanica: per-
formance) seems to be governed by the inferior frontal convolution and
the area adjacent to it around the lower part of the fissure of Sylvius,

* Ferrier origiually placed the visual centres in the angular convolution of the parietal
lobe (Fig. 4). Iam led to believe that this is an error. This seems to be proven by an
analysis of cases collected and published by Starr and Seguin. Wernicke has also lately
shown that the visual fibres pass beneath the cortex of the angular gyrus in order to reach
the occipital cortex. This discovery helps to explain the effects of destruction of the
angular gyrus upon sight, as observed by Ferrier, Dalton, and others. Sight was de-
stroyed by these observers, probably, by damage done to tracts of fibres lying beneath
the cortex, rather than by a destruction of the cortical cells alone.
16 LECTURES ON NERVOUS DISEASES,

(Fig. 24.)* Butit must be remembered that our remarks are usually
called forth by some form of excitation, such as a spoken question, an
impression upon the eye, or some form of irritation of the sensory
nerves, as in the case of pain, tickling, etc., for example. Disease of
this limited area of the brain surfice causes patients to frequently
interpolate wrong words in conversation, in spite of the fact that they
grasp the meaning of all that transpires about them, and have the
memories of past events perfectly at their command. Such a subject
could write a reply to any spoken or written question with perfect
accuracy, although he might speak it incorrectly. If he were asked
to repeat words selected as a test of codrdinated movements of the
tongue and lips, he would probably fail to do so with his accustomed
facility. This subject will be discussed in subsequent pages.

8. That we are endowed with memories of muscular movements is
well illustrated by a case observed by Professor Charcot, of a gentleman
who was rendéred incapable, by disease of his brain, of recognizing either
printed or written language, but who could grasp the meaning of both
with ease by tracing out the curves with his fingers. The habit of
writing had impressed the mind with the symbols of thought, through
the agency of the muscles.

9. Some collections of cells within the deeper parts of the brain
(the corpus striatum and optic thalamus of each cerebral hemisphere)
are probably distributing centres for all impulses that pass either to or
from the cerebral cortex.

They act as “‘middle-men,” as it were. They are capable, as illus-
trated in the case of the mutilated frog previously referred to, of an au-
tomatic control over movements; but, as far as we know, there is no
reason to think that they are associated in any way with the attribute of
consciousness.

10. The functions of the cerebellum, the pons Varolii, and the me-
dulla oblongata (see Fig. 1) are too complex to be fully discussed here.
Their cells are called into action in a reflex manner, rather than by voli-
tion. There is reason to believe that the cerebellum is an “informing
depot” for the cerebrum (Spitzka), and a ‘store-house for nerve force”
(Mitchell). The medulla oblongata presides over acts that are chietly
outside of the domain of the will; such as the beating of the heart, the
worm-like movement of the intestine, the regulation of the calibre of the

* Destruction of the centre of Broca and the island of Reil, seems to deprive the indi-
vidual of those memories which are associated with the proper cobrdination of the apparatus
of speech. Such patients cannot pronounce words which they may be able either to recog-
nize by sight or to understand perfectly when spoken. The substitution of wrong words
in conversation (paraphasia) is more commonly encountered than true ataxic aphasia
when the island of Reil is involved. This subject will be more fully discussed later,
THE NERVE FIBRES. 17

blood-vessels to the wants of the different organs, the modifications of
blood-pressure, and other functions that are essentially vital.

THE NERVE FIBRES.

We now come to the second anatomical element of nervous tissues.
If we pull a brain apart so as to expose its central portions, we shall be
able to see that distinct bundles of extremely delicate white threads com-
pose each “crus cerebri,” or the leg of the hemisphere (Fig. 1), and
that the thousand filaments which form each bundle diverge within the
hemisphere and pass to its surface. We have grounds for the belief that
each of these threads becomes united to a cell.

These are the nerve fibres. Each of these threads is insulated by
a protective covering so as to prevent the diffusion of its currents to
other fibres. The white substance of the brain is composed exclusively
of fibres.

Of those that constitute the central portion of the cerebrum, one set
serves to connect the cells of different areas of the cortex of each hemis-
phere (the “associating fibres”). These do not cross the mesial line of
the skull. ‘They allow of comparison of different memories, etc., and are
probably essential to the higher mental faculties. The areas of sight,
hearing, smell, motion, general sensibility, and taste, of each cerebral
hemisphere, are thus brought into communication with each other.
These fibres will be discussed at a greater length in connection with
aphasia.

A second set serves to join the cortical cells of homologous parts
of the two hemispheres of the cerebrum. They are evidently designed
to promote a simultaneous action of the two hemispheres upon corre-
sponding parts of the body, as illustrated in rowing a boat with two
hands, swimming, etc. These are called “ commissured fibres.” (Fig. 6.)

A third set comprises those fibres that pass from each hemisphere
into the spinal cord. These are known as the “ peduncular fibres,”
because they help to form the stem of the brain, or the crus cerebri (see
Figs. 1 and 6). :

A fourth set may be said to comprise those fibres that are associated
directly with the organs of special sense, the nose, eye, ear, tongue, and
skin. Some of these belong to the peduncular group.

Finally, a fifth set, known as the fornia, serves to connect the corti-
cal cells of the temporal lobe of each cerebral hemisphere with a mass of
cells buried deeply within the corresponding hemisphere, known as the
optic thalamus. The function of these peculiarly arranged fibres is not
yet determined with positiveness.

We have already discussed the réle which the nerve fibres play in
connection with the brain cells. They are the channels of transmission

9

al
18 LECTURES ON NERVOUS DISEASES.

of nerve impulses. Some carry impressions of a sensory character ;
hence their currents travel from peripheral parts to the cells of the brain.
Others convey motor impulses from the brain cells to the muscles.

 

 

 

eo
some 2

 

Fic, 6—A DIAGRAM DESIGNED BY THE AUTHOR TO SHOW THE GENRRAL ARRANGEMENT OF
Tur Fires OF THE CEREBRO-SpINAL System. (Modified from Landois.) The shaded
_portions represent the collections of gray matter. Qn the left side of the diagram, the sea-
sory fibres of the crus are traced upward from the spinal cord to different portions of the
cerebrum; onthe right side, the »zofor fibres are similarly represented. Numerals are used
in designating the sexsory and commissural fibres; the motor fibres are lettered in small
type. The cortical layer is shown at the periphery of the cerebral section, with commis-
sural fibres (1) connecting homologous regions of the hemispheres, and associating fibres
(a.s.) connecting different convolutions of each hemisphere. c¢.#., Caudate nucleus of the
THE NERVE FIBRES. 19

corrus sreratum; L.N., lenticular nucleus of the same; O, T., OPTIC THALAMUS of
each hemisphere, united to its fellow in the median line; ¢. g., CORPORA QUADRIGEMINA }
c, 2., CLAUSTRUM, lying to the right of the letters; c.¢., CORPUS CALLOSUM, with its commis-
sural fibres; S, FISSURE OF SyLviuS; /’, LATERAL VENTRICLE, the fifth ventricle being shown
between the two layers of the sepévan lucidum, C,the motor tract of the CRUS CEREBRI (Jas7s
cruris—crusta); 7, the sensory tract of the CRUS CEREBRI (¢eg7entum cruris); C/, the
cerebellar fasciculus; e,the point of decussation of the motor fibres of the spinal cord; /, the
course of the decussating motor fibres of the spinal cord below the medulla, showing their
connection with the cells of the anterior horns of the gray matter, and their continuation into the
anterior roots of the spinal nerves (g); a, fibres which radiate through the caudate nucleus; 4,
fibres of the “‘¢xternal capsule ;’’ ce, fibres which radiate through the lenticular nucleus; ¢@,
fibres of the “external capsule; 2, 3, 4, 5, 6. 7, 8, 9, sensory fibres radiating from the
tegumentum cruris to the cortex by means of various nodal masses of gray matter; 11, course
of the sensory fibres of the spinal cord (shown by dotted lines), intimately connected with
the posterior root of the spinal nerve (12), and decussating at or near to the point of entrance
into the spinal cord. This diagram may be studied in connection with Figs. 12, 15, 16, 36,
and 37, with possible benefit to the general reader. In this diagram, the direct pyramidal
fbres are not shown (see Fig. 29), nor the gray matter of the pons.

Different observers have been able to trace the course and termina-
tions of the separate bundles with exactness hy means of methods lately
discovered. Nature, under certain conditions, makes the dissections
during life; and we, after death, can study out the details of her work.
In this way we have learned facts that no human dissection could have
determined. The discovery of Tiirck that nerve fibres degenerate (as a
result of malnutrition) when severed from the nerve cells, enables us to
investigate the results that follow destruction of ccrtain limited areas
of the cortex of man by disease or mechanical injury. When sections
across such a brain are made and examined under a glass (proper stain-
ing reagents being employed) the area of the degenerated fibres be-
comes as clearly depicted from that of healthy brain fibres as would
an ink-spot upon a table-cloth. An examination of successive sections
enables us to trace the course of the fibres that were originally connected
with the cells of the diseased area to their peripheral connections. Some
years after Turck’s original paper, Flechsig opened another field of inves-
tigation. Heshowed that during the development of the embryo, certain
bundles of nerve fibres in the brain and spinal cord became completely
formed before others. By means of sections of embryotic brains, he and
his followers have been able to confirm many of the facts made known to
us by Turck’s method. Finally, Gudden has lately proven that extirpa-
tion of the eye and some other organs, as well as the divisions of some
nerve-tracts, in the newly-born animal, are followed by a proximal degen-
eration. of the fibres connected with the organ removed.

Let me remark here that every nerve impulse sent to the brain does
not travel along a continuous fibre to reach the cell of the cortex that is
capable of receiving it; and the same holds true of all motor impulses dis-
patched from the brain to the muscles. All impulses are passed from cell
to cell by means of connecting fibres. In this way they eventually reach
the cerebral cortex, just as water-buckets are passed up a ladder, in case
of fire, to use an illustration borrowed on account of its aptness. The
object of this arrangement is to allow of an independent action of certain

collections of cells (that are subservient to the cortical cells of the cere-
20 LECTURES ON NERVOUS DISEASES,

brum) in case the required response does not necessitate volition or con-
sciousness. Many of the vital processes (such as the beating of the heart)
are governed by what is known as ‘reflex action.” We cannot check
them by the will, and, as a rule, we are unconscious that they are con-

stantly going on.

THE GANGLIA AT THE BASE OF THE CEREBRUM.

Buried within the substance of each cerebral hemisphere, isolated
gray masses (composed of nerve-cells) exist. They may be revealed by
vertical or horizontal cross-sections of the hemispheres.

Among these may be prominently mentioned : (1) the caudate and
lenticular nuclei of the corpus striatum (so named from the striped appear-
ance which they present); (2) the optic thalamus (a term which signifies
the “bed” of the optic fibres); (8) the geniculate bodies, connected with
the optic tracts (Fig. 21); (4) the amygdale, each being formed by the
tail-like prolongation of the caudate nucleus of the corresponding hemi-
sphere (Fig. 9); and (5) the basal ganglia of Meynert.

The limits of this chapter will preclude more than a hasty and very
imperfect summary of the functions of the corpora striata and the optic
thalami.

In the Journal of Nervous and Mental Diseases, | published some
years ago two lectures delivered by me upon these ganglia. In some
respects, I have changed my views relating to a few disputed points con-
cerning the structure and probable functions of these bodies since these
lectures were published. I shall quote, howevcr, some paragraphs from
these articles from time to time, with modifications in the phraseology.

THE CORPUS STRIATUM.

Within each cerebral hemisphere, two nodal masses of cells are im-
bedded, known as the corpus striatum and the optic thalamus (Fig. 1).
Because these bodies lie near to the base of the cerebrum, they are col-
lectively called the ‘ basal gangliu” of the hemispheres.

Each corpus striatum is divided (hy the fibres which constitute
the so-called “internal capsule” of each hemisphere) into two distinct
portions ; one of which projects into the Interal ventricle, while the other
does not. These are known as the ¢ntra-ventricular portion, or the
“ caudate nucleus,” and the exrtra-ventricular portion, or the “ lenticular
nucleus.” Fig. 6 will make this apparent to the reader.

The two nuclei of the corpus striatum become jotned both anteriorly
and posteriorly ; hence the separation of these masses is only partial.
Horizontal and vertical cross-sections of the cerebrum show these nuclei
as distinct from each other, as a rule.

Space will not allow of an anatomical description of these bodies.
THE CORPUS STRIATUM. Sl
I quote, therefore, a few paragraphs from two monographs of mine, re-
lating to these nuclei :—*

“The clinical results of lesions of either nucleus are attributed by

Afferent fibres of
corpus striatum
“‘cortico-striate
group.”

 

 

 

|
Efferent fibres : \ |
of corpus striatum, | |
\ | Cerebellar fibres to
, | \ corpus striatum
ise Date a abil A Peed | A secouding to
a ii c Uys).
B

Fic. 7.—A Diacram DESIGNED BY THE AUTHOR TO SHOW THE AFFERENT AND EFFERENT
FIBRES OF THE CoRPUS STRIATUM. C.J, “caudate nucleus,’’ or ventricular portion of
corpus striatum; Z, WV, ‘lenticular nucleus,’’ or extra-ventricular portion of corpus stria-
tum; d—S, median line, separating cerebral hemispheres; P—/’, psycho-motor regions of
the cortex; a, peduncular fibres connected with Z, 4; 4, fibres of the so-called “internal
capsule ;”’ ¢, fibres connected with C. NV; O, olfactory fibres. (Luys.)

most authors to pressure effects upon the motor fibres of the internal
capsule. In no instance, to my knowledge, has the destruction of these
nuclei produced psychic manifestations.

* Journal of Nervous and Mental Diseases, 1883.
22 LECTURES ON NERVOUS DISEASES.

The hemiplegia, which follows injury to the corpus striatum, is
confined chiefly to the side opposite to the lesion; in cases of extreme
rarity, paralysis of motion on the same side has been clinically recorded.
Flechsig has proved that such cases are to be interpreted as the result
of an individual peculiarity in the relative number of decussating and
direct pyramidal fibres (Fig. 29).

“The corpus striatum, like the optic thalamus, may possibly (as Luys
suggests) be considered, as a territory in which cerebral, cerebellar, and
spinal activities are brought into intimate communication. It probably
acts as a ‘halting place for voluntary motor impulses’ emitted from the
cerebral cortex. It enables these impulses to ‘become modified and pos-
sibly reinforced by currents derived from the cerebellum; and, by its
efferent fibres, it transmits centrifugal motor impulses along the projec-
tion system to different groups of cells within the spinal gray matter,
whose individual functions they tend to evoke,’”

Luys states that this ganglion probably acts as a condenser and
modifier of all motor acts which are the result.of volition ; and manifests,
through the agency of its satellites (the cells of the anterior horns of the
gray matter of the spinal cord), the outward expressions of our person-
ality. Without the influence of the cerebral hemispheres, it is also
capable, by means of cerebellar innervation, of governing all the complex
muscular movements required in maintaining equilibrium (coérdinated
movements). Finally, it may be presumed to “ possess the power of
analysis of cerebral and cerebellar currents received simultaneously, and
of materializing them by the intervention of its nerve-cells, projecting
them in a new form, amplified and incorporated with the requirements
of the general organism.”

Experiments made upon the caudate and lenticular nuclei can hardly
be said to have afforded results which can be made the basis for positive
deductions respecting the functions of each. Nothnagel employed injec-
tions of chromic acid into the substance of each, and also destroyed them
by means of an instrument devised for that purpose, but he arrived at no
positive conclusions, save that the lenticular nucleus seemed to have a
more decided influence upon motion than the caudate nucleus, when the
nuclei of both sides were simultaneously destroyed. Observations in
comparative anatomy seem to show a relationship of the caudate nucleus
with the fibres of the leg and of the lenticular nucleus with those of the
arm.

Some observers claim to have destroyed the entire ganglion without
any marked disturbance of sensory or motor phenomena. Collected
cases of lesions confined to cither nucleus fail to show that any perma-
nent symptoms have been produced which are diagnostic of such lesions.
THE OPTIC THALAMUS. 23

THE OPTIC THALAMUS.

Efforts have been made by some of the later anatomists and physi-
ologists who have specially investigated the brain, to subdivide the gray
matter of the thalamus into circumscribed masses or nuclei, and to trace
the fibres which appear to arise from these nuclei to special regions of the
brain and spinal cord. Among the most attractive of these attempts may
be mentioned that of Luys, whose views will be subsequently given in
detail. Whether clinical research and physiological experiment will con-
firm all of these attractive theories, and place them upon a ground as
worthy of credence as the deductions of Broca, Munk, and Ferrier re-
garding the functional attributes of other parts of the brain, time alone

 

 

Fic. 8.—A DraGeam or tHe Nuciet or THE Optic THALAMUS AND THE CONVERGING Freres
ASSOCIATED WITH THem. (After Luys.) 1, converging fibres of posterior convolutions;
2, same, of middle convolutions; 3, same of posterior convolutions; 4, 4’, 4/’, cortical
periphery as related to the central gray masses; 5, optic thalamus; 6, corpus striatum; 7,
anterior (o¢/actory) centre; 8, middle (oftzc) centre; 9, median (sexsztive) centre; 10, pos-
terior (acoustic) centre; 11, central gray region; 12, ascending gray fibres of visceral inner-
vation: 13, gray optic fibres; 14, ascending sensitive fibres; 15, ascending acoustic fibres;
16, series of antero-lateral fibres of the spinal axis going to be lost in the corpus striatum.
can decide. They are opposed to many of the conclusions of Meynert,
Flechsig, Wernicke, Spitzka, Starr, and others.

“According to the researches of Luys, four isolated ganglions may
be demonstrated in the thalamus. Arnold, in common with some other
anatomists, has recognized three of these, and the fourth is now added
by the author quoted. This author states that these ganglia are arranged
in an antero-posterior plane, and form successive tuberosities upon the

thalamus, giving that body the appearance of a conglomerate gland.
24 LECTURES ON NERVOUS DISEASES.

“The anterior ganglion of Luys (corpus album subrotundum) is
especially prominent. It is said by this author to be developed in ani-
mals in proportion to the acuteness of the sense of smell. By means of
the ‘ tenia semi-circularis,’ this ganglion (according to this author) may
be shown in the human species to be connected with the roots of the
olfactory nerve. Respecting it, he says: ‘Direct anatomical examination
shows that there are intimate connections between the anterior centre

 

Fic. 9.—A TRANSVERSE SECTION OF THE Human BRAIN FROM Berore Backwarp. (After
Flechsig.) MC, caudate nucleus; N C’, the tard of N-C, cut across (the amygdala);
L WN, lenticular nucleus, with its three subdivisions (/, //, ///); TH, optic thalamus; F,
frontal lobe; 7S, temporal sphenoidal lobe; Q, occipital lobe; Cls, c/austrum,; IK,
thalmo-tcnticular portion of internal capsule; K, knee ofsame; /A’, caudo-lenticular
portion of same; EA, extermsl capsule, lying between the lenticular nucleus and the claus-
trum; 4, fornix cut across; /n, insula, or island of Reil; Op, depth of Sylvian fissure
beneath the operculum; sc, middle commissure of the thalamus; #/, posterior horn of
lateral ventricle; a4, anterior horn of same; SZ, septum lucidum.

and the peripheral olfactory apparatus. On the other hand, in confirma-
tion of this, in the animal species, in which the olfactory apparatus is
very much developed, this ganglion itself is proportionally very well
marked. Analogy has thus led us to conelude that this ganglion is
THE OPTIC THALAMUS. Ds

in direct connection with the olfactory impressions, and that this marks
it as the point of concentration toward which they converge hefore being
radiated toward the cortical periphery.’

“The second or middle centre is in apparent continuity, according
to Luys, with the fibres of the optic tract. JIe considers it on the
same grounds as those previously quoted respecting the anterior centre,
asa seat of condensation and radiation of visual impressions.* There
seems to be undisputable grounds for the belief that the thalamus, the
outer geniculate bodies, the anterior corpora quadrigemina, and the cor-
tex of the occipital lobes are, in some way, associated with the percep-
tions atforded by the retina. (Munk, Wernicke, Monakow, and others. )

“We know that extirpation of the eye is followed by more or less
complete atrophy of the outer geniculate body of the opposite side,
although the inner geniculate body scems to remain unaffected. The
experiments of Longet, who destroyed the optic thalami upon both sides
without being able to note any impairment of vision, or influence upon
the movements of the pupil; and those of Lussana and Lemoigne, who
found that blindness of the opposite eye followed unilateral destruction of
the thalamus, may suggest the possibility, in the former, of the escape of
this centre, and, in the latter, its destruction. It is diflicult to devise any
experiment which will positively settle the bearings of the thalamus upon
vision; because it is almost impossible to destroy special portions with
accuracy, or if this were insured, to avoid injury to adjacent. structures.
Fournié claims to have effected the separate annihilation of the special
senses of smell and vision by injections made into different parts of
the thalamus of animals; and his experiments, if subsequently verified,
will tend to confirm some of the theories advanced by Luys.

“ Ritti has pointed out that irritation of the thalamus may play an
important part in the development of hallucinations.

“The third centre (‘median ganglion’ ‘of Luys) is described as
about the size of a pea, and situated mathematically in the exact centre
of the thalamus. To it, the discoverer ascribes the function of presiding
over and condensing all sensory impressions.

“The fourth posterior centre is stated to act as a halting place and
condenser of auditory impressions. Two instances where the brains of
deaf mutes were found to present a localized lesion of this centre are
reported by Luys.

“The views here expressed are quoted on account of their origi-
nality; and because the author of them ranks high as an authority upon

*Luys states that it is scarcely visible in those animals (the mole as an example)
where the optic nerves are rudimentary. The view is now more generally accepted that
the posterior tubercle of the thalamus (the pulvinar) is functionally associated with the
optic fibres.
26 LECTURES ON NERVOUS DISEASES.’

the subject of which he speaks. ‘The numerous cases of cerebral hemor-
rhage which have been reported, where the thalamus was apparently the
seat of localized injury, are too often accompanied with a clinical history
which points toward pressure upon the internal capsule, to be of value
as confirmatory evidence of the existence of special centres in the thala-
mus.* The effort of Luys to adduce cases of hemianesthesia in support
of his views regarding the function of the ‘median centre’ of the thala-
mus, merely because a lesion of that ganglion was found in an area
defined by him as the normal limits of that special centre, must not be
deemed conclusive; because the same effect might have been produced
by pressure upon the fibres within the posterior third of the internal
capsule of the cerebrum, There is reason to hope, and possibly to be-

 

Fic. 10.—Srction Across THE Optic THALAMUS AND CoRPUS STRIATUM IN THE REGION
oF THE MippLe Commissure. (Shafer after a preparation by Mr. S. G. Shattuck ) Natu-
ralsize. ¢/., thalamus; a., é., z.,its anterior, external, and internal nuclei respectively ; w, its
latticed layer; 7. c., middle commissure ; above and below it is the cavity of the third ven-
tricle; ¢. ¢., corpus callosum ;_/, fornix, separated from the third ventricle and thalamus by
the velum interpositum. In the middle of this are seen the two veins of Galen and the choroid
plexuses of the third ventricle; and at its edges the choroid plexuses of the lateral ventricles ;
z.s., tania semicircularis; cv., forward prolongation of the crusta passing laterally into the
internal capsule, 7. c.; s. t. »., subthalmic prolongation of the tegmentum, consisting of
(1) the dorsal layer, (2) the zona incerta, and (3) the corpus subthalamicum ; s. 2., substantia
nigra; #. ¢., nucleus caudatus of the corpus striatum; #. 2., nucleus lenticularis ; ¢. ¢., e2-
ternal capsule; cé., claustrum; J, island of Riel. : 7

lieve, that sooner or later isolated ganglia within the optic thalamus will
be demonstrated to exist by normal and pathological anatomy, as well
as by physiological experiment; but the conclusions even of so promi-
nent an author should not be fully accepted without further testimony
to substantiate their accuracy. Some of the later observations respecting
the optic fibres, seems to disprove the view of Luys. ,

“A few interesting cases have, however, been brought forward, which
certainly seem to sustain the views advanced.. A case reported by Hun-

*If permanent symptoms remain after a lesion of the thalamus is suspected to exist,

the internal capsule is probably indirectly involved. (See subsequent pages relating to the
internal capsule. )
THE OPTIC THALAMUS. 27

ter,* where a young woman successively lost the senses of smell, sight,
sensation, and hearing, and who gradually sank, remaining a stranger to
all external impressions, disclosed at the autopsy a fungus hamatodes
which had gradually destroyed the optic thalamus of each side, and the
optic thalami alone, if the drawing given is reliable. Again, Fourni¢’s
experiments on living animals points strongly to the existence of local-
ized centres in the thalamus. Three instances of unilateral destruction
of smell, observed by Voisin and reported by Luys, have been found to
be associated with a destruction of the anterior centre of the thalamus.
A hemorrhagic effusion into the thalamus, on a level with the soft com-
missure (the situation of the optic centre of Luys), produced (in the ex-
perience of Serres) a sudden loss of sight in both eyes. Later observa-
tions seem, however, to point toward a relationship between the poste-
rior extremity of the thalamus (the ‘pulvinar’) and the optic fibres.

“Ritti's paper upon the effects of irritation of the thalamus upon
the development of hallucinations, lends strength to the view that that
ganglion in some way regulates the transmission of sensory impressions
of all kinds to the cerebral cortex; and confirms the opinion that ‘the
optic thalami are to be regarded as intermediary regions which are inter-
posed between the purely reflex phenomena of the spinal cord and the
activities of psychial life.’

“The view taken by Lussana and Lemoiegne, that the optic thalami
contained motor centres in animals for the lateral movements of the fore-
limbs of the opposite side, seems to be completely overthrown by patho-
logical statistics in the human race. The results obtained by these ex-
perimenters are also at variance with the belief, which has now become
general among neurologists, that the thalami are intimately connected
with the sensory tracts of the cerebrum and cord; since they concluded
that no evidence of pain or any loss of sensibility resulted from injury
to these bodies.

“The effects of all experiments on animals, however, agree entirely
with the general experience of pathologists, that lesions of both the
thalamus and corpus striatum produce results upon the opposite side of
the body; whether the symptoms produced point to a disturbance of the
kinesodic (motor) or ssthesodic (sensory) tracts. The view originally
advaneed by Carpenter and Todd, that the thalami are concerned in the
upward transmission and claboration of sensory impulses, in contradis-
tinction to the corpora striata, which are concerned in the downward
transmission and elaboration of ‘motor impulses, seems to be gaining
ground, and many facts may be urged in its favor.”

The experiments of Monakow on rabbits lead him to views not en-
tirely dissimilar to those advanced by Luys. He places the cortical

* Medico-Chirurg. Trans., London, 1825, vol. xiii.
28 LECTURES ON NERVOUS DISEASES.

connections of centres in the thalamus, somewhat differently, however,
from the conclusions already mentioned. According to this observer,
the posterior tubercle (the pulvinar) is related to the visual tracts, as is
also the external geniculate body; the internal geniculate body is related
to the auditory fibres, and the cortical centres of hearing in the first
temporal convolution; and the anterior tubercle and median nucleus
are related to the frontal lobes.

The pillars of the fornix seem to unite the thalamus with the cor-
tical centres of smell and taste; and, according to Ferrier, with the cor-
tical centres of tactile sensibility.

Hemichorea and hemiathetosis have been observed in connection
with lesions of the thalamus; but they must, to my mind, be regarded as
an evidence of irritation of the motor fibres of the internal capsule
(which lie closely adjacent to the thalamus). Fig. 9 will make this rela-
tionship clear to the mind of the reader.

THE CAPSULAR FIBRES OF THE CEREBRUM.*

Vertical and horizontal cuts made through the cerebrum exhibit a
well-defined tract of fibres in each hemisphere which separates the len-
ticular nucleus from two other gray masses of the same hemisphere,
viz., the caudate nucleus and the thalamus.

This tract of fibres (inclosed between these nodal masses of cells)
is termed the “internal capsule,” because it bounds the lenticular nucleus
on its mesial aspect. <A similar tract of fibres also separates the len-
ticular nucleus from the ‘‘claustrum” of the same hemisphere. This is
known as the “external capsule” (Figs. 7 and 9).

The fibres, which form the “internal” and ‘‘external capsule” of
each hemisphere, seem to pass through the substance of the cerebrum
without any structural relationship with the cells of the caudate- or lentic-
ular-nuclet, or the thalamus (Flechsig). In this respect they differ from
all other fibres which serve to connect the cells of the cerebral cortex
with collections of nerve cells outside of the cerebrum.

From a physiological and anatomical standpoint, the fibres of the
internal capsule possess greater interest than many other bundles. Late
researches have shown that it contains (1) the so-called “pyramidal
fibres” (the “will tract” of Spitzka) which controls voluntary move-
ments of the limbs; (2) the so-called “sensory tract,” whose fibres con-
yey sensations of all kinds from the surface of the body to the cells of the
cerebral cortex where they can be appreciated by consciousness; (3) the
so-called “speech tract,” whose fibres allow of communication between the
“speech area” of the cortex and the nuclei of origin of the seventh, tenth,

* This term is a misnomer. These fibres form a capsule to the “lenticular nucleus,”
properly speaking, and not to’the cerebrum,
CAPSULAR FIBRES OF THE CEREBRUM. 29

eleventh, and twelfth cranial nerves (within the medulla); (4) the motor
fibres of the face; (5) bundles of fibres connected with the special
senses (sight, smell, hearing, taste, and touch); (6) the so-called “ hypo-
glossal tract,” which connects the cortical centre for movements of the
tongue with the nucleus of origin of the twelfth cranial nerve within the
medulla; finally, many other bundles of fibres (whose functions are not
yet determined) occupy the anterior part of the capsule in front of its
“knee.” (Fig, 9).

If a horizontal cut be made through the substance of the cerebrum
at a level which shall include the basal ganglia (the caudate nucleus, the
lenticular nucleus, and the thalamus of each hemisphere) in the plane of
the section, we shall see that the outline of the internal capsule is marked
by an angle, termed the “genu” or “knee” of this capsule. This is
shown in the cut of Flechsig (Fig. 9), and also in another which is intro-
duced later. A subsequent diagram offered as explanatory of some of
the results of cerebral hemorrhage may be consulted in this connection
with benefit to the reader.

That portion of the internal capsule which lies between the len-
ticular and caudate nuclei has been named the ‘caudo-lenticular”
portion (Spitzka). It lies anteriorly to the “knee.”

The part posterior to the “knee” has been termed by the same
author the “thalamo-lenticular” portion.

In studying the cut of Flechsig (Fig. 9) it must be remembered
(1) that the fibres which constitute the internal capsule pass vertically
to the plane of the section; (2) that, above the upper limits of the
basal ganglia, they radiate to different areas of the cerebral cortex; (3)
that the component fibres of the capsule may be subdivided into groups.
The functions of some have been quite positively determined of late.
This has been done by a study of their apparent cortical distribution, and
of secondary degeneration of special nerve tracts; by an analysis of the
symptoms produced during life, when well-defined lesions of the internal
capsule have existed; by the so-called “development method” of Flech-
sig; and by the effects of section of nerve tracts in newly-born animals
(Gudden’s method).

The following statements seem to be now quite well established, and
to be of service as clinical guides to the localization of cerebral lesions
which directly involve or create pressure upon these fibres.

(1) The “caudo-lenticular” portion is composed of fibres whose func-
tion is imperfectly understood. They seem to pass chiefly to the cortex
of the frontal lobes.

(2) In the region of the “knee,” the “thalamo-lenticular” portion
tontains the motor fibres of the face.

(3) Posterior to the facial tract lie the fibres of the so-called “pyra-
30 LECTURES ON NERVOUS DISEASES.

midal motor tract” or the “will tract.” Those of the arm probably lie
anteriorly to those destined for the leg. Lesions affecting this part would
create chiefly a hemiplegia of the opposed side. These fibres constitute
the anterior pyramid of the corresponding half of the medulla oblongata;
hence the name which is commonly applied to them.

(4) Posterior to the general motor fibres, we encounter the so-called
“sensory tract,” <A lesion of the entire bundle would induce hemianses-
thesia of the opposed side.

(5) Next in order from before backward, the fibres of the “speech
tract” are supposed to pass (Wernicke). A lesion confined to this bundle
would produce aphasic symptoms.

(6) Finally, the optic fibres pass through the extreme posterior part
of the capsule. Lesions of this bundle cause “homonymous hemian-
opsia” (the blindness being confined to the right lateral half of each eye
if it affect the right capsule, or vice versa).

(7) The course of the fibres associated with the special senses of
taste and smell is not yet as positively determined, as in the case of the
optic and auditory fibres. The auditory tract probably passes through
the lower and posterior part of the internal capsule.*

(8) The hypoglossal cerebral tract probably joins the lower third
of the precentral gyrus (ascending frontal convolution) with the medul-
lary nucleus cf the twelfth cranial nerve by passing through the region
of the “knee” of the internal capsule, anteriorly to the motor fibres
which govern the limbs (Raymond and Artaud). Lesions of this tract
produce symptoms closely allied to those of Duchenne’s disease (‘ bulbar
paralysis ”’—*‘ glosso-labio-laryngeal paralysis ”’).

The outlines of the surfaces of the thalamus and the lenticular
nucleus of the corpus striatum, as seen in all vertical sections of the cere-
brum, may be roughly compared to the form of a square, whose two
halves are defined by a diagonal band (the “internal capsule,’+) run-
ning from the upper and outer corner to the lower and inner corner.
These halves correspond to the respective ganglia. It may be worthy
of remark, in this connection, that the surface of the thalamus, which
lies in contact with the internal capsule of the cerebrum marks the cen-
tral or receiving pole for the fibres, which join it with the cortex of the
cerebral lobes. This is not the case with the lenticular nucleus.

* Spitzka, in a late article, states his conclusion that sound is transmitted from the
cochlea through the following structures to reach the cortical centres of hearing. 1, the
posterior division of the eighth pair; 2, the trapezium of the same side—w here the sand tay
fibres cross to the opposite side; 3, a part of the lemniscus; 4, the posterior pair of the
corpora quadrigemina ; 5, the internal geniculate body}; 6, the corona radiata; 7, the cor-
tical centres in the superior temporal gyrus, (See also foot-note on page 42.)

7 This bundle of fibres ceases with the posterior limits of the lenticular nucleus of the
corpus striatum,
THE CRUS CEREBRI. 31

The external surface of the thalamus (which lies in contact with the
internal capsule of the cerebrum) presents a peculiar appearance, which
has given it the name of “ lattice layer” (Kolliker). Allalong this surface,
radiating fibres pass out of the thalamus to become intermingled with
the fibres of the internal capsule, and to be distributed to the cerebral
cortex. Those from the front of the ganglion pass to the frontal lobe;
those from the middle are distributed to the posterior part of the frontal
and to the parietal and temporo-sphenoidal lobes; those from the pos-
terior part can be traced to the temporo-sphenoidal and occipital lobes.
From the region of the pulvinar, or posterior tubercle, fibres can be
traced into the optic tract.

The internal capsule will be considered in its clinical aspects in
subsequent pages of this section, and also in connection with the symp-
tomatology of cerebral apoplexy. Diagrams will then be given which
will help to make the subject clear to the reader.

THE CRUS CEREBRI.

The stem of each cerebral hemisphere (Fig. 1) is composed of fibres
that serve to connect the cells of some of the component parts of each
cerebral hemisphere with other cells, situated either within the crus itself,
the pons Varolii, the cerebellum, the medulla oblongata, or the gray matter
of the spinal cord. These fibres are therefore of different lengths.

The shortest fibres of the crus probably terminate in the gray matter
of the crus (substantia nigra of Scemmering, and the red nucleus of Still-
ing, see Fig. 11). The longest fibres terminate in the lowest segments
of the spinal cord.

The diagram of a cross-section of the crura cerebri, introduced at
this point, will make some of the most essential points in their archi-
tecture apparent. It shows the gray masses of each crus; and also the
situation of several different nerve tracts cut across.

The “tegmentum cruris” lies posterior to the substantia nigra. It
contains the fibres designed for sensory conduction to the brain; and,
possibly, a few motor filaments.

The “crusta cruris” (basis cruris) lies in front of the substantia
nigra. It is chiefly composed of motor fibres.

The fibres of the third cranial nerve (motor oculi) traverse the crus
(in the plane of the section), from the nucleus of that nerve in the gray
matter around the Sylvian aqueduct (iter e tertio ad quarto ventriculo)
to its point of exit.

The fibres of the pyramidal tracts (see Figs. 12 and 29) occupy but
limited area in the crusta cruris (as shown in the diagram).

The red nuclei are closely related to the fibres of the superior
32 LECTURES ON NERVOUS DISEASES.

peduncles of the cerebellum* (processus e cerebello ad cerebrum), and the
fibres of the third cranial nerve. Their function is not positively deter-
mined. Lesions of these bodies seem to create symptoms of incodrdi-
nation of movement and paralysis of the third cranial nerve.

This diagram (Fig. 11) may aid the reader in mastering the grounds
for many clinical deductions respectiny lesions of the crus, which will he
mentioned later in this section.

   
 

Lateral
\ (groove

Fro. 11.—A DiraGramMmatTic REPRESENTATION OF THE CRURA CEREBRI IN CROSS-SECTION.
(After a blackboard drawing by the Author.) ¢. q., coxpora guadrigemina; S, agueduct
of Sylvius (iter etertio); 4g, nucleus af the fourth cranial nerve in the gray matter which
surrounds the aqueduct; .3, 2zcleus of the third cranial nerve, whose fibres are depicted ;
q.t., root of fifth cranial nerve; p. |. f., posterior longitudinal bundle; R. N., the red
nuclei of Stilling; S. WV. the sadstantia nigra; P, the portion of the ‘crusta’’ occupied
by the fyramidal fibres (Fig. 29). The tract of the fillet or “lemniscus,’’ as well as the
relative situation of the “crusta’’ or “basis cruris,”” and the “tegmentum cmuris”’ is also
shown in the cut.

Respecting the formation of the lemniscus tract, Flechsig believes
that the tract is composed of a very large bundle (which degenerates
downward) and a smaller one (which degenerates upward).

This author thinks that the larger bundle arises from the outer body
of the lenticular nucleus (Fig. 7), and he places its termination in the
olivary body of the medulla. The smaller bundle is believed by this
observer to start in the sensory decussation at the lower part of the
medulla and to terminate in the corona radiata of the cerebrum.

* The termination of the fibres of the superior cerebellar peduncle, after their associa-
tion with the red nuclei of the tegmentum (Fig. 14), is not yet determined. Flechsig be-
lieves that they go to the lenticular nucleus, or radiate in the corona radiata after passing
through the thalamus. The cells of the ‘‘ substantia nigra”’ are deeply pigmented, giving
to it a blackish color. ?
THE PONS VAROLII. 33

Spitzka, who has written a very complete and lucid article upon
this tract (see bibliography) differs from Fleehsig in some of his con-
clusions. He traces the ‘olivary” bundle of Flechsig to a spinal origin,
and the smaller bundle, described by Flechsig, beyond the sensory decus-
sation to the nuclet of the columns of Goll and Burdach of the opposite
side. These nuclei are shown in Fig. 37, which also illustrates Aeby’s
views respecting the ‘“lemniscus tract.”

The close proximity of the corpora quadrigemina to the tegmentum
cruris, leads us to regard blindness, nystagmus, strabismus, and an ab-
sence of the pupillary reflex (which clinically mark a lesion of the an-
terior pair) as strongly diagnostic. From a similar train of reasoning,
amarked disturbance in codrdination would point to the fact that the
postertor pair were involved, or that the red nuclet are diseased. A
defective action of homologous branches of the third nerve of the two
sides points strongly toward a lesion of the latter bodies.

THE PONS VAMROLII.

This portion of the brain may be compared (as a homely illustra-
tion) to a collar around the crura, which helps to bind the cerebellar
hemispheres together, and to tie them fast to adjacent parts.

As was the case with the crus, cross-sections made through the pons
reycal (1) isolated gray masses (composed of nerve cells) in great alyund-
ance, and (2) distinet bundles of fibres. The direction of these fibres may
he seen to be both horizontal and vertical.

The vertical bundles pass into the substance of the medulla and
spinal cord, and are extended upward to the cerebrum.

The horizontal bundles probably serve two purposes: (1) to connect
the two cerebellar hemispheres; and (2) to unite each cerebellar hema-
sphere with the opposite cerebral hemisphere.

The number of fibres which compose the crus is very largely in ex-
cess of that which exists within the medulla; hence we are justified in
assuming (as Meynert first suggested) that many fibres derived from the
cerebrum are deflected within the pons. A certain proportion only of
the cerebral fibres is prolonged to the spinal cord. Some of those so
prolonged are functionally associated with the transmission of motor
impulses from the cerebrum to the muscles of the extremities,—the so-
called “pyramidal tracts,” because they form the “anterior pyramids”
of the medulla. Others convey sensory impressions from the peripheral
organs to the cells of the cerebrum,—the so-called “sensory tracts.”

The gray matter of the pons seems to be composed of cells that serve
to interrupt the paths of communication between the cerebrum and
ecrebellum, and also between the two cerebellar hemispheres.

2
By
34 LECTURES ON NERVOUS DISEASES.

The association of the fibres which constitute the middle peduncles
of the cerebellar hemispheres with the “cerebral tracts” (by means of the
multipolar cells in the pons) is a crossed one—the left cerebellar hemi-
sphere being joined to the right cerebral strand,.and vice versa. This prob-
ably brings the cerebellar hemispheres into association with those motor
fibres which act upon the corresponding limb; because the pyramidal
fibres decussate to a great extent at the lower part of the medulla.

Basal ganglia
of cerebral
hemisphere

   

Medulla

 

Spinal Cord

Fic. 12.—A DiaGram DesiGnep By THR AUTHOR To ILLUSTRATE THE CouRSE OF CERTAIN
Nerve-Tracts WirHIn THE CERERRUM, Crus, Pons, Mrputta, aANp Spina Corp.
Modified from Flechsig.) C. V., caudate nucleus; Z. N., lenticular nucleus; OQ. 72, optic
thalamus; G. ?., gray matter of the pons; /, &., formatio reticularis; C. D., corpus denta-
tum; 0, olivary body; WV. C., clavate nucleus; 7; N., triangular nucleus: C. Q., corpora
-quadrigemina; / C., upper limit of the capsular fibres : mm, Mt, 72, motor centres around the
‘fissure of Rolando; c.7., fibres of the “corona radiata.’’ 1, the “pyramidal tract,”
THE PONS VAROLII. 35

arising from the motor centres of the cerebrum and terminating in the cells of the anterior
horns of the spinal gray substance (13 and 14); 2; 3, and 4, fibres connecting the cerebral cor-
tex, the caudate nucleus and the lenticular nucleus with the gray matter of the pons after
decussation (see Fig. 87), and then prolonged as 6 and 7 to the cerebellum ; 5, fibres of the
superior cerebellay peduncle, 6, 7, 8, 9, and 10, show by their colors the tracts svhicli they are
associated with, as well as their origin and termination: 11 and 17, the “ad7rect cerebellar
tract’’ of the spinal cord (whose probable termination is not correctly shown in the cur, as it
probably ends in the vermiform process); 12, the Zesndscus or “fillet” tract, connecting
the olivary body with the optic thalamus and the corpora quadrigemina; 13, the cells of the
cord connected with the direct pyramidal tract ; 14, the cells of the cord connected with the
crassed pyramidaltract; 15, fibres of the column of Burdach, terminating superiorly in the
triangular nucleus; 16, fibres of the codenn of God, terminating superiorly in the clavate
nucleus; 19, fibres of the cord which terminate in the so-called ‘reticular formation”

directly; 18, fibres of the red. form. going to the cerebellum. [The reader should com-
pare this diagram with Figs. 36 and 37, and note the difference in the course of the sensory
tracts during their passage through the ‘medulla, there shown, both in profile and in transverse
section. The differences between the diagrams will make the various views held at the
present time more apparent than a verbal description. In this diagram the crus is intention-
ally shown as distinct from and not related to the pons, in order to bring certain tracts of
fibres into prominence. Some of the tracts shown in this diagram decussate.—See Fig. 37.]

This arrangement probably allows of an automatic action of the cere-
bellum upon the skeletal muscles, as exhibited in the maintenance of a
fixed attitude (Spencer), the finer feats of rhythm (Spitzka), and diffi-
cult acts of equilibrium. Fig. 12 shows in a diagrammatic way the fas-
ciculi.that are deflected in the pons to the cerebellum, as well as other im-
portant bundles of nerve fibres. It should be contrasted with Figs. 15, 36,
and 37, since each will aid in the comprehension of the other, and at the
same time illustrate different views which are held in reference to the
course of the sensory tracts in the medulla.

A magnified section, made through the pons shows, in addition to
those points in its architecture already referred to, (1) the fibres of the
sixth cranial nerve and its nucleus of origin; (2) a part of the trigeminal
nucleus; (3) a part of the facial nucleus; (4) the superior olivary body ;
(5) the posterior longitudinal bundle; (6) the round bundle (fasciculus
teretes); and many other points whose functions cannot be described here
in detail (Fig. 13).

The reticular formation (Fig. 15) is divided by the fibres of the
hypoglossal nerve, into a median area (between the nerve root and the
raphe) and a lateral area (lying to the outer side of the nerve root).

The former area is chiefly composed of medullated fibres; while the
latter contains numerous nerve cells. The fibres of the anterior root-
zones of the spinal cord become lost chiefly in the median area, according
to some observers; while those of the lateral column of the cord prob-
ably have an association of some kind with the cells of the lateral area.

The fibres of the reticular formation appear to end, in part, in the
substantia nigra of the crus and the medullary lamine of the thalamus;
while some appear to join with a bundle of fibres from the red nucleus
of the tegmentum, and to pass through the posterior part of the internal
capsule, and to radiate toward the cortex.

The posterior longitudinal bundle (Fig. 11) is believed by Spitzka to
arise in the deep gray of the corpora quadrigemina, and to unite the cells
of these bodies with the nuclei of the fourth and sixth nerves, and the
nuclei of the muscles of the neck. He is led to the conclusion that it
36 LECTURES ON NERVOUS DISEASES.

presides over the automatic relationship between the movements of the
head and the visual apparatus.

Within the substance of the pons, those fibres of the facial nerve
which are prolonged cephalad, decussate. The level of this decussation
may be designated by an imaginary line, which shall connect the ap-
parent origins of the fifth cranial nerves (Gubler).

Lesions of the pons above the line of Gubler, which affect the facial
fibres, produce facial paralysis on the side opposed to the lesion, and,
when below that level, upon the same side as the lesion.

 

Fic. 13.—A TRANSVERSE SECTION THROUGH THE Pons, ON A LEVEL WITH THE Roots OF THE
SIxTH AND SEVENTH CRANIAL Nerves From A Ning Montus’ Embryo. (Modified from
Erb and Ross.) The right half represents a section made a little lower than the left. 77.,
transverse fibres of the pons; /, pyramidal fibres (see Figs. 12, 36, and 37); se, superior
olivary body; JZ, posterior longitudinal fasciculus; ¢, fasciculus teretes (round bundle); Rv,
root of abducens; #/'//, root of facial; a/, ascending root of trigeminus. (This figure shows
well the interlacing of the vertical pyramidal fibres with the horizontal (transverse] fibres of
the pons.) &, round bundle; 4, peduncle of cerebellum ; a, 7., upward prolongation of the
anterior root-zone of the spinal cord; a. é. c., anterior nucleus of the facial nerve; 4. 2. ¢.,
posterior nucleus of the facial nerve.

The pyramidal fibres, the fibres of the sensory tracts, the fibres of
the so-called “speech tract,” some of the facial fibres, and also of the
trigeminal and hypoglossal nerves, run cephalad through both the pons
and the crus to reach cortical centres of the cerebrum. For this reason,
lesions of the crus or pons may produce symptoms which indicate de-
struction of one or more of these tracts. Among these symptoms may be
mentioned the following: Hemiplegia, hemiansesthesia, facial palsy, facial
aneesthesia, disturbances of speech, paralysis of the third and sixth
cranial nerves. ‘These conditions will be discussed separately in subse-
quent pages of this section.
THE CEREBELLUM. 37

THE CEREBELLUM.

Although the cerebrum usually overlaps the cerebellum in animals
of the higher types, the fact that it does not do so is not necessarily an
indication of a lower grade in the scale of development, The construc-
tion of both the cerebrum and cerebellum becomes more intricate as de-
velopment progresses. Benedict has advanced the view that in criminals
brains the cerebrum did not overlap the cerebellum. Statements of this
kind have been shown by Wilder to be open to suspicion, from the de-
fective methods employed in the examination of the brain. The contour
of the brain (when hardened im situ by Wilder’s method) presents a
marked contrast to the outlines commonly accepted as normal.

This ganglion is connected with many other component parts of the
brain by fibres which compose three pairs of processes, called the in-
ferior, middle, and superior peduncles of the cerebellum.

1. The fibres which compose the INFERIOR PEDUNCLE (restiform body
—processus e cerebelload medullam) joins the cerebellum to the medulla.
Although authorities differ respecting its formation, it probably com-
prises three distinct sets of fibres. These are as follows: (1) those con-
stituting the direct cerebellar column of the corresponding lateral half
of the spinal cord; (2) a set derived from the olivary body of the opposite
side of the medulla; (3) a set derived from the nucleus of Burdach’s
column of the same side of the cord.

These three sets carry impressions of different forms of sensation to
the cells of the cerebellar corter and the corpus dentatum (a collection
of cells within the substance of the cerebellum).

The cerebellum receives, therefore, through its inferior peduncle,
two centripetal tracts at least, one derived from the lateral columns, and
the other from the posterior columns of the cord. Spitzka believes that
the muscular sense is conveyed to the cerebellum by means of Clarke’s
columns, acting in conjunction with the direct cerebellar columns, and
the tactile sense by means of Burdach’s columns and the olivary nuclei
of the medulla.

The fibres of the direct cerebellar column are supposed by Starr to
connect the cerebellum (indirectly through the cells of Clarke’s column)
with the thoracic and abdominal viscera. The other fibres, according
to this observer, transmit to it certain impressions of the tactile muscular-
sense from the lower and upper extemities.

2. The fibres which compose the MIDDLE PEDUNCLE (processus e cere-
bello ad pontem) assist to form the pons. Its fibres are probably asso-
ciated by a direct communication with the gray masses found within the
pons. Some of these act as commissural tracts between the cerebellar
hemispheres. Others are probably a part of the motor and auditory
apparatuses.
38 LECTURES ON NERVOUS DISEASES.

The fibres of the SUPERIOR PEDUNCLE (processus e cerebello ad cere-
hrum) connect the cerebellum with the higher centres. They pass into
the posterior part of the corpora quadrigemina (optic lobes), converge
beneath these bodies, decussate into the red nuclei of Stilling (Fig. 14),
and then pass to the cerebral hemisphere. Their termination within
the cerebral hemisphere is, as yet,a matter of doubt. Luys believes that
they pass to the caudate nucleus, and assist in charging its cells when
exhausted. Meynert considers that they help to form a part of the
motor apparatus.

CRURA
CEREBRI

 

 

 

Fie, 14.—A Dracram DesiGNep BY THE AUTHOR TO ILLUSTRATE THE VARIOUS SETS OF
Fipres Comprisep WITHIN THE CEKEBELLO-SPINAL SysTEM. (Modified from Ross.)
C. R., crusta cruris; T. E. G., tegmentum cruris; A. S., aqueduct of Sylvius, surrounded
by the tubular gray matter; S. N., substantia nigra; R. N., red nucleus of the tegmentum;
G.M. P., anterior gray matter of the pons; C. C., cerebellar cortex; N. D., nucleus denta-
tum; ©. B., olivary body; C. N., clavate nucleus; ‘I. N., triangular nucleus; D. C. T.,
fibres of the ‘direct cerebellar tract’’ of the spinal cord; P. R. Z., fibres of the ‘posterior
root zone’ of the same; G., fibres of the «*column of Goll;’’ 1, cerebro-cerebellar fibres ; 2,
fibres from the red nucleus of the tegmentum to the dentate nucleus of the cerebellum ; 3, fibres
from the red nucleus to the cerebellar cortex ; 4, fibres from the cerebellar cortex to the den-
tate nucleus ; 4, fibres from the dentate nucleus to the olivary body of the opposite side; 6,
fibres from the cerebellar cortex to the olivary body of the opposite side; 7, fibres from the
cerebellar cortex to the anterior gray nucleus of the pons of the opposite side; 8, fibres of the
direct cerebellar tract; 9, fibres connecting the clavate nucleus and the olivary body of the
same side ; 10, fibres connecting:the triangular nucleus and the olivary body of the same side ;
11, fibres passing from the olivary body to the horns of spinal gray matter ; 12, fibres passing
from the anterior gray matter of the pons to the horns of spinal gray matter; 13, fibres passing
frora the red nucleus of the tegmentum to the anterior horns of the spinal gray matter ; 14, fibres
escaping from the spinal cord through the anterior root of a spinal nerve; 145, fibres of the
posterior root of aspinal nerve, entering at the posterior horn of the spinal gray matter. The
dots in the cut end of the spinal cord, near to 15, indicate the relative position of the dif-
ferent tracts with which they are connected. A, A, A, represent fibres which are destined to
connect different convolutions of the cerebellar cortex (fibre: propriz).
THE CEREBELLUM. 39

That the red nucleus has no direct connection with the sensory
tracts of the central nervous system, seems to be proven by the fact that
lesions of that nucleus tend rather to disturb codrdination of movement
(probably by disturbing the relationship between the nucleus and the
cerebellum) than the conduction of sensory impulses. Atrophy of one
cerebellar hemisphere is always accompanied by a similar change in the
opposed red nucleus.

Spitzka regards the cerebellum as an “informing depot,” by which
the cerebrum is made cognizant of “the relations which the body bears
to time and space.” This author believes that all rhythmic movements
(such as dancing, etc.) and skillful feats of equilibrium are presided over
by this ganglion, Mitchell is led to think that the cerebellum is simply
a storage reservoir for nerve force.

It is stated by different observers that some filaments of the nerves
of hearing (eighth pair), and of the trigeminal (fifth pair), the motor oculi
(third pair), the abducens (fourth pair), and the pneumogastric (10th
pair), can be traced (directly or indirectly) to the cerebellum.

The masses of gray matter comprised within the cerebellum (which
have been specially named) comprise (1) the cerebellar cortea; (2) the
“nucleus of the ventricular roof” (Spitzka) or the nucleus fastigii; (8)
the nucleus emboliformis; (4) the nucleus globosus; and (5) the corpus
dentatum.

I quote from a lecture of mine, published by the Jedical Record
some ‘years ago, the following paragraphs, subject to some corrections :—

“From a standpoint of our present knowledge, the cerebellum must
be considered as the ‘terra incognita’ of the brain. The clinical evidence
is discordant. The anatomical connections of the cerebellum with other
parts of the nervous system are remarkable, and their minute structure
is, as yet, imperfectly understood. The region overlapped by the cere-
bellum is interspersed with important collections of gray matter, which
act as.nuclei of origin for important nerve tracts; so that all experiments
made upon the cerebellum itself or its peduncles are liable to cause injury
to some of the neighboring parts, and thus to yield results which are puz-
zling and unreliable. Conjecture inevitably forms an important element
in all of the theories advanced respecting the functions of the ganglion
itself, or of certain of its parts. Nothnagel claims to have demonstrated
that mechanical stimulation of the surface of the cerebellum will give rise
to muscular movement without signs of pain being perceived. He found
that these movements developed slowly, appearing first on the side oper-
ated upon and then ceasing, only to appear upon the opposite side. He
states that he has demonstrated that the fifth, facial, and hypoglossal
nerves, as well as nerves distributed to the trunk and extremities, can be
thus called into action. The same observer concludes that destruction
40 LECTURES ON NERVOUS DISEASES.

of the commissural fibres and the vermis produces incodrdination of
movement. Hitzig and Ferrier believe that injuries to the lateral lobe
produce the same varieties of ‘forced movements’ as are noticed after
section of the middle peduncle. Flourens observed that injuries to the
anterior or posterior parts of the vermis caused animals to fall forward
or backward respectively, and his views hive been confirmed by others.
Ferrier found that stimulation of the cerebellar cortex, by the inter-
rupted electric current, produced in monkeys, cats, and dogs movements
of the eyeballs, with associated movements of the head, limbs, and pupils.
Adamuck produced the same effects, however, by stimulating the corpora
quadrigemina. Hitzige refutes the view that Ferrier’s results were due to
an escape of the current by claiming to have produced similar effects by
mechanical irritation of the cortex. Eckhard has brought forward facts
which tend to show that in certain parts of the cerebellum lesions tend to
produce diabetes or simple hydruria, thus resembling the effects of irrita-
tion of the medulla in the region of the floor of the fourth ventricle.

“In the face of this conflicting mass of experimental evidence, I
mention now one of the most plausible and attractive theories respecting
the relation of the cerebellum and cerebrum to muscular contraction,
which has been advocated by Spencer and sustained by Hughlings-Jack-
son, Ross,and others. It is believed by these authors that all continuous
tonic muscular contraction is governed by the cerebellum, and the alter-
nate or clonic muscular contractions by the cerebrum, in so far as they are
required to maintain a posture or produce a change in attitude. In all
efforts to maintain an attitude (once assumed as the result of some cere-
bral impression received) the cerebellum holds the museular apparatus
in its proper state of tonicity; but when the attitude is to be changed,
for any possible reason of which the cerebrum is conscious, the proper
muscles are relaxed and others thrown into a state of contraction by
means of the higher ganglion. The body 1s then intrusted to the infiu-
ence of the cerebellum if the attitude is to be again maintained. Thus
it is suggested that the cerebellum be considered as capable of auto-
matic action, but still as a subordinate tu the cerebrum, which possesses
the power of overcoming it in one of two ways~ First, by increasing the
supply of nerve force to certain sets of cells, then under the intluence of
the cerebellum, and thus altering their action upon muscles; or second,
by inhibiting or totally arresting the cerebellar influx to the antago-
nistic sets of muscles. Both are designed, according to this view, to
act cither automatically or in unison, but the cerebellum is the servant
of the cerebrum to do its bidding when required.

“Tt will be at once perceived that this theory applies to the complex
physiological acts of walkiny; the prolonged maintenance of any given
posture ; the transfer of the centre of yravity; the passive state of groups
THE MEDULLA OBLONGATA. 41

of muscles; and many of the morbid phenomena observed in muscles, as
the result of impairment of the higher nerve centres. It will be impos-
sible to discuss all of these conditions in this connection. Hughlings-
Jackson and Ross have covered the more important points in their works.
If we form our views of the physiological functions of the cerebellum
purely from the standpoint of the anatomical connections which that
ganglion is known to possess, we cannot but agree with Bechterew in
some of the conclusion which he has lately advanced. This author he.
lieves that the cerebellum is intimately connected with three organs.
which tend to exert an influence upon equilibrium, as follows: First, the
semicircular canals, connected with the organ of hearing; second, the
organ. of sight, since the movements of the globe of the eye and possibly
the sense of vision may be traced to a relation with the gray matter in
the floor of the third ventricle and subsequently with the cerebellum;
third, the olivary gray matter, which this author thinks is probably con-
nected with the organs of tactile sensibility.

“The views of this author have been in part anticipated and sus-
tained by Spitzka, who, in an article published some years ago, con-
siders the cerebellum as the centre where ‘impressions of touch and _ po-
sition are associated with those of time and space,’ and hence the seat of
codrdination of the most delicate forms of movements; such as are neces-
sury, for instance, ‘to the proper adjustment of the druam-membrane of
the ear for the correct appreciation of sounds, the appreciation of time
and rhythm, and the finer acts of equilibrium.’ Jn filling this position,
the latter author believes that the cerebellum is subordinate to the cere-
brum, to which it acts as an ‘informing depot’ for codrdination, rather
than as a distinet centre.”

THE MEDULLA OBLONGATA.

Space will not allow of a description of the architectural details of
this very intricate structure. Its component parts may, however, be thus
classified: 1. Certain fibres which are known to pass without interruption
through its substance; thus joining the cerebrum or cerebellum with the
spinal cord.* 2. Other fibres which arise within the medulla from the
cells of its different nuclei. 3. Collections of gray matter, which are
analogous to well defined parts of the spinal gray matter. 4. Collections
of nerve cells which are destined for special cranial nerve roots; these
have no analogue in the spinal gray substance.

* The ‘ direct cerebellar fibres”’ first appear in the second or third lumbar segment,
and are continued upward to the inferior peduncle of the cerebellum. The cells of Clarke’s
column are multipolar and much smaller than those of the anterior horns. According to
Ross aud Gaskell, the homologues of these cells are observed in the nucleus of the vagus
nerve (Fig. 15).
42 LECTURES ON NERVOUS DISEASES.

Under heading (1) may be enumerated: the motor or “pyramidal
tracts” (direct and crossed); the so-called “sensory tracts” to the cere-
brum: and the ‘direct cerebellar tracts” formed indirectly through the

agency of the cells of Clarke's column within the spinal cord.

Fia. 15. Fia. 16.

 

 

 

Fic. 15.--l1AGRAM OF THE CHIRF TRACTSIN THE Mgnuiea. (After Erb.) (‘Phe formatio reticu-
laris is represented by shading.) O7., olivary body; J’ anterior; S, lateral, and //, posterior
spinal funiculi; @, pyramido-anterior tract ; @,pyramidu-lateral tract; /’y, pyramidal tract; 4,
remainder of anterior column; c, remainder of the lateral column; c¢, ¢, cerebello-lateral tract ;

SA; funiculis gracilis; and_/”, nucleus of the same; g¢, funiculus cuneatus, and g’, nucleus of the
same; /.¢.2,, internal fasciculus of the pedunc. cerebelli; /.c.e., external fasciculus of the
same; Cg./¢, tract from corp. quadr, to format. retic. ; Cg. the same to the olivary body ;
Yhal, tract from the thalamus opticus,

Fic. 16—Transparenr LATERAL View oF THE MapULLA, SHOWING THE RRLATIVE Post-
TIONS OF THE Mosr Importanr Nucrer; RiGHT HALF oF THE MEDULLA, SEEN FROM
THE SurPace oF Section; THE Parts THAT Lig Closer To THIS SURFACE ARE Dugvur
SHapvep. (After Erb.) /y, pyramidal tract ; Py. A%, decussation of pyramids ; QO, olivary
body; Q.s, superior olivary body ; /’,motor, /”, middle sensory, /’’, inferior sensory nucleus
of trigeminus; /’/, nucleus of abducens; G_/, genu facialis; /’//, nucleus facialis; /°///,
posterior median acoustic nucleus ;* /.\, glossu-pharyngeal nucleus ; .\, nucleus of vagus ;
-\/, accessorius nucleus; .\//, hypoglossal nucleus; A, nucleus of the funiculus gracilis ;
AI, trigeminus roots; those of the A’'//, abducens, and A’ ///, facialis.

*Respeeting the auditory nerve roots, Spitzka believes that the posterior auditory
root is the direct path for the transmission of sound impulses, and that the anterior audi-
tory root is a path for the transmission of impressions which assist in the determination of
equilibrium. Edinger rather inclines also to a somewhat similar view.
THE MEDULLA OBLONGATA. 43

Under (2) the following bundles might be classed: The fibres which
form the “fillet” or ‘“lemniscus tracts;” those which join the nuclei of
Goll’s and Burdach’s columns with the olivary bodies; those which
pass into the inferior cerebellar peduncles from the olivary bodies; some
fibres of the formatio reticularis; the hypoglossal, facial, and trigeminal
cerebral tracts; the so-called “speech tract,” ete.

Regarding the ultimate distribution of the fibres of the lemniscus
tract, a wide diversity of opinion between authors of note exists. Flech-
sig believes that its sensory fibres pass lateral of the red nucleus. then
into the posterior third of the internal capsule, then to the centrum ovale,
and that they end in the cortex. Others, among whom may be men-
tioned Wernicke, Forel, and Roller, believe that they end in the medul-
lary laminz of the thalamus. Others again trace fibres from this tract
to the corpora quadrigemina. (See also paragraphs on page 32.)

Under (3) and (4) come the nuclei of the cranial nerves; the olivary
bodies; the cells of the “‘formatio reticularis;” the nuclei developed at
the upper end of Goll’s and Burdach’s columns; and the accessory
olivary bodies. The two diagrams of Erb which are introduced here will
aid the reader in gaining a conception of the situation and extent of the
more important nuclei, and the course of some of the tracts of fibres
mentioned. It may be well, for one not familiar with the subject, to
compare them with Fig. 13, and also with a section of the spinal cord
which shows the situation of the columns spoken of (Fig. 32).

Note (particularly in Fig, 16) the situation of each of the nuclei, the
peculiar course of the facial fibres, the situation of the olivary body and
the superior olive, the enormous length of the inferior sensory nucleus of
the fifth cranial nerve,* aul the situation of the decussation of the “ pyra-
midal” or motor tracts.

The looping of the fibres of origin of the facial nerve around the
nucleus of the sixth cranial nerve in the medulla, has caused some ob-
servers to favor the view that these fibres are associated in some imper-
fectly understood way with the cells of that nucleus.

In Fig. 15 the reader should trace separately the course of the pyra-
midal tract (from above downward); that of the direct cerebellar tract
(from below upward); the course of the tibres derived from the nuclei of
the columns of Goll and Burdach; the various tracts that terminate in
the reticular formation, as well as those that pass through it; and, finally,
the fibres of the cerebellar peduncle.

*The trigeminus nerve is known to possess motor, sensory, and vaso-motor or secre-
tory fibres. Spitzka concludes that the vaso-motor fibres spring from sub-ependymal
nuclei; that the motor root arises in part from a continuation of the lower facial nucleus ;
and that the sensory root can be shown to arise from cells within the medulla, the cervical
segments of the spinal cord, and the cerebellum, © ‘
44 LECTURES ON NERVOUS DISEASES.

Spitzka compares the medulla to ‘a hypertrophied segment of the
cord, in which the longitudinal associating fibres outweigh in number
and length those of any other spinal segment.” He considers it as a
ganglion which presides over all reflex acts in which rhythm ws an essen-
tial factor,

Regarding the course, termination, and function of some of the sen-
sory nerve tracts depicted in this diagram, it may be well to state that
differences of opinion exist among authors of note. Whether some are
first deflected to the cerebellum (being compelled to pass through the
substance of that ganglion in order to reach their termination in the cor-
tical centres of the cerebrum) is still an open question (see Figs. 12, 14,
15, 36, and 37).

Respecting the ettects of the formation of the fourth ventricle upon
the central gray masses, Spitzka remarks, that if we start with the com-
parison of the gray substance of the cord to a capital letter H,and imagine
the vertical branches of the H to be separated posteriorly till they become
almost horizontal, the anterior horn becomes the most internal, the lateral
cornua intermediate between the anterior and the posterior, and the pos-
terior horns the most external. Thus the “motor system” is to be
sought for nearest the median line; the “mixed system” to its outer
side; and the “sensory system” becomes the outermost.

The saine author remarks, in this connection, that “as the me-
dian line of the cord becomes changed by the horizontal expansion of
the fourth ventricle in the medulla, we may surmise that the more axial
muscles will be represented by nuclei situated near the ventricular floor,
the more appendicular muscles further away from it.”

Concerning the trigeminal nerve roots and their nuclei, he also makes
the following suggestions: “On the strength of the law of segmental
harmony, we can theoretically infer that the part of the trigeminus origin
situated in the level of the cervical spinal cord corresponds to the tem-
poral cutaneous branches, which, with the upper cervical nerves that
originate at the same level, share the distribution to the occipito-temporal
region. That part which is in the level of the hypoglossal nucleus, will
presumably correspond to the distribution of the lingual branch of the
fifth. Further forwards (cephalad) in the level of the facial and motor
trigeminal nuclei, we will have the dental, mental, and infra-orbital dis-
tribution projected, and in such a way that the nerves of the upper jaw
will be above that of the lower. Still further cephalad, in the altitude
of the oculo-motor muscles, will be the centre of the ophthalmic distri-
bution area.”

The statement is now eenerally accepted by neurologists as proven,
that both the motor and sensory tracts, which unite the cerebral cortex
with the cells of the spinal gray matter, are functionally associated with
both sides of the body.
THE MEDULLA OBLONGATA. 45

The main distribution ix to that lateral half of the body which is
opposed to the cerebral hemisphere to which the fibres can be ultimately
traced. The decussation of both the motor and sensory nerve tracts is,
therefore, not complete. The motor fibres decussate at the lower part
of the medulla. Some of the sensory fibres (probably those which pre-
side over the so-called ‘* muscular sense’’) decussate also in the medulla
(called by Spitzka the ‘‘ piniform decussation,” because it occupies a cone-
shaped area in cross-sections of the medulla made at that level). Those
tracts, which convey sensations of pain, touch, and temperature, prob-
ably decussate within the substance of the spinal cord.

Fia. 17. Fig. 18.
| 3425'6' 65243 1’ C B

   
  

LOWER LIMIT OF
MEDULLA.

 

 

 

 

 

lee
Ne
a

Fic, 17.—A_DiaGramM Desicgnep sy THE AUTHOR TO SHOW THE CouRSE OF THE FIBRES
WHICH COMPOSE THE SPINAL Corp. 1,1’, direct pyramidal bundies; 2, 2’, crossed pyra-
midal bundles, decussating in medulla; 3, 3’, direct cerebellar fibres; 4,4’, fibres related to
“muscular sense,’’ decussating in medulla; 5, 5’, and 6, 6’,-fibres related to the appreciation
of touch, pain, and temperature. The motor bundles (rect) have a dot upon them to repre-
sent the motor cells of the cord (ant. horn). Note that the red fibres escape from the ante-
rior nerve root (a. ».) and that the sensory bundles enter at the posterior nerve root (f. ”.),
which have a ganglion (g) upon them. :

Fic. 18.—A DraGram or THE Lower Parr or THE Mevutta (as if transparent) ro Sirow
THE DECUSSATION OF THE Motor Bunp.es. (After Erb). a, the non-decussation bundle
(direct pyramidal fibres) ; 6, the decussating bundle (crossed pyramidal fbres The former
occupy the column of Tiirck (Figs. 19 and 29) and the latter a portion of the lateral columns
of the spinal cord (Figs. 19 and 29).

The “reticular formation” acts probably as a conductor of sensory
impulses of pain and temperature which pass cephalad to reach the cells
of the cerebral cortex where they hecome transformed into conscious re-
alities (Starr).
46 LECTURES ON NERVOUS DISEASES.

The lemniscus tract or the “ fillet”? probably conveys impressions
of muscular sense to the cerebral cortex, after the fibres related to that
sense have decussated in the medulla (Starr). (See also page 32.)

The pyramidal fibres in the medulla tend to displace in a backward
and outward direction, the fibres which probably assist to form the an-
terior root zone (Fig. 18).

Spitzka advances the view that the nuclei of origin of the spinal
accessory nerve have different functions; that within the spinal cord is
probably designed to innervate the trapezius and the sterno-mastoid
muscles; the inner accessory nucleus is associated with the fibres dis-
tributed to the larynx, and may, therefore, according to this observer,
be called the “nucleus laryngeus;” finally, the outer accessory nucleus
is termed by him the “ deglutitory nucleus,” because it apparently shares
in the motor supply of the muscles of deglutition.

The posterior longitudinal bundle becomes closely intermingled with
the interolivary tract in the medulla; hence it is impossible to distin-
guish these fibres below the level of the pons..

THE DIAGNOSTIC VALUE OF SOME OF THE SPECIAL SYMPTOMS OF
NERVOUS DERANGEMENT.

Some three years since, I published in the Medical Record, as an
abstract of lectures delivered by me, a series of articles which discussed
the various tests that have to be made at times by a neurologist to detect
the existence of organic disease in the brain, the spinal cord, and the
cerebro-spinal nerves. These articles will be reproduced in this and the
following section, with such modifications and additions as subsequent
reflection and experience on my part have suggested to me. A por-
tion of the matter included under this heading constitutes a portion of
this course of lectures. They were delivered in the New York Post-
Graduate Medical School and Hospital, and also before the classes of the
Medical Department of the University of Vermont. I quote from them
as follows :—-

‘Before the various tests which are employed by the specialist in
neurology to determine the existence of diseased states of the nerves and
muscles are separately discussed (as they will be in Section II. of this
work), it may be necessary to hastily summarize a few of the more
important facts in nervous symptomatology.

‘Not only are some of the tests, described later, complex in them-
selves, and therefore difficult of comprehension, but they would be abso-
lutely uscless in practice if the clinical bearing of each were not clearly
comprehended. For example, a physician who has acquired a smatter-
ing of nervous symptomatology may be called npon to examine a patient
who gives evidences of impairment of motor power in some part of his
body.

his patient. his spinal cord, or in some special iierve.
physician is called upon to decide (for himself at least) whether it is sit-

SPECIAL SYMPTOMS OF NERVOUS DERANGEMENT.

This paralysis may be due to some trouble either in the brain

 

Fic. 19.—A Dracram ILLustRATING THE DEVELOPMENT OF THE DIFFERENT SYSTEMS OF

FIBRES IN THE SPINAL Coxp. (After Flechsig.) A, section at level of 3d cervical nerves ; B,
at level of 5th cervical; C, at level of 6th dorsal; D, at the level of 4th lumbar nerves. 1, prin-
cipal mass of anterior columns ; 2, Burdach's columns ; 3, lateral columns; 4, lateral bound-
ary of gray substance ; 5, columns of Goll; 6, direct cerebellar columns ; 7, crossed pyramidal
columns ; 7’, Tiirck’s columns ; zv, anterior roots. Note that Tiirck’s columns disappear in
D>; that Goll’s columns increase in size from below upward; that the direct cerebellar col-
umns appear in C, and increase in size in B and A; that the crossed pyramidal columns
reach the surface in D; and that the shape of the gray substance differs in all the sections.
The numerals employed in the cuts indicate the order of development of the various parts
designated. It will be seen that the motor-tracts of the cord are the last to attain their com-

‘plete development.

47

of

If in the brain, the
48 , LECTURES ON NERVOUS DISEASES.

uated in (1) the coverings of the brain, (2) the external gray matter that
invests it like a cap (the cerebral cortex), or (3) in parts more or less dis-
tant from its exterior. It is important, from a standpoint of prognosis
and treatment, that he comes to some definite conclusion also regarding
the character of the trouble. If the disease he confined to the spinal
cord of the patient, it becomes necessary for the physician to discrimi-
nate again between affections that follow separate bundles of nerve fibres
' (systematic lesions of the cord) and those that spread transversely from
column to column (focal lesions of the cord); and to decide also as to the
height of the lesion, its pathological character, and the special regions
that are affected by it. Finally, if the paralysis be due to some spinal
nerve, the possibility cither of brain or spinal disease must be excluded,
and the cause must be sought for along the course of the nerve whose
function is impaired.

Betore I discuss the clinical tests of nervous diseases in detail, I
direct. the attention of the reader to some extracts from the chapters on
the Disenses of the Brain and Spinal Cord that are embodied in the third
edition of my work on ‘Surgical Diagnosis.’

MOTOR PARALYSIS.

Anything which tends to impuir the generating power of the nerve
centres or the conducting power of nerve fibres may produce paralysis
of motion or sensation.

“Motor paralysis (when due to a lesion affecting the cerebro-spinal
axis) can result, therefore, from any condition which interferes with the
motor conyolutions of the brain, or the nerve fibres which start from
them and are continued «as the so-called ‘motor tract.’ The latter aid
in all voluntary movements of the ertremities, They pass through the
following parts successively: (1) The white substance of the cerebral
hemispheres; (2) the corpora striata; (8) the crura cerebri; (4) the pons
Varolii; (5) the medulla oblongata; and (6) down the motor columns of
the spinal cord.

“ The disturbing lesions may be therefore classified as: (1) Those of
the gray matter of the convolutions of the brain (cortical lesions) ; (2)
those of the central mass of the cerebral hemispheres, including lesions
of the ‘‘ internal capsule ;” (3) those of the corpora striata; (4) those of
the crura cerebri; (5) those of the pons Varolii; (6) those of the medulla
oblongata; (7) those of the spinal cord.

“The various tests which are employed to determine the existence
and extent of a loss of muscular power will be given later.”
CORTICAL PARALYSIS OR SPASM. 49

CORTICAL PARALYSIS OR SPASM.

These may be dependent upon some lesion of the gray matter of the
cerebral convolutions (the cerebral cortex). They may occur in con-
nection with abscesses, blood-clots, spots of softening, tumors, depressed
bone, meningeal thickenings and exudations, embolism, thrombosis, etc

The researches of Ferrier, Luciani, Exner, Horsley, Beevor, and
others have lately taught us the situation of special motor centres scat-
tered over the convolutions of the so-called “motor area” of the cere-
brum. From this standpoint we are often enabled to judge of the seat
of the lesion by the aid of the groups of muscles which exhibit the
paralytic state (monoplegia). Hughlings-Jackson and Brown-Séquard
have added to our knowledge of the relative effects of destructive and
irritative lesions of the cerebral cortex.

“ Trritative lesions of the cerebral cortex are usually ushered in by
convulsive attacks, which leave the subject paralyzed in some special
group of muscles (monoplegia); or, if hemiplegia ensues, some parts of
the body are more affected than others. The paralysis is usually tran-
sient, and returns again after subsequent convulsive attacks. These irri-
tative lesions are particularly liable to be of syphilitic origin.

“ Destructive lesions of the cerebral cortex are characterized by
paralysis of special groups of muscles (monoplegia, or mono-anesthesia),
as was the case with the irritative lesions. This is in marked contrast to
the hemiplegia, or hemianzsthesia which follows lesions of the central
portions of the brain. If the lesion be very extensive coma may be pro-
duced, but consciousness is not usually lost unless the attack be accom-
panied by convulsions. Pain ofa local character within the head is often
complained of, and percussion over the seat of the lesion frequently elicits
it, if it should be absent. The sensibility of the paralyzed parts is not
impaired unless more or less sensory paralysis exists as a complication.
The paralyzed muscles exhibit the normal electro-contractility. As is
the case with all cerebral lesions, the paralysis is developed on the side
opposite to the exciting cause (except in very rare instances). In cor-
tical lesions of the motor area, the muscles frequently exhibit a state of
post-paralytic rigidity in the early stages of the disease. The various
types of monoplegia and the surgical guides for trephining over special
motor centres have been discussed in the Author’s work upon the anatomy
of the nervous system.

Iforsley has lately added a valuable contribution to the subject of
cortical localization, based upon experimentation on monkeys, and also
on observations in ten cases where the diseased area was successfully
determined in the human subject prior to operative procedure. IIis con-
clusions are therefore worthy of note. They may be summarized as
follows :— 4
50 LECTURES ON NERVOUS DISEASES.

1. Sulct, or fissures, are not to be regarded as accurate boundaries to
cortical areas, although they constitute valuable landmarks for operative
procedures upon the cortex.

9. The motor centres, according to this observer, are capable of
further subdivision than those described by Ferrier, and they overlap
each other at their borders.

3. The face area, taken as a whole, embraces the lower third of
both central convolutions (Fig. 4). This is subdivided into (a) an upper
and anterior portion, which controls the upper part of the face and the
angle of the mouth; (b) the anterior half of the lower portion, which
governs the movements of the vocal cords ; and (c) the posterior half of
the lower portion, which governs the lower part of the face and the floor
of the mouth.

4. The area for the upper limb occupies the middle third of both
central convolutions, and also the base of the superior and middle frontal
convolutions. It joins, and also merges with, the area for movements of
the head and neck in the middle frontal gyrus, and with that of the leg
in the superior frontal gyrus.

In the area described as pertaining to the upper limb, the uppermost
part is thought to control the muscles of the shoulder; below, and pos-
teriorly, the elbow is represented; still further below and somewhat an-
teriorly, the wrist; next in order, anteriorly, the finger-movements are
placed, and lowest of all, and posteriorly, the thumb-movements are
located. These views he substantiates by observations made in cases of
cortical tumors, where spasm was developed and appeared first in ar
isolated region of the upper limb.

5. The area for the lower limb is described by this observer as em-
bracing the upper portions of the two central convolutions; also the
whole of the superior parietal, the base of the superior frontal convo-
lutions, and the para-central lobule. This description is not materially
different from that of Ferrier (Fig. 3).

The subdivisions of this area are as yet incompleted, but the points
given are of interest to the surgeon. The movements of the big toe are
referred to the para-central lobule; those of the leg alone to the middle
part; those of the leg and arm combined to the most anterior portion.
Most of these conclusions agree in the main with those of Ferrier
(Fig. 3).

6. The area for movements of the head and neck, and also for con-
jugate deviation of the eyes, is placed by this observer (in common with
Ferrier and Munk) in the bases of the three frontal gyri (see 12, in Fig. 3).

“'. Respecting the steps required to locate the fissures of Rolando
and Sylvius upon the human subject during life (as a basis for surgical
procedures) the following conclusions are reached :—
CORTICAL PARALYSIS OR SPASM. 51

(a). The method first described by Thane for locating Rolando’s
Jissure is adopted. A careful measurement is first made along the mesial
line of the skull, starting from the root of the nose and extending to the
occipital protuberance. This distance is then halved. The fissure of
Rolando at its upper part lies one-half inch posteriorly to its central
point. A strip of flexible iron (with a movable arm placed at an angle of
sixty-seven degrees to it) is now laid upon the middle line of the head;
the point of junction of the movable arm with the mesial strip being
carefully located at the point previously determined as overlying the
upper end of Rolando’s fissure. When this is accurately done, the
movable arm marks the course of the upper two-thirds of the fissure of
Rolando, but, as the lower third tends to bend slighty backward, it does
not as clearly define the lower third of that fissure.

(b). To accurately locate the fissure of Sylvius upon the skull no
little precision is required. A few points in the bones of ‘the skull have
first to be accurately determined. These are as follows:°(1) The point
where the temporal ridge crosses the coronal ‘suture (the “stephanion”).
This can usually be felt with the finger, the coronal suture appearing to
the touch either as a depression or as a ridge lying between two grooves.
(2) Exactly midway between the stephanion and the upper border of the
zygoma, ona line drawn vertical to the zygoma toward the stephanion,
lies another point known as the “ pterton.” (3) To determine the highest
point of the suture which exists between the squamous portion of the
temporal bone and the inferior border of the parietal bone (the “ squamo-
parietal” suture) a measurement has to be made, because that suture
cannot be felt beneath the temporal muscle.

In front of the temporo-maxillary articulation, an upright upon the
line C-D in Fig. 20, would cross the zyzoma. The junction of the upper
and middie thirds of the measurement made upen such a vertical line
between the upper border of the zygoma and the ridge formed by the
temporal muscle, indicates the situation of the highest point of the
squamo-parietal suture.

The anterior limb of the Sylvian fissure starts from a point which
lies from one-half to one line (one-twenty-fourth to one-twelfth of an
inch) in front. of the “pterion.” It runs anteriorly and upward from
that point. The posterior limb passes backward and slightly upward
from the same point.

8. The sulci of the frontal lobe, and also the inter-parietal sulcus
(which limits the so-called “motor area” of the cortex posteriorly), are
next to be located upon the exterior of the skull, in order to map out
the convolutions. The guides to the sulci are as follows :—

The precentral sulcus lies somewhat behind the coronal suture and
parallel to it. It extends to about the middle of Rolando’s fissure.
52 LECTURES ON NERVOUS DISEASES,

The inferior frontal sulcus diverges from the precentral at about
the level of the temporal ridge.

The superior frontal sulcus starts at a point in the precentral gyrus
somewhat posterior to the line of the precentral sulcus if continued
upward. The exact point is about midway between the fissure of Ro-
lando, and an upward continuation of a line in the direction of the pre-
central sulcus. Its altitude in the cerebrum is slightly above the level
of a point (midway between the mesial line of the skull, and the centre
of the parietal eminence) which designates the lower nes of the superior
parietal convolution.

The inter-parielal sulcus in its ascending course starts from a point
on a level with the junction of the middle and lower thirds of Rolando’s
fissure. It turns backward on a level situated midway between the
mesial line of the skull (marked by the longitudinal fissure) and the
centre of the parietal eminence.

HEMIPLEGIA.

This condition is characterized by a paralysis of motion in one
lateral half of the body. It is often associated with more or less anzs-
thesia, but it may exist independently of it. I quote from a previous
article of my own, as follows :—

“ Hemiplegia may be produced by any lesion which interferes with
the free action of the ‘motor tract’ of fibres during their passage from
the motor convolutions of the cerebrum to the columns of the spinal cord;
and lesions of the spinal cord itself (if sufficiently high up and restricted
to a lateral half of the cord on the side which corresponds to the paral-
ysis) may also induce it.

“Tf the lesion be within the cavity of the cranium the hemiplegia
will be on the opposite side of the body; if it be spinal the hemiplegia
will be upon the same side.*

“ Hemiplegia from intracranial lesions may be the result of embolism,
thrombosis, apoplexy, softening, abscess, tumors, compression of the
brain from traumatic causes, destruction of limited portions by injury,
general pressure from inflammatory exudations, etc.

“Consciousness is generally lost when cerebral hemiplegia is de-
veloped. Convulsive attacks are not usually present at the onset of
the paralysis. The paralysis is more profound, as a rule, than that of
cortical lesions, and of longer duration. The special senses are not
infrequently involved to a greater or less degree. Other cranial nerves,
which are not associated with the special senses, may also give evidence
of being implicated by the lesion. The facial nerve is most frequently:
affected.

*This rule is not absolutely true, but the exceptions to it are so rare that it is a safe
one to follow in clinical deductions.
CROSSED AND COMPLETE PARALYSIS. D3

“By means of anatomical guides the seat and extent of an intra-
cranial lesion may often be determined with positiveness. The co-exist-
ence of impairment of sensation with motor paralysis is a valuable
diagnostic sign that the exciting lesion is within the substance of the
brain and not upon its surface. The exceptions to this rule are ex-
tremely rare.

“ The localization of non-cortical lesions is more difficult and some-
what less certain than those which are confined to the cortex. A careful
study of all the symptoms presented (when combined with «a knowledge
of modern cerebral and spinal anatomy) will often, however, lead to the
most positive deductions. It should be remembered that accuracy of
diagnosis often leads to- success in treatment of disease, and in no case
is it better exemplified than in the nerve centres.”

CROSSED PARALYSIS.

A condition in which the face or some organ of special sense gives
evidence of an impairment of a cranial nerve, while the body is simul-
taneously rendered hemiplegic on the opposite side, is termed “ crossed
paralysis ”"—the “ paralysie alterne” of the French authors. We owe
much of our knowledge of this subject to Professor Romberg, of
Berlin, who has written extensively upon it.

‘‘The more common forms of crossed paralysis are named from the
cranial nerve which exhibits an impairment of its functions. They are
as follows: First cranial nerve (olfactory) and body type; third cranial
nerve (motor oculi) and body type: fifth cranial nerve (trigeminus) and
body type; seventh cranial nerve (facial) and body type. They will be
discussed later.

“It may be well to remark in this connection that ‘crossed paral-
ysis’ is of special clinical importance, because it often imparts the most
positive information to the surgeon in regard to the seat of the intra-
eranial lesion which has produced it.”

COMPLETE PARALYSIS.

When a lesion is situated at the base of the brain, and is sufli-
ciently large to involve the motor fibres of both hemispheres, the body
may be completely paralyzed below the head.

“Various cranial nerves—chiefly the third, fifth, sixth, and seventh
—are liable to then exhibit the effects of simultaneous pressure upon
them; hence the general paralysis of the body is apt to be associated
with paralytic symptoms confined to the face.

“ Bilateral spinal lesions when situated high up in the cervical
region, may also cause a form of complete paralysis of the body—the so-
called ‘cervical paraplevia.’”
Dt LECTURES ON NEKVOUS DISEASES.

SENSORY PARALYSIS.

The sensation of special parts of the body may be so modified by
lesions of the nerve centres as to constitute a type of paralysis. The
various forms of this condition may exist independently of motor paral-
ysis, or may co-exist with it. The tests commonly employed to detect
the limits and degree of sensory paralysis will be given later.

“Sensory paralysis may be classified as follows: (1) Paralysis of
those cranial nerves which are not endowed with motor attributes; (2)
paralysis of sensory nerves below the head. The latter subdivision
comprises hemiansthesia, general anvesthesia, and local anesthesia.

 

Fic. 20.—A DiaGram J)ESIGNED BY THE AUTHOR TO ILLUSTRATE THE REGIONS OF THE
Cortex or THE Brain ASSOCIATED WITH SpeciaL PARTS oF THE Bopy, as a GuiIDE
TO THE SEAT oF Destructive Processes IN CONNECTION WITH MoToR PARALYSIS OR
Spasm.—A, 8&, dotted line to indicate the relative depth of the brain in the anterior, middle,
and posterior fossz of the skull; C, D, a line running from the cusps of the teeth of the upper
jaw to the tip of the mastoid process of the temporal bone, ‘This is useful as a base line from
which to erect vertical lines, by careful measurement during life, which shall intersect the
different centres of the brain. Trephining for the relief. of #zonoplegia and afphas7ya can
thus be performed with scientific accuracy. The circle designated in the diagram as the
speech area is related only to the wofer acts required in speech. It has no relationship to
the various forms of sensory aphasia.

The views lately advanced by Horsley (p. 49), seem to suggest that this diagram might
be modified somewhat,

“Among the various clinical evidences of lesions which affect the
sensory nerve tracts of the brain and spinal cord, the folowing may be
mentioned: (1) hypervwsthesia, or an excitation of sensibility ; (2) numb-
ness; (38) formication, or a sensation like the creeping of ants; (4) aboli-
tion of sensation, or complete anresthesin—this condition may be general
or local; (5) anosmia and hemianopsia; (6) delayed sensation, as is
evidenced hy a perceptible interval of time between the contact of a
foreign body with the skin and its conscious ‘appreciation hy the patient

 
HEMIANZSTHESIA—NUMBNESS AND FORMICATION, 55

when the eyes are closed. The pricking of the skin with a needle is a
test commonly employed to determine the latter condition.

“Some of these conditions will be now considered in their more
important aspects. Others will not be separately described, as they
would require too much space, provided such a résumé was attempted.”

HEMIAN HSTHESIA.

This condition is characterized by a loss only of sensation (not of
motion) in one lateral half of the body. It is often associated with more
or less marked hemiplegia. When hemiplegia and hemianesthesia exist
upon the same side a cerebral lesion may be strongly suspected; when
upon opposed sides, a spinal lesion probably exists.

The tests employed to determine the existence of this state and its
degrees of intensity are the same as those employed in any form of sen-
sory paralysis. They will be described later.

“ Wemianzesthesia (when not due to hysteria or spinal lesions) indi-
cates that the exciting lesion has impaired the conducting power of the
fibres associated with the so-called ‘sensory area’ of the cerebral convo-
lutions (Fig. 5). There is strong clinical evidence to sustain the opinion
that these fibres run in the posterior third of the ‘internal capsule.’
Lesions of this latter region are not infrequently the cause also of more
or less impairment of sight, smell, hearing, and taste, in addition to their
effects upon general sensation. Charcot, Ferrier, Rendu, Raymond, and
others who have studied the effects of lesions of the posterior third of
the internal capsule of the cerebrum concur in this statement.

“ Hemianesthesia is frequently accompanied by the development of
choreiform movements after the paralysis has developed. These may
assume the type of athetosis, true ataxia, or tremor. The same may
also be said of that type of hemiplegia which occurs as the result of
lesions of the internal capsule of the cerebrum. Finally, in cerebral
hemianesthesia there is usually more or less insensibility to touch, pain,
and temperature, and also abolition of muscular sensibility with complete
retention of electro-motor contractility. The mucous membranes of the
eye, nose, and mouth, are also frequently rendered anesthetic. Aphasic
symptoms have been observed to co-exist with hemianzsthesia (see
page 68).”

NUMBNESS AND FORMICATION.

In connection with sensory paralysis, a condition of numbness,
which the patient describes as feeling as if some special part was “fast
asleep” is often experienced. In others, a sensation which has been com-
pared to the “creeping of ants” over some special region is complained
of. The latter has been termed “formication.”
56 LECTURES ON NERVOUS DISEASES.

“These abnormal sensations are confined exclusively to those parts
in which the sensory nerves are more or less impaired. This impairment
may result from some lesion of the nerves after their escape from the
brain or spinal cord, or from lesions of the nerve centres which involve
their fibres of origin.

“By a careful study of the symptoms, a skilled anatomist is often
enabled to decide whether the lesion is cerebral, spinal, or confined to
special nerve trunks. This field is too extensive, however, to be consid-
ered in detail here.”

HYPERASTHESIA.

In connection with lesions of the brain and spinal cord. a condition
of excessive sensibility is sometimes encountered. It is termed “ hyper-
zesthesia.”

“Tt may exist independently of motor or sensory paralysis; or, again,
it may co-exist with them. Its clinical significance depends upon its seat
and extent and the other evidences of disturbed nervous functions which
co-exist. It will be discussed from a clinical point of view in subsequent -
pages.”

HEMIANOPSIA.

A loss of vision in one lateral half of each retina is termed * hemi-
anopsia” and “ hemianopia.” It is called “ hemiopia” hy some authors:
although incorrectly so, as that term means ‘ half-vision,” while the two
others mean what they are intended to express.

The following steps are commonly employed to detect the existence
of this symptom: Request the patient to close one eye by pressing the
lid down with the finger, and to so direct the open eye as to concentrate
its gaze upon some fixed object near to it. [I usually hold up the fore-
finger of my own hand within a foot of the patient’s open eve, and tell
him to look steadily at it.] Having donc this, take some object which is
easily seen (such as a piece of white paper) in the unemployed hand, and
move it to the right and left of the object upon which the patient is
gazing, and also above and below the object, asking the patient, in each
case, if the two objects are seen simultaneously and with distinctness,
and notice upon which side of the fixed object the patient cannot perceive
the moving object. It is self-evident that the retina is blind upon the
side opposite to that upon which the moving object is lost to sight.

The most common form of hemianopsia is that in which the nasal
half of one eye and the temporal half of the other is blind. This condi-
tion is termed homonymous hemianopsia. It is the result of pressure
upon, or actual destruction of one of the optic tracts, the pulvinar of
the thalamus, the cortex of the occipital lobe (probably the cuneus), or
the fibres that connect it with the optic tract. (This seems to be proven
by the late researches of Munk, Wernicke, Starr, Seguin, and others.)
HEMIANOPSIA. 57

 

   
 

Optic Ne res

   
    
 

RIED Saas Optic
‘ chiasm.

  

pulvinar.

Corpora quadri-
piece gemina or the

  

  
  
  
  

1 \ i
tea ml es St \ fRight tract
2 i | 4 —_—- 0.
Wernicke / . lw ernicke.
,

D

 

Cortical visual
area of right
cerebral hemi-
sphere.

Cortical visual
area of left
cerebral hemi-
sphere.

Fic. 21.—A D1iaGRAM By THE AUTHOR ExpLicaTive oF HemianopsiA. The lines (.4 and
B) indicate the fibres associated with the left cerebral hemisphere. Those of the right
hemisphere (C and 7) appear as separate lines. Both will be seen in the diagram to
pass from the retina through the following parts: The optic nerves; the crossing fibres
through the optic chiasm ; the optic tracts ; the external geniculate body ; the corpora quad-
rigemina or the ‘ pulvinar”’ of the optic thalamus ; and the internal capsule. The fibres are
shown to end in the cortex of the occipital lobes.

A lesion situated at the points designated as 1, 2, 3, 4, and 5, will cause homonymous
hemianopsia. Lesions of the right hemisphere of the cerebrum produce blindness of the
right half of each eye, and vice versa
58 LECTURES ON NERVOUS DISEASES.

Lesions at the base of the skull frequently produce this variety of
hemianopsia, if they le posteriorly to the optic chiasm. In this situa-
tion, the lesion usually produces the symptoms which are referable to
pressure upon, or destruction of the bundles of motor or sensory fibres
found in the crus and below it, or some of the nerves which escape from
the base of the. skull. Fig. 21 will aid the reader in appreciating the
clinical value of this suggestion.

‘Whenever the chiasm is affected, we meet the binasal type. Regions
ec and 6, in Fig. 21, would then be deprived of visual perceptions.

There is still one more form of hemianopsia which is occasionally
encountered, viz., the bitemporal type. This has been interpreted by

F

VISUAL AREA

   

MEDULLA.

Fic. 22.—A DraGram DesiGNED BY THE AUTHOR TO SHOW. THE GENERAL COURSE OF FIBRES
OF THE ‘Sensory’? anp *Moror Tracts,’’ AND THEIR RELATION TO CERTAIN Fas-
CICULI OF THE (pric NERVE TRACTS. Grodines from Seguin.) S, Sensory tract in posterior
region of mesocephalon, extending to O P and T, occipital, parietal, and temporal lobes of
hemispheres ; M, motor tract in basis cruris, extending to P and F, parietal and (part of)
frontal lobes of hemispheres; C Q, corpus quadrigeminum; © T, optic thalamus; N L,
nucleus lenticularis; NC, nucleus caudatus; 1, the Fibres forming the ‘‘tegmentum cruris’’
(Meynert); 2, the fibres forming the ‘basis cruris’’ (Meynert); a, fibres of the optic nerve
which become associated with the ‘‘optic centre’’ in the optic thalamus, and are subse-
quently prolonged to the * visual area”’ of the occipital convolutions of the cerebrum; 6,
optic fibres which join the cells of the “ corpora quadrigemina,"’ and are then prolonged to
the visual area of the cerebral corten.

an autopsy made upon a case intrusted to the eare of Professor H.
Knapp, of this city. It must be evident that the chances would, of
necessity, be extremely small of ever encountering a bilateral lesion
which would affect only those fibres of the optic chiasm or optic tract
which supply the temporal half of each retina. and at the same time
leave the decussating fibres intact. How, then, are we to account for
the fact that this form is sometimes met with? I would call attention
to a peculiar arrangement, of the arteries in the region of the optic
chiasm as a factor in causing this condition. It has been shown that
atheromatous degencration of the “circle of Willis” (a peculiar arrange-
HEMIANOPSIA. 59

ment of blood-vessels at the base of the brain) so impairs the elasticity
of the arteries as to create through their pulsation a type of injury to
the chiasm, so limited in its extent as to impair only the fibres dis-
tributed to the temporal halves of the retinz, and thus to create bi-
temporal hemianopsia.

Hemianopsia will be more fully discussed in connection with the
effects of lesions of the optic nerve. The diagrams introduced will, I
trust, make the facts stated clear to the mind of the reader.

 

MEDULLA

Fic. 23,—A D1racram DesIGNED BY THE AUTHOR TO SHOW SOME OF THE RELATIONS OF THE
Oprric AND OLFAcTORY NEkVE Figres ro SURROUNDING Parts. F, Frontal lobes of cere-
brum; P, parietal lobe; T, temporo-sphenoidal lobe; S$, fissure of Sylvius; R, fissure of
Rolando; O, occipital lobe; C, cerebellum; M, medulla oblongata; 1, olfactory nerve; 2,
optic chiasm ; 3, motor-oculi nerve; 4, corpora quadrigemina; 5, trigeminus nerve; a, basis
cruris; 4, tegmentum cruris. The diamonds in the occipital lobe, the cortical visual centres
of Munk, ‘The cerebellum and pons Varolii are shown as if separated from the cerebrum,
in order to made the relations of the crus to the optic tracts apparent. This diagram should
be compared with the preceding ones (Figs. 21 and 22) to make its bearings upon cerebral
localization apparent.

We may, therefore, summarize the clinical significance of this peculiar
form of blindness as follows: (a) The homonymous variety indicates
lesions affecting the optie tract or its continuation backward ; or, possibly
a lesion of the cortex of the occipital lobe of the same side. (6) The bi-
nasal variety indicates a lesion pressing upon the central portion of the
chiasm. (c) The bitemporal variety indicates atheromatous degene-
ration of the circle of Willis. Symmetrical lesions of the outer part of
the chiasm might possibly (?) also canse it.
60 LECTURES ON NERVOUS DISEASES.

APHASIA.

An impairment of the idea of language or its expression (inde-
pendent of paralysis of the tongue) constitutes this condition.

It is commonly described as of two varieties—the sensory or ‘am-
nesic form,” in which the memory of words or of symbols is more or less
effaced, and the motor or “ataxic” variety, in which the memory is per-
fect, but the subject cannot properly pronounce words, from an inability
to perfectly cobrdinate the muscles concerned in articulation.

The symptoms of this malady in either of its forms are always of
great clinical interest, because some peculiarity in each case causes it to
differ from others which may have been previously encountered.

I quote from the third edition of my work on “ Surgical Diagnosis,”
some selected paragraphs relating to this symptom, with occasional
changes in their phraseology :—

“In the amnesic variety the most familiar objects are commonly
misnamed; the subject being oftentimes aware that the error has been
committed, and yet is not able to correct it. The form which this loss
of memory takes is liable to vary with each case. As an illustration of
this, some forget only names; others only numbers. In certain reported
cases, the names of things only in dead or foreign languages were re-
tained; in others, the reverse had been observed, the patient losing all
memory of acquired tongues. Again, the sound of words often will not
be recognized when the letters which form them will; and the reverse of
this condition is not infrequently met with in aphasie subjects.

“We owe to Broca the credit of the discovery that the centre for
the codrdination of the movements of the tongue, lips, and palate, neees-
sary to articulate speech, could be located in the posterior portion or base
of the third frontal convolution; and to many of the later pathologists
the debt of overthrowing what once was the popular view, viz., that this
centre is not confined exclusively to the left cerebral hemisphere. Sub-
sequent pathological observation seems to have added strength to the
view that lesions of the ‘island of Reil,’ as well as the medullary sub-
stance which intervenes between it and the centre of Broca, must be in-
cluded in the so-called ‘motor speech area.’ The amnesic form may be
dependent likewise upon lesions of the so-called ‘sensory areas’ of the
cortex.

“ The ‘centre of Broca’ is supplied with blood by the middle cere-
bral artery. An embolus within that vessel will tend, therefore, to arrest
the circulation, of that important area, and, at the same time, it will in-
terfere more or less with the nutrition of the motor area of the cortex
and the corpus striatum—the ganglion which probably modifies all motor
impulses sent out from the brain to the muscles of the opposite side of
APHASIA. 61

the body. Now we know clinically that embolism is a frequent cause
of aphasia, and that hemiplevia almost always accompanies it. We also
know that the middle cerebral artery of the left side is the most frequent
seat of embolic obstruction. This fact helps us to interpret the devel-
opment of right hemiplegia in connection with aphasia, as is found to
exist in the large proportion of such cases. Seguin found two hundred and
forty-three cases in which right hemiplegia existed out of a total of two
hundred and sixty—left hemiplegia being present in but seventeen cases.

“Tn the ataxic variety of aphasia, the patient can usually write what
cannot be spoken, thus proving that the memory of words seen or heard
is not effaced, but rather the ability to so codrdinate the muscles of speech
as to properly pronounce them. This condition must not be confounded
with aphonia (loss of voice). Several cases have been reported where the
amnesic form has given place to the ataxic, and the lesion has been found
over the centre of Broca. It would seem, therefore, that the third frontal
convolution (although placed in close relationship with the oral and
lingual centres of Ferrier) has some imperfectly understood connection
with the memory of words, as well as with the codrdinated movements
of the apparatus of speech.

“Tf irritative or destructive lesions of the cerebral cortex exist as
the exciting cause of the aphasia, convulsions may be associated with its
development.

“Tf numbness or anesthesia co-exist with hemiplegia and aphasia, it
indicates that the ‘motor and sensory tracts’ which connect the cere-
brum with the extremities are involved, as well as the centre of speech,
or the ‘speech tract.’”

We have reason to believe that the cortical cells of the so-called “ sen-
sory area” of the cerebrum not only enable us to appreciate the many
facts telegraphed to them by the organs of smell, sight, hearing, taste,
and touch; but that each cell is able furthermore to store up such impres-
sions as it is specially designed to take cognizance of, and to recall them
at the command of the will as memories of past events.

Munk has lately demonstrated that the cortical cells of the oecipital
lobes preside over vision; and that a permanent loss of sight follows the
total destruction of these lobes. The same observer has shown, also,
when a circumferential ring of cells in the occipital lobes were not in-
cluded in the experiment (the central portions only of the lobes being
removed), that an animal will slowly regain its familiarity with surround-
ing objects through the sense of sight. A dog, for example, will learn
to again recognize faces, can be taught anew to fear the lash, to recognize
food by sight, ete. The only explanation of such facts is that the new
sight-memories are formed in place of those that were obliterated by the
operation.
62 LECTURES ON NERVOUS DISEASES,

Experimental investigation and pathological facts lead us to the
conclusion that the various forms of memories recognized are stored up
in those cortical cells which were originally thrown into activity by the
fact remembered. Thus, for example, the cells of the area of hearing
- give to us our memories of sound; those of the sight area our memories
of visual impressions; and those of the smell area our memories of odor.
Some remarkable clinical facts sustain the view that the cells of the motor
area even are capable of giving to us memories of muscular efforts. These
are totally distinct from other forms of memory. Professor Charcot lately
reported a case where a gentleman could read by tracing the lines with
his finger, when a lesion of the brain had deprived him of his ability
to recognize written or printed characters by sight. He could write with
ease, but could read what he had written only by retracing the lines, or
going through the motions necessary to reproduce the letters.

Dr. M. A. Starr has lately written two popular articles,* in which
the physiology of speech is discussed at some length. It is illustrated
with some admirable diagrams. This author cites many interesting cases
which illustrate the various types of aphasia, and he supports the view
that the parietal convolutions, which are not related to muscular move-
ments, are the seat of our conscious appreciation of tactile impressions
and of touch-memories. Ross, Hughlings-Jackson, Bastian, Broadbent,
Kussmaul, and others, have written extensively upon this subject.

Much light has been shed by recent investigations upon those cases
of aphasia where the ability to respond to spoken questions has been
destroyed by focal lesions of the brain, and the patient has still been
able to appreciate written interrogations and to reply to the same. Cases
also where the reverse has been observed, are now understood.

The condition known as “ word-deafness” is to be clinically regarded
as a symptom of a lesion affecting the superior temporal convolution, in
which the centres of hearing are situated. The condition known as
“ word-blindness”’ indicates a lesion of the occipital lobes.

The centre of Broca must, therefore, be regarded as related exclu-
sively to motor speech memories, which can be called into activity by the
different parts of the cortex in case any impression received by them
demands a verbal response.

We are in possession of facts to-day that render it certain that the
nuclei of origin within the medulla oblongata of the nerves which preside
over the tongue, lips, and palate, are connected with those cortical cen-
tres that are functionally related to speech by the fibres of the so-called
“speech tract.” Wernicke has lately traced the course of these fibres by
a study of reported cases which bear upon this field. He places them in
the posterior part of the internal capsule (Fig. 24), and states that they

* Popular Science Monthly, Sept., 1884; Princeton Review, May, 1886.
PARAPHASIA—-TRUE MOTOR APHASIA. 63

pass also through the external capsule to reach the third frontal convo-
lution, This discovery enables us to explain the co-existence of aphasia
with hemianzsthesia and hemianopsia, which has been observed. It also
clears up those cases where lesions of the crus, pons, and medulla have
produced aphasic symptoms. The “speech tract”? must not be con-
founded with the cerebral extension of fibres of the hypoglossal nerve,
which have a different course.

Clinically, we may be called upon to recognize the following varie-
ties of defective speech produced by brain lesions :—

(1) Moror or “ Araxic” APHastA. Paraphasia.

(2) Sunsory or “ AMNESIC” APHASIA. . et ocemne teens
Word-blindness.

Agraphia.

PARAPHASIA.

This is a condition where the substitution of wrong words or symbols
occurs in conversation or during attempts at writing. The patient is
conscious of this error, but is unable to correct it. Nouns are more
frequently lost than verbs. Patients of this type often exercise great
ingenuity in avoiding, during conversation or writing, the words which
they are liable to fail in properly recalling. By means of oddly-con.
structed sentences they will often hide this defect in speech from
strangers. A good test often for such cases is to request the patient
to say his alphabet, and to count until requested to cease. These pa-
tients will probably substitute wrong letters or figures for the proper
ones.

Paraphasia is due to a lesion of the island of Reil. On the left side
of the brain in right-handed subjects, or vice versa.

TRUE MOTOR APHASIA.

This condition is due to a lesion in the centre of Broca (third
frontal convolution).

These patients cannot articulate correctly. They are painfully con-
scious of this defect; hence they frequently become mute rather than
to expose themselves to criticism or ridicule. I have known such
patients to be deemed a melancholiac because they could not be induced
to talk.

In case certain words are retained or regained after the attack, these
words or expressions are used in a peculiarly automatic way by the
patient in reply to any question asked. It is not uncommon for a
patient with motor aphasia to use some absurdly irrelevant phrase as an
answer to any question which may be propounded. Occasionally, this
phrase may be traced to some peculiar expression which existed in the
64 LECTURES ON NERVOUS DISEASES.

mind of the patient at the time when the attack occurred. As examples,
a case is reported by Hammond where a patient would reply “hell to
pay ” under all cireumstances; and another by Hughlings-Jackson where
the unyarying reply was, “1 want protection.”

AGRAPHIA.

This term is applied to a condition where, from cerebral disease or
other causes, the power of writing is suddenly or gradually lost.

The explanation of this condition rests in the fact that the patient
has lost certain memories which previously enabled him to make the
necessary finger movements for placing upon paper results obtained by
his mental processes.

Such a person might be able to perform any or all movements of
the fingers (that are not connected with the writing of letters or figures)
with his accustomed delicacy. He cannot write from dictation, or copy
from a printed or written slip. He is not paralyzed, nor is he affected
with “ writers’ cramp.” The memory is alone at fault; hence this con-
dition is a variety of ‘amnesic aphasia.”

In some instances, delicate finger movements required in the me-
chanical trades, the use of musical instruments, ete., have been known to
be suddenly taken away from a similar loss of motor-memories, Such
cases are not included under the term “agraphia.”

WORD-DEAFNESS.

This is a form of sensory aphasia which is dne to a lesion of the first
temporal convolution. These patients cannot be made to understand
spoken language, because their centres of hearing have been impaired.
They are not deaf to sound, but they fail to appreciate the meaning of
certain sounds. Their own tongue is as unintelligible to them as a
foreign language.

This condition prevents the patient from speaking correctly, because
of an inability on his part to recall the proper sound of many words pre-
viously employed by him. Their efforts to talk or to read aloud, result
in an “ unintelligible jargon” which the patient does not recognize as in
any respect unnatural or inexpressive of ideas he desires to commnu-
nicate to you, because his ear does not properly interpret his own
utterances.

You may test such a patient, therefore, by asking him to read aloud
some printed selection, or to write at your dictation. With neither of
these tests will he be able to fully comply.

Starr quotes from Broadbent the following illustrative case:—

“One such person was asked to read the sentence, ‘You may receive
a report from other sources of a supposed attack on a British consul-
WORD-BLINDNESS. 65

general. The affair is, however, unworthy of consideration.’ He rend it
slowly, and in a jerky manner, as nearly as could be taken down, thus:
‘So sur wisjee coz wenement apripsy fro freuz fenement wiz a seconce
coz foz no Sophias a the freckled pothy conollied. This affair eh oh
cont oh curly of consequences.’ It was evidently an effort to rend aloud,
requiring close attention, and he read seriously and steadily, apparently
unconscious of the shinrdiity of his utterances, till interrupted by
laughter, which it was impossible to restrain. He was never able to
write at dictation, but he signed his name quite well, and could copy
accurately, though as he wrote each letter he would attempt to name it
aloud, but always pronounced a wrong letter.”

WORD-BLINDNESS.

This is another form of sensory aphasia. It is due to a lesion of
the visual centres in the occipital lobes. It is accompanied by a loss of
memory of the meaning of prinied or written symbols. Such patients can
generally recognize familiar. objects or faces, but they cannot read cor-
rectly.

When asked to read a printed selection or a written slip, their inter-
pretation is an incorrect one. They can often write from dictation, but
they cannot read what they have written. Their conversational powers
are not impaired unless “ word-deafness ” is also present.

The following illustrative case is quoted by Starr, from a contri-
bution of Ross upon this condition :— :

““One man who had suttered from this affection seemed at first un-
conscious of his actual condition. When asked to read he would make
very elaborate preparations, putting on his spectacles and moving the
paper or book backward and forward until he seemed to get it into a
position where he could see well. He would then read aloud, uttering a
few sentences which had not the remotest connection with anything that
was before him on the printed page. He was handed a note which read
as follows: ‘Dear Sir, I shall be much obliged if you will let me know
whether or not you consider it likely that A. B. will recover.’ He looked
at it carefully, and seemed to glance it through, and then read slowly
and deliberately, and without much hesitation: ‘Dear Sir, You are re-
quested to bring this note with you the next time you come to the in-
lirmary;’ and then he added, ‘that is what I make of it; I don’t know
whether it is right or not.’ He often tried to read a newspaper aloud,
and his wife said that he ‘read a lot of stuff all made up out of his own
head.’ On one occasion she took the paper and read it to him. He was
very quiet for a time, and then asked, ‘Is that what it says in that paper?’
and when she assured him that it was, he said,‘ Well, then, I must be an
idiot.’ At that time he would remark, ‘I don’t know what is the matter

5
66 LECTURES ON NERVOUS DISEASES.

with the newspapers nowsdays, they are filled with such silly stuff.’
Soon, however, he began to maalize that the trouble lay in himself rather
than in the papers, and then he gave up attempting to read.”

It ig not uncommon to encounter this form of aphasia in conjunction
with word-deafness, a fact which is easily explained by the close prox-
imity of the visual and auditory centres (see Fig. 5).

GENERAL DEDUCTIONS RELATIVE TO APHASIA.

In summary, the following deductions relative to disorders of speech
may be given :—

1. The cortex of the posterior part of the third frontal convolution,
and possibly the island of Reil also, presides over the codrdination of such
muscular acts as are necessary to speech. It also stores the memories of
such acts, so that any combination of articulate sounds can be voluntarily
seitoduend when the proper form of excitation is furnished (chiefly in
response to sight or sound-impressions).

This centre is connected by “ associating fibres” with the centres of
hearing (first temporal convolution) and those of sight (the occipital con-
volutions). It is also put in communication with the nuclei of the facial,
hypoglossal, pneumogastric, and glosso-pharyngeal nerves (within the
medulla) by means of two distinct tracts of fibres, viz., the ‘ hypoglossal
cerebral tract,” and the so-called ‘‘speech tract.”

Thus, this cortical centre of codrdinated speech-movements is ca-
pable of receiving excitation from the centres of hearing, when replies
to spoken language are demanded; and from the centres of sight, when
written or printed language calls for a verbal response. It is also put in
direct communication with the nerves which preside over the apparatus
of speech (whose nuclei of origin are situated within the medulla).

2. The form of amnesic aphasia, known as ‘* word-deafness” (Kuss-
maul) indicates the existence of a lesion of the first temporal convolu-
tion* of the left side, which has impaired the memories of spoken lan-
guage. Hearing may not be impaired, in spite of the fact that the appre-
ciation of words, music, etc., may be totally absent.

3. The condition known as “ word-blindness” (Kussmaul) indicates
the existence of a lesion of the left occipital convolutions, which has im-
paired the memories of written or printed symbols of language, numerals,
familiar objects, etc.

4. The condition termed “ paraphasia” by Kussmaul (in which the
amnesic and ataxic varieties of aphasia seem to be peculiarly combined)
may be excited by a lesion which interferes with the action of the asso-

*In right-handed subjects the left hemisphere, and in left-handed subjects the right
hemisphere, secnis to monopolize the function ef sound-interpretation to the speech centre.
GENERAL DEDUCTIONS RELATIVE TO APHASIA. 67

ciating tracts of fibres between the areas of hearing or sight and the
motor speech centre of Broca (Wernicke).

5. The condition of imperfect speech, termed “ anarthria,” is pro-
duced by a lesion of the medulla, which interferes with the functions of
the nuclei of the cranial nerves associated with’speech. It is occasionally
observed in connection with focal lesions of the floor of the fourth ven-
tricle. These cases are to be differentiated from aphasia of cortical origin
by the co-existence of other symptoms produced by the medullary lesion
(see subsequent page).

6. In order to properly pronounce any word, it is essential that
both the cortical centre of speech, and also the nuclei of the medulla,
which are associated with it, must be called into action.

  

ASSOCIATING-~
TRACT

   
   
  

THE SO-CALLED --—-|
"SPEECH TRACT“

  

»)-~1 > WUCLE! OF ORIGIN
—[--- OF NERVES

-“EMPLOYED JN SPEECH

Fic. 24.—A DiaGcram DESIGNED BY THE AUTHOR TO ILLUSTRATE THE MECHANISM OF THE
APPARATUS REQUIRED IN SPEECH.—The reader must not regard this diagram as intended
to accurately portray the anatomical relations of the various centres and tracts to each other.

7, The peculiar course which the fibres of the “ speech tract” take
within the cerebral hemisphere, sheds light upon those reported cases of
aphasia where the lesion was situated posterior to the centre of Broca,
These fibres run from the third frontal gyrus close to the surface of the
hemisphere, and in an antero-posterior direction (passing in the external
capsule) to reach the posterior part of the lenticular nucleus. They dip
at this point into the posterior part of the internal capsule. They then
pass through the middle part of the crus and pons to the medulla
“SUOISO[ UIVAG [vOOJ JO sIsOUSvIp oy} Suroods
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puy SuLIwaT JO arjuad ayy Useayoq sauqy’ Busporo0ssy oy} UIA, “ET

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09 0} 9IG¥IT 9 pom ‘vison seuviMy 10 ‘eisdouvtutay ‘aznsdpo pousay
“ut ayy fo worsa, B Jo yNser v sv ‘padoteasp eq visvqde prnoyg °s
‘qov1y ATosuas at} JO oso}
pue saiqy odo oq} waemjaq (aaadasO stg} 0} Surpso998) AIT .,40¥r4
qooods ,. of Jo saiqn ey? ‘afnsdvo peurequ ay] UTA “(@yPrute AA )

“SUSVESIG SQOAWAN NO SAUNA LOgT 89
CORTICAL LESIONS OF THE CEREBRUM. 69

Frequent references will be made in subsequent sections of this
volume, to these clinical deductions ; hence the importance of a thorough
mastery of the closing pages of this section cannot be too strongly im-
pressed upon the reader.

CORTICAL LESIONS OF THE CEREBRUM.

Lesions of the motor convolutions, when of small size, produce some
form of monoplegia, or mono-anesthesia; when of large size, a hemi-
plegia may be produced.

Consciousness ix not necessarily lost at the time of the attack. Asa
rule, the patient is not rendered totally unconscious.

Early rigidity of the paralyzed muscles is often present. This is
probably due to irritation of the cortex. .

Cortical hemianesthesia will be produced when the entire parictal
cortex is involved by a cortical lesion, and, in addition, the balance also
of the motor area, which lies outside of the parietal lobe. Such an ex-
tensive cortical lesion is rarely, if ever, encountered. We, therefore, do
not observe co-existing hemiplegia and complete hemianesthesia in cor-
tical disease.*

Localized pain in the head is a symptom which is often present in
connection with cortical lesions. If it be absent, percussion over the
lesion will generally tend to excite. This step will also tend to incréase
the pain, in many cases, where it exists prior to this test.

* The experiments of Munk, made with a view of determining the area of common sen-
- sation in the cerebral cortex, lead to the conclusion that the entire parietal cortex must. be
destroyed, and the ascending frontal convolution as well, before complete and permanent an-
zsthesia is produced on the opposite side of the body below the head. These results make
the motor area overlap the sensory area to some extent, and tend to refute the deductions
of Ferrier, who places the centre of tactile sensations in the temporal lobe, and to confirm
the views held by Luciani and Exner. Ifa partial destruction of the sensory area of Munk
be produced in animals, the anesthesia persists only for a few weeks, because the adjacent
regions learn to perform vicariously the functions of the part destroyed.

Tripier, of Montpellier, France, has lately affirmed the conclusions of Munk, respect-
ing the existence of sensory centres in the central convolutions, as has, also, Moeli, of
Berlin. | These three observers support the view that the motor and sensory centres of any
one limb coincide. This view was advanced theoretically by Luys some years ago.

Exner has collected from European journals all cases of cortical disease that have
been associated with disturbances of sensation, and M. Allen Starr has lately performed
the same labor in American literature. An analysis of the cases so collected seems to
justify the conclusions of Munk and his followers, and to add some clinical suggestions of
value. These cases demonstrate (1) that the cerebral cortex of each hemisphere appreci-
ates sensory impressions from both sides of the body, but are chiefly associated with the
sensory tracts of the opposite lateral half of the body; (2) that the sensory area includes
the central convolutions (Fig. 4) and the posterior part of the parietal lobe; (3) that the
sensory centres coincide to some extent with the motor centres of similar parts; (+) that
no disturbances of geueral sensation have been known to result from lesious continued to
the frontal, temporo-sphenoidal, or occipital lobes.
70 LECTURES ON NERVOUS DISEASES.

Convulsions, when followed by transient attacks of paralysis (Jack.
sonian epilepsy), indicate an irritative lesion of the cortex. They are
frequently encountered in connection with syphilitic disease of the brain.
- Subjective sensations (paresthesie) may also be excited in limited por-
tions of the limbs.

Blindness of that half of each retina, which corresponds to the cere-
bral hemisphere affected, occurs when extensive cortical disease of the
euneus in the occipital lobe is present. ‘“ Word-blindness” may also be
produced by lesions of these lobes (especially if upon the left side).

Abolition of hearing, and also the condition known as ‘“ word-deaf-
ness” occur from lesions of the first temporal convolution (chiefly upon
the left side).

Abolition of the sense of smell, or of taste, may result from lesions of
the tip of the temporal lobe. The memories of taste-and-smell-percep-
tions may also be impaired or lost.

Alaxie aphasia and paraphasia may be developed as a result of cor-
tical lesions, which involve respectively the speech centre of Broca and
the island of Reil.

The face is never rendered totally hemiplegic by cortical lesions;
as far as my clinical observation and research among reported cases goes
to show.

The conditions known as “ mono-anesthesia,” by which we mean an
impairment, or total arrest of sensation in some distinctly localized part,
as, for example, the hand, arm, leg, etc., and, also, the condition known
as “ mono-paresthesia,” which signifies the existence of subjective sensa-
tions of a definitely localized character, are particularly diagnostic of
cortical lesions lying posterior to the fissure of Rolando. The former
indicates a destructive lesion, the latter an irritative lesion.

The muscular sense is liable to be impaired (when a cortical lesion
of the motor area exists) in the parts functionally associated with the
limits of the part diseased.

Monoplegia and monospasm are pecularly diagnostic of a cortical
disease anterior to the fissure of Rolando,

The memories of sensory impressions are more frequently impaired
by cortical lesions of the left hemisphere than of the right (as shown, for
example, in ataxic aphasia, word-blindness, word-deafness, paraphasia,
etc).

Motor memories may be impaired by cortical disease affecting the
motor area. Subjects may thus lose a dexterity with the fingers, arm,
hand, leg, ete., which they had acquired previous to the development of
the lesion. A knowledge of this fact may sometimes aid in the locali-
zation of a lesion.

Irritative lesions of the cortex of the cuneus (a part of the occipital
CORTICAL LESIONS OF THE CEREBRUM. 71

lobes) may cause hallucinations of vision. If one hemisphere only is
affected, the objects seen will appear to lie on the side opposed to the
lesion, and to move with the eyes as they are turned from side to side.

Lesions of the “island of Reil,” or “ insula” of the left side (Fig. 9),
seem to create (in some instances) symptoms of ataxic aphasia, and also
paraphasia (the substitution of wrong words). The motility of the face
and arm of the opposed side may occasionally be impaired from cortical
lesions of this region.

Lesions of the cortex confined to the apex of the temporal lobe (Fig.
3) are liable to cause an impairment of the sense of smell or of taste (if
destructive in character); or subjective odors and tastes (if irritative in
character).

 

 

 

2);—M-—_——_

Se
._ MEDULLA

 

 

 

 

Fic. 25.—A Dracram Desicnep To ILLUSTRATE THE GENERAL CouRSE AND DISTRIBUTION
oF tHE Motor AND SENSORY TRACTS OF THE CEREBRUM. (Modified slightly from Seguin.)
P, Parietal lobes, F, frontal lobes, T, temporal lobes; O, occipital lobes ; M, motor bundles ,
S, sensory bundles, N C, nucleus caudatus ; N L, nucleus lenticularis ; O T, optic thala-
mus, C Q, corpora quadrigemina , 1, sensory (posterior) bundles of the medulla, pons, and
crus; 2, motor (anterior) bundles of the same. Note that the motor fibres are associated with
the frontal and parietal lobes; and the sensory fibres with the parietal, temporal, and oc-
cipital lobes

Destructive lesions of the cortex of the motor convolutions (Fig. 5)
are followed by a descending degeneration of the fibres which arise from
these gyri. This may account (?) for the late rigidity of the muscles
paralyzed, which is occasionally observed after such lesions.

Cortical lesions of the base of the brain are especially liable to pro-
duce vomiting, choked disc, bilateral paralysis, and symptoms of impair-
2 LECTURES ON NERVOUS DISEASES.

ment of some of thé cranial nerve trunks. The crus, pons, and island of
Reil may also be involved and give additional symptoms.

Cortical disease of those frontal gyri which lie anteriorly to the
motor centres (Fig. 5) is often attended with no marked symptoms of a
diagnostic character. The higher mental faculties may occasionally give
signs of more or less impairment. Connected thought, the control of
the emotions, accurate reasoning, and concentration of the attention are
particularly difficult under such circumstances.

The memories of sound- or sight-impressions, as well as those of
smell, taste, muscular movements, etc., may be separately annihilated by
cortical disease (see Fig. 5).

NON-CORTICAL LESIONS OF THE CEREBRUM.

Many of the clinical facts pertaining to non-cortical cerebral lesions
may be thus summarized :—

Profound coma is more often encountered in non-cortical lesions
than in cortical; possibly because the cerebro-spinal fluid is more liable
to be displaced from the ventricles (Duret).

Hemiplegia commonly exists in combination with more or less hemi-
anesthesia, and paresis of the lower part of the face. These symptoms
are observed, as a rule, upon the side of the hody opposed to the cere-
bral lesion.

Pain, when present in the head, is less circumscribed than in cor-
tical disease ; and is not increased by percussion; or, when absent, elicited
by that step.

Muscular rigidity in the paralyzed muscles develops late. Typical
monoplegia is probably never observed.

Tremor, hemichorea, and athetosis are not uncommon sequele of
non-cortical cerebral lesions.

The senses of sight, smell, hearing, and tactile sensibility are occa-
sionally impaired to a greater or less extent by non-cortical lesions. The
seat of the lesion will modify the evidences of such impairment, because
the fibres of some of the cranial nerves may be involved by the lesion,
while others may escape injury.

Typical attacks of Jacksonian epilepsy do not occur; although gen-
eral convulsions may be excited,

LESIONS OF THE EXTERNAL CAPSULE.

These may cause (if within the left cerebral hemisphere) the con-
dition of paraphasia, which has been previously described. This is due
to the fact that the “speech tract” probably passes through it before it
enters the internal capsule
LESIONS OF THE INTERNAL CAPSULE, ETC. 73

LESIONS OF THE INTERNAL CAPSULE.

These often result in the development of hemiplegia, hemianaes-
thesia, or a combination of the two. Hemiparalysis of the lower half of
the face may be produced. The nerve fibres of sight, hearing, and smell,
and the so-called “speech tract” may be implicated. Conjugate deviation
of the head and eyes is not infrequent. ‘“Choked disc” may accompany
this condition, because it is a clinical evidence of an excess of intra-
cranial pressure, The different forms of tremor already mentioned are
most common when the internal capsule is implicated, Paraphasia may
be induced, if the “ speech tract’ is involved.

LESIONS OF THE CAUDATE NUCLEUS.

These are seldom, if ever, associated with hemianzsthesia. Hemi-
plegia, if developed, is probably due to pressure upon the motor fibres
of the internal capsule. The face may develop paralysis in its lower part
upon the opposed side for the same reason.

Many of the symptoms enumerated above (as indicative of a cap-
sular lesion) may exist also when the caudate nucleus, the lenticular

nucleus, or the thalamus, are individually attacked by any lesion which
' markedly increases their size, and thus creates pressure upon the fibres
of the internal capsule (see page 22).

LESIONS OF THE LENTICULAR NUCLEUS.

- These chiefly affect motility. Hemianzsthesia may occur if the pos-
terior capsular fibres be pressed upon.
Hallucinations are very common in connection with disease of the
thalamus (Ritti). The senses of sight, hearing, smell, and tactile sensi-
bility are perhaps more liable to be affected than motility.

: LESIONS OF THE CRUS CEREBRI.

The symptoms which point to a lesion of the crus (Fig: 11) may be
summarized as follows :—

Crossed paralysis of the “third nerve and body type” never occurs
except from a lesion of the crus.

If the lesion be confined to the legmentum cruris (the sensory por-
tion), hemianesthesia of the opposite side will ensue, and the third and
fifth cranial nerves of the same side may possibly be paralyzed. Inco-
érdination may be developed; provided that the fillet (lemniscus) is in-
volved.

If the crusta cruris (the motor portion) be alone suciiivedl, paralysis
of the third nerve will generally co-exist with hemiplegia on fhe opposed
side. The lower part of the face may be rendered paretic, in some in-
stances, showiug that filaments of origin of the facial nerve are impaired.
74 LECTURES ON NERVOUS DISEASES.

Symptoms referable to lesions of the corpora quadrigemina may
be developed in connection with lesions of the teqgmentum cruris (Fig.
11). Among these, the following may be prominently mentioned: Inco-
drdination of movement; sbolition of the pupillary reflex; nystagmus ;
and strabismus. Blindness may be found to exist independent of the
presence of a choked disc, atrophy of the optic nerve, or an optic neu-
ritis.

  
 

ass } Line of Gubler.

(3

MEDULLA
Fic. 26—A Dracram oF THE Base oF THE Brain, DesicNep To SHOW THE Parts Ap-
JACENT TO THE OPTIC NERVE TRACTS AND CHIASM,—The nerves are represented by
their respective numbers. , optic; III., motor oculi's- 1V., trachlearis; V. » trigeminus ,
VI., abducens; C, crus ca of each hemisphere ; 3b, infundibulum, the pituitary body
being cut off to'show the optic chiasm; a, the corpus albicans (mamillary tubercle) ; 4, ex-
ternal geniculate body ; z, internal geniculate body. The dotted line which crosses the pons
Varolii, connecting the roots of the fifth nerves, is Gubler’s line, an important guide, since
lesions of the pons in front of it cause ‘ crossed facial paralysis.” Lesions in the region of
thecrwsmay involve the third and second nerves simultaneously, Lesions about the chiasm
may press upon the corpus striatum within the mass of the cerebrum, ‘lhe crus comprises

both the motor and sensory tracts of the cerebrum,

LESIONS OF THE PONS VAROLII,

Apoplectic clots and foci of softening are not infrequently met with
in this region (Fig. 18), and tumors are sometimes encountered. Certain
clinical deductions of value can be drawn from a study of reported lesions
of the pons, as follows :—

The imaginary line that connects the apparent origin of the tri--
geminal roots (line of Gubler) marks the level of decussation of the
fibres of the facial nerves that pass cephalad.

Lesions above the line of Gubler are liable to produce facial palsy and
hemiplegia upon the same side of the body (the one opposed to the lesion).

 
LESIONS OF THE PONS VAROLII. 75

Lesions below the line of Gubler produce * crossed paralysis of the
seventh nerve and body type,” the face being paralyzed upon the same
side as the lesion, while a hemiplegia is developed upon the opposed side
of the body.

The trigeminus nerve may be paralyzed by lesions of the pons, if it
lies within the inner two-thirds of the reticular formation (according to
the researches of Starr).

If such a lesion be situated high up in the pons, trigeminal paralysis
will co-exist with a hemianesthesia of the opposed half of the body; if
situated low in the pons, the trigeminal paralysis and the hemianesthesia
will be upon the same side. The point of union of the ascending and
descending roots of the fifth nerve is nearly at the level at which the fifth
nerve escapes from the pons (line of Gubler).

Difficulties of articulation may often be considered as diagnostic
of lesions of the pons or medulla, provided the presence of aphasia of
cerebral origin can be excluded by the history of the case. There is
unquestionably a tract of fibres (the motor speech tract) that serves to
connect the centres in the medulla with the cortical centres for the move-
ments of the face and tongue.

Conjugate deviation of the eyes may accompany a lesion of the pons.
This symptom is not pathognomonic, however, because it may occur also
with cortical lesions of the cerebrum and lesions of the internal capsule.

The motor, sensory, and vaso-motor effects of lesions within the
pons are manifested in the extremities, chiefly, but not exclusively, upon
the side opposed to the lesion. This is not the case with those cranial
nerves whose fibres of origin probably traverse the pons (the fifth, sixth,
seventh, eighth [7], eleventh [7], and twelfth). The effects of intrapon-
tine disease upon some of these nerves, at least, are modified by the seat
of the lesion, as has been shown in preceding ‘paragraphs.

Contraction of the pupils during an apoplectic attack is to be re-
garded as strongly diagnostic of a clot within the pons.

Hemorrhage into the pons is usually followed by coma and sudden
death, if the clot be large or if the blood escape into the fourth ventricle.
The diagnostic points mentioned above apply, therefore, more particularly
to foci of softening and destructive lesions of small size and slow devel-
opment. When blood escapes into the fourth ventricle, convulsions are
observed, and death is liable to follow rapidly.

Disturbances of the circulatory and respiratory functions may occur
in connection with lesions of the pons; but they are to be regarded rather
as evidences that the medulla oblongata is directly implicated or sub-
jected to pressure.
76 LECTURES ON NERVOUS DISEASES.

LESIONS OF THE CEREBELLUM.

The functional attributes of this ganglion are as yet imperfectly
determined, and the effects of lesions (tumors, hemorrhage, softening,
atrophy,and sclerosis) which involve its different regions vary with their
seat. The following deductions are chiefly those of Nothnagel, who has
devoted special attention to diseases of this ganglion. Seguin has also
lately contributed to this field a valuable article.

Lesions of one of the cerebellar hemispheres are often incapable of
diagnosis, especially if only one hemisphere be involved.

Lesions of the vermiform process are generally attended with symp-
toms of a more decided character.

Incoérdination af movement, an intense vertigo (identical with that
of Ménitre’s disease), and a ‘“ titubating gait,’ are the more common
effects of cerebellar lesions; but these are not in themselves pathogno-
monic of cerebellar disease, because they may he produced by lesions of
other parts of the brain. The consideration of all the morbid phe-
nomena of each case (both of a positive and negative character) is
required to render the diagnosis certain.

A staggering qait is especially liable to be developed in case the
“worm” of the cerebellum is directly involved, or is pressed upon by
lesions of adjacent parts. It only exists when the subject is in the upright
posture, and the ataxic symptoms rarely affects the delicate movements
of the fingers.

Gastric crises (chiefly exhibited by persistent vomiting) are a diag-
nostic feature of lesions of the cerebellum, in many cases. When de-
structive lesions of the cerebellum exist, vomiting is less frequently
observed than when that ganglion is encroached upon by lesions of other
parts.

Atrophy of the cerebellum has been observed to produce imperfec-
lions of speech (ANARTHRIA). The difficulty seems to be confined ex-
clusively to the motor apparatus, The memory of words is not disturbed.
It is probably to be attributed to interference with the “speech tract”
(Fig. 24).

Pain in the occipital region is often present in cerebellar disease. It
may exist also in the frontal region, or be entirely wanting.

The organ of vision may be affected. Occasionally, the eyes may
exhibit, incodrdination of movement and nystagmus; and also the evi-
dences of choked disc, amblyopia, and amaurosis.

Hemorrhage into the cerebellum is sometimes associated with a loss
of facial expression, due toa slight paresis. The patient may also ex-
hibit a tendency to assume one position, and to return to it when moved
by the attendants. Should hemiplegia oceur, in such a case, it indicates
’

LESIONS OF THE MEDULLA OBLONGATA. 77

that the lesion exerts pressure-effects upon the pyramidal tracts, either in
the crus, pons, or medulla.

Irregularity of the heart’s action, which is sometimes observed in
connection with a cerebellar lesion, indicates a pressure upon the cardio-
inhibitory centre of the medulla.

Abnormal mental symptoms are generally absent in connection with
cerebellar lesions. When atrophy of the organ is present, or when other
parts of the brain are diseased simultaneously with the cerebellum, mental
derangements may be observed.

When the middle crura of the cerebellum (going to the pons) are
affected by lesions which create irritation, rotary movements of the body
and a lateral deflection of the head and eyes may be developed. As
a rule, these rotary movements are toward the healthy side; but this is
not invariably the case, as they sometimes are toward the side upon
which the lesion is situated. It is a curious fact that most of the effects
of cerebellar lesions are attributable to a greater or less extent to irrita-
tion of the crura.

Lesions of the superior peduncle of the cerebellum are liable to in-
duce paralysis of the motor oculi nerve, as shown by the development of
ptosis, external strabismus, and dilatation of the pupil. Hemianzsthesia
and more or less ataxia may be induced by pressure upon the tegmentum
and the fillet tract (lemniscus) respectively.

“ Bulbar symptoms” may develop late in the course of a cerebellar
lesion. Such phenomena are usually attributable to obliteration of the
vertebral and basilar arteries and their branches, as a result of arteritis
obliterans (Seguin).

LESIONS OF THE MEDULLA OBLONGATA.

The size of this ganglion almost precludes the existence of lesions,
even if small, which do not influence to a greater or less extent the nerve
nuclei contained within it.

An implication of the cranial nerve roots (Figs. 16 and 26) may
cause disturbances of respiration, circulation, phonation, deglutition,
and articulation.

The sensory and motor tracts to the extremities may be simulta-
neously involved; and thus anesthesia (7) and paralysis of motion may
occur upon the side of the body opposed to the lesion. The fillet tract
(Fig. 11) may be also affected by the lesion, in which case evidences of
ataxia will be developed in the extremities. Finally, the lower part of
the face may be rendered paretic.

Of the above-mentioned symptoms, aphonia and the impairment of
the respiratory and circulatory symptoms are particularly diagnostic of
medullary lesions.
78 LECTURES ON NERVOUS DISEASES.

The symptoms of Duchenne’s disease are present only when chronic
progressive degeneration of the nuclei of the medulla exists.

Suddenly developed lesions of the medulla are liable to cause in-
stantaneous death.

Diabetes and albuminuria may be excited by lesions of the medulla,

When the pneumogastric nerves are implicated, dyspnoea, irregu-
larity of the action of the heart, and gastric or intestinal derangements
are encountered. ,

 

Fic. 27.—A TRANSVERSE SECTION OF THE MEDULLA (PARTLY SCHEMATIC) MADE THROUGH
THE Mippie oF THE OLivary Bony. (Modified from Spitzka.) A, and 4, nuclei of origin
of the hypoglossal nerve (twelfth cranial); #. &., reticular formation, with its cell masses ;
O, olivary body; P, pyramid; a, . /., antero- median fissure; G and Pu, masses of cells
probably associated respectively with the glosso-pharyngeal and pneumogastric nerves; Ja,
ascending root of fifth cranial nerve; 2, restiform column; a. /., arcuate fibres; 7, fibres
passing through the inter-olivary tract; ¢ and @, bundles of ‘fibres from the posterior ‘spinal
tracts, cut across on their way to the inferior cerebellar peduncle after decussation; 7, the
“trincural fasciculus’’ of Spitzka; ‘‘solitary’’ or ‘‘round’’ bundle of other authors. Note
that the solid masses represented in the cut in red and yellow are composed of cells; the black
areas are designed to represent conducting fibres running ‘vertical to the plane of the section;
the white lines represent fibres which run in the plane oF the section; and, finally, that some
of the conducting strands are left uncolored (as, for example, 7, l’a, F, ¢ “and ays

In a few instances, tumors and foci of softening in the medulla have
been known to exist and create no symptoms of a diagnostic character.

Dysphasia, and the loss of the power of protrusion of the tongue,
points to an implication of the hypoglossal and glosso-pharyngeal nuclei.

FOCAL LESIONS INVOLVING CRANIAL NERVES.

In the third edition of ny work upon “ Surgical Diagnosis,’* I have

incorporated some axioms which bear upon the diagnosis of focal lesions
of the brein that affect cranial nerves,

* William Wood & Co., New York, 1883.
LESIONS AFFECTING THE OLFACTORY NERVE. 79

Some of the axioms there given require modification, when viewed
from the standpoint of our present knowledge. Many of the suggestions
referred to had been selected by me from some of my earlier writings
on this field, and, if taken literally, would now be in conflict with later
observations of an anatomical and clinical character published since that
date by others. Some other points given by me in that work are more
or less imperfect, although perhaps technically accurate. I have, there-
fore, seen fit to alter the wording of certain parts of this work, which
I shall now repeat in substance :—

 

Fic, 26.—Tue Base oF THE SKULL wiTH THE NERVES WHICH ESCAPE FROM ITS ForA-
MINA. The cranial nerves are numbered in their customary order,

LESIONS AFFECTING THE OLFACTORY NERVE.

Anosmia (loss of smell) may occur from :any lesion which involves
the first cranial nerve. It is usually unilateral.

Whenever it occurs in connection with hemiplegia, the body pa-
ralysis is on the side opposite to, and the anosmia on the same side as
the lesion. This condition is known as crossed paralysis of the “ first
cranial nerve and body” type. Anosmia indicates the existence of a
lesion situated in the anterior fossa of the cranium, or a destructive
lesion of the cortex of the temporal lobe near to its apex.
80 LECTURES ON NERVOUS DISEASES.

Crossed paralysix of the “olfactory nerve and body type” may
occur whenever a localized pressure is exerted chiefly upon parts within
the anterior fossa of the skull. The fibres of the so-called “ motor tract”
(Fig. 12) are involved by an upward pressure upon the caudate or lentic-
ular nucleus; or the fibres of the internal capsule are directly affected by
the lesion. This accounts for the hemiplegia of the opposite half of the
body. The olfactory nerve (which lies near the optic chiasm) is affected
by pressure in the downward direction, and the optic chiasm or tract may
be simultaneously involved; hence, a loss of smell in the nostril on the
same side as the lesion may co-exist with some form of hemianopsia, as
well as with a crossed hemiplegia.

LESIONS AFFECTING THE OPTIC NERVE.

Hemianopsia may occur when the optie chtasm, the optic tracts, the
thalamus, the posterior part of the internal capsule, or the corter of the oc-
cipital lobes (chiefly the cuneus) are pressed. upon or destroyed. It is
evident, therefore, that the trephine cannot aflord relief of this symptom
in most cases, because the lesion is commonly situated at the base of
the cerebrum. When syphilitic gummata may be suspected, the prog-
nosis is extremely favorable if active treatment be employed.

The variety of hemianopsia may indicate the seat of the lesion with
great exactness. Fig. 21 will make this apparent.

If paralysis (in any of its forms) co-exists with hemianopsia, a valu-
able guide may often be afforded in determining the extent of the lesion.

The binasal, and also the bitemporal varieties of hemianopsia are
due (as a rule, at least) to lesions confined to the anterior fossa of the
cranium; hence we sometimes find the olfactory nerve (of the side cor-
responding to the seat of the lesion) simultaneously affected, and creating
anosmia (loss of smell) with or without subjective odors.

If the lesion be situated within the middle fossa of the cranium, the
optie tracts may be affected, thus causing homonymous hemianopsia
(Fig. 21). The motor nerves of the eye may be simultaneously pressed
upon, as they pass through that fossa on the way to their foramen of
exit from the cranium (the sphenoidal fissure), and thus more or less
impairment of the movements of the eyeball of the same side may be
created.

The value of these complications cannot be over-estimated, when
they exist, because they may be of the greatest aid in diagnosis. They
may often enable the skilled anatomist to positively determine the seat
of the lesion.

Hemiplegia may occur in connection with hemtanopsia, provided
that the lesion is of sufficient size to affect any part of the so-called “ motor
tract” of fibres simultaneously with the optic nerve fibres (Fig. 23).

 
LESIONS AFFECTING THE OPTIC NERVE. 81

Motor paralysis is, under such circumstances, developed chiefly if not
exclusively on the side opposite to the lesion, because the fibres of the
motor tract decussate, to a greater or less extent, at the lower part of
the medulla. Flechsig has shown that, in rare cases, exceptions to this
rule are to be explained by an abnormality in the decussation of the
motor fibres.

Hemiplegia is seldom observed in connection with hemianopsia alone.

The olfactory, motor oculi, trigeminus, or facial nerve roots are
especially liable to be simultaneously involved. This explains the
mechanism of the four varieties of ‘crossed paralysis” which are
clinically encountered. The hemiplegia being developed on the side
opposite to the lesion as a rule, while the symptoms produced by pa-
ralysis of the cranial nerve are confined to the side corresponding to
the lesion.

Homonymous hemianopsia, when it occurs without any impairment
of mobility or sensibility, points strongly toward a lesion of the cuneus.

Ataxie manifestations, occurring in connection with evidences of
impairment of the sense of sight, open a wide field for speculation. The
proximity and intimate structural relations of the cerebellum with the
optic lobes, basal ganglia, crus, and medulla, suggest the possibility of
cerebellar lesions when these two symptoms are present to a marked
degree, and the patient can stand with the eyes closed.

Hemianesthesia may occur in connection with hemianopsia and
other disturbances of vision. It indicates some disturbance of the
nerve fibres of the so-called “sensory tract; the loss of sensation being
confined to the lateral half of the body opposite to the lesion which
causes it, because the sensory fibres decussate in the spinal cord.

In cerebral hemianesthesia, there is more or less insensibility to
touch, pain, and temperature, and also an abolition of muscular sensi-
bility with complete retention of electro-motor contractility. The mu-
cous membranes of the eye, nose, and mouth are also anesthetic. If it
be due to hysteria, the special senses are cither abolished or rendered defi-
cient, and Ayperesthesia over the ovaries exist (Ferrier). These facts
will often enable the diagnosis to be made between hysterical and cere-
bral hemianzsthesia of organic origin.

Choked disc is a common symptom of lesions situated at the base
of the cerebrum, and also of any intra-cranial disense which produces a
gradually increasing pressure. It is especially diagnostic of cerebral
tumors.

It is not associated with impairment of vision until late, so that it
is often unsuspected when present. The ophthalmoscope is necessary
for its detection. It may co-exist with hemianopsia, and is always bi-

‘lateral. It is a positive contra-indication to trephining.
6
82 LECTURES ON NERVOUS DISEASES.

Lesions at the base of the skull may cross the mesial line, and still
involve only one optic tract. If this occurs, the hemianopsia will he
accompanied by other symptoms of diagnostic importance, no longer
confined to one side. Double anosmia, general paresis or complete pa-
ralysis, general anaesthesia, and paralytic symptoms referable to both eye-
balls might be thus produced. Lesions of this character are more liable
to affect the chiasm of the optic nerves than the optic tracts; in either
case, however, hemianopsia would result, and its type would be a reliable
guide to the seat of pressure. ;

Motor aphasia sometimes co-exists with hemianopsia. I have met
with two instances of this kind. In one there was slight paresis of the left
side, tending to prove that aphasia can occur with lesions involving the
right hemisphere. Both were cured with specific treatment. We must
attribute the development of this complication to pressure upon parts in
the neighborhood of Broca’s centre.

LESIONS AFFECTING THE MOTOR OCULI NERVE.

The nucleus of origin (Fig. 12) of the third cranial nerve of each
side seems to be capable of subdivision into groups of cells which pre-
side over movements of special muscles of the orbit.

_ Thus we may clinically recognize the existence of a special nucleus
for visual “accommodation,” for pupillary movements, and for the
internal rectus, the superior rectus, the levator palpebre, the inferior
oblique, and the superior oblique muscles.

This fact probably explains how the existence of “external oph-
thalmoplegia” and other distinct forms of orbital paralysis may occur
from organic lesions in the region of the tegmentum.

Paralysis of this nerve is indicated by the following symptoms: (1)
a falling of the upper eyelid (ptosis); (2) external strabismus; (3) dila-
tation of the pupil; (4) a slight bulging of the eye forward, on account
of muscular relaxation ; and (5) a loss of accommodation of vision, .

When the third cranial nerve is paralyzed from cerebral lesions
the lower part of the face is often paretic on the same side as the lesion.
This is not the case when a lesion involves the nerve after it escapes
from the crus cerebri, viz., within the middle fossa of the cranium or the
orbital cavity.

Crossed paralysis of the “motor oculi nerve and body” type, indi-
cates a lesion situated within the crus cerebri. We find that the eye on
the same side as the lesion can no longer be turned toward the nose,
or made to act in parallelism with the opposite eye; that the pupil is
dilated; and that the upper eyelid droops over the eyeball, giving it a
sleepy appearance. On the side opposite to the lesion the body is hemi-
plegic. There are few conditions which are of greater clinical importance '
LESIONS AFFECTING THE CRANIAL NERVES. 83

than this type of crossed paralysis, because the seat of the lesion is posi-
tively indicated.

If the optic tract, which lies in close relation with the crus be
simultaneously affected by the lesion, the evidences of “ homonymous
hemianopsia,” will be superadded, viz., the eye on the same side as the
lesion will be blind in its temporal half, and that of the opposite side
in its nasal half,

One half of the pupil may fail to react to light when hemianopsia
exists. This is known as the “hemiopic pupillary reaction.”

LESIONS AFFECTING THE FOURTH AND SIXTH CRANIAL NERVES.

The nerves which are associated with the movements of the eyeball
—the third, fourth, and sixth cranial—pass through the middle fossa of
the cranium in company with the fifth cranial nerve. For this reason,
lesions situated at the base of the brain are liable to involve any of
these nerves separately, or all simultaneously, according as its pressure-
effects are felt in one direction or another.

In addition to cranial causes, lesions of the orbdié may also create
impairment of the third, fourth, ophthalmic branch of the fifth, or sixth
cranial nerves—all of which pass through the sphenoidal fissure into the
orbit. ,

Impairment of the sixth cranial nerve is indicated by the develop-
ment of internal strabismus; the extent of which varies with the degree
of the paralysis.

If this nerve be affected by lesions within the cranium, other nerves
are liable to be simultaneously involved; and an impairment of the cere-
bral motor tract may also be evidenced by a co-existing hemiplegia or
paresis of the side of the body opposite to the seat of the lesion.

 

LESIONS AFFECTING THE FIFTH CRANIAL NERVE.

The following propositions will cover the diagnostic points which
relate to lesions of the trigeminal nerve (after it escapes from the pons),

Peripheral lesions cause anesthesia of special parts supplied by
small branches or single filaments of the nerve.

The co-existence of paralysis of other cranial nerves with anes- -
thesia of the face, indicates a lesion in the vicinity of the base of the
cerebrum.

If a part of the face and the corresponding facial cavity (orbital,
nasal, or buccal) are simultaneously affected with a loss of sensation, the
lesion is within the cranium, and so situated as to involve one of the
three main divisions of the nerve.

If the anesthesia extends over the entire area supplied by all of
the branches of the nerve, and evidences of disturbance in the nutrition
84 LECTURES ON NERVOUS DISEASES.

of the parts are also present, the lesion affects the ganglion of Gasser or
its immediate neighborhood.

If the muscles of mastication are paralyzed, and no anesthesia
exists, the lesion is outside of the cranium and involves only the motor
root of the inferior maxillary branch of the nerve.

The anterior two-thirds of the tongue, the mucous lining of the
floor of the mouth, and the integument of the chin will be rendered
anesthetic simultaneously if the sensory trunk of the inferior maxillary
nerve is involved; and taste may be affected also on the same side as the
sensory paralysis.

Neuralgia of the various branches of the fifth nerve may exist in
place of anesthesia, whenever the lesion simply zrritates the nerve trunks,
but does not impair their power of conduction of sensory impulses.

All late authorities agree in the statement that the deep trigeminal
fibres may be traced as two roots: the so-called descending root (which
comes from the cerebrum), and the ascending root, which is apparent in
cross-sections at different levels of the medulla. ‘The view of Mcynert,
that the fibres of the descending root cross within the substance of the
pons, is sustained by clinical facts, as shown by Starr. This author
draws the following deductions, respecting the clinical significance of
facial anesthesia :—

1. Lesions affecting the ascending root-of the trigeminus produce
anwsthesia of the face upon the same side as the lesion.

2. Lesions affecting the descending root of the trigeminus produce
anesthesia of the face upon the side opposed to the lesion.

3. Disturbances of sensibility in the face indicate a lesion situated
within the medulla or pons, and in the external lateral part of the for-
matio reticularis (provided it be not due to neuritis of the trigeminus or
a cerebral lesion).

4. If the face be rendered anesthetic upon one side, and the body
upon the opposite side (the condition known as “crossed sensory pa-
ralysis’’), the lesion affects the entire extent of the formatio reticularis,
and lies, in the medulla or pons, below the point of union of the ascend-
ing and descending roots of the trigeminus.

5. If the face and limbs be rendered anesthetic upon the same side.
the lesion lies in the brain at a point higher than the junction of the two
roots of the trigeminus. It may, therefore, be found within the formatio
reticularis of the upper part of the pons and crus, or, if cephalad of the
crus, it may affect the posterior third of the internal capsule of the cor-
responding cerebral hemisphere, the centrum ovale of that hemisphere,
or the sensory area of the cerebral cortex, in which all the sensory tracts
terminate,
LESIONS AFFECTING THE CRANIAL NERVES. 85

LESIONS OF THE SEVENTH CRANIAL NERVE.

The following propositions will cover the diagnostic points of lesions
which induce facial paralysis (Bell’s palsy) :—

If the paralysis be limited to distinc! parts of one lateral half of
the fuce, the lesion affects only individual branches of the nerve, and is
outside of the cranium. An apparent exception to this rule is sometimes
smet with in connection with lesions of the internal capsule and of the
crus cerebri—paralysis of the lower half of one side of the face being
clinically observed to occasionally accompany hemiplegia, and also pa-
ralysis of the motor oculi nerve on the same side as the lesion,

If the fauces and palate exhibit-paralytic changes the lesion is within
the cranium or in the temporal bone.

If the sense of taste be lost in the anterior two-thirds of the lateral
half of the tongue (on the same side as the general facial paralysis), the
lesion is either within the cranium, or in the temporal bone above the
origin of the chorda tympani branch.

If the sense of hearing is rendered very acute upon the same side
as the facial paralysis, the lesion is probably within the temporal bone
and involves the ganglionic enlargement found. upon the nerve in the
aqueduct of Fallopius.

Facial paralysis (when dependent upon cerebral lesions, or those
of the crus cerebri or the pons) is commonly associated with hemiplegia,
which may be upon the same side as the lesion or on the opposite side.

Crossed paralysis of the “facial nerve and body type” indicates a
lesion of the pons Varolti posterior to the line which connects the
trigeminus nerve with its fellow at their escape from the pons. (Gubler.)
The reader is referred to Fig. 2.

If the lesion be situated in front of Gubler’s line, the facial pa-
ralysis and the hemiplegia will be on the same side.

LESIONS AFFECTING .THE CRANIAL NERVES ARISING FROM THE
MEDULLA OBLONGATA.

The facial, auditory, glosso-pharyngeal, pneumogastric, spinal ac-
cessory, and hypoglossal uerves have their apparent origin from the
medulla, and are more or less imperfectly understood in regard to their
connection with different parts of the encephalon.

Labio-glosso-pharyngeal paralysis (“ Duchenne’s disease” or “ bulbar
paralysis ’’) is associated with successive destruction of the nerve nuclei
in the floor of the fourth ventricle and a secondary degeneration of the
nerve trunks connected with them.

The nerve which exhibits the first evidences of paralysis will often
afford. clinical data from which some deductions respecting the original
86 LECTURES ON NERVOUS DISEASES.

seat of the lesion may be drawn. The more coimmon lesions of the
medulla include arteritis, thrombosis, traumatism, softening, hemorrhage,
sclerosis, and tumors.

The development of ‘ bulbar paralysis’ is associated, as a rule, with
neuralgic pains, muscular spasms, anesthesia, and disorders of special
senses.

Compression of the medulla oblongata has been shown to cause the
respiratory phenomena termed “ Cheyne-Stokes respiration,” and also
albuminous and diabetic urine. In the former, the frequency and char-
acter of respiration constantly changes in some regular order—gradually
increasing to a certain maximum, and then gradually decreasing in fre-
quency till they cease, when they begin again to increase in frequency
and in depth.

The vaso-motor centres, which are situated within the medulla. help
to explain many other visceral phenomena which are observed when it is
diseased. These are too numerous and complex in their nature to be
discussed here.

The differential diagnosis of suddenly-developed lesions of the
medulla, which are not immediately fatal, must rest upon the co-exist-
ence of certain functional disturbances. Among these may be chiefly
mentioned: 1, epileptiform attacks, occurring at the onset or later; 2,
hemiplegia or paraplegia; 3, loss of consciousness; 4, hyperesthesia or
circumscribed anesthesia; 5, dysphagia, vomiting or hiccough, and
Cheyne Stokes respiration, from interference with the pneumogastric
nerve; 6, embarrassment of speech, from interference with the hypo-
glossal nerve; 7, deflection of the velum palati and uvula, from interfer-
ence with the facial nerve; 8, hydruria, from interference with the centre
of renal circulation; 9, diabetes, probably from interference with the
centre of the vaso motor nerves of the liver; 10, normal electro-mus-
cular contractility in the paralyzed parts.

If the lesion be very erlensive and of sudden advent, death may
occnr without the bulbar symptoms being well defined.

A SUMMARY OF THE MORE IMPORTANT PHYSIOLOGICAL AND PATHO-
LOGICAL FACTS PERTAINING TO THE SPINAL CORD.* :

Much of an anatomical nature relating to the spinal cord might he
introduced at this point with profit to the reader if space would permit.
It is hoped, however, that by the aid of the diagrams incorporated, the
various “ tracts”? or bundles of fibres which compose the cord will be
comprehended. Additional information of an anatomical kind may be

* Some parts of this section have already appeared in the chapter upon the Diseases

of the Spinal Cord in the last edition of the Author’s work, ‘ A Practical ‘Tea on Sur-
gical Diagnosis.”’ William Wood & Co., N. Y., 1884.

 
SUMMARY OF FACTS PERTAINING TO THE SPINAL CORD. ST

   

      
   
 
  
    
  

 

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De GP oe

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Fic, 29.—A DrAGRAMMATIC REPRESENTATION OF THE CONDUCTING TRACTS OF THE SpinaL
Corp. (Modified from Bramwell.) 7, fibres of Tiirck’s coliimn (direct pyramidal bundle) ;
C. P., crossed pyramidal fibres;’’ G, fibres of the column of Goll (postero-median column) ;
D. C., fibres of the ‘‘ direct cerebellar column.’’ Note that the arrows show the direction of
the impulses carried by each tract of fibres, Also that the motor fibres of the lateral column
decussate at the dower part of the medulla, Each of the ‘‘anterior pyramids’ of the
medulla is composed of the motor fibres (direct and decussating) above the lower limits of
the medulla.
88 LECTURES ON NERVOUS DISEASES.

gained by the reader (in case the diagrams prove insufficient) by refer.
ring to the introductory pages of a subsequent section which treats of
diseases of the spinal cord. :

1. The anterior and lateral pyranudal columns of each side con-
tain only motor fibres. Those in the former (Turck’s columns) are con-
nected with the corresponding cerebral hemixphere, while those of the
latter (the “crossed pyramidal tracts”) are connected with the opposite
cerebral hemisphere. (Fig. 29.)

2. The posterior column of each side (comprising two portions—
that of Goll and Burdach) serves to convey sensory nerve fibres appa-
rently connected with the tactile sense, and also commissural fibres (?)
which connect different segments of the cord; hence they are physiologi-
cally associated both with tactile sensation and the codrdination of mus-
cular movement, (Fig. 29.)

3. The lateral column of exch side (exclusive of the crossed pyra-
midal fibres and those of the direct cerebellar column) probably conveys
vaso-motor fibres and possibly those of sensation also. It has been proven
also to convey fibres directly to the cerebellum (the “direct cerebellar
column ”), The crossed pyramidal tract occupies a distinct area of this
column.

4. The multipolar nerve cells in the anterior horn of the spinal
gray matter possess a ‘trophic function.” When they are destroyed,
the nerve fibres arising from them, and the muscles also which are sup-
plied by those fibres, undergo atrophy. (Fig. 33.)

5. The fibres of the anterior and lateral pyramidal columns have
their “trophic centre” in the motor area of the cerebral cortex. Any
lesion which tends to sever these fibres from this centre creates a de-
scending degeneration of all the nerve fibres so disconnected, as far as
their ultimate distribution, viz., to segments of cord below the lesion.

6. The spinal nerves may be regarded as guides to the various
segments of the spinal cord; each segment ‘consisting of a disc of the
cord of sufficient thickness to include a separate pair of spinal nerves
which are attached to it. (Fig. 31.)

1. Each spinal seqment, with its attached nerves, may be figura-
tively regarded as a distinct spinal cord for that limited portion of the
body to which its nerves are distributed, viz., the mascles to which the
anterior roots of the spinal nerves proceed, and the parts supplied with
sensation by means of the posterior roots of the same.

8. The super*mposed segments of the cord are hound together by
tracts of nerve fibres. Some of these are continued into the brain, while
others are purely commissural tn type. We can attribute to the former
group (the “ motor” and “sensory tracts”) the conduction of motor im-
pulses from the brain to the various spinal segments, and of impressions
SUMMARY OF FACTS PERTAINING TO THE SPINAL CORD. 89

of a sensory character from the periphery of the body to the brain itself
The other group mentioned (the “associating fibres”) serves to assist the
different spinal segments in the performance of all acts where a har-
monious and simultaneous action of sevrral segments of the spinal cord
is demanded. :

9. The two lateral halves of each segment of the spinal cord are
not totally distinct from each other, because « connecting band of the
gray substance of the cord (the gray commissure), and also one of
white substance (the white commissure), bind them together. The
white commissure lies at the bottom of the anterior median fissure; the
gray commissure fills the remaining space between the anterior and
posterior median fissures (Fig. 30).

10. The anterior horns of the spinal gray matter contain cells of
large size which are connected (1) with motor nerve fibres, joining each
spinal segment with the brain (somewhat indirectly), and (2) with the
fibres of the anterior root of the spinal nerve (associated with the muscles
controlled by each segment). Thus these nerve cells are interposed be-

   
 
  
 
 
 
     

ANTERIOR
ROOT

SPINAL, |
© NERVE H gf MUSCLE

MOTOR
BRANCH

 
  

POSTERIOR
ROOT
GANGLION

SENSORY
RANCH

Fic. 30.—A SPINAL SecmENT. The two roots of the spinal nerve are shown; also the sensory
and motor fibres of which each is composed.

tween the fibres which pass from the brain to the cord and those dis-
tributed to the muscles, an arrangement which permits of an automatic
action of the cord, irrespective of cerebral influences.

The cells of the anterior horns appear to control also the nutrition
of the muscles, connected with them by means of the nerve fibres.

ll. The cells of the posterior horns and central portion of the spinal
gray matter are probably connected more or less intimately with the
fibres of the posterior or sensory roots of each spinal segment, and
possibly also with the paths of conduction of pain ful impressions to the
brain. They do not exert any apparent influence upon the nutrition of
the parts associated with them by means of the spinal nerve fibres.

12. The spinal refleres are probably performed }y means of un
anastomosis of the processes of the cells of the anterior and posterior
horns of each lateral half of a spinal segment. This enables a sensory
90 LECTURES ON NERVOUS DISEASES.

| Ni
lll v MOTOR. | SENSORY. REFLEX,

c Neck and scalp
St.-Mastoid
rapezius
Y { Neck and shoulder

 

T
{ Diaphragm

=
'
'
-
awe

|
@ Serratus

5 fo H | 5) Cerra Shoulder _Shoulder

6c 6 6) ----7 Arm mus. Arm | Scapular
CF |
7 1 /.2) BER ds Hand || ‘Hand '
h (ulnar lowest) ; |
D.! GET j pe ie i - J

 

 

 

 

4 Hh |
64 5) Oat egmonneee 5 | ¢ Front of thorax
Ol | ‘_ Intercostal | |
VA @ Peete eiciat= 6 Muscles | Epigastric
3 Ensiform area
OOO NM ... ----- 7
oI
e ~- --------8
0
9 Y Nl 1Q\ fie amie ta 1 ie Abdominal Abdomen
; omina) oi
fe : Umbil 10th
10 | BB Laseee | Mupcles one ) Abdominal
11 A
2 Fe pele Buttock, upper
12 s "| part
tl J) 4 =. ----- iL | ? Groin and scrotum
+ 4j 35 front
i 21 5 il ( outer side
2 Gl —.  —- C Flexors, hip | | | | ee
3 fe os ene it i een knee ail front j Hee amie
is { navetors al |
|
| Lhiy ‘Buttock, lower
f Adductors pare Gluteal
ob ssi eel

Flexors, knee (?) 2 |

Leg
and
Foot

except
Muscles of leg inner part

i
cl moving foot Foot clonus

| Back of Thigh

Plantar

{ Perineal and Anal
Muscles

J
inner side
Leg, inner side
|
|
| |
!
} |
\

Perinzum and Anus

Skin from coccyx to
Anus

 

1
4 i
Fic. 31.—A DiaGcram DesiGNED TO SHOW THE RELATIONS OF THE VERTEBRA TO THE
SpinAL SEGMENTS, AND OF THE SPINAL Nerves To THE Movor, Srnsory, AND REFLEX
FUNCTIONS OF THE SPINAL CORD. (GOWERS.)
SUMMARY OF FACTS PERTAINING TO THE SPINAL GORD. 91

impression, which is conveyed to the spinal segment by means of the
fibres of the posterior root of the spinal nerve, to become transformed
into motor impulses in the cells of the anterior horn. These are then
transmitted to the muscles hy the fibres of the anterior root of the spinal
nerve.

13. The sense of touch may be destroyed, in parts below the point
of injury, by section or disease of the posterior columns. The sense of
pain and the appreciation of temperature are apparently still conducted,
provided the gray matter escapes injury.

14. The sense of pain is destroyed when the gray matter is rendered
incapable of transmitting such sensations. The sense of touch apparently
remains unattected, if the posterior columns escape.

15. The sensation of pain and of touch may be independently re-
tarded by lesions of the cord that impair, but do not totally destroy the
conductivity of the paths for such sensations. The amount of such
retardation depends upon the extent of the destructive process within
the cord. Cases have been reported where thirty or more seconds would
elapse between each painful contact on the periphery of the body and its
appreciable sensation.

16. Destruction of a posterior root of a spinal nerve, or the net-
work of fibres formed by it within the substance of the cord, must affect
the transmission of all sensations of touch, pain, and temperature from
the peripheral area of distribution of the nerve so affected (Fig. 31).

li. Destruction of « posterior nerve root causes anesthesia to pain,
temperature, and touch. Trophic disturbances of the skin are also liable
to follow, particularly if the nerve-root is injured outside of the gang-
lionic enlareement developed upon it (Fig. 30).

18. Destruction of the columns of Burdach and Goll is followed
by tactile ansesthesia of definite areas, that correspond to the spinal seg-
ments affected, and sometimes in parts below the injury. Anesthesia of
the arms is especially characteristic of a lesion in Burdach’s column;
when in the legs, of Goll’s column.

19. When the posterior columns of the cord are affected with dis-
eased conditions that create ¢rritation of the parts, the so-called “ girdle
pain,” or » vincture-feeling” is developed in-‘those nerves that traverse
the disease area of the cord. Below the level of the spinal lesion, sub-
jective sensations of touch (such as formication, numbness, abnormal
sensations of heat or cold, etc.), and more or less hypersthesia are
usually created.

20. Lesions of the sensory tracts (the so-called “ sesthesodic sys-
tem”) cannot induce paresis, paralysis, spasm, or muscular atrophy.
They can only create sensory manifestations (such as anesthesia, hyper-
esthesia, numbness, formication, abnormal sensations of heat and cold,
92

LECTURES ON NERVOUS DISEASES.

      
   
 

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oS

Puss oneweunceeesanees,

 

 

 

 

  
 
 

   

 

 

i i
;

i)
i

   
   

 
 
   

Sea

wee B

acl lap Gizrie op

Fic, 32.—A Dracram Desicnep To ILLUSTRATE THRE CONNECTIONS OF THE MoToR AND

Sensory ConpuctinG TRAcTS OF THE CORD WITH THE SprnAL Nerves. (Modified
from Bramwell.) AZ, motor fibres of the anterior root of a spinal nerve; 5S, S’, sensory fibres
of the posterior root. Note that the course of S and S’ are not the same. Some sensory
fibres pass directly through the posterior horn of the spinal gray substance, and others through
Burdach’s column to read the gray substance. ‘The direct cerebellar column is composed of
fibres which start in Clarke's column of cells (Fig. 33). The fibres of the two pyramidal
tracts become united to the motor cells in the anterior horns of the spinal gray substance.
SUMMARY OF FACTS PERTAINING TO THE SPINAL CORD. 93

and pain), and, in addition, an inability to properly codrdinate muscular
movements (ataxic symptoms).

21. Sensory phenomena are manifested, as a rule, upon the side of
the body opposed to the seat of the lesion. If they occur upon the same
sie, either the posterior nerve roots are directly involved, or the sensory
tracts are affected during their ascent in the posterior columns belore
their decussation.

22. The so-called “cincture feeling” or “girdle pain” may be taken
as a valuable guide in deciding as to the probable limits of a focal lesion
of the cord.

23. Pain in the region of the spine is a rare symptom of disease of
the spinal cord. When it exists, it commonly indicates a disease pro-
cess that is confined to the vertebre or the spinal meninges.

24.0 Destructive lesions of the posterior coliimns (if bilateral) are
commonly associated with a band of complete anesthesia that corre-
sponds to the area of distribution of nerve roots affected by the lesion.
Below this girdle of anesthesia, sensations of touch are usually impaired
or absent, and sensations of pain are localized with difficulty, but are still
trausmitted by the gray matter of the cord.

26. Lesions that cereale vrritation of the cervical gray substance are
accompanied by dilatation of the pupil. If destructive processes are
subsequently developed, the pupil becomes contracted (Argyll Robert-
son’s pupil).

26. Lestans of the posterior columns that irritate primarily and
subsequently destroy the spinal substance tend, as a rule, to progress
upward. As they advance, the girdle of pain travels upward and leaves
behind it a girdle of anesthesia that’ steadily increases in width. In
parts situated below the level of the lesion, the sense of touch is usually
lost, although subjective sensations of touch, such as formication, ting-
ling, numbness, etc., may exist.

27. The existence of a girdle pain, without any impairment of the
sense of touch in parts below it, or the presence of motor paralysis,
points strongly to some lesion that involves the posterior nerve roots
only.

28. Lesions that affect only the motor tracts (the so-called “ kine-
sodie ‘system ) may induce paresis or paralysis, spasm, and atrophy of
muscles, They never cause sensory symptoms (such as marked and per-
manent pain, hyperesthesia, anesthesia, numbness, formication, etc).

29. Paralysis of motion and muscular atrophy, when due to spinal
lesions, develop upon the same side of the body as the lesion. The same
is generally true of the symptoms referable to incodrdinalion of move-
ment,—the so-called “ataxic” symptoms. The fibres that convey the
“ muscular sense” do not decussate until they reach the medulla.
94 LECTURES ON NERVOUS DISEASES.

80. Alrophic changes in muscles notes strongly toward a degen-
erative change in the motor nerve-cells of the anterior horns of the spinal
eray matter. These cells are the trophic centres for the fibres of the
anterior nerve roots. (Fig. 33.)

31. Contracture, or a permanent shortening of paralyzed muscles,
is strongly diagnostic of a lesion that involved the “ crossed pyramidal
tract’? within the lateral column of the cord. (Fig. 29.)

32. Symptoms referable to special organs (when dependent upon a
spinal lesion) indicate that some of the special centres of the cord are
involved. Such symptoms may be of value in determining the extent
and situation of the lesion.

 

 

 

Fic. 33.—Srmi-DiaGkamMMaTic TRANSVERSE SECTION OF THE GRAY SUBSTANCE OF THE
Cervicay (4) ann Lumbar ENLarGemenr (2) OF THE Srinat Corp. (Erb.) 4. a,
median group of cells; 4, antero-lateral group; ¢, postero-lateral group; @, vesicular column
of Clarke, 2B, a, median group; @’, group that appears first in the lumbar region, possibly,
belonging to a; 3, antero-lateral group} c, postero-lateral group. Note that the cells are
few and scattered in the posterior horns, and also that the shape of both horns differs
markedly in 4 and 2.

33. Lesions of the so-called “ motor tracts” of the cord (the “ kine-
sodi¢ system”), if destractive in character and sufliciently large to sever
the connection of the motor fibres from their connection with the cells of
the cerebral cortex, produce complete paralysis of motion below the level
of the lesion on the corresponding side of the body. The paralyzed
muscles will probably undergo subsequent contracture, and the deep or
tendon-retlexes will become exagecrated.

me
SUMMARY OF FACTS PERTAINING TO THE SPINAL CORD. 99

34. Lesions of the anterior horn of the spinal gray matter are liable
to produce paralysis in the areas of distribution of the related nerves,
without disturbance of sensibility, but with marked trophic¢ disturbances.

35. Slight pressure upon the cord may induce moderate paralysis
(paresis) of the extensor muscles and secondary contracture of the
flexors.

36. Lesions of one lateral half of the cord produce complete motor
paralysis, vaso-motor disturbances, incodrdination of movement, and
hypereesthesia on the corresponding side below the level of the lesion,
and a loss of sensibility on the opposite side with more or less paresis
in some cases. <A zone of anesthesia, surmounted by one of hyperes-
thesia, may exist at the level of the lesion on the corresponding side.

 

Fic. 34.—A DraGram Desicnep BY THE AUTHOR TO ILLUSTRATE THE VARIOUS CHANNELS
THROUGH wHicH A Motor Ceti of THE Corp MAY BE CALLED INTO ACTION.—A. H.,
anterior horn: C. P. C., crossed pyramidal column; P., posterior horn; B., column of Bur-
dach; G., column of Goll; 1, fibre for pain sensations; 2,. fibre for touch, tendon, ete. ; 3
motor cell; 4, motor fibres; 5, fibre from opposite cerebral hemisphere going to cell (3); 6,
ganglion, or posterior nerve root; 7, fibre from cerebral hemisphere of same side, going to

* cell (3).

37. Complete compression or division of the spinal cord causes an
exaggeration of the reflexes of the spinal segments below the seat of
injury on both sides; in addition to serious disturbances of motility and
sensibility.

38. Localized destruction of the gray matter of the dorsal region of
the cord seems to arrest‘the control of the will over the reflex acts of
micturition and defecation, which are governed hy the lumbar region of
the cord. ‘These functions are still performed with nearly their normal
revularity, however, by reflex action, if the centres that govern those acts
are not included in the diseased area.

39, Scratching or stroking the skin over certain regions of the body
causes a reflex contraction of special muscles when the cord is healthy.
These are the so-called “ superficial spinal refleres.” They are of value
96 LECTURES ON NERVOUS DISEASES.

oftentimes in deciding as to the upper limits of a lesion. Among the
more important of these superficial reflexes may be enumerated the
plantar, cremasteric, abdominal, epigastric, and scapular. Both cerebral
and spinal lesions create modifications of them, which possess clinical
value.

40. The so-called “deep spinal reflexes” are called into action by
first putting a muscle ina state of moderate tension, and then exciting it
to contraction by some artificial stimulus, as a slight tap or blow for
example. Among the more important of these may be mentioned: (1)
The knee-jerk or patella-reflex ; (2) the foot- or ankle-reflex ; (8) the per-
oneal or lateral foot-reflex. These tests are employed, like the preceding
ones, to determine the state of the spinal cord when the existence of a
lesion is suspected; they may be increased, diminished, or abolished,
according to the character of the lesion.

41. A persistent foot-clovus never occurs in health. It indicates
that the lateral columns of the cord are probably involved by some spinal
lesion. In supposed hysterical affections, this symptom will often decide
the question of the existence of organic disease. It must not be mis-
taken for the involuntary foot-clonus which sometimes occurs when an
unnatural posture is long maintained, even in health. It is usually asso-
ciated with exaggeration of all the other deep reflexes.

42. All reflex texts become abolished when the muscles are sepa-
rated from their connection with the spinal cord ; hence, severing of a
nerve, posterior sclerosis, compression of the spinal nerve roots. destrue-
tion of the gray matter of the cord, poisons, etc., are often associated
with their complete abolition.

43. Disense of the /aferal columns usually decreases the skin re-
Jleres, especially those of the trunk. This is particularly true of the
so-called descending degeneration of these columns, which follows cere-
bral lesions.

44. When marked incotrdination of movements is present and the
deep reflexes are not abolished, it indicates that sclerosis of the lateral
columns probably co-exists with similar changes in Burdach’s or Goll’s
columns,

45. Spasm is a marked symptom in many diseases of the spinal
cord. It commonly indicates an excessive action of the reflex motor
centres. It is particularly common as an acute symptom in spinal me-
ningitis. In chronic organic diseases of the cord, it assumes the form of
contracture of muscles, especially if the lateral columns are attacked.
This condition hecomes transformed into that of genuine spasm when the
slightest, forms of peripheral impressions are experienced, as in delicately
manipulating the muscles for example.
SUMMARY OF CEREBRO-SPINAL ARCHITECTURE. 97

A DIAGRAMMATIC SUMMARY OF SOME OF THE PRINCIPAL FEATURES
OF CEREBRAL AND SPINAL ARCHITECTURE.

I have endeavored, as a sequel to my previous remarks, to represent
in a schematic way the mutual relations of the encephalic and spinal
centres, and to show the mechanism by which various phenomena ob-
served during life may be explained. Let us examine different parts
of the diagram separutely.

HEMISPHERES

       
 

AND

MOTOR -ocuLI
‘MiESENCEPHALON

Opric Nerves’

Fig. 35.—A SCHEMATIC REPRESENTATION OF THE CEREBRAL AND SPINAL CENTRES AND
VHEIK COMMUNICATIONS. Jf, A/’, 47’, A/’’, motor centres; S, S’, 5’, S//?, sensory
centres; C. S., corpus striatum; QO. 7., optic thalamus; A. C,, anterior cornua; P. C., pos-
terior cornua, The arrows indicate the direction of the currents. The text will further
explain the significance of the diagram.

THE CEREBRAL HEMISPHERES.

1. The circles (M) represent the motor-and psychic centres of the
convolutions; the circles (S$) represent the sensory centres of the same.
The lines in the diagram which connect these centres with the basal
ganglia are the fibres of conduction to and from the cells of the gray
mutter of the convolutions (cerebral cortex). These fibres are the so-
called “ peduncular,” “radiating,” and “ converging” fibres of different

7
OS LECTURES ON NERVOUS DISEASES.

authors, Taken as a whole, they constitute the so-ealled “ corona
radiata,”

The fibres of both the drternal and erlernal capsule of the cerebrum
do not become assoctated with the cells of the basal ganglia, They pass
without interruption from the colls of the cerebral cortex to those of the
eray matter of the spinal cord. Although net separately shown in the
diagram, they can he imagined as passing over CLS. and Q. Zin the cut
as unbroken lines.

The lines marked (7) represent the so-called “associating fibres ”
of the cerebral hemispheres.

Throughout the diagram, all efferent fibres, or those which carry im-
pulses /vow the various centres, are represented by unbroken lines, and
all efferent fibres, or those which carry impulses fo the various ccutres,
by dotted lines. The arrows also show the direction of the currents,
The fibres connected with the centres of the hemispheres can be traced in
the drawing downward to their union with the cells of the basal ganelia,
the mesencephalon, the medulla, and the spinal cord. In any of these
regions separately, or in all simultancously the cerebral cortex ean prob-
ably exert its direct influence; the smaller centres are then either over-
powered or controlled in their respective automatic actions by the ereat
centre of inteluvence—the cerebrum.

THE BASAL GANGLIA.

2. The corpus striatum (CL S.) is shown to be associnted with the
inotor regions of the cortex (AV). A direct communication probably also
exists between it and the optic thalamus (0. 7.) .as shown by the line
(b). The cerebellum is thought by some to communicate indirectly with
it by means of the © processus e cerebello ad cerebrum”? (4)—known also
us the “ superior cerebellar pedunele.”

These three sets comprise its aferent fibres. Its efferent fires (1.2,
and 3) pass to the cells of the erus, medulla, and spinal cord. The con-
nection shown between the cerebellum and the so-called *imetor tract.”
will help to interpret the view held by some that that eanelion assists the
cerebrum in its control over the muscular apparatus of the body.

The oplle thalamus (O. T.) has afferent tires, which arise from the
spinal cord, medulla, and mesencephalon (5, 6,and 7),2nd from the cere-
bellum (8). Itcis thus broueht into relation with all sensory impulses
conveyed by the spinal nerves, and also by those eranial nerves which
are nol motorinfunetion. Tmpressions derived Irom sieht, smell, hearing,
and taste, as well as tactile Hpressions, and the sensation of pain, are
prohably more or Tess intimately associated with this eanelion. The
efferent fibres of the optie thalamus sre shown to le in the posterior part
of the corona radiata, and to distribute themselves among the sensory
SUMMARY OF CEREBRO-SPINAL ARCHITECTURE, ue

eontres of the cerebral cortex (S-. The tibves of direct communication
between the optic thalamus and the corpus striatum (4), help to explain
the ability ef an animal to perform automatic cotrdinated movements
after the cerebral hemispheres have been removed and the basal gangha
left intact. Those phenomena are in marked contrast to the forms of
reaction witch take place within the hemispheres between the sensory
and moter centres ef the cortex: sinew oocsttes se cvss and volition are
evoked by the fatter, while the tormer ix purely automatic. Conscious
appreciation of scnsations and voluntary motion are only posstbtc when
the cerebral hemispheres are present.

THE CEREBELLUM,

3.0 This diagram shows. in an imperfect way. the relations ef the
cerebellum to the pats of sensory and meter conduction, The sensers
and moter ventres of dius ganslion (S7 and WW’) have not been anatenn-
cally differentiated from each other, but we have reasen to believe that
both varieties exist. The atterent diorcs of the cerebellum (2, /e,and) 22)
probably bring it inte direct: relation with taetile Tmpressions by mews
of the spinel eord, with sensations of pain (?) by the same ehannel, ancl
with various other impressions by means of nerves of special sense. [ts
viferont tibres (g and J) are related in an imperfectly understood wey,
to the path of motor conduction. The mos: detivate feats of equidbrium
are probably impossible without an intact cerebellum. ‘This sudject will
be discussed hereafter. Each hemisphere of the cerebellum is new be-
lieved to be associated with the dbres of the oppesite heuvsphere of the
vere Gru,

THE MUSENCEPHALON.

4. As shown in the diagram, tits term includes all the parts com-
prised between the cerebrum abeve and the medulla below, The col-
lections of gray matter represented by the circles (AZ) and (> 0), comprise
ehietlt the so-called substantia nigra and the ‘red nucleus of the teg-
mentum.” The fibres associated with them (2. 2.8. $e. So 10,
2icand 72), constivute, collectively, the dasés and fegmentum eruris of
Mey neit. whieh are separated by the substantia nigra. The red nucleus
lies beneath the corporn quadrigemina in the feymenéwm (the sensory
portion of the crus). and is in intimate relation wich the fibres of the
~coorior eerebellar peduncle (3). The corpora quadrigemina (not shown
in the diagram) should be also included among the ganelioniG masses of
this region. The third eranial nerve is represented as) structurally
related to the mesencephalon. The optie nerve has also intimate rela-
tions with some of its parts. Fibres ef many of the eranial nerves. which
spring from the medulla, aro prolonzed through the pons and crus to
reach the cerebrum.
100 LECTURES ON NERVOUS DISEASES.

The functions of the mesencephalic centres are too complex to
justify any generalizations. All of the complex forms of muscular
activity which are more especially clicited in response to some form of
impression received from without by means of the nerves of special
sense, Such as locomotion, emotional expression, etc., are to be attributed
partly, if not wholly, to these ganglionic centres. The special attributes
of the red nucleus of the tegmentum and the substantia nigra are, as yet,
somewhat conjectural.

THE MEDULLA OBLONGATA.

5. Within this ganglion, the nuclei of origin of many of the cranial
nerves have been found, and special centres which preside over important
physiological functions have also heen demonstrated. The circles (.W’”’)
and ($’’’) in the diagram are supposed to represent the sensory and motor
collections of gray matter, which give to this portion of the central
nervous system its peculiar powers. The motor centres (J/'’) are repre-
sented as in communication with certain cranial nerve roots, and also
with motor fibres which serve to connect the medulla to the corpus
striatum and the ganglionic masses of the mesencephalon above, and the
seements of the spinal cord below. The sensory centres (S’’’) are shown
to be in relation with the sensory cranial nerve roots (the term “sensory”
being used in its broadest sense to include all fibres bearing atterent
impulses), as well as with the paths of cerebral and cerebellar sensory
conduction (6 and ZO). Thus it is that the cerebellum as well as the
cerebrum probably is made cognizant not only of tactile sensations and
of other varieties of sensory impulses transmitted along the spinal tracts,
but also of other facts which our special senses reveal to us. The view
that the cerebellum acts in part as an “informing depot” (Spitzka) for the
cerebral hemispheres can be comprehended by a study of this diagram.

The fibres which are drawn in the diagram between the motor and
sensory centres of the medulla help us to comprehend the probable
inechanism of many forms of complex coirdinated reflex actions, of
which the medulla is capable when all the nerve centres above it have
been removed. It is apparent that each of the segments of the nervous
system here depicted is capable (by means of. associating fibres) of an
action of its own which is independent of those centres above it, but
which may be controlled or overpowered by the higher centres when they
are called into action.

THE SPINAL CORD.

6. The diagram shows the cells of the anterior horns of the spinal
gray matter Cd. C.) to be in connection with the fibres of the direct motor
tract which we have now traced from the cerebral cortex downward
(although some have lheen deflected from the direct path ly the cells of the

 
SUMMARY OF CEREBRO-SPINAL ARCHITECTURE. 101

mesencephalon :nd medulla). These motor fibres of the spinal cord are
prolonged by means of the interposed cell (4.C.) as fibres of the anterior
or motor roots of the spinal nerves, The cells of the posterior horns
of the spinal vray matter (2. C.) are likewise shown to receive the afferent
impulses conveyed to them from without by the posterior or seusory
roots of the spinal nerves (as shown ly the arrow), and to transmit then
upward by means of fibres which connect them with higher ganglionic
masses (6,6,and 7), The exact paths of motor aud sensory conduction
through the spinal cord are not positively settled. The antero-lateral
columns of the cord are commonly regarded ‘as the chief motor paths,
although all observers are not in agreement respecting the anterior
columns. The sensory tracts probably run partly in the central gray
matter of the cord, and partly in the lateral and posterior columns. Sen-
sory impulses travel on tlie side opposite to that on which the nerves
enter, with the exception of impressions of the so-called muscular sense
(Starr). The views held respecting the functions of the spinal columns
have been given in preceding pages.

Finally, it will be observed that the motor and sensory cells of the
spinal cord communicate. This arrangement allows of an automatic
spinal action. Beheaded animals can be made to exhibit definite mus-
cular invvements when any irritation of the sensory nerves of the skin
is employed to call them forth. A frog so mutilated will scratch with
the opposite foot a spot on the leg which has-been touched with an acid.
Robin has observed similar phenomena in a beheaded criminal. These
movements are purely reflex in type, because all parts which we know to
be essential to consciousness or volition have been taken away, They
can only be attributed, therefore, to a communication (not yet well un-
derstood) between the sensory and motor cells of the spinal segment.
Many of the acts which constant and long-continued practice enable us
acquire during life—as, for example, the running of scales upon a piano
—are unquestionably performed automatically by the spinal cord, with-
out assistance of the higher ganglia in many instances.

In closing this section, the Author feels that much has of necessity
been omitted; and that some of the views advanced are apt to be
modified or possibly overthrown hy subsequent investigation.

He trusts, however, that the difficulties of the task will not be lost
sight of by the reader; and that the chapter, 1s a whole, may prove of
material assistance in fathoming the mysteries of obscure neuroses.

The two diagrams which follow are copied from Aeby. They pre-
sent, to the Author’s mind, the main points in cerebro-spinal architecture
with singular lucidity.
LECTURES ON NERVOUS DISEASES.

FIG. 36.

      
 

  
 

   

eer TTT Spl

ir

Figs. 36 and 37.—A DiAGRAM oF THE Course or THE Nexve Fisxes iy THE SUBSTANCE
OF THE BRAIN AND SPINAL Corp. (After Aeby.) I, view of a transverse section; II, Pro-
file view; II], the nuclei of the medulla (partly after Erb). The crosses of color corre-
sponding to the lines upon which they are placed, designate the point of section of each tract
as it passes through different levels (the crus and pons). C i, ¢aferual capsude, with
radiating fibres (in yellow), pyramidal fibres (red), and fibres going to the pons (in purple):

C, the crwra cereéré, with the pyramidal fibres and the.fibres going to the ganglia of the
pons anteriorly, and posteriorly, the substantia nigra, the fillet tract (in dotted lines), the
fibres of the superior peduncle of the cerebellum (in blue); Pc, the peduncles of the cere-
écllum, showing the fibres going to the cerebrum, the pons, and the medulla; P, jaws
Varolii, with its ganglia on either side (in purple). In III, the 2uclet of the cranial nerve
roots are numbered to correspond with the nerves. Red is used for the motor nuclei, and

 
SUMMARY OF CEREBRO-SPINAL ARCHITECTURE.

Fia. 37.

 

blue for the sensory nuclei. The ¢vacts im the cord are designated by the area similarly
colored in the cross-section of the cord beneath, c’, Column of Tiirck; c, crossed pyramidal
column; a, anterior horn; a’, anterior root zone; e, direct cerebellar column; b, posterior
horn; b’, column of Burdach; d, column of Goll. Higher up are seen b’’, the inferior
peduncle of the cerebellum; d’, the fillet or lemniscus tract; f, the fibres connecting the
ganglia of the pons with the cerebrum and cerebellum, b’’’, the fibres of the superior cere-
bellar peduncle; h, the caudo-lenticular and thalmo-cortical fibres ; i, the commissural fibres
(see Fig. 6); Th, optic thalamus; nc, nucleus, caudatus; nl, nucleus lenticularis ; gc, central
convolutions.

In this diagram, the course of b/’ seems to be in error in not undergoing a decussation
(Author’s note).

103
LON aL,

PRACTICAL HINTS REGARDING THE CLINICAL
EXAMINATION OF PATIENTS AFFLICTED
WITH NERVOUS DISEASES, AND THE
VARIOUS TESTS WHICH MAY
BE EMPLOYED AS AIDS
IN DIAGNOSIS.
SECTION II.

THE METHODS OF EXAMINATION EMPLOYED IN THE DIAGNOSIS OF
NERVOUS DISEASES.

#
THE majority of practitioners apparently join in the feeling (which
happily conduces largely to the benefit of specialists in neurology) that
nervous anatomy and physiology is “too complex a subject for them to
master,” and that they must be, therefore, given over to those who are
devoting themselves particularly to the department of nervous diseases.

While this may be true in part, I believe that it is not only possible
but comparatively easy for any medical practitioner (who is willing to
make the necessary effort) to grasp certain general principles which are
applicable to the examination of cases afflicted with nervous diseases.

These can be applied without expensive apparatus, and with decided
benefit both to himself and his patients. They will tend to render his
diagnosis more scientific and accurate. They will aid him in properly
directing his treatment. Finally, they will often save him the humiliation
of seeing his patient seek advice from other hands.

The intelligence of laymen is always strongly impressed by evidences
on the part. of the physician of great care and marked skill, as shown in
the first examination. The impressions left upon the patient’s mind by
the results of the first interview are of the greatest importance to both
parties. While the doctor is studying the patient, the patient is, as a
rule, studying the doctor with even greater interest.

Every step which is taken by the physician, as a means of forming a
positive and final judgment, is watched with an earnestness on the part
of the patient that invariably accompanies mental anxiety. Hach ques-
tion that is asked regarding the previous history of the patient, the pos-
sibility of similar troubles in his parents or blood-relations, the origin
and course of the more important symptoms, ete., are even more indelibly
impressed upon the mind of the patient than upon that of the physician,
who keeps the written record.

When, later in the examination, the power or electrical reactions of
the muscles, and the sensibility of different regions of the body to touch,
temperature, and pain are being tested in various ways, and the results
of such tests are being recorded in the case-book of the physician, the
reasoning faculties of the patient are even more keenly alive, and seek to
penetrate (as far as his intelligence will permit him to do) into the mys-

teries of the science, and to draw conclusions regarding the clinical
(107)
108 LECTURES ON NERVOUS DISEASES.

sionificance of certain symptoms, of which, perhaps, he was unconscious
up to that time. It will often be necessary, therefore, for the physician to
quiet evidences of alarm on the part of the patient, from time to time, as
the examination of the symptoms proceed, by judicious explanation or
words of encouragement.

It should ever be remembered by the physician that any omission
on his part to investigate the condition of the motor or sensory nerves,
the pulse, the respiration, the temperature, the spinal reflexes, etc., in
each and every case, will sooner or later be remarked by some patient,
who has either read extensively or had, from time to time, different
metical advisers. Moreover, interested friends (sometimes very intelli-
gent from past experiences of their own) may often drop hints to the —
patient which will tend to strengthen or weaken his or her views that
have previously been formed of the accuracy and care of the first exami-
nation of the symptoms.

It is my intention to give here, with some detail, the description of
the various steps that are commonly employed by specialists in neurology
in the examination of their patients; and to suggest a simple method of
recording symptoms, as a basis for the diagnosis and subsequent treat-
ment of nervous affections.

I shall discuss the subject under the following heads :—

First—The clinical history of the patient, and how to record the
chief symptoms of each case.

Second.—The symptoms revealed to the physician by his sense of
sight.

Third.—The symptoms revealed to the physician by instruments of
various kinds, and other tests.

I,

THE CLINICAL HISTORY OF THE PATIENT.

Every physician should be provided with a case-book. In it the
main features of each patient’s case should be first recorded, and a memo-
randum of the treatment and modifications of the symptoms should be
subsequently jotted down at each visit. In this way only can the results
of an extended experience be made useful for scientific purposes at some
later date. It will furthermore aid the doctor in utilizing his leisure
hours by studying the cases which he meets during the busy routine of
his office work. One case well studied is worth a hundred casually
glanced at and hastily prescribed for.

-1t will help to economize time if the case-book is printed in sucha
way as to have the more important symptoms already upon the page;
spaces being left blank to allow of a record of any modifications of these
THE CLINICAL HISTORY OF THE PATIENT. 109

that may exist. This plan adds to the legibility of the notes, and also
admirably adapts them for comparison with those of previous or subse-
quent cases. Hach physician may alter the arrangement of the pages of
his case-book to suit his individual practice, but it is best for a general
practitioner to have it adapted for all classes of patients.

In.a subsequent portion of this chapter I will suggest a form of case-
book which seems to me to be well adapted to the requirements of a
specialist in nervous diseases.

Let us now suppose that 2 patient enters the office of a physician for
medical advice relating to a nervous malady. After the usual questions
have been asked the patient regarding the name, the age, the condition
as to marriage, the nationality, and the occupation, and the answers
recorded, the patient should be brought rapidly to a concise statement of
the more important symptoms for which he seeks medical relief. This
can be usually accomplished by a little tact; and much valuable time is
saved by so doing. These symptoms can then be separately recorded
upon a page in your case-book.

With these especially marked symptoms as a starting-point, ques-
tions may then be asked regarding certain of them which the physician
deems the most important from a clinical aspect; seeking in each instance
to learn all about the present and past history of one symptom at a time,
and the modifieations which have been observed concerning it, so far as:
the patient’s memory will prove of assistance.

Now, the ability on the part of the doctor to ask questions that are
pertinent to each symptom will depend entirely upon the knowledge
which he himself possesses of the subject. J have often tested medical.
students and young practitioners in this regard, and have been amused
to see how rapidly their stock of pertinent inquiries became exhausted.

In order to intelligently ask about pain, for example, the physician
must know all the axioms of nerve-distribution which Hilton so ably
advanced; he must be a master, in the second place, of the course of
separate nerves which enable definite regions to tell the doctor (by
the presence of the sense of pain) of disease that is sometimes far re-
mote from the painful area; again, he must be able to correctly trace
the course of affected nerves, and thus to seek for abnormal condi-
tions along the line of each nerve which might produce local pressure
upon them; he must be familiar, in the fourth place, with the individual
peculiarities of pain in special diseases, as, for example, the characteristic
pains of rheumatism, neuralgia, locomotor ataxia, etc.; finally, he must
be familiar with all the possible causes of pain in different regions of the
body or extremities.

When we shall have discussed the various symptoms revealed by
inspection of the patient, as well as the tests employed to determine ab-
110 LECTURES ON NERVOUS DISEASES.

normal states of the motor or sensory nerves, and the reactions of muscles
to different electric currents, many points will have been given that may
prove of assistance in suggesting pertinent questions, to be employed in
obtaining the clinical history of patients so afflicted; but it will require
continued practice, much study, and close observation to excel in the art
of quickly and accurately gathering pertinent facts, from which con-
clusions can be drawn regarding the diagnosis and treatment of nervous
diseases,

A few general hints may, however, be thrown out here as to special
lines of inquiry, each of which may afford us valuable information re-
specting nervous maladies.

Tur Duration or Extstrna Symproms.—It is important to ascertain
the exact date of the commencement of the symptoms for which the
patient seeks relief, or of others which may be detected by the physician
at the first interview.

This will often decide as to the acuteness of the attack, and also
afford in some instances information respecting the seat and type of the
disease.

In the chronic varieties of spinal disease (as, for example, progressive
muscular atrophy, locomotor ataxia, disseminated sclerosis, etc.), the
patient cannot, as a rule, fix the date at which the symptoms commenced
because the development has been extremely ‘slow and gradual.

On the other hand, a hysterical fit may be followed immediately by
an attack of hysterical paralysis; a hemorrhage into the brain or spinal
cord, that has ploughed up the substance of these organs, causes paralytic
symptoms that develop instantly; inflammatory changes of the brain or
cord are usually attended by a more gradual onset, although it may be
comparatively rapid.

As an illustration of the clinical bearing of the duration of symptoms,
let us take the following: Two patients present a deformed hand from
atrophy of the muscles of the thumb and interossei. The one has been
slowly developed, and is probably the result of progressive muscular
atrophy; the other has been very rapidly developed, and is probably due
to some disease or local injury of the ulnar nerve. Should the deformity
have occurred in years past, and have shown no evidences of steady pro-
gression, the existence of progressive muscular atrophy could be then
safely excluded.

Tue Excitina Cause or Existinc Symproms.—If there has been any
external violence received, it is important to ascertain the exact nature,
seat, und severity of the injury.

Concussion of the spine may cause severe and often fatal disease of
the spinal cord. Violence to the head may depress the inner tablet of the
skull without any evidence of depression upon the exterior. The brain
THE CLINICAL HISTORY OF THE PATIENT. 111

may be seriously injured, when the bones that encase it may escape.
Some of the spinal nerves may be implicated in a wound or bruise, and
thus paralysis may be induced independently of the nerve centres.

Mental anxiety or overwork is a frequent cause of brain diseases,
Eye-defect acts very frequently as an etiological factor in many cases of
headache, neuralgia, hysteria, epilepsy, chorea, and some obscure visceral
derangements. Some defects in the eye are inherited (as are peculiarities
in feature and mental traits). This field will be discussed later in this
chapter.

A family tendency to gout or rheumatism, etc., may suggest the
possibility of an abnormal blood-condition as an important factor in
creating nervous disturbances.

The urine should always be carefully examined, as well as the heart,
to exclude the possibility of renal or cardiac disease as a factor in the
nervous derangement.

Tue AGE or THE Patient.—Much may be suggested to the mind of
the physician by the age of the patient; because some diseases are
more common at one period of life than at another.

During early childhood we are particularly Hable to encounter the
symptoms of idiocy, epilepsy, and chorea, as well as those of an inflam-
mation of the anterior horns of the gray matter of the spinal cord, the so-
called “ poliomyelitis anterior.” The acute variety of the latter disease is
most common between the ages of one and four, and it is seldom devel-
oped except in childhood. In the vast majority of cases, the condition
termed “pseudo-hypertrophie paralysis” (because the muscles are over-
grown like those of an athlete) is developed during the first few years of
life. Again, the tubercular form of inflammation of the meninges, both
of the brain and spinal cord, occur in the young child. Among the rarer
forms of disease of the spinal cord, a congenital variety of the so-called
“spastic paralysis,” and also of ‘locomotor ataxia,” is encountered in
young children. Reflex paraplegia is also occasionally seen in very
young subjects. Cases of disseminated sclerosis of the spinal cord have
been reported in the child.

Between the ages of puberty and the fully developed adult, Pott’s
disease of the vertebra may develop and create compression of the spinal
cord; and attacks of rheumatism may render the development of embolic
hemiplegia and aphasia possible. Meningitis of the brain and spinal
cord are not uncommon during this interval. Hysterical paraplegia
occurs in young females in connection with uterine disturbances. Be-
tween the ages of twenty and thirty, cerebro-spinal sclerosis is most
commonly developed.

In the adult, progressive muscular atrophy, myelitis, meningitis of
the cord, locomotor ataxia, the chronic form of poliomyelitis, and amyo-
112 LECTURES ON NERVOUS DISEASES,

trophic lateral paralysis are among the spinal diseases often encountered.
Cerebral meningitis, and softening, tumors, and embolism of the brain
are frequently recognized. Shaking palsy seldom occurs except in ad-
vanced life. The symptoms of Duchenne’s disease, and the paralysis of the
insane are most commonly developed between the ages of thirty and sixty.

Linked with adult life, also, comes apoplexy associated with paralysis;
and a late rigidity of the paralyzed muscles is developed whenever the in-
jury excites a descending degeneration of the fibres that are torn across by
escaping blood, or deprives the cerebrum of its power of control over the
cerebellum. Excessive indulgence in eating and drinking, coupled with
the absence of proper physical exercise, and the possibility of acquired
syphilis, render males more subject to paralysis than females.

Tus Sex.—Males suffer much more frequently from organic nervous
affections than females.

This fact is to be accounted for partly by the liability of that sex to
injury, exposure to cold or dampness, and excessive mental or physical
labor. But habits of indulgence in alcohol and venery, with its danger
of syphilitic infection, are also far more common in males than in females,
and are often prominent factors in the causation of morbid conditions of
the nerve centres. Certain occupations, tending toward great muscular
strain, or lead, arsenic, and mercurial poisoning, may be exciting causes
of serious nervous affections. Prolonged exposure to compressed air (as
in the case of divers) is often followed by paralysis. Many such cases
have occurred among workmen in submarine excavations,

Tue Ierepiry,—After you have exhausted the special lines of
inquiry indicated by the prominent symptoms that each patient seeks
relief for, questions should then be propounded to the patient touching
upon the possibility of hereditary predisposition to nervous affections
or of some hereditary ‘diathesis.”

Some nervous affections exhibit a marked dependence upon a heredi-
tary predisposition, either to the disease actually present, or to some
allied disorder. Epileptics, for example, are frequently the offspring of
tubercular or syphilitic parents, or of epileptics. Again, chorea and
hysteria may be developed from the most trivial excitement (even from
imitation of others so affected) in subjects predisposed to nervous ex-
citability or debility. Apoplectic subjects not infrequently beget. off-
spring who manifest in adult life a decided tendency to vascular disease.
Certain spinal affections seem to be particularly associated with heredity.
A predisposition to cancer and tuberculosis is unquestionably transmitted,
and these conditions are not infrequently found in the brain and spinal
cord, or their envelopes.

A marked hereditary tendency toward some spinal affections seems
to be well established, Pseudo-hypertrophic paralysis is transmitted
THE CLINICAL HISTORY OF THE PATIENT. 113.

through the mother. Locomotor ataxia occasionally runs in families, and
progressive muscular atrophy is markedly hereditary. Quite a lar ge pro-
portion of hysterical women can be shown to haye sprung from ancestry
in which tuberculosis, epilepsy, or insanity has existed; and idiotic
children and epileptics sometimes owe their disease to a so-ealled “hys-
terical temperament” on the mother’s side. I believe that, in many cases,
this predisposition can be traced to an inherited defect in the ocular
muscles, or a refractive error in the eye itself, which creates eye-strain
when binocular vision is attempted. This view is based upon an exami-
nation of quite a large number of such cases.
: Hasirs or tHE Parient.—These should be the next subjects of
inquiry.

Alcoholic subjects are always surrounded by dangerous possibilities.
Inflammation, when once started in such patients, is liable to be of a
severe and fatal form. ‘Trivial injuries often excite serious complications
in such subjects, and hereditary or acquired diseases, which have been
comparatively dormant for some time, may be kindled into activity by a
“spree.”

Again the habitual use of drugs for nervousness, sleeplessness, and all
the other ailments with which the laity often experiment at the suggestion
of friends, but without the knowledge of their doctor, may be a factor in
nervous symptoms that have become aggravated or actually developed
by their injudicious use. Some patients can use tobacco without ap-
parent injury, while it is a rank poison to others; tea and coffee are like-
wise injurious to many patients. The long-continued use of chloral, the
bromides, opium, or other drugs may result in nervous affections of a
serious character.

THE OccuPATION OF THE PatiENT.—This may be a possible factor
in the development of nervous diseases.

Sewing-girls frequently develop ulceration of the stomach from the
pressure exerted upon that organ by stooping. Painters are peculiarly
liable to lead-poisoning; and in some arts, where mercurial, phosphoric,
and arsenical preparations are extensively employed, symptoms of these
forms of poisoning may be developed. Constant or prolonged exposure
to cold or dampness is very often an exciting cause of spinal affections.
Excessive exercise or occupations demanding an unusual strain upon the
muscles may induce actual disease of the muscles, peripheral nerves,
spinal cord, or brain. Extreme mental labor or anxiety is a frequent
cause of brain inflammation and changes within the coats of the blood-
vessels of that organ.

Tue AcqgurreD Drsrases.—Finally, the previous history of the
patient in respect to acquired diseases is especially important as an aid
in deciding as to the probable cause of the existing symptoms.

8
114 LECTURES ON NERVOUS DISEASES.

All attacks of illness which have been passed through should be
carefully inquired into.

The presence or absence of latent syphilis should always be investi-
gated as perhaps one of the most common causes of nervous aftections.
The presence or absence of tubercular deposits in the lungs, or of cancer
in the breast or viscera, should be decided by a physical examination,
because similar deposits may exist elsewhere in the body. Some of the
fevers often cause sequel that create impairment of the senses of sight
and hearing, as well as other nervous phenomena, Cerebro-spinal men-
ingitis may leave after-effects upon the nerve centres that last for an in-
definite period. Kidney diseases may result in serious changes in the
blood-vessels, and thus be a factor in the development of brain troubles.
Diphtheria is frequently followed by paralysis of the throat and limbs.
Diabetes may itself indicate an existing brain disease; or, as the result
of imperfect performance of the digestive processes, create, in turn,
symptoms referable to the nervous mechanism. In point of fact, few, if
any of the more common diseases are entirely exempt from a more or
less direct association with nervous phenomena.

There is a prevalent opinion among the laity (and unfortunately,
with some of the profession also) that the nervous system is a distinct
and separate part of the human organization; an entity entirely inde-
pendent of the other organs and having functions peculiarly its own.
They seem to forget that it is nourished by the same source as muscle,
bone, organs, etc., e.g., the blood; also that every part of the body is
capable of sending telegraphic communications to the brain and spinal
cord by means of the sensory nerves; and, finally, that these organs
are called into action rather as the servants of the other parts of the
body than as independent organisms, by the various impressions which
they receive from without. All the mental processes are based, of necessity
upon some impressions of the outer world gained by means of the organs
of sight, smell, hearing, touch, taste, or the nerves of general sensibility.

The apparent disassociation which exists between the nervous cen-
tres and the viscera often misleads the practitioner of medicine, and
causes him to disregard the importance of a complete examination of the
various organs before a final judgment is expressed concerning nervous
phenomena that are brought to his notice.

Some of the more common forms of nervous affections are purely
functional. Text-books abound in cases where some disease of the intes-
tine, ovaries, uterus, kidneys, bladder and urethra have been the exciting
cause of paralysis, and of serious effects upon the nerve centres. The
eye is also a very frequent factor in functional nervous diseases—although
the fact is not generally recognized by authors, This field will be dis-
cussed later. Iysteria is often associated with an attack of paralysis
THE CLINICAL HISTORY OF THE PATIENT. 115

that is not easily differentiated from the types of paralysis produced by
destructive processes within the brain and spinal cord. Epilepsy and
St. Vitus’ dance are purely nervous diseases, and yet they may sometimes
be the indirect result of a defective assimilation of food, general de-
bility, some poverty of the blood, and many other causes that are not
directly associated with the nervous system proper.

‘On the other hand, diseased conditions of the nervous centres may
induce so-called trophic changes, or changes of nutrition, not only in the
muscles—as is evidenced by atrophy of a more or less complete kind—
but also in the skin, the various organs, the joints, and even in the bones.

The peripheral nerves preside, not only over the muscles to which
they give the power of contraction, and the tactile organs of the skin, to
which they contribute the ability to perceive all varieties of impressions,
such as the tactile sense, the sense of cold and of heat, the feelings of
pain, etc., but they have another equally important function, which they
exercise chiefly by means of the so-called vaso-motor filaments, viz., the
regulation of the blood supply to the viscera, organs of special sense.
muscles, bones, joints, and skin. Now, when the nerve centres become
involved by any form of destructive process that cuts off these so-called
“trophie fibres” from connection with certain parts of the spinal cord or
brain, definite regions of the body may waste away without exhibiting
paralysis, the eye and ear may lose their marvelous functions, and the
skin may develop different forms of eruptions, bed-sores, etc.

Finally, the spinal cord and the medulla oblongata (which is its
uppermost portion) contain certain collections of nerve cells or “reflex
centres” that preside over the more important functions, or those essen-
tial to life.

By means of an excitability which is present in these collections of
cells, the heart is kept pulsating; the respirations go on, even in spite of
any voluntary efforts made to arrest them; the pupil dilates and con-
tracts when exposed to different degrees of light; and the bladder and
rectum expel the excretions that accumulate within them. In the same
way the sexual act is rendered possible in the male; the stomach and
intestine keep up a perpetual worm-like movement; swallowing is per-
formed in such a way that the food does not enter the ar-passages or pass
upward into the nose; the calibre of the blood-vessels is constantly altered,
so as to meet the demands of different parts of the body when active or
at rest; and the acts of vomiting, hiccough, sneezing, sighing, laughing,
etc., are rendered possible, and often involuntary.

In closing this section of the chapter, I take the liberty of presenting
a sample page of my own case-book, specially designed for the recording
of the results of the first examination of patients afflicted with any form
of nervous malady. Some of the headings will be discussed in subsequent
116

pages.

Their bearings upon diagnosis will then be made clear.

LECTURES ON NERVOUS DISEASES.

The

page which faces the printed one is left blank to allow of subsequent
record of the treatment and any new symptoms that may arise.

Namem........ ALN ee i AGH siiaicianieis e OCCUPATION, os cceeoseccees es DATEssseees nets ate aren TOS steve

 

Clinical history:
Acquired diseases— ©
HeVCES esciunssaeipicie recs sie
LUM gS seidictes Aer
Kidneys ........
Pelvic organs....

  

 

 

Vernereal.....sccceeccencecercccoes siemieaiotetiaiciers
Habits, as to dict...05. ceccesee sa cnee ce eendeoe ete
es © -aleoholl 1g asaiaeeseeweleis eels
ee « ‘tobacco or drugs... sss eee sera een
“ “© -venery. sneeeeareesesane
Motor PHENOMENA... cee ciecreesenneeeceneeneseeee
SCNSOVY PHENOMENA, ce rgevererercesceceeccens aerate
Allitude sc sssceaccs tence cesses eesssccees ease aNeg
Cath aunhenoastaw send eeeni iat eeGeeess, ace
Senseof Siell came meinen + eater sana eetaiahaw
Eye:
Pupils ..

  

Lar:
DGfOrmMiti eS ccewis caecameunaeearne texans

 

 

Mauth:

Articulation s
Deglutition....
Attitude of lips......

Movements of tongue.........00..eeseeee Hamels

 
 

Brain:
Memory ......
Emotions......
Logical powers
Sleep ... 046%

  
  
 
 

Vertigo...3--+-
Spinal cord:
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LI,

SYMPTOMS OF NERVOUS DISEASES REVEALED

TO THE PHYSICIAN

BY HIS SENSE OF SIGHT.

When a patient and his medical adviser meet for the first time there
are many medical facts which may be detected simply by a glance, with-
out a question being asked. Sometimes information thus gained is in-
valuable to the doctor, and of the greatest importance in diagnosis. To
become skillful in this line, however, both study and practice are requisite.
SYMPTOMS REVEALED BY THE SENSE OF SIGHT. 17

Some years since I published, in the New York Medical Journal, a
contribution to the study of medical physiognomy which has been
honored by two foreign translations; and, in my late work on “ Medical
Anatomy” (Wood's Library for 1882), I have devoted an entire chapter
to the subject. In this article, however, I shall only touch upon such
points as are related to the diagnosis of nervous diseases,

This section of my article I shall discuss under the following heads:
1, The study of the features and general appearance of the patient. 2,
The study of the gait and the attitude of the patient, when sitting, stand-
ing, or reclining.

Tue FEATURES AND GENERAL APPEARANCE OF THE Parient.—
One glance at a face affected with such striking alterations as those
produced by Bell’s paralysis, Duchenne’s palsy in its advanced state,
marked atrophy of the facial muscles, and some other nervous conditions
which are associated with extreme facial deformity, would be sufficient
with even an inexperienced practitioner fora diagnosis. But all diseases
of the nervous centres, or of the cranial nerves themselves, independently
of the brain, are not so forcibly evidenced in the face. Something of value
can, however, usually be learned by a careful study of each of its parts,
especially the forehead, eye, lips, tongue,and ear. It has been my custom
for some years to have impressions from untouched photographic nega-
tives made of many of my patients before any mode of treatment was
commenced, J have found them very useful in many ways; and they
certainly constitute the easiest and most reliable method of recording
some medical facts.

A prominent and tortuous artery upon the temple may catch the
eye of the doctor. It is well to know that such a condition often accom-
panies kidney disease.

A scanning of the face will show whether the complexion is ruddy,
as in health, or pale from some cachexia; clear and free from eruptions,
or sallowed and dingy; waxy and transparent, as in Bright’s discase, or
tinged with blue from imperfect oxygenation of the blood.

In children, certain lines or wrinkles may possibly exist that point
strongly to some complicating disease of the brain, lungs, heart or
digestive organs, the presence of persistent pain, and other valuable data.
In adults, or the aged, these lines are of less clinical importance. I have
discussed them in other articles, previously referred to.

A collar loosened or open may suggest some difficulty in breathing.
An untied shoe may cover a dropsical foot; a slit in the region of the
“oreat-toe” joint may have been made as a relief to gouty inflammation;
one shoe badly worn at the toe may tell of an existing hemiplegia, Pa-
tients with enfeebled mental powers and drunkards are particularly liable
to have their clothing wrongly or incompletely buttoned; the pants im-
‘

118 LECTURES ON NERVOUS DISEASES.

perfectly closed or open; the shoe down at the heel; the hair uncombed,
and to present other evidences of indifference to neatness of appearance,

Good, strong hair in abundance, and teeth that are free from defects,
are evidences in the adult of a naturally vigorous constitution. Broad
shoulders and deep chests are likewise an indication of inherited strength
both of the organs and muscles.

Tue Diarnesis.—The general appearance of the patient may afford
some valuable information respecting an hereditary diathesis. Laycock
has admirably described them.

Patients of the ‘ gouty” diathesis usually have a heavy frame, well-
developed muscles, a large head and jaw, strong hair and teeth, a robust
appearance, and an erect carriage. They are peculiarly susceptible, in
adult life, to diseases of the blood-vessels, apoplexy, aneurism, and heart
troubles,

In contrast to this type, those of the well-marked “ strumous” dia-
thesis have a light, bony framework, which is often characterized by an
enlargement of the ends of the long bones. The hand is sometimes un-
shapely from this peculiar defect, or the rings which will pass the joints
are too large for the finger. The chest of such subjects is also small.
The glands of the neck tend to become enlarged at about the age of
puberty.

The hair of strumous subjects is apt to be thin and fine. The eye-
lashes are usually long and silken, although the lids may sometimes be
diseased and the lashes more or less disfigured. As children, they
are liable to be unusually precocious. The teeth are crowded into a
narrow arch and are liable to decay early. The under jaw is light. Evi-
dences of rickets in childhood may exist during adult life. Scrofulous
children inherit “ either a velvety skin, dark-brown complexion, dark hair,
dark brilliant eyes and long lashes, with the lineaments of a face finely
drawn and expressive; or a fair complexion, thick and swollen nose,
broad chin, teeth irregular and developed late, inflammation of the Mei-
bomian glands, scrofulous ophthalmia, eruptions of the head, nose, and
lips, and enlarged cervical glands.” These subjects are often ‘“chicken-
breasted” and “bow-legged.” The “strumous diathesis” entails a pecu-
liar liability to defective nutrition, glandular. enlargements, and “con-
sumptive” changes within the lungs during early manhood. Epilepsy
and hydrocephalus often develop in such subjects during infancy or
childhood.

The so-called “nervous” diathesis is commonly associated with small
but perfect bones, an absence of fat, a well-formed cranium, small features,
quick intelligence, and an active frame. They usually have a bright eye
and small abdominal organs. They bear fatigue well, but are peculiarly
susceptible to nervous excitability and depression. In adult life they

'
SYMPTOMS REVEALED BY THE SENSE OF SIGHT. 119

become the more common victims to neuralgia, epilepsy, hysteria, dipso-
mania, and many other nervous diseases,

Dark-haired and swarthy subjects are often of the so-called “ bilious”
temperament. They commonly possess large frames, strong muscles, and
a tendency to moderate obesity. They are active rather than lethargic.
The digestive organs are often disturbed by habits of over-indulgence at
the table or excessive mental efforts. Such subjects commonly suffer
from “sick-headaches” from early childhood, and often develop gouty
symptoms in early adult life. They are not infrequently victims to vas-
cular changes, kidney disease, and apoplexy, after the age of fifty years.

The “lymphatic” diathesis is generally met with in sluggish, lazy,
and large subjects. They are commonly addicted to alcohol (because
they suffer from fatigue) and to excessive eating. They have heavy
bones, but soft and flabby muscles. They are often pale. They usually
thrive best in invigorating climates.

Now, it must be remembered that it is ‘seldom that.the physician
meets either of these types unadulterated. A man of the gouty diathesis,
with a wife of the “nervous” type, will probably have children that ex-
hibit certain characteristics of both. Hence it is often desirable, before
making a diagnosis, to inquire into the peculiarities of build and tem-
perament of the ancestors of patients afflicted with nervous diseases, as
well as to their duration of life and the causes of their death.

Tue CacHExtA.—These are diseased conditions. The ones which
are most frequently recognized by the neurologist are those of syphilis,
cancer, gout, mercurial or lead-poisoning, and malaria. In all of these
there is poverty of the blood, because the red corpuscles are more or less
destroyed and the constituents of the blood-plasma are altered. If a
cachexia is superimposed upon some special form of diathesis, a double
danger to the patient is the result A strumous subject, for example,
may have his tubercular tendencies materially hastened, if not actually
developed, by malaria, syphilis, and mercurial or lead-poisoning.

Spectra, Puystognomy.—As the physician scans the features of his
patient, it is best to inspect different parts of the face separately, as it
were. Let us note what he should particularly observe.

The Forehead.—If the forehead be well developed, the “nervous
diathesis”’ is liable to be present. If protuberant and overhanging a
small and imperfectly-developed face, rickets, hereditary syphilis, or
hydrocephalus have probably existed in childhood. If hereditary
syphilis has conduced toward the cranial deformity, the teeth will be
found to be defective. Ulceration upon the forehead, unless it be due to
a wound, is invariably syphilitic. Scars of this region or copper-colored
spots are equally significant and suggestive. Depressed fractures over
the frontal region are not necessarily associated in the adult with injury
120 LECTURES ON NERVOUS DISEASES.

to the brain, even if extensive, because the frontal sinuses are deyel-
oped after puberty, and the front wall of the sinus may be then crushed
in without disturbing the back wall or the underlying brain. A very
small cranium and a retreating forehead are often present in imbeciles.

The Eye.—In the aged, if the cornea be cloudy, you should lift the
upper eyelid and seek for an are of a lighter shade—the so-called “ arcus
senilis.”

If it exist, and its edges are indistinctly defined, there is reason to
suspect that the tissues of the body (especially the heart) are under-
going fatty degeneration.

The pupils should be examined to see if they are equal in size, and
if their movements are in any way impaired.

There is one condition, called from its discoverer the ‘“ Robertson
pupil,” that is of the greatest significance to the neurologist, because it
indicates a hardening, or “sclerosis,” as it is called, of the spinal cord. It
occurs only when this disease has involved the “cilio-spinal centre” of
the cord. This condition is indicated in the eye by preternaturally small
pupils that do not respond to light, but which still move when efforts to
accommodate the vision to near objects (7.e., within a radius of twenty
feet) are demanded.

To test this fact, place the patient at a window and instruct him to
look fixedly at some abreet more than twenty feet off whenever his eyes
are open, so that the pupil need not contract in order to focus the vision.
Now tell him to close the eyes and keep them closed until instructed to
open them. After sufficient time has elapsed for the pupils to have be-
come dilated, tell him to open his eyes. Watch carefully at this moment
for a response in the pupils, as they will contract instantly in health. If
they fail to do so, the existence of spinal sclerosis is almost positively
indicated.

Abnormalities of the pupils may afford the practitioner material aid
in diagnosis,

The pupils are found to be dilated dur ing attacks of dyspnea and
after excessive muscular exertion, in the later stages of anwsthesia, and
in cases of poisoning from bell: damon and other drugs of similar action.
A contracted state of the pupils exists during aleoholic¢ exvitement, in the
early stages of anaesthesia from chloroform, and in poisoning by morphia
or other preparations of opium, physostigmine, chloral, and some other
drugs. Paralysis of the third cranial nerve ‘creates a dilated condition
of the pupil of the same side, since that nerve controls the circular fibres
of the iris.

Again, one pupil may dilate irregularly in a weak light. This sug-
gests the existence of adhesions of the iris, as.a result of past inflamma-
tion. Ivitis is often syphilitic, and this symptom may tell of past

 
SYMPTOMS REVEALED BY THE SENSE OF SIGHT. 121

infection. The inner surface of the eyelid is a valuable guide to detect the
presence of anemia, as it shows a pallor that is in marked contrast, to the
redness of health. Alcoholic subjects are apt to have a vascular redness
of the eyeball. Bright’s disease often causes a drop of' fluid beneath the
conjunctiva that might be mistaken for a tear. It can be moved, how-
ever, while a tear cannot without causing its disappearance.

In connection with hemianopsia (see previous section) there may be
an absence of pupillary movement upon one lateral half of each eye——
the so-called “ hemiopic pupillary reaction.”

The movements of the eye should be a subject of special inquiry.
Brain diseases sometimes manifest their existence very early by some
form of paralysis of the ocular muscles. Strabismus or cross-eye may
exist when the third or sixth cranial nerves are impaired. We meet it
chiefly in connection with hydrocephalus, apoplectic clots, brain-tumors,
cerebral meningitis, growths within the orbit, and as a congenital or ac-
quired deformity. This subject will be fully discussed later.

It is a fact well known among oculists, and one which often helps
them materially in diagnosis, that the defects of vision occasioned by a
serious impairment in the power of some of the muscles which control
the eyeball, cause the patients. unconsciously to assume an abnormal
position of the head, which tends to assist them in the use of the affected
eve. So diagnostic are some of the attitudes assumed by this class of
afflicted people, that the condition which exists may be told at « glance,
as the patient enters a room, by one thoroughly familiar with diseases
of this important organ. The explanation of this tendency on the
part of this class of patients lies in the fact that a loss of power in the
ocular muscles nay immediately show itself in the perception of every
object, as it were doubled; and it is to overcome these double images
that patients almost instantaneously discover their ability to get rid of
the annoyance by some special attitude, which, of course, depends upon
the muscle that is weakened or paralyzed.

It will be necessary, in order to clearly understand the mechanism
of this peculiarity, that the separate action of the six muscles which
directly act upon the globe of the eye be considered.

The action of each of the ocular muscles may be given, then, as fol-
lows, with the proviso that many of the motions of the eye are not the
result of the contraction of any single muscle, but often of a number
acting either in unison or successively.

The superior oblique muscle turns the eye downward and outward;
the inferior oblique muscle turns the cye upward and outward; the
superior rectus muscle turns the eye downward and inward; the internal
rectus muscle turns the eye directly inward; the external rectus muscle
turns the eye directly outward,
122 LECTURES ON NERVOUS DISEASES.

This statement as to the above muscles reveals nothing which would
not be immediately suggested by the insertion of each, with the exception
of the superior and inferior recti muscles, which, besides the action that
their situation would naturally suggest, tend also to draw the eyeball
inward, on account of the obliquity of the axis of the orbit, and the same
obliquity of the muscles, since they arise at the apex of the orbit. The
action of the oblique muscles is, as any one familiar with their origin
and insertion would naturally surmise, to control the oblique movements
of the eyeball.

Now, as soon as any one of these six muscles becomes pressed upon
and weakened by the presence of tumors, inflammatory exudation,
syphilis, or other causes, the patient at once perceives double images,
and, in order to get bis eye into such a relative position with that of the
healthy side as to enable them both to focus upon the same object ina
natural manner, the patient soon learns to so move his head as to compel
the two eyes to look in parallel directions.

A very simple rule can be suggested by which the physician may he
enabled not only to tell in what direction a patient would move his head
in case any special muscle be rendered weak or utterly useless, but also to
diagnose the muscle affected, when he looks at the patient, without any
knowledge of his history. The rule may be thus stated: In paresis of any
of the ocular muscles, the head is so deflected from its normal position that
the chin is carried in a direction corresponding to the action of the af-
fected muscle.

Thus, in paresis of the external rectus,* the chin would be carried
outward toward the affected muscle; while in paresis of the internal
rectus muscle the head would be turned away from the side on which the
muscle fails to act. In case the superior oblique muscle is impaired, the
chin would be carried downward and outward; while in case of the inferior
oblique muscle, the chin would have to be moved upward and outward to
benefit the vision of the patient. The superior and inferior recti muscles,
when impaired by disease or other causes, would likewise create a de-
flection of the head in a line corresponding to that of their respective
actions.

Paresis of the external and internal recti muscles occasionally causes,
in addition to the facts already described, another point of very great
value in diagnosis, viz., an alteration in the apparent size of the objects
seen from what they would be in health. The condition of vision

*While this statement would be absolutely true in theory in all cases, we must ac-
knowledge, as a clinical fact, that paticnts learn to utterly disregard the image in the
affected eye when the internal or external rectus is the seat of paresis, and to use the
normal eye only for the purposes of vision, thus rendering this attitude of the head less
diagnostic than when the oblique muscles are affected.

ea ee
THE EYE AS A WHOLE. 123

termed by oculists “ megalopsia,” or “macropsia,” often signifies paresis
of the external rectus; while the opposite condition, called “ micropsia,”
‘may indicate a loss of power in the internal rectus muscle,

In the former of these conditions, the objects seen by the patient
seem to be greater in point of size than the intelligence of the patient
assures him is the case; while in the latter, objects seem smaller to the
patient than they really are.

THE EYE AS A WHOLE.

I take the liberty of inserting, in this connection, an extract respect-
ing the eye from my brochure on medical physiognomy :—

The intimate communications between the fifth, the seventh, and
the sympathetic nerves, through the media of the ciliary, optic, and
Meckel’s ganglia, would lead us to expect that the eye should exhibit in
its altered appearance the derangement of internal structures. ‘“ When a
glance of this organ is caught, what a field of mute expression is open to
the mind! This silent or instructive index of the whole man may be
bright or dull, heavy or clear, half-shut, or unnaturally open, sunken or
protruded, fixed or oscillating, straight or distorted, staring or twinkling,
fiery or lethargic, anxious or distressed; again, it may be watery or dry,
of a pale blue, or its white turned to yellow.”

The pupils may be contracted or widely dilated, insensible to or
intolerant of light, oscillating or otherwise, unequal in size, or changed
from their natural clearness of outline. “The noble arch of the brow
speaks its varied language in every face of suffering humanity. It may
be overhanging or corrugated, raised or depressed; while the lid of the
eye, animportant part of this vault, exhibits alternations of puffiness or
hollowness, of smoothness or unevenness, of darkness or paleness, of
sallowness or brown discoloration, of white or purple. Lines intersect
this region, and the varied tints are perpetually giving new color, new
feature, new expression, by their shadows.” If the frontal muscle acts in
connection with the corrugator supercilii, an acute deflection upward is
given to the inner part of the eyebrow, very different from the general
action of the muscle, and decidedly expressive of debilitating pain, or of
discontent, according to the prevailing cast of the rest of the countenance.
An irreeularity of the pupils of the two eyes indicates, as a rule, pressure
upon nerve centres or upon the optic nerve itself. In adynamic fevers
the eyes are heavy and extremely sluggish, and are, as a rule, partially
covered by the drooping eyelid; while in certain forms of mania they
are seldom motionless. This latter peculiarity is also often noticed in
idiocy.

In the so-called ‘“ Bell’s paralysis,” due to failure of the facial nerve,
the eyelids stand wide open, and cannot be voluntarily closed, since
124 LECTURES ON NERVOUS DISEASES.

the orbicularis palpebrarum muscle is paralyzed. This condition may be
further recognized, if unilateral, by a smoothness of the affected side,
since the antagonistic muscles tend to draw the face toward the side
opposite to the one in which the muscular movement is impaired; an
inability to place the mouth in the position of whistling, because for this
act the two sides of the face must act in unison; loss of control of saliva,
which dribbles from the corner of the mouth ; and a tendency to accumu-
lation‘ of food in the cheek since the buccinator muscle no longer acts.

When the third pair of nerves are affected upon either side, the upper
eyelid: cannot be voluntarily raised, for the levator palpebre muscle fails
to act; and the eye is caused to diverge outward, because the external
rectus muscle, not being supplied by the third pair and having no counter-
balancing muscle, draws the eye from its line of parallelism with its
fellow. In photophobia, attempts to open the eye create resistance on
the part of the patient, since the entrance of light causes pain; while, as
death approaches; or in the state of coma (save in a few exceptions), the
eyes are usually open. In cardiac bypertrophy, an unusual brilliancy of
the eye is perceived, since the arterial system is overfilled from the
additional power of the heart. A peculiar glistening stare exists during
the course of scarlet fever, which is in marked contrast with the liquid,
tender, and watery eye of measles. Many diseases of the eye itself tend
to greatly alter the normal expression of the face. Prominently among
these may be mentioned cataract, glaucoma, cancer, staphyloma, exop-
thalmus, iritis, conjunctivitis, amaurosis, etc., but the special peculiarities
of each need not be here described.

THE EYE AS A FACTOR IN THE CAUSATION OF SOME COMMGN
NERVOUS SYMPTOMS. ,

Although something has been written within the past few years in
relation to the deleterions effects of errors of refraction and accommeda-
tion of vision and the condition known as “ muscular insufficiency ” upon
the functions of the nervous system and the viscera,* the profession at

* Priority in this field (save in respect to ocular defect as a cause of headache, which
has been recognized in a somewhat imperfect way for many years) is justly claimed, as far
as I know, by Dr. George T. Stevens of New York. Although his views have been regarded by
some as extreme and untenable, those who have carefully and accurately investigated the
eyes of nervous subjects cannot, I think, deny that defects in refraction and accommoda-
tion, and insufficiency of the ocular muscles, are very important and generally neglected
factors of causation. Authors cannot afford to-day to utterly discard all mention of the
tests for muscular insufficiency from neurological works, as they have done in the past.
In point of fact, even the tests for errors in refraction are not described in the standard
works on nervous maladies. Mcst authors secm to have been content with showing a cut
of some opbthalmoscope and dismissing the subject with a few lines. It is safe to infer
that such writers are either not familiar with the field here discussed, or not in the habit
of employing the tests herein described upon their patients. Iam sure (if this is not the
case) they could not remain so apathetic and apparently indifferent to the results obtained.
THE EYE AS A FACTOR IN NERVOUS SYMPTOMS. 125

large is not yet thoroughly awakened to the importance of the detection
and correction of such errors. J deem it of the greatest importance,
therefore, to call attention to it again in this connection, and to give a
full description of the testing of vision and of ‘the eye muscles.
Most of you know that some persons can be made dizzy by looking
‘from a height or inspecting a water-fall; you have doubtless seen laymen
suffer pains in the head and be made “sick at the stomach” by trying on
a pair of spectacles which gave relief to a friend.* You doubtless know
that a “squint” in the eyes is very often due to some defect in the refrac-
tion of the eye or a weakness of its muscles; but possibly some of you do
not know that a squint will occasionally disappear at once when the
proper glasses are given to such a patient, without recourse to cutting
the muscle. Perhaps it has never occurred to most of you that sight is
the only special sense which. we use constantly except during the hours of
sleep. There is not a moment of the day or evening when we are not
acquiring visual impressions of some kind.

 

ee ee ica Tie ck fake, th cooler ar an tine e

eye; H, represents the Aypermzetopic eye; M, the myopic eye.

Fortunately for our nervous system, the normal eye takes pictures of
surrounding objects without any muscular effort when the object is more
than twenty feet away; hence, during the larger part of each day, the
normal eye is passive, and is practically at rest, although performing its
functions. How different is the condition of the far-sighted or “byper-
metropic” eye, however, from the normal! For this eye (since it is (oo
short in its antero-posterior axis) all objects have to be focused by mus-
cular effort, irrespective of their distance from the eye. Such an eye is
never passive. It has no rest while the body is awake. It is always
straining more or less intensely to bring properly upon the retina the
images of objects seen.

* Let a healthy child try on its grandfather’s spectacles and wear them for a time, and

the effects of ‘‘eye-strain’’ will be very clearly exhibited by distressing symptoms in u few
minutes. :
126 LECTURES ON NERVOUS DISEASES.

THE HYPERMETROPIC EYE.

The “hypermetropic” condition of the eye, or ‘‘far-sightedness,” as
it is called, is a very common defect. It is especially frequent in persons
of tubercular parentage.* It is well, therefore, to suspect the existence
of this defect in children or adults whose ancestors have died of “con-
sumption.” ;

Hypermetropia cannot be corrected too early in life. It is unquestion-
ably one of the most frequent causes of “ sick-headache,” which, as you
know, runs in families. It is commonly encountered also (among other
optical defects) in subjects afflicted with chorea and epilepsy.f Itisa
congenital defect, and will never be “outgrown,” as many people think.
A hypermetropic child, from the days of babyhood, suffers (unconscious
perhaps of the fact) from a variety of symptoms which indicate the
“strain” to which it is subjected in consequence of its efforts to see dis-
tinctly. Its eyes are liable to become easily suffused when it plays or
looks steadily at near objects. A slight cast in the eye is sometimes
developed. Jt occasionally “sees double” after it learns to read. It
usually prefers and excels in out-of-door sports, which require only
slight efforts at accommodation of vision. It finds that study and close
application to books bring an indescribable sense of weariness and dis-
comfort; hence, study becomes irksome and play brings a sense of pecu-
liar relief. Some years ago Dr. Loring, of this city, wrote an article for
Harper’s Monthly which treated of hypermetropia and myopia in a
charmingly lucid and popular manner.

* This is probably due to the shallowness of the orbits.

} Dr. George T. Stevens was the first, so far as I know, to advance the general propo-
sition that ocular defect was an important factor in causing functional nervous diseases,
that muscular insufliciency (chiefly of the externi) was particularly apt to cause such dis-
turbances, and that they could be relieved by tenotomy. I haye an epileptic child under
my care at the present time whose attacks have averaged four a day for several years. The
fits will cease at once when the child is at sea, possibly because efforts of accommodation are
almost entirely dispensed with when on deck. Hypermetropia, astigmatism, and external
insufficiency exist in this patient. The use of atropine causcd a complete cessation of the
fits for several days. Why cannot the eye act as a disturbing element as well as phimosis,
sexual excesses, ovarian irritations, etc., concerning which so much has been written?

fIt is a well recognized fact that people who are victims to sick-headuches early in
life tend, as a rule, to suffer less {rom such attacks after the age of forty. This is not
generally attributed (as in my opinion it should he in many cases) to the enforced use of
glasses. in writing, sewing, reading, and other forms of near eye-work. Most of this class
of sufferers are hypermetropic to a marked degree; hence they are compelled to relieve
their “accommodation”? by a glass earlier than most adults.

These subjects, therefore, do not “ outgrow their malady ;”’ nor does the eye improve
in regard to its refractive error as age advances. They simply aid the eye at last with a
glass, which it has too long needed ; not voluntarily in most instances. but from compul-
sion, because the focusing muscle of that organ is unable after a while to continue to work
under the strain which the refractive error has entailed wpon it.
THE HYPERMETROPIC EYE. 127

Now, one peculiar fact should be noticed here—viz., that Ayper-
melropic subjects often have remarkable acuteness of sight. They are very
apt (when young adults) to boast of their power of vision. They can often
read all the test-types made for distance (twenty feet or more) without
anerror. If the defect exists in a child, the parents will frequently tell
you how the child can see things with distinctness which possibly they
themselves cannot see at all; how they have tested its eyes from time to
time; how absurd the idea seems to them and their friends that the vision
of the child is defective; and how unnecessary the use of glasses seems
to them (even if the eye is abnormal) so long as the child can get along
without them. In some cases no amount of explanation or pleading will
persuade the parents to have atropine used upon the echild’s eyes in
order.to positively decide the question of the existence of “latent”
far-sightedness.

 

Fic, 89.—Srcrion or THE Front Part or tHe Eyn, SHowinc THE Mrcnanism oF Ac-
commopaTion, (Fick.) The left side of the figure (7°) shows the lens adaptel to vision
at distances of over twenty feet; the right side of the figure ()} shows the lens adapted to
the vision of near objects, the ciliary muscle being contracted and the suspensory ligament of
the lens consequently relaxed.

Some years ago I pleaded with a medical man to allow some oculist of
reputation to examine his children’s eyes, all of whom had weekly attacks
of sick-headache, inherited from both the mother and father, and in whom
a tubercular tendency was strongly marked. Iwas refused, and the state-
ment was made that never, while the father lived, should a child of his
wear glasses with his consent. One of these children wears to-day a con-
vex glass with a twelve-inch focus for distance; another wears the same
glass with five degrees of prisms added. These only partially correct an
insufficiency of the muscles which exists in addition to the Lyperme-
tropia, A third child is highly hypermetropic and astigmatic. In every
one of these subjects immense relief has been afforded by the correction
of an optical defect which had rendered their early life one of suffering.
This is not an uncommon experience. I could cite many more, if I
deemed it necessary to prove what is already accepted by ophthalmolo-
gists as proved—viz., that hypermetropia and eye-defect of other forms
may prove to be fruitful sources af headache.
128 LECTURES ON NERVOUS DISEASES.

There is a prejudice among laymen and some medical men that
classes are an injury when they can be avoided, because, as they say, “a
person becomes so dependent upon them when he once puts them on.”
This argument should be exactly reversed, and construed as follows:
Because nature becomes dependent upon a glass which gives relief and
corrects an existing strain upon the eye, no time should be lust in afford.
iny this relief.

Should a hip-splint be avoided (when the pain in the joint is arrested
hy it) because the patient feels his dependence upon the splint? Should
a child be allowed to go through life with a deformed eye simply because
the defect is not apparent to himself or his friends on account of an un-
naturally-developed ciliary muscle (see Fig. 39), which for a time renders
the eye capable of getting along tolerably well in spite of its deformity?

More harm is beine done to-day to the community at large by this
fallacious argument than it is possible to compute. Thousands of suf-
ferers from sick-headache and neuralgia are to-day struggling along
through life with an optical defect uncorrected, and, in many instances, -
after costly experimentation with drugs and doctors, are left in despair
of cure.

I speak strongly upon this point because I believe that the gastric
symptoms which accompany typical attacks of sick-headache are not to
be explained (as they commonly are) on the ground that the “liver is
inactive,” or that “dyspepsia exists,” or that “the gastric juice is weak,”
or that “the patient uses tobacco to excess,” or that “he has been living
too high.”” Every one who has suffered for years with these attacks knows
that they often occur without explainable cause; that they are cured some-
times by eating, drinking, and smoking, and made worse at other times
by similar indulgences or excesses; that every known reinedy is spt,
sooner or later, to prove inoperative, and that a sure specific for them is
unknown among the drugs of our Pliarmacopeia. These subjects also
know that life is rendered almost unendurable by the attacks at times.
They are tractable patients, and will try anything, live in any way
specified, and bear any privation without a murmur, if it will insure a cure.

I believe, from a personal experience of my own of this kind (which
it is unnecessary to relate here), and from some experience also in exam-
ining the eyes of this class of sullerers, that the symptoms of sick-head-
ache are reflex in character to a larve extent, and are due primarily in
almost every case to some ocular defect, We can easily demonstrate
that disturbed brain-action from “eye-strain”’ may produce in a healthy
child and in some adults all of the symptoms of these attacks in a few
minutes. Why is it irrational, therefore, to affirm that a brain (disturbed
by the constant efforts made to use eyes which are abnormal in respect
to the refraction, accommodation, or the equilibrium which should exist
THE MYOPIC YE. 129

between its various muscles) may manifest its disturbed state by nausea,
headache, vomiting, dizziness, constipation, and other evidences of im-
perfect performance of the functions of the viscera? Does not our cen-
tral nervous system regulate and directly control those functions? Is it
not as probable that the master when upset disturbs the servants under
him, as to advance the argument that the servants themselves are the all-
important factors in causation ?

THE MYOPIC EYE.

When the eye is too long from before backward, the patient is said
to be “ myopic,” or near-sighted. Distant objects are more or less indis-
tinct to such an eye in proportion to the excessive length of the antero-
posterior axis of the eye over the normal standard. No amount of mus-
cuiar effort can overcome or improve this defect in vision; hence these
individuals are not subjected to the muscular strain which far-sighted
persons constantly and unconsciously exert in order to see at a distance.
Again, the near-sighted eye can read or perform any of the functions
required of it (when brought sutliciently close to the object) without any
muscular effort of an unnatural character. In contrast, the far-sighted
eye has to exert a still greater muscular effort to see near objects dis-
tinctly than when employed upon distant objects; hence the fatigue, the
blurring of letters upon a printed page, the watering of the eyes, the pain
in the eyes and head, and the many other ills previously described.

Near-sighted subjects are generally conscious of an eye-detect, be-
cause they cannot see across a room with distinctness or recognize
familiar faces on the street. They are apt to become very fond of occu-
pations which brings the eye close to their work, because they have no
difficulty in seeing the object. Near-sighted children are liable to be con-
sidered precocious beyond their years, because they prefer to read rather
than to play out-of doors. It is generally safe to conclude that a child is
near-sighted when it avoids out-of-door amusements in order to gratify a
taste for reading or in-door occupations.

Near-sightedness is less liable to induce nervous disturbances than
far-sightedness, provided it is not accompanied by astigmatism or mus-
cular insufficiency. Yet it should be remembered that myopic subjects
are more frequently sent to the oculist for relief than hypermetropic
subjects are, because the defect in vision is very apparent to all in the
former class, and is more often unsuspected than recognized in the latter.

THE ASTIGMATIC EYE.

You may find, in the third place, when you have examined the eyes
of patients or friends who suffer from headache, persistent neuralgic
attacks, ete., that a condition of the eye known as “astigmatism,” may

9
130 LECTURES ON NERVOUS DISEASES.

be detected, co-existing with far- or near-sightedness, or independent of
these refractive errors. In such subjects the cornea or the lens of the
eye (see Fig. 39) has a greater curvature in some meridians than in
others; hence the images of all objects seen are more or less distorted
when they fall upon the retina. To this class of sufferers some letters in
the tests employed will be distinct, while others will not. If a number
of dots are made upon a blackboard or a sheet of paper, some will appear
as ovals, with a hazy border, or as lines, while others will more closely
resemble the normal appearance of the dots. Finally, if a card, with .
lines running from its centre to its periphery (the “ clock-face test”), is
used, some of the lines will appear blacker than. the rest and more clearly
defined. Now, there can be no comfort to such subjects in their visual
efforts. They learn by practice and experience to properly interpret,
after a while, the imperfect images of objects seen, and they are aided in
so doing by the fact that the outlines of letters, ete., become clearer in
some positions, as regards the eyes, than in others; but, in spite of all
that may be said to the contrary, the strain of using imperfect eyes tells
upon most astigmatic persons sooner or later, and tends to excite reflex
nervous phenomena of various kinds. To properly correct astigmatism
by glasses is often an extremely difficult matter. It requires experience,
a thorough knowledge of optics, and a familiarity with the practical use
of the ophthalmoscope. There are comparatively few physicians (outside
of the specialists in ophthalmology) who are capable of managing a bad
case of this kind with perfect success. You ean, however, easily detect
its existence in most cases. When you discover it, I would advise you
to intrust its correction to skillful hands,

Certain abbreviations are employed by oculists to designate various
forms of astigmatism which may be detected. These are of use in re-
cording the results of an examination :—

Ah stands for simple hypermetropic astigmatism.

Am stands for simple myopic astigmatism.

H + Ah stands for compound hypermetropic astigmatism,

M + Am stands for compound myopic astigmatism.

M+ Ah, or H + Am, stands for mixed astigmatism.

THE ASTHENOPIC EYE.

Finally, it is very important that you determine (in each patient
whose eyes are examined by you) the condition of the muscles of the eye.
The term “asthenopia” is commonly applied to that condition of the
visual apparatus which entails suffering in consequence of a defective
“equilibrium” in the muscular power exerted upon that organ when a
fixed ‘position of the eye is maintained for any length of time. When a
state of perfect equilibrium is impaired from a weakness in some muscle
THE ASTIIENOPIC EYE. 131

of the eye, the effects become manifested sooner or later by pain and ereat
discomfort after the eyes are used for any length of time. I have scen
patients who could not attend a place of amusement, or read or sew, for
even a short time, without great distress from this cause. These patients
may or may not have a refractive error. In some instances, no glasses
but prismatic ones will benefit them.

A high-couraged horse feels the will, as well as the support, of his
driver through the reins by means of the wits Although his course and
rate of speed are changed from time to time at the will of the driver, the
reins are never slackened. The horse becomes acquainted with the de-
sires of his master by a sense of increased or diminished tension upon the
reins. He is guided to either side by a difference in the tension of the
two, although the driver does not entirely relax his hold upon the op-
posing rein while he uses the guiding one, and the difference in tension
may be very slight.

So it is with the normal eye. It is both controlled and supported
while performing ite movements within the orbit by the eye muscles (which
are its reins). The brain is the driver. At its command the eye revolves
or remains stationary at any desired point. The tension of muscles,
opposed to any movement of the eye required,.is so modified by the brain
as to insure the requisite support to the eyeball, and to steady it as it
moves. Thus a perfect equipoise is constantly established between op-
posing forces, adjusted with the nicest care to meet the full requirements
of the organ under all possible circumstances. ‘The normal eye does not
tremble or wabble when it moves or the attempt is made to hold it in any
fixed attitude. It is a piece of machinery, perfect in all its parts, relinble
in its movements, perfectly controlled by its master.

The eye with “muscular insufficiency” is like a horse with an inex-
perienced and incompetent driver; the proper teusion upon the reins is
not maintained at all times, as it should be; there is no equilibrium be-
tween antagonistic muscles; fixed attitudes are maintained with difficulty
for any length of time; the brain becomes more or less disturbed by its
inability: to properly control the eye movements, and exhausted by the
continual strain imposed upon it by the efforts required to do so even
imperfectly.

Asthenopic subjects are very frequently encountered in the practice
of a neurologist. The oculist, perhaps, sees them still oftencr, because
they are generally conscious that something is wrong with their eyes.
Still, there are exceptions to this rule. I have examined patients who
showed, in response to appropriate tests, very high degrees of muscular
“insufficiency,” that came to me for the relief of symptoms which had
never been referred by themselves or their physician to any possible eye
detect. I recall the case of an epileptic who was p:aced under my charge.
132 LECTURES ON NERVOUS DISEASES.

His family assured me he had “wonderful eyes;” and they were sur-
prised when I examined them with care. The results of this examination
showed, however, that twenty-five degrees of external insufficiency ex-
isted (as measured by the vertical diplopia test), and that he was hyper-
metropic and astigmatic to a marked degree.

Insufliciency of ocular muscles seems to me to bea congenital defect
in most cases—possibly in all. It is encountered in very young subjects.
It is not a paralysis or a true paresis. It is not uncommon to note wide
variations in the same case, if examinations are made from time to
time. Possibly this fact helps to explain why competent observers do
not always estimate the degree of insufficiency in a given case alike,
even when similar tests are employed and equal care is given to the case.
We have no way as yet of determining “latent” insufficiency,* as we

*Because this term was used by me, ina prior publication, I have received several
communications from oculists of prominence denying the existence of ‘“‘latent”’ or hidden
insufliciency, and taking me to task for the use of such an expression. I would state,
therefore, that there are, to my mind, most positive evidences that the condition thus de-
scribed does exist in some cases; in fact, I would go so far as to assert that it is the rule,
rather than the exception, to find a certain amount of masked insufficiency, in connection
with ‘‘functional’”’ nervous maladies, that cannot be elicited by any means yet known to
the science of opties.

My expericuce in relieving ocular ‘‘insufficiencies’’ by tenotomy of the recti muscles
has shown me that the amount of tissue divided is almost always greatly in excess of the
apparent defect to be overcome. Again, after the eyes have been perfectly balanced by a
tenotomy (as shown by careful tests made after the operation), it is very frequently found
that more “insufficiency” develops within a short time than was detected before surgical
interference was resorted to as a step for its correction. In the third place, I have found
that repeated tenotomies (performed as often as indicated by the tests described) eventu-
ally bring the patient to a point where the eyes remain permanently corrected—a fact that
proves quite conclusively the error of supposing that the tenotomy was in any way re-
sponsible for the lack of equilibrium which developed later. In the fourth place I have
found it to be advisable in some cases to cut the muscles to excess, so as to over-correct an
error in equilibriwm—knowing that by so doing I anticipate a certain amount of “latent”
insufficiency, which will assist in making the results more satisfactory to the patient
within twenty-four or forty-eight hours.

If it were necessary, in my opinion, to argue this question at greater length, I might
add (1) that a persistent wearing of prisms for the correction of insufficiency almost in-
variably results in the development of a latent weakness‘of the muscles not discovered at
first; (2) that persistent daily exercise of the eyes by prisms usually accomplishes the
same result; and (3), that my views are in accord with all who have had much experience
in the use of prisms—irrespective of partial tenotomies, which demonstrate the facts even
more satisfactorily.

I take the liberty of quoting from the late work of Prof. H. D. Noyes (pp. 87 and 89)
the following passages :—

“Give due opportunity for disclosure, and what at first seemed to be a moderate de-
gree (referring to insuficiency) may at length declare itself in much larger proportions.”

“While great advantage is gained by Graefe’s test, it is not true that latent insuf-
ficiency is always thus brought to view.”’

Again, I may quote from a late article by Dr. G. T. Stevens as follows: ‘‘ Muscular
anomalics of the orbit may be totally or partially latent.”
THE TESTS OF VISION AND OCULAR MOVEMENTS. 133

do latent hypermetropia by atropine. Should a patient show us an
insufficiency counteracted by a prism of a certain angle to-day, it only
proves that he has aé least that amount, not that he has no more. This
statement can, I think, be demonstrated. It is an important fact to
remember when the results of examinations of such patients made by
yourself are at variance with the observations made by another.

Without further preparatory remarks, I pass to the consideration of
the steps commonly taken to determine if the eye (regarded purely as a
piece of mechanism) is perfect or imperfect. The study of the eye, when
any of its component parts become the seat of disease, has no hearing
upon the subject under discussion. ‘his field is properly relegated to
oculists.

THE TESTS OF VISION AND OCULAR MOVEMENTS.

The steps which should be employed in examining the eye for errors
in refraction and accommodation, as well as those employed to detect
defect in the power of ocular muscles, have not thus far been discussed.
J expect to offer nothing new, but I hope to make the detuils of such an
examination simple and within the comprehension of all.

The importance of this department of diagnosis ean hardly be over-
estimated in nervous maladies. It has been my custom for three years past
to examine the vision of nearly every patient sent to me, as my experience
has shown me many times that remarkable cures may be made by the light
thus shed upon the causation of obscure nervous symptoms.

Unfortunately for the sick, in many instances, physicians in general
seem to think that the examination of the eye is too difficult a field for
them to intrude upon without some special preparation for it. While
this is undoubtedly true, in case the ophthalmoscope is to be employed,
it is by no means a difficult matter for a person acquainted with physics
to acquire a practical and satisfactory knowledge of the few tests here
described in a comparatively short time, and with but a limited number
of patients, provided that he works faithfully and intelligently. The
healthy (?) as well as the sick can often be used to familiarize the be-
ginner with the practical adjustment of prismatic, spherical, and cylin-
drical glasses, and also with the tests employed to detect “asthenopia”
or anomalies of the eye-muscles.

Defective vision does not always produce ill health; hence among
your friends or in your immediate family you may find a field for inves-
tigation and practice.

Now, in the first place, it is not necesssary to have a complete
Nachet case of lenses. Such a case is very expensive. By selecting a
limited assortment of lenses and prisms, different combinations can be
made to meet the needs of alinost every eye-defect encountered in medical
practice.
134 LECTURES ON NERVOUS DISEASES.

There is furnished, with the various small cases designed by
prominent oculists, a sheet of Snellen’s test-types for distance, and also
one contsining several paragraphs printed in an assortment of types of
various sizes to be used as a test for reading power. Each paragraph is
numbered so that a record can be kept of the one read by the patient as
a test. These test-type slips can be purchased separately, however, of
any optician. It is best to have each mounted on card-board, and it is
well to have the one used in testing for distance a double one with dif-
ferent letters on the opposed sides. If you suspect that the patient is
using his memory during the tests employed rather than his sight, the
board can then be exposed upon different sides at various periods of the
examination.

You will find that the letters are mathematically made for testing
distant vision. Above each linea numeral or Roman character is placed
to designate the number of feet at which the normal eye should read the
line with ease, Thus, the large letter on the top line will be designated
usually by 200, or C C, while small letters of the lower line will be marked
10,or X. This shows that the top letter should be read easily at two
hundred feet by the normal eye, and the lower line at ten feet. After
you have provided yourself with a good trial-case,a set of prisms, and
the necessary test type, let us see how you should proceed with an exami-
nation of a patient’s vision. We may illustrate the steps by using one
of the class as a patient.

I first hang upon the wall, as you see, the test-tvpe card; and
I place the patient with his eye on the same level and at a distance from
it of exactly twenty feet. J then take the triple-grooved spectacle frame
from the trial case and insert a plate of metal in the left rim of the frame,
so that when itis used by the patient the left eye will be covered. I
then place this frame upon the patient, and ask him to read aloud the
letters on the testing card from the top downward, line by line. This
act tests his vision in the right eye. I note (while he reads) the following
facts: (1) If he calls all the letters properly; (2) if he reads without ap-
parent effort; (3) at what line he fails to read. I then make a record

, 20 (feet)
as follows: O. D. (oculus dexter, or right eye) V = — Cece The dash
in the fraction is filled with the number which indicates the last line which
the patient reads. Wuhen the vision is normal, the fraction will be as

 

20 20
follows: V. == — or If the patient fails at the line next above the
20 XX
: 20 20
normal point the fraction would be expressed by — or —-. Remember
30 XXX ‘

that the numeralor represents the distance (in feet) between the patien
THE TESTS OF VISION AND OCULAR MOVEMENTS. 135

and the test-type, and that the denominator represents the numeral on
the test card placed above the last line of type read by the patient
(which indicates the normal distance in feet at which it should be legible
to the normal eye. Now, if the vision of the right eye is found to be
defective, try and improve it, and, if possible, to rendcr it normal, or
as nearly so as possible, by testing the effects of concave or convex
glasses. upon it as the case seems to indicate, beginning with the weakest
lenses-and gradually increasing their strength until the vision reaches its
highest acuteness. This takes some little practice and experience. If
conver glasses are found to be indicated, note the strongest which gives
the best vision to the patient; if concave, record the weakest glass that
overcomes the defect.

In some cases you may find yourself unable to obtain normal vision
in either eye by means of cylindrical or spherical glasses. I presuppose

.a certain degree of acquired facility on your part with glasses of the
forms specified, and a carefully made effort to overcome the existing
defect.

In such a case it is well to consult some expert oculist (if near at
hand), and thus to ascertain the results of an ophthalmoscopic examination.
The patient may have some mechanical impediment to vision, such as an
opaque lens within the eye (cataract), or an opacity of the cornea; or he
may have a high degree of astigmatism, which can often be estimated
with some accuracy by the ophthalmoscope. Again, he may be found to
be suffering from morbid changes within the optic nerve or the retina.

When it is found that a patient is so blind in an eye as to be unable
to recognize any of the letters on the testing-card at any distance, jou
should note (before sending him to an oculist) if he can recognize with
accuracy the number of fingers which you hold before the eye, and record
the results of such investigation. You should make this test with the
fingers in all possible positions in reference to the diseased eye (directly
in front, above, below, and to either side of it). ;

We might record the results of an examination of a suppositious case
up to this point as follows :—

20 20
O.D. V. = —— (manifest) made — by + 30 glass.
XXX XX

The word “ manifest” in this record means that the far-sightedness or
“hypermetropia,” which apparently exists, is overcome by a convex or
(+) glass which focuses at thirty inches. After the use of atropine, any
increase over this amount which may be developed is recorded as ‘ latent”
farsightedness. I use here the old style of numbering glasses for the sake
of perspicuity, althoueh I personally prefer the metric system (dioptre),
as it allows of more rapid combinations when the trial-case contains only
a limited supply of lenses.
136 LECTURES ON NERVOUS DISEASES.

You will understand, when I exhibit the method of recording such
observations more fully to you, why it is that the right and left eyes have
to be separately examined and corrected (as already described) before
the binocular vision is tested with and without the needed correction. I
usually make upon the page of my own case-book a note relating to each
eye of the patient, prior to the use of atropine somewhat as follows:—

20 20
0. D, (right eye) V. == —~ (manifest) made — by + 30.
Sx XX
20 20
0.8. (left eye) V. = — made — by — 30
xl xX
20 20
Brnocunar V. = —- made — by this combination.
XXX XX

Such a record of a suppositious case would show that the patient was
far-sighted or “hypermetropic” in the right eye, and near-sighted or “nuy-
opic” in the left eye. It would lead me to believe also that the right eye
(when under the influence of atropine) might show a still greater defect,
which is now rendered “latent,” or hidden, by an excessive development
of the muscle of accommodation.

In all far-sighted eyes Nature tries from the date of birth to com- ~
pensate for the congenital defect (an eye which is too flat) by a hyper-
trophy or enlargement of the ciliary muscle (see Fig. 89); hence, when
this muscle is temporarily paralyzed by atropine, the true refractive con-
dition of the eye is no longer masked. Far-sighted patients, therefore,
lose their clearness of vision more or less at once when atropine is used.
The normal or the “myopic” eye, on the contrary, is but little affected
(as regards the outline of objects seen at twenty or more feet from the
eye) by the use of atropine, although excessive light may annoy the eye
in any case.

Let us now suppose that during the examination of a patient we first
have examined each eye separately, carefully corrected all existing error

20
found, and succeeded in getting —, or normal vision, for each eye sepa-
XX
rately; that we have then tried both eyes together with the glasses best
adapted for cach, and found the patient able to read the normal type for
distance without fatigue or conscious effort; and, finally, that we have made
acareful record of each point noted during our observations. Are we now
prepared to order glasses for the patient? Have we noted all that is im-
portant to note? To both of these inquiries I would say to the beginner,
emphatically, “No.” Several steps still remain to be taken, even before
the use of atropine (which it is generally best to employ before a final
decision is arrived at).
THE TESTS OF VISION AND OCULAR MOVEMENTS. 137

This brings us to the tests for the detection of muscular anomalies
in the orbit. :

Until within a comparatively few years ‘the necessity of carefully
measuring the power of adduction and of abduction of the eyes, and
of determining the presence or absence of muscular insufficiency in
“nervous” subjects, seems to have been practically disregarded even by
oculists. Even to-day this defect (which probably is, as a rule, con-
genital) seems to be omitted from prominent mention among the
enumerated list of ztiological factors of nervous symptoms by almost
all authors of note. In some cases I have known it to be overlooked
even by opthalmologists of world-wide reputation, simply on account of a
careless and hasty examination for the defect. It is an extremely
common defect of the eye; and may prove a very serious one to the
patient. It is an important factor in many subjects afflicted with head-
ache; it often exists to a high degree in epileptics ; it is frequently found
among children who suffer from chorea; it may unfit a patient for
sewing, reading, attending places of amusement, or using the eyes in
any way for any length of time. I have known it to cause vomiting and
so-called periodical “‘bilious attacks” by exciting a reflex irritability of
the central nervous system. One patient of mine (a close student) was
completely cured of chronic dyspepsia by the use of prisms which cor-
rected an insufficiency of 6° of the external recti muscles. He sub-
sequently had tenotomy performed and now uses his eyes without
fatigue. All bodily ailments have disappeared without the use of drugs.

In order to properly determine the condition of the ocular muscles,
several tests have to be made. I do not personally regard any of these
alone as sufficient for diagnostic purposes. The tests which I advise you
to invariably employ are as follows :—

1. Direct the patient (as you see me do with a member of the class)
to look fixedly with both eyes at some small object (say the end of a
pencil), and to follow it with the eyes as I move it before the face of the
patient at a distance of about ten inches. I watch both eyes carefully at
the same time and note if a tremulous movement in either eye is present
in any position of the eye as it moves about, and if the two eyes act in
perfect unison with each other.

2. While the patient is instructed to fixedly gaze at the same object,
I next shield one eye with a card or sheet of paper so as to exclude
the object from view. Now I shift the card rapidly from one eye to the
other, and I observe at the same time any deflection or trembling of the
covered eye, which may show itself as I shift the card. If deflection or
trembling occurs, it indicates a weak muscle.

3. Deviations of the visual axis ofan eye in a vertical direction are
not always revealed by the two tests previously mentioned, nor are they
1388 LECTURES ON NERVOUS DISEASES. .

always apparent to a careful observer of faces. They are of the
greatest clinical importance, however, and should be looked for early
in the examination. A pair of prisms of five or more degrees each are
placed in a spectacle frame with their bases inward* in order to overcome
the power of fusion of images by the externi, and the patient is directed
to look through them at a candle flame placed twenty feet from the pa-
tient’s eyes and on the same level, The head is placed in natural position
for distant vision and steadied by a photographer’s head-rest. If either of
the two candle flames (seen by the patient in consequence of the prisms)
be higher than the other, « prism is selected, which, with its base upward
or downward, when placed before one eye overcomes the defect. The
angle of this prism (in degrees) is then noted and recorded in the case-
book.

4. I next place upon the patient a spectacle-frame previously ar-
ranged with a disc of ordinary glass, tinted red, to cover one eye, and
a prism of 5°, with its base directed accurately upward or downward,
before the other eye. I then direct the patient’s vision upon a candle-
flame at a distance of twenty feet. The prism causes two candles to
appear (one being colored red by the glass of that hue), both of which
to the normal eye should be scen as if in a vertical line. If the red
image is seen to the same side of an imaginary vertical line dropped.
through the white image as the eye covered with the red glass, the
external recti are insufficient; if the red image is seen on the opposed
side of the vertical line, the internal recti muscles are weak.t

5. Any deviation of the candle which exists can be remedied easily
by placing a prism with its base outward before one eye for external in-
sufficiency, and with its base inward for internal insufficiency. The
strongest correcting prism that can be worn without an over-correction
marks the degree of the “ manifest” insufficiency only ;{ hence we will

* Dr. Stevens had devised an rectangular and elongated form of glass for this pur-
pose. Its great adyantages must be apparent to all who have worked in this field.

+ I have lately employed in my consultation room a device which seems to me to be
of great assistance to patients while their eye-muscles are being tested. It consists of two
pieces of white tape which are stretched upon a dark background at right angles to each
other ; so that one lics exactly vertical and the other horizontal. The flame from a small
gas burner at the tip of a porcelain candle lies directly opposite to their point of intersec-
tion and between them and the eye of the patient, all of which should be on the same
level.

During the tests described, the patient can tell at once if either line appears double
as well as the image of the candle flame.

t My experience with tenotomy, as a means of producing an equilibrium between
opposing forces in the orbit, has convineed me that the amount of insufficiency detected by
prisms is but a small proportion of what actually exists in some cases, A persistent use of
prismatic glasses will often develop a degree of insufficiency which the patient did not at
first apparently possess. In my experience this is the rule rather than the exception. Itis
comparatively rare for me to encounter a case where a full correction of an existing insuff-
THE TESTS OF VISION AND OCULAR MOVEMENTS. 1389

note variations from time to time, I usually note both the weakest and
the strongest prism which corrects the candle-deflection.

6. I next test and measure the power of adduction and abduction
(convergence and divergence) of the eyes by means of prisms. To do
this I set a lighted candle twenty feet from the patient on a level with his
vision when seated. I then hold before one eye a prism, with tts base di-
rected oulward, of sufficient angle to cause two images of the candle to
appear when both eyes look at the object. I then instruct the patient to
make an endeavor to draw the images together and to fuse the two into one
image. This is the test for adduction or convergence. The normal eye
should overcome a prism of at least 23° to 25°. It may overcome 60°
in some instances.

In the same way a prism with its base directed inward is used to
test the power of abduction or divergence. The external recti muscles
should not fail to overcome a prism of at least 8°. By combining
prisms of varying angles, one of the requisite angle can be easily ob-
tained with but a few prisms in your trial-case.

The power of abduction and adduction should always be recorded
when accurately determined. One fact should be stated, however, in
this connection—viz., that several sittings are usually required before
the patient learns to use his eye-muscles to the best advantage; hence
the records of daily tests should be kept for purposes of comparison
fora short time (when practicable to do so).

7. The power of convergence and divergence of the eyes can be
estimated for near objects by means of a stereoscope modified by Pro-
fessor Henry D. Noyes, into which prisms may be dropped at will. I
have used it of late with some satisfaction. I find that the accommo-
dation often modifies the power of ocular muscles (as determined by
the previous test at twenty feet distance). Prisms vary, moreover,
according to the glass used in their construction.

8. The power of fusing images of the test-object at twenty feet
when a prism is placed with its base up or down before each eye is next
determined. This is recorded as the “sursumduction” test for the right
or left eye. This test should not be employed successively upon the two
eyes without some minutes of rest have been given the patient. It aids
us in determining the relative strength of the superior and inferior recti
of the two cyes, and offers suggestions regarding the proper muscle to
divide for the relief of vertical deviations of the visual axis (see test 3).
ciency of the ocular muscles by prismatic glasses insures a perfect equilibrium of the eyes
for any great length of time. When we attempt to correct this peculiar muscular defect in
the eye by weakening the stronger muscle (as I am constantly doing with brilliant results)
the existence of ‘‘latent”’ insufficiency cannot, in my opinion, be doubted. Unfortunately

for science, we have as yet no way of fully developing it, as we do ‘‘latent’”’ hypermetropia
by the aid of atropine.
140 LECTURES ON NERVOUS DISEASES.

9. It is well to exercise the muscles of the eye with prisms before
the results of the diplopia tests are finally recorded. I have found
that, after a flexibility of the eye muscles has been obtained by the aid
of prisms, an insufliciency of the internal or external rectus muscle will
sometimes manifest itself where it was not apparent at first. That this
is not simply the result of fatigue seems proved by the fact that the insuf-
ficiency remains more or less apparent during subsequent examinations.*

I have lately adopted some new terms suggested by my friend Dr.
George T. Stevens, in recording the results of my tests made to deter-
mine the condition of ocular muscles.

I quote the article referred to in full, because I deem it of great
practical value. Dr. Stevens says :—

“The relations of the eyes to each other, in the act of vision, exercise important in-
fluences, not only in occasioning the condition known as asthenopia, but in the causation
of many other important nervous disturbances.

“Tf this statement is admitted, it will be evident that the subject of irregularities in
the actions of the ocular muscles must assume a greater importance than when disturb-
ances of equilibrium were regarded as only occasional factors of asthenopia, and when
these disturbances were looked for mainly in a single direction, in case they were not en-
tirely disregarded. It is true, even at the present time, that ‘insufficiency of the interni’
is the only disturbance of the ocular muscules, excluding strabismus or some of the results
of paralysis mentioned in the majority of the text-books upon the eye. Indeed, the im-
portance of even this defect is hardly dwelt upon at any considerable length in many of
these works, and it is not at all uncommon for the oculist to overlook the condition in his
practical work,

“Defects which result in lasting difficulties and perplexities in the performance of
binocular vision are not to be ignored; and the réle of the ocular muscles in the causation
of many nervous disturbances is undoubtedly of very considerable importance.

“As the investigator in this department of ophthalmology proceeds in his researches,
or attempts to record his observations, he is met by the fact that the terms now in use are
not only frequently inaccurate and misleading, but wholly inadequate to describe many
of the states observed.

‘To illustrate the two factors of the proposition just made, a few ordinary conditions
may be adduced :—

“1, The expressions employed to designate the deviations from the state of physio-
logical equilibrium are often incorrect and misleading.

“The term ‘insufficiency of the interni’ is used to express a state of the muscles of
the eyes which is shown by the equilibrium test of Graefe at reading distance. In this
test. the images seen by the two eyes are separated by a prism held vertically, with its
base exactly up or down before one of the eyes. If, under these circumstances, the images
deviate laterally in directions opposite to the two eyes—that is, if the image of the right
eye deviates to the left, and of the left eye to the right—there is said to be ‘insufficiency
of the interni’ of as many degrees as equals the strength of a prism which, with its base
toward the nose, will bring the two images in a vertical line. The expression, ‘insufficiency
of the interni,’ in this relation, is used to indicate the fact that the internal recti muscles
are ‘insufficient’ to counterbalance the external recti; and it also carries the idea
that tho externi are, in proportion to their physiological state, stronger than the

* This fact also confirms the views expressed in the previous foot-note (p. 138).
THE TESTS OF VISION AND OCULAR MOVEMENTS. 141

interni, or that the interni are, proportionally to the others, abnormally weak; tending
thereby to balance the eyes outward, so as to cause an unusual and excessive demand
upon the internal recti in close work.

“The fact that a great many cases, in which the equilibrium test of Graefe shows the
conditions described, are really ‘insufficiency of the externi’ and not of the interni, must
occur to any careful observer. Such a one will often find that, if he makes his test of
equilibrium while the ocular muscles are in a comparative state of repose, as when looking
at an object at a distance of six metres or more, he may find very marked ‘insufficiency
of the externi,’” He may even observe that, if a screen is passed before one of the eyes
while the other continues its gaze, at the distant object, the covered eye will deviate ina
marked manner inward. If the screen is quickly changed to the opposite eye, he will see
the lately covered eye move outward in order to fix the object. He may make various
other tests which will demonstrate beyond a doubt that the real balance of the eyes is in-
ward, and yet, when he makes the test of the dot and line of Graefe, or any similar test, at
near point, he has marked ‘insufficiency of the interni.’

“Tt is manifestly incorrect to say of such a muscular arrangement that the interni
are ‘insufficient,’ and especially when by such a term it is generally understood that the
outer are the stronger of the two opposing sets of muscles.

“Again, in certain cases of what is known as ‘insufficiency of the interni,’ one of the
eyes actually deviates inward while the other deviates outward, while in a still greater
number an apparent ‘insufficiency of the interni’ results from irregularities in the superior
or inferior recti.

“Many other illustrations of the truth that this term as employed is misleading
might be cited, but, without further expenditure of time or space, we may pass to the other
factor of the proposition.

“2. The term ‘insufficiency’ is quite inadequate to express the conditions of devia-
tion from the equilibrium as they may be observed.

“ Graefe, as one of the great pioneers in modern cphthalmology, and as the greatest
authority on the subject of muscular asthenopia, recognized some of these deviations, and
not only regarded ‘insufficiency of the interni’ as a condition of notable importance, but
wrote also of the ‘insufficiency of the externi’

“ Notwithstanding his remarkable observations, much remained to be learned in
this department of ophthalmology. While Graefe’s great authority is to be fully recog-
nized, the knowledge of these important conditions may yet be greatly extended.

“A class of deviations not at all uncommon, and one which induces great nervous
perplexity, is that in which the tendency is for the visual line of one eye to deviate above
that of the other.

“In examining some thousands of cases of ‘insufficiencies’ I have found a very im-
portant proportion of such tendencies. There is no term now in use which definitely ex-
presses this condition. We cannot say that it is insufficiency of one or other superior or
inferior rectus, for it is, in the great majority of cases, impossible to determine through
what special influence the equilibrium is lost. We have not here, as in paralysis of the
muscles, the definite guides of restricted motions by which we may determine the exact
location of the trouble. Indeed, the defect. may include an inclination on the part of the
one eye to deviate upward, and on the part of the other to deviate downward. We might,
perhaps, call such a condition ‘insufficiency in a vertical direction,’ with the right (or left)
line of vision inclined to deviate upward.

“This would be a descriptive and somewhat extended expression. It would still be
inaccurate, for it implies a weakness of some muscle, when the actual state may be an ex-
cess of tension on the part of some other muscle.
142 LECTURES ON NERVOUS DISEASES.

' “Again, there may and often does exist a combination of faulty tendencies in more
than one direction. The eyes may incline to deviate in both the vertical and the hori-
zontal planes, the result of which will be a tending of the visual lines to deviate in an
oblique manner. It must be apparent that the term ‘insufficiency’ is inadequate to
express all these tendencies.

“There may be some propriety in using the expression ‘insufficiency of the interni’
in many cases, but in these just cited it would be impossible for us to speak of insufficiency
of this or that oblique muscle without more accurate information than we are likely to
possess. Indeed, in the majority of vases these muscles may not be influential factors in the
condition described.

“Some term better adapted to express just what is intended, and nothing more, is
needed. It is after much hesitation and doubt whether a suggestion involving the use of
new terms in connection with a subject which has already engaged the attention of many
able investigators might not be regarded as needless and presumptuous, that I have ven-
tured to propose such an innovation. If, however, a change is to be made at any time in
the classification and nomenclature of these defects, such change should be made before the
literature becomes still more extended.

“The first need in a scientific classification of these muscular defects is the possession
of such terms as, with proper modifications, shall justly express the conditions described.

“The terms which have already been employed are all unsatisfactory, and are not
uniformly employed by different writers to describe precisely similar conditions. No terms
now in common use occur to me as being in all respects desirable.

“We may, therefore, select some word which shall convey the general idea and which,
with its proper modifications, will express our meaning. with specific variations. Such a
term should not, like the word ‘insufficiency,’ attempt to describe the exact nature of the
muscular conditions, for this is often, if not generally, a subject of uncertainty. It should
rather indicate the resultant facts as shown by the tendency of the visual lines to deviate
from the physiological equilibrium. Nor should the term convey the idea of an actual
turning, or deviation of one of the visual lines from what should be the common point of
fixation. It should express a tendency to such deviation of such character that, should the
force of the will be removed, this actual turning would result.

“The visual lines, in the conditions under consideration, are held in such relations to
each other as to permit of more or less perfect binocular vision, but at an expense of a cer-
tain excess of nervous effort. In this we have the distinction between these conditions
and those known as strabismus; for, while in these there is habitual binocular vision, in
strabismus there is habitual diplopia, either conscious or unconscious. It is true that a
fusion of images is possible in many cases of strabismus, and that slight diplopia may be-
come to a certain degree a habit, in the conditions under consideration. Nevertheless, a
condition of habitual diplopia should in general be regarded as distinguishing strabismus
from these conditions.

“The Greek word ¢époc (a tendency) seems to fulfill the conditions required, and
accurately expresses our meaning in regard to this class of defects. With this for our
central idea we may easily express every variety of tendency to deviation, as well as
the absence of such tendency. Thus the two generic: terms orthophoria (ope, right,
déopoc, a tending) and heterophoria (érepoc, different) would express respectively a ten-
caine straight forward and a tendency in some other direction.

“In order that these terms should possess precise signification, the relation of the
visual lines to which they are apphed should be determined under the uniform conditions
which are here given.

‘The eyes should be directed toward an object situated at a given distance from
THE TESTS’ OF VISION AND OCULAR MOVEMENTS. 143

them, and the head should be in the position known as the ‘natural’ or ‘ primary’ posi-
tion. The most convenient distance for the object is that at which tests for refraction
are commonly made; that is, twenty feet, or six metres. This distance is, therefore, chosen
as the standard for the determination of orthophoria and heterophoria. The best object
for use in these determinations is a lighted candle against a dark background. It should
be on a level with the eyes and at a distance of twenty feet. . If ametropia exists, the eyes
should be supplied with suitable correcting glasses. In the ‘natural position’ the body
and head are erect, the eyes are in the same horizontal,plane, and the median line (a
horizontal line at right angles with the line connecting the two ‘eyes) is directed exactly
toward the object. Under these circumstances there should be in orthophoria the minimum
of muscular innervation.

“These conditions being observed, we may ascertain the existence of muscular equi-
librium. or its absence by means of prisms in the manner familiar to all oculists,

“The determination of the muscular conditions at near points will occupy our atten-
tion as we proceed. It is to be remembered that the results in such examinations are by
no means absolute. Heterophoria may, like hypermetropia, be partly or entirely latent.
Indeed, as in actual hypermetropia, we sometimes have apparent myopia, so with an actual
inward tendency an apparent outward tendency may be observed.

“The different relations of the visual lines which may be now found may be defined
and arranged as follows, a state of the most complete relaxation of muscular effort attain-
able being always supposed :—

“T. Generic Terms —Orthophoria: A tending of the visual lines in parallelism.
Heterophoria: A tending of these lines in some other way.

“TL. Specific Zerms—Heterophoria may be divided into:—

“1. Esophoria: A tending of the visual lines inward.

“9. Exophoria: A tending of the lines outward.

“3. Hyperphoria (right or left): A tending of the right or left visual line in a direc-
tion above its fellow.

“This term does not imply that the line to which it is referred is too high, but that it
is higher than the other, without indicating which may be at fault.

“III. Compound Terms.—Tendencies in oblique directions may be expressed as
hyperesophoria, a tending upward and inward; or hyperevophoria, a tending upward and
outward, The designation ‘right’ or ‘left’ must be applied to these terms.

“In recording the respective elements of such compound expressions I have employed
the sign L.. For example, if it is desired to indicate that the right visual line tends above
its fellow 3°, and that there is a tending inward of 4°, the facts are noted thus: Right
hyperesophoria, 3° L- 4°.

“Tn the absence of any means of producing a uniform state of relaxation of the long
ocular muscles, such as we possess in atropine for the ciliary muscles, we must resort to
every known device to ascertain as nearly as possible the true relations of the muscles.
Methods other than that of measuring the deviation when diplopia is produced should,
however, be regarded as auxiliary, and the record of ortho- or heterophoria should be
made from the diplopia test.

“The powers of the different pairs of muscles to overcome prisms should next be de-
termined. Some confusion has existed in the use of terms to express this power. Thus,
the words adduction and abduction have been employed by Graefe and succeeding writers
to express the power of the eyes to overcome respectively a prism with its base out or in.
They have, however, been employed to express this power both when the object of fixa-
tion has been at a considerable distance, and when at the ordinary reading distance.

The same words are also used to express: the limits of excursion of the eyes outward.
or inward in the act of fixation,
144 LECTURES ON NERVOUS DISEASES.

“The words convergence and divergence have similarly been employed to express
different classes of phenomena. As the words adduction and abduction are necessary to
express the power of moving outward and inward of either eye singly, and as the terms
convergence and divergence must in all cases imply the approach or the separation of the
axis of the two eyes, whether in the act of overcoming a prism or otherwise there might
be an advantage in employing the word convergence to indicate the highest degree of power
of blending images ata distance of twenty feet when a prism with its base out is inter-
posed; and the term divergence to indicate the limit of power to overcome a prism with its
base in. This latter would also be less liable to objection for the reason that, while each eye
is habitually directed in abduction and adduction, the two are rarely by voluntary effort
caused to diverge except by the influence of a prism. The fact, however, that Graefe in
his classic treatise on muscular asthenopia employed the words abduction and adduction
to indicate the ability to overcome prisms must, beyond a doubt, determine the point, and
these words should, therefore, represent the diverging and converging power with prisms.
The standard of distance should, however, be uniform with that for the test for ortho- and
heterophoria.

“Tt often happens that images can be united when a prism is placed before an eye
with its base up or down, but that diplopia is produced if the prism is reversed, or if it is
placed in the first position before the other eye. In other words, the tendency of one
visual line being higher than the other, the power to blend images is greater when the
prism is placed in one than when placed in the opposite direction.

“This condition is one of great importance, and no examination of muscular equi-
librium should be regarded as complete in which its presence or absence is not determined.
The ability to overcome a prism with its base down may‘be called sursumduction, and the
eye before which the prism is placed is indicated by the word ‘right’ or ‘left.’

“Tt remains to consider the relations of the muscles when the eyes are directed to
objects at the usual reading distance,

‘‘These relations may be uniform with those manifested at a distance, or they may
vary in degree or in the direction of greatest apparent energy. To these conditions it
might at first appear best to apply the familiar terms ‘insufficiency of the interni’ or
‘externi.’

‘The objections are that the terms have already been employed to express the rela-
tions of the eyes in accommodation and also in repose, and that only two of many con-
ditions can be described.

‘The relations of the visual lines in accommodation do not always depend upon the
comparative strength or weakness of the opposing muscles, but upon a peculiar state of
innervation of the muscles.

“The habit of maintaining an excessive tension upon the outer muscles in order to
overcome esophoria frequently manifests itself in the near test as ‘insufficiency of the in-
terni’

“ These considerations render it desirable that a uniformity in the descriptive terms for
the near and distant tests should be maintained. The tertns already employed for distance
may, therefore, be properly used if the modifying phrase ‘in accommodation’ is added.
Thus we should have for insufficiency of the interni exophoria in accommodation, ete.

“The relations of the ocular muscles should, as Graefe has shown, occupy a prominent
place in the record of all examinations of the eves for asthenopia or kindred troubles.

“Tf the system of words here introduced at first appears to be superfluous, and, there-
fore, unnecessary, a careful consideration of the subject w ill be likely to convince a candid
observer that new and more definite terms are needed to convey uniform meanings, and to
express more conditions than are described by terms now in use. The terms here proposed
ASTIGMATISM AND ESTIMATION OF THE VISUAL FIELD, 145

are explicit in meaning, and the system, by arranging the various deviating tendencies
into classes, suggests to the examiner the conditions concerning which he should inform
himself.”

Thus far, then, in the examination, our record page in blank would
stand as follows :—

Name............ Residence............ DSC cicescnguny
Ra ees Wadendsyaier ed corrected by ...... glass
lp Se ah vsaanseatess a a a
ASTIGMATISM ........0..04. e SS amenity sand eamaniete’
Hsophoria................. in accommod...............0.
Exophoria................. in accommod..............00.
ABOUCEss cosuseve ced Leptin AUG asters. sae ttunneteat aa acai
Hyperphoria, R............ Livcsisserstavsc teiaeaca trtracdahiaxareaalinines
Sursumduct, R...... 2.2... Noi ccivarn caterer a penaunciAana tp aedaetaes
Reading power at fourteen inches, eonractal DY cawawss glasses
VISUAL FIELD OPTHALMOSCOPE

Pe ee ee eee ee ee ee wm wee | we ee ee ee ee ee beer ete eet eee

Cc ey

All the data indicated for record in this table, excepting the esti-
mation of the degree of astigmatism and the outline of the visual field,
have been referred to, and the tests for each have been given with some
detail.

The estimation and correction of astigmatism is a difficult matter for
a novice, and sometimes for an expert. It will be better understood by
reference to and close study of the standard text-books on ophthal-
mology. Moreover, the ophthalmoscope is often required to properly
estimate the degree and kind of astigmatism which exists. I would say,
in passing, that a high degree of astigmatism should never be disregarded
or left uncorrected, especially if present in connection with abnormal

“nervous phenomena. It is a very common cause of headache and as-
thenopic symptoms.

In estimating the visual field, an instrument specially designed for
that purpose (the perimeter) greatly simplifies the step, and gives us at
the sume time an accurate representation of its outline for subsequent
reference. A drawing can be roughly made, however, of the visual field
of any patient, by means of a blackboard and a piece of chalk, through a
simple method described in most of the text-books. In some nervous
cases it is very desirable that a register of the visual field be taken from
time to time and preserved for reference.

10
146 LECTURES ON NERVOUS DISEASES.

Now, when we have carefully examined our patient respecting all
the data indicated in the preceding table, are we safe in passing an
opinion respecting the condition of the eyes? I would again say,
4 No. ” y

We have now reached a point where we should administer atropine
to the patient. I usually employ a solution of gr. iv of sulphate of atro-
pine to an ounce of distilled water. This can be kept constantly in your
office in a phial with a rubber-top dropper substituted in place of a cork,
A drop or two in each eye will suflice in most subjects to dilate the pupil
widely and to paralyze the power of accommodation of vision for near
objects in about three hours. In occasional instances it becomes neces-
sary to keep the patient under its influence for several days, but this is
not the rule. A :

It is well to caution the patient, after using this drug, that he may
possibly suffer from the sunlight, and that colored glasses will relieve him
of this-annoyance. It is also best to tell him that his vision may becume
very blurred for distant objects in case he is far-sighted; and that, in any
case, he will be unable to read or to write by the aid of vision without
glasses for several days. I- have known hypermetropic patients to be-
come greatly alarmed at the rapid loss of vision which has followed the
use of atropine; all of which could easily have been avoided had they
been prepared for it by timely words of explanation. It is always well
to explain to far-sighted subjects the difference between ‘manifest ” and
“latent” hypermetropia, and to make them intelligent as regards the
effect of atropine upon the ‘focusing’ muscle before you administer it.
If they are forced by their business to use their eyes for near-work while
under the influence of atropine, a pair of cheap glasses may be given
them for temporary use while under its influence.

I cannot impress too strongly upon you the necessity of using atro-
pine upon a patient (if young) for diagnostic purposes when an error of
refraction or of accommodation is suspected. Personally, 1 do not regard
an examination as complete without it. It solves the question of the pres-
ence of “latent”? hypermetropia—a very common defect and a very im.
portant one (from the standpoint of the neurologist) if allowed to go
unrecognized. It reveals the existence of a previous ciliary spasm.
It ‘often arrests headache as if by a magic touch, and solves the nervous
origin of many other similar symptoms.

Patients who boast of their acuteness of vision, and who apparently
justify their statement by reading test-type at a distance without the aid
of glasses, are often astonished and sometimes alarmed at the immediate
loss of this power which is brought about hy the use of atropine, ‘This
surprise is heightened when (by the use of proper lenses) their power of
vision for distance is immediately restored, and they become conscious
LATENT ERRORS OF REFRACTION. 147

for the first time of the muscular effort which they have been compelled
in the past to exert in order to see without them. I shall never forget, per-
sonally, the sensation which I experienced of “ seeing without effort ” when
a latent hypermetropia was discovered in my own eye, and corrected by
glasses.

These experiences are well-known fhinlis among oculists, but to the
profession at large aay often occasion as much of a surprise as to the
patient.

I could point to case after case in my own practice where the cause
of neuralgic attacks, excruciating headache, vomiting, extreme nervous-
ness, and many other symptoms (not apparently connected with eye-de-
fect) would have remained unrecognized if atropine had not been em-
ployed. There is a rule given by most oculists—viz., to give to a hyper-
metropic patient the strongest conver glass* with which he can comfortably
read the normal test-type (xx) at a distance of twenty feet. It is impos-
sible in many cases to decide this fact without atropine or an ophthal-
moscope. The former method is unquestionably the most accurate one,
because the accommodation of the oculist, as well as that of the patient,
has to be excluded in the latter; and it has the advantage, moreover,
that it can be employed by the general practitioner as well as by the
specialist. +

Now, after the patient returns to you with widely dilated pupils, you
should carefully repeat each step of the previous examination. You
should record the results of these tests and then compare them with those
obtained before atropine was employed. If the eye is a normal one, the

20
vision will be — after atropine has been used, as it was on the first ex-
SK :

amination; but, when an error of refraction or accommodation exists,
changes of a greater or less degree may be noted. You may find, more-
over, that the power of adduction and of abduction of the eve will be mod-
ified in some patients by the action of the drug upon the accommodation of
vision, and that a different degzee of muscular insufficiency may be detected.
You can now decide intelligently as to the glass which is best ndapted to
restore vision for distant and near objects in each eye of the patient, and
you are prepared to advise the patient respecting the use of the glasses

* The advisability of a full correction by glasses of existing hypermetropia can only be
decided after the condition of the patient, his age, his susceptibility to reflex irritation from
eye-strain, etc., have been carefully considered. It is not usually advisable to force a
young subject to wear a glass which fully corrects the latent hypermetropia. I am in the
habit of correcting all latent hypermetropia in excess of one dioptre.

t Personally, I have of late discarded the ophthalmoscope as a means of estimating
errors in refraction, except in children and feeble-minded persons. It cannot always be
relied upon, even in the hands of an expert, for this special object.
148 LECTURES ON NERVOUS DISEASES.

selected. You can decide also respecting the question of the utility of
prisms or of tenotomy if the patient has marked insufliciency of the
muscles. You can judge more accurately respecting the proper angle of
the prism required in case their use is indicated. I would caution you,
however, against deciding this latter point before the error of refraction
(if such exists) is corrected, and not until the “diplopia tests”
have been employed, after such lenses as are required to correct it have
been placed before the patient’s eyes. I have seen patients who gave
evidence of marked insufficiency (5° to 8°), when the refractive error was
uncorrected, exhibit no such defect when glasses which corrected that
error were worn. Prisms in such a case would inflict injury upon the
patient rather than afford relief.

In closing, | would remark that views which I have advanced respect-
ing the dependence of abnormal nervous phenomena upon eye-defect are
not new. They are in antagonism, however,.to those of some authors,
and have been more or less actively combated of late, especially in regard
to eye-defect as a cause of chorea and epilepsy. I do not think the re-
lationship between “eyestrain” and attacks of headache or neuralgia
can be denied, although it is only hinted at by Anstie and is omitted
by most authors who have written on the causes and cure of these dis-
tressing maladies. Some of our best neurologists, as well as most oculists,
are now investigating with renewed interest not only the ametropie con-
ditions of the eye, but also the eye with “insufficient” muscles. Facts
are being daily substantiated beyond dispute which met with ridicule
some years since. Every day, in my own experience, I am strongly im-
pressed with the curative effects of glasses and partial tenotomies of the
ocular muscles in various forms of functional nervous disturbances. In
my opinion, the neurologist of to-day who fails to familiarize himself
thoroughly with the examination of the eye omits an evident line of
duty both to himself and his patients. No neurologist can send all of
his cases to an oculist for an opinion, and, even if he could do so, he
should at least be able to verify the opinion thus gained respecting the
refractive errors found and the state of the eye-muscles. He requires
a case of lenses. and prisms in his office as much as an electrical outfit,
and he should know how to use both—the one as an aid in diagnosis,
and the other as a means of cure. Personally, I have come to regard
the examination of any patient sent to me as incomplete until I have
tested the state of refraction and accommodation, and examined with
care the condition of the ocular muscles. This view has not been
hastily formed, and my daily experiences confirm me in it. I believe
the time will come when the tests employed in eye-examinations will
rank in importance in neurology with the knee-jerk test, which for
generations, as Gowers remarks, simply “amused school-boys.”
 

THE USE OF THE OPHTHALMOSCOPE. 149

THE OPHTIALMOSCOPE,—In connection with the eye, it may be well
to mention the instrument which is employed to detect abnormalities of
that organ, viz., the ophthalmoscope.

All forms of this instrument consist (1) of a concave mirror which
is perforated at its centre, in order that the observer may look directly
into the illumined field; (2) a series of lenses by which it is possible to
correct errors of refraction in the eye of the patient or observer; (8) a
bi-convex lens, which brings the deeper parts of the eye into prone,
and enables the observer to-inspect them minutely.

Hutchinson (as quoted by Hamilton) gives some concise and prac-
tical suggestions respecting the use of this instrument, which will bear
repetition. Ile says :—

 

Fic. 40.—Tue OpntHatmoscorg. (Loring’s Pattern.)

“Having placed the patient’s head in such a manner that the light (a
lamp, candle, or gas-light) is on a level with his temple, and slightly he-
hind it and his face, as a consequence, in shadow, the observer sits in
front.and applies the ophthalmoscope mirror to his own eye. He should
keep both eyes open that he may sce where the light falls, and then move
the mirror until the light falls full upon the pupil of his patient. Ina
moment he will perceive the first fact which this instrument reveals, that
the fundus is not black, as it has always appeared to be before, but that
it is of a brilliant fire-red. He will, however, see nothing of the fundus
distinctly, only a genera) reflex Now at this point the student must
150 LECTURES ON NERVOUS DISEASES.

stop awhile and use his mirror to inspect first the transparency of the
cornea, and next, that of the lens and vitreous, and to do this he must
make the patient move his eye in various directions. After a little prac-
tice he will be able to manage his light well, and to throw it with pre-
cision wherever he may wish, and to keep it steadily on any given part.
At a first lesson, he may even with advantage practice for awhile by illu-
minating the second button of the patient's waistcoat. Tact in directing
the light having been obtained, we may now proceed further. Instruct
the patient to look, not full in your face, but’ over one shoulder; if you
are inspecting his rzght eye, over your /e/t shoulder. You will, when he
does this, notice at once that the tint of the light reflected from the
fundus is changed, that it is no longer fire-red, but canary yellow. The
reason of this is, that a different part of the fundus is exposed to view,
that, namely, of the optic disk itself, which is much lighter in color than
the rest. The area of yellow is very large,—occupies, indeed, the whole
of the field, while we know that the disk itself is very small. This proves
that the objects thus distinctly seen are immensely magnified. Magnified
by what? By the patient’s own eye, which, as we have said, is equivalent
to a lens of one-inch focus.

“Hitherto we have seen nothing distinctly, but if the observer now
brings his head very close to the patient’s face, he will be able with more
or less facility to observe the details of the bottom of the eve, the trunks
of the vessels of the retina, the optic disk, ete. What he sees is now
equivalent to type looked at through a one-inch lens, placed exactly one
inch in front of it.”

; In the ophthalmoscope now generally employed, a revolving disk

containing a series of lenses is placed behind the mirror. These are in-
tended for the purpose of correcting any error of refraction in the eye of
the observer or patient. It is important that such error be determined
first with accuracy and properly corrected, before the fundus is examined.

The ophthalmoscope is an important and valuable aid to those who
are skilled in its use in detecting changes in the deep parts of the eye,
chiefly those of the optic nerve and the vessel of the retina, by means of
the sense of sight.

Dr. William C. Ayres has lately published in The American Journal
of the Medical Sciences (1881) an exceedingly valuable and complete
article upon this branch of diagnosis

By means of the ophthalmoscope the neurologist determines the
presence or absence of 2 neuro-retinitis, or a “ehoked disk” as it is called,
which is peculiarly suggestive of some brain lesion, that is creating a
gradually increasing pressure within the cavity of the skull. Again, the
vessels of the retina are derived from the same source as those of the
brain; hence chanves in the one are liable to be associated with similar
chanves in the other.
THE EYELIDS AND MOUTH IN DIAGNOSIS. 151

Tue Eyeirps.—These may atford valuable aid in diagnosis. The
upper lid sometimes drops over the eyeball and cannot be raised, con-
stituting the condition termed “ptosis.” This indicates a paralysis of
the third cranial nerve. Again, when the facial nerve is paralyzed, the
eyelids of the attected side cannot be closed. Pufliness of the lower
eyelid, especially in the morning after rising, suggests the possibility of
kidney disease. Alcoholic patients often exhibit a quiver of the mus-
cular fibres of the eyelids. Spasm of the lids produces the peculiar
winking so often seen in St. Vitus’ dance and other nervous affections.
In imbeciles and cretins the lids are often obliquely placed.

The expression of the eye is influenced to a large extent by the eye-
lids and may often be characteristic of certain nervous diseases. Melan-
choliacs exhibit the downcast eye. Maniacs may look excited, suspicious,
or distrustful. A vacant stare is often present in dementia. Some forms
of brain disease exhibit in the eye an air of exaltation. Masturbators
seldom direct their gaze at the questioner, but look furtively about as if
to avoid scrutiny.

Tue Movuru.—The lips are sometimes paralyzed. The pronunciation
of the labials is then rendered indistinct or impossible, and a facial de-
formity is also created. The various diseases in which the mouth is
affected may be considered separately with advantage.

A, In Bell’s paralysis the lips are rendered incapable of movement
on one side only and the mouth is drawn toward the opposite side ly
muscles which are no longer antagonized, on account of the facial
paralysis. The act of whistling is rendered impossible, hecause * pucker-
ing” of the lips requires a contraction of the symmetrical muscles of the
face. The saliva is no longer retained, and the patient ‘‘drools.” All
expressions except that of repose are those of a face alive on one side
and dead and motionless on the other; hence, they would be particularly
grotesque and striking (were it not so frightful and distressing) even to
a casual observer.

In those rare cases where the facial nerve of both sides is impaired,
symptoms similar to those mentioned above exist, except that the tongue
has its normal capabilities of movement, save in the perfect articulation
of the labial consonants only, and that a complete absence of facial ex-
pression is present.

Certain rules, which prove of value in making a diagnosis of the seat
of the exciting cause of the condition have been given in the preceding
chapter (p. 85). They are based entirely upon anatomical facts, and are
therefore very important, because they admit of no exceptions :—

B. The lips and tongue are particularly affected also in that disease
of the medulla called Duchenne’s disease (glosso-labio-laryngeal pa-
ralysis), So marked is this loss of power, in severe cases, that a most
152 LECTURES ON NERVOUS DISEASES.

characteristic facial deformity is induced. As this disease is commonly
bilateral, the lips usually hang apart from each other and cannot be
approximated. The tongue lies trembling and immovable in the floor of
the mouth, if the paralysis be complete; but if paresis only exists, it can
be imperfectly protruded with difficulty, and is tremblingly and slowly
retracted. If the paralysis be unilateral, the healthy side of the tongue
becomes full and prominent, in comparison with the affected side, when
called into action. Speech and mastication are seriously embarrassed.
The saliva is constantly expectorated, because swallowing is performed
with extreme difficulty.

C. The facial muscles, as well as the tongue, exhibit a peculiar
tremor in paralytic dementia. Small bundles of fibres composing parts

 

Fic. 41.—Be’s Paratysis. (After a Sketch from Life by the Author.)

of the tongue, or the delicate muscles of the face, are thrown into non-
rhythmical contractions hy emotion, or the performance of any voluntary
movement, as when showing the tongue or teeth. These fibrillary tremors
may sometimes exist even in the quiescent state of the muscles. The
tongue occasionally exhibits coarser movements of a convulsive character,
Late in the disease it may become atrophied or shriveled.
The effects of this form of tremor upon speech are aggravated by an
imperfect codrdination of the muscles of the tongue and lips, which is
simultaneously developed. Long or difficult words are omitted in con-
versation by these patients in a half-unconscious way, and the terminal
syllable of other words is commonly left off. The speech becomes thick,
and of a tremulous character. The shortest words possible are employed
THE LIPS, GUMS, TEETH, AND TONGUE. 1538

by the patient to convey his ideas. A distinct pronunciation of conso-
nants and polysyllabic words, such as ‘‘constitution,” “inrallibility,”
“prognostication,” etc., is impossible; hence, a test is thus atlorded
between carelessness of utterance and a physical inability to articulate.

An unnatural quietude of the muscles of the face and a slight dis-
parity of the pupils are prominent features of its stage of development.

It is well to note, in this connection, a test which is of some value
in deciding as to the existence of this special form of disease. Extend
the patient’s fingers and place them between your own, and a delicate,
“parchment-like” fremitus will be felt, which is due to an otherwise imper-
ceptible tremor of the hand muscles.

D. The lips participate to a marked degree in severe types of facial
spasm. In the clonic form of the muscles on one side of the face, are
violently contracted and as suddenly relaxed. The eye is commonly
affected simultaneously with the angle of the mouth. The spasms are
marked by distinct paroxysms, whose duration varies from a few seconds
to an hour or so. If the spasm is of atonie variety, mastication and
articulation are interfered with, and the paroxysms are of longer duration.

It is always well to search carefully for carious teeth in these cases ;
but the spasms may be due to cold, wounds, injuries to the trigeminal
nerve, or chorea.

E. The lips may indicate some form of defect in the heart's action
if blue or purple in color.

Sears at the corners of the mouth are strongly suggestive of previous
syphilitic ulceration, a point of importance in the treatment of some
forms of nervous disease.

F. The gums should always be inspected. If pale, anaemia exists.
If blue along the line of junction with the teeth, lead poisoning is
present. If the teeth are loosened and the gums are soft and bleed easily,
mercurial poisoning may be suspected; this is rendered positive if the
breath has the “mercurial odor” and the saliva is excreted in very large
quantities. Various cachexias, phosphorus poisoning, purpura, and
scurvy, produce marked and often characteristic changes in the gums.

G. The teeth may afford much valuable information respecting the
possibility of hereditary syphilis. Hutchinson has described the char-
acteristics of such teeth with accuracy and detail. It is impossible to
quote his deductions here, but the peculiarities of syphilitic teeth are
now generally well recognized, and are often-a valuable aid to the neu-
rologist, both in diagnosis and treatment.

H. The tongue. Some diagnostic points regarding the tongue have
been touched upon already. When the face exhibits any form of pa-
ralysis, it should be always carefully noted if the tongue exhibits fibril-
lary tremors; also whether it can be protruded in a straight line and
154 LECTURES ON NERVOUS DISEASES.

moved freely in all possible directions. In testing speech those words
should be employed that require the normal power of movement of the
lips (the labials) and of the tongue (chiefly the consonants). It should
be also noted whether the words are clearly, rapidly, and distinctly
articulated, or if the utterance of words is slow, thick, or slurred.

Ragged edges in the tongue indicate epilepsy, because it is frequently
bitten during the paroxysms.

Imperfect mastication of food and difficulty in swallowing may be
due to loss of power in the tongue.

A “furred condition” ‘of one lateral half of the tongue indicates
some irritation of the branches of the fifth cranial nerve; hence. the
presence of decayed teeth, disenses of the gums, or the maxillary bones.
etc., should be carefully searched for. The tongue may be paralyzed on
one side or on both. This condition is not infrequently due to hemor-
rhage, softening. or tumors of the brain, and it occurs in connection with
embolixm or the general paralysis of the in<ane.

Fic. 42 —Sypuititic TeetH. (Hutchinson.)

 

Spasm of the tongue may be perceived in connection with chorea,
epilepsy. hysteria, facial spasm. and as a result of slight compression or
irritation of the hypoglossal nerve. Fibrillary tremors of the tongue are
often encountered in patients afflicted with paralytic dementia.

I. The soft palate may be implicated when the facial nerve is injured
above the origin of the petrosal nerves. It is important to examine the
palate, therefore. whenever Bell's paralysis exists. since the seat of the
exciting cause may be decided ly it. It may participate also in atrophic
changes.

Tue Ear.—Deposits of urate of soda are often found in the ear in
gouty subjects. These may cause ulceration, Again, the lobe of the ear
may become swollen, red, and glistening as an attack of cout is. being
developed.

Among insane patients, the car frequently becomes deformed from
othe matoma.
THE FACE, AS A WHOLE, IN DIAGNOSIS. 155

Persistent discharge of pus from the ear indicates disease within the
temporal bone. Fatal brain complications may arise from an extension
of such ear troubles to the coverings of that organ.

Tue Face as A WHoLe.—Among the diseases of the nervous system,
there are certain types of physioenomy which are so characteristic as to
be of the most positive value in diagnosis.

In attacks of epilepsy the neck at first becomes twisted, the chin
raised and brought round by a series of jerks toward one shoulder. The
features are greatly distorted. The brow is knit; the eyes are sometimes
fixed and staring, at other times rolling about in the orbit, and again
turned up beneath the eyelid, so that the cornea is covered, and only the
white sclerotic is to be seen; the mouth is twisted to one side and dis-
torted; the tongue is thrust between the teeth, and, caught by the violent
closure of the jaws, is bitten, often severely; and the foam which issues
from the mouth is reddened with blood. The turgescence of the face
indicates obstruction of the venous circulation; the cheeks become pur-
plish and livid, and the veins of the neck are visibly distended.

During the fit of exacerbation, in an attack of tetanus or lockjaw, the
aspect of the sufferer is sometimes frightful. The forehead is corrugated
and the brow knit, thus expressing the most severe type of bodily suf-
fering; the orbicularis muscle of the eye is rigid, and the eye itself
staring and motionless; the nostril is widely dilated, indicating the
extreme distress of breathing; the corners of the mouth are drawn
back, exposing the teeth, which are firmly clinched together; and the
features, as a whole, have a fixed and ghastly grin—the so-called “risus
sardonicus.” During such paroxysms as in those of epilepsy, the
tongue is liable to become protruded between the teeth and to be
severely bitten.

In chorea the facial muscles participate in the general eccentricity
of movement. Watson thus describes the peculiarities of this strange
affection: “The voluntary muscles are moved in that capricious and
fantastic way in which we might fancy they would be moved if some in-
visible mischievous being, some Puck or Robin Goodfellow, were behind
the patient and prompted the discordant gestures. With all this the
articulation is impeded; there is the same perverse interference with the
muscles concerned in the utterance of the voice. By a strong figure of
speech the disorder might be called ‘insanity of the muscles.’”

In catalepsy the patient lies often with cyes open and staring, yet
without expression indicative of life; more like a wax figure or a corpse
than like a living subject. The features may be made to assume any ex-
pression, no matter how absurd, as the tissues have their normal pliability,
and they will remain so placed until again mechanically altered. This
same peculiarity is also present in the muscles of the extremities, and
156 LECTURES ON NERVOUS DISEASES.

forms one of the distinguishing tests of the disease. The mental faculties
are in abeyance, and all power of voluntary motion is lost. The sensi-
bility of the body seems also to be lost.

In hystero-emlepsy the contortions of the face and body are often

frightful. In rare cases consciousness may he retained throughout the
attack.
The deformities of face and intellect which seem to be the result of
residence in special atmospheric conditions, or of certain well-defined lo-
calities, are illustrated in that race of people found in Valais and the ad-
joining cantons of Switzerland, called “cretins.” Many of these wretches
are incapable, according to Watson, of articulate speech; some are blind,
some are deaf, and some suffer from all of these privations. They are
mostly dwartfish in stature, with large heads; wide, vacant features; gog-
gle eyes; short, crooked limbs, and swollen bellies. The worst of them.
are insensible to the decencies of nature, and in no class of mortals is
the impress of humanity so pitiably defaced. They are usually the de-
scendants of parents afflicted with goitre.

 

Fie. 43.—Tur Hanp in ProGressive Muscutar ATROPHY.

THe Hanp.—Among certain forms of nervous disease characteristic
deformities of the hand are sometimes encountered. These will be con-
sidered separately. Tremor and spasm of the fingers are also developed,
in some cases, and require a hasty description.

The deformities of the hand that are commonly observed include (1)
that of so-called “ progressive muscular atrophy ;” (2) that of a spinal
disease known as “amyotrophic lateral spinal sclerosis ;” (3) that of in-
jury of the ulnar nerve; (4) that of injury of the musculo-spinal nerve;
(5) that of injury of the median nerve; (6) that of paralysis agitans ; and
(7) that of gout and rheumatism.

The tremors of the hand include (1) those of a condition called
“athetosis;” (2) those of chorea or St. Vitus’ dance; (3) those of paral-
ysis agitans;.(4) those of the general paralysis of the insane; and (5)
those produced by circumscribed lesions of the nerve centres.
THE HAND, AS AN AID IN DIAGNOSIS. 157

In progressive muscular atrophy the ball of the thumb is often the
starting-point of the disease. This eminence vradually shrinks and dis-
appears. It should be remembered that the disease affects symmetrical
and homologous parts; hence both hands are liable to present the same
deformity. Gradually the muscles between the bones of the hand shrink,
so that the bones stand out unnaturally. Fibrillary twitchings over the
affected muscles should always be looked for, as they are seldom absent.
The temperature is lowered over the atrophied muscles.

 

Fic. 44.—ULnar Paratcysts. (After Bramwell.)

In amyotrophic lateral spinal sclerosis the hand, when affected, is
strongly flexed upon the forearm, the fingers are shut tightly upon the
palm, and the thumb is drawn inward toward the fingers. Attempts to
straighten the fingers, thumb, or hand, will be strongly resisted, and
cause pain. In course of time the affected muscles become markedly
shrunken, thus adding to the deformity described. Fibrillary twitchings
may be easily excited in the affected muscles, provided they do not spon-
taneously exist.

When paralysis of the wlnar nerve exists, adduction of the hand is
no longer performed in a perfect manner, since the flexor carpi ulnaris
can no longer act in unison with the extensor carpi ulnaris. Flexion
158 LECTURES ON NERVOUS DISEASES.

of the hand is performed imperfectly, and by means of the flexor of
the radial side of the forearm only, since that muscle is supplied by
the median nerve. The ability to move the little finger is almost entirely
abolished. Complete flexion of the inner three fingers is rendered difli-
cult and sometimes impossible. The fingers cannot be separated from
each other, or compressed into a close lateral juxtaposition, owing to
paralysis of the interossei muscles; and flexion of the first phalanx and
extension of the two terminal phalanges of all the fingers are rendered
impossible, for the same reason.

When the ulnar nerve is paralyzed above the wrist, so that the in-
terossei and lumbricales are alone paralyzed, the hand assumes a diag-
nostic attitude, the so-called ‘‘claw-hand,” in which the extensor com-
munis digitorum muscle extends the first phalanges of all of the fingers,

 

Fic. 45.—Mep1an PARALYSIS.

while the other two rows of phalanges are flexed by the common flexor
muscles of the fingers (the interossei and lumbricales being no longer
able to flex the first row of phalanges, or to extend the two other rows).
This same condition of the hand may, however, be produced by a con-
dition of progressive muscular atrophy of these muscles.

It must be remembered that this condition, if dependent upon ulnar
paralysis alone, is more marked in the two inner fingers than in the three
outer, since the lumbricales are supplied in part by the median nerve.
This clinical fact seems to stamp the action of the lumbricales as similar
to that of the interossei. Finally, the effects of ulnar paralysis may be
manifested in the movements of the thumb, since it supplies two muscles
which control it. This will be most apparent when the patient is re-
quested to press the thumb forcibly against the metacarpal bone of the
index finger, or to adduet the thumb.
THE HAND, AS AN AID IN DIAGNOSIS. 159

When paralyiss of the median nerve exists, the second phalances of
all the fingers, sud the third phalanges of the index and middle fingers
cannot be flexed, and the thumb cannot be flexed or brought into contact
with the little finger. On the other hand, flexion of the first phalanx,
with extension of the other two, can be performed in all the fineers by
the aid of the interossei, which are supplied by the ulnar nerve. The
position of the thumb is peculiar; it is extended and adducted and thus
closely applied to the index finger, as in the hand of the ape. The hand,
when flexion at the wrist is attempted, is strongly adducted by the action
of the flexor carpi ulnaris, because the antagonistic muscle of the radial
side is paralyzed. The act of phonation of the hand is seriously im-
paired. The inner three fingers can be brought into a partially flexed
condition, since the flexor profundus digitorum muscle is partly supplied
hy the ulnar nerve. These combined effects give to the hand and fingers,

 

Fic. 46.- MuscuLo-spiraL Paratysis.

and especially to the thumb, a position so peculiar that paralysis of the
median could hardly be mistaken by an anatomist for any other deformity.
when the paralyzed muscles begin to show the results of atrophy, the
deformity in the forearm and in the ball of the thum) will further assist
in the diagnosis of this affection.

The museulo-spiral nerve is more frequently affected with paralysis
than any of the nerves of the upper extremity. It is particularly liable
to both peripheral and central causes of paralysis; thus in the cerebral
hemiplegia, the muscles supplied by this nerve are, perhaps, more com-
monly affected than those supplied by any other nerve, while paralysis
of these muscles is common as the result of chilling of the upper ex-
tremity, traumatism, and lead-poisoning.

The anatomical situation of the musculo-spiral nerve and. the pecu-
liarity of its course around the humerus, probably explain the frequent
occurrence of paralysis, since it may be casily compressed by sleeping
upon the arm, It is common to mect with this type of paralysis in
160 LECTURES ON NERVOUS DISEASES.

patients who have used their arms as a pillow, or in drunkards who have
slept in some constrained position upon benches, steps, etc. Persons
who have fallen exhausted and have rested upon the arm, and soldiers
who have slept upon the damp ground, often arise with this form of
paralysis. It is stated by Brenner that the coachmen of Russia, who are
in the habit of sleeping upon the box with the reins wound around the
upper arm, are victims to this condition; and Bachon reports the same
result as common among the water-carriers of Rennes, since they pass
their arm through the handle of the heavy water-pails to more securely
compress them against'the chest. The habit of the Russians of tightly
bandaging the arms of infants to the body, and allowing them to sleep
upon one side for long intervals, seems to promote the frequent occur-
rence of this trouble.

Among the other forms of traumatism which conduce toward this
form of paralysis may be mentioned the use of poorly-padded crutches,
the kicks of animals, cuts, stab-wounds, fractures of the humerus, dislo-
cation of the humerus at the shoulder-joint, and the development of an
excessive amount of callus after a fracture.

Rheumatic affections and a neuritis of the musculo-spiral nerve are
reported as causes by Bernhardt and others; and cases of hysterical
origin have been rarely but positively authenticated.

Finally, lead-poisoning must be mentioned as one of the most com-
mon causes of paralysis of the muscles supplied by the musculo-spiral
nerve. The existence of this form of poisoning will have generally been
indicated, previous to the appearance of paralysis, by colic, jaundice, and
arthralgia, as the muscles are seldom affected until the latter stages. The
extensor communis digitorum muscle is usually affected first, and the
paralysis gradually extends to the other muscles supplied by the musculo-
spiral nerve. The muscles of the arm are much less frequently affected
than those of the hand and forearm; but in severe cases the muscles of
the upper arm are involved, and the thumb and the index-finger cannot
be extended or abducted ; the patient cannot supinate the hand when the
forearm is extended (this position being assumed in order to exclude the
action of the biceps muscle), nor can the forearm be half bent and the
hand half supinated by the supinator longus muscle; and, finally, when
the patient is instructed to flex the forearm, when placed in a position of
half flexion and semi-pronation, the supinator longus muscle lies flaccid,
and does not become tense and hard as in health. The loss of power in
the triceps muscle renders it impossible for the’ patient to extend the fore-
arm upon the arm when the arm is first raised above the head; nor can
the forearm be extended with the same degree of force as the healthy
side in any position of the arm, When the hand is laid upon the table,
the patient is unable to raise the hand from contact with it, but the lateral
movements of the fingers can be performed as in health,
THE HAND, AS AN AID IN DIAGNOSIS. 161

In gout the joints become enlarged and seriously crippled by deposits
of urate of soda, that cause prominent nodules upon the fingers. These
often ulcerate. The index and middle fingers are the ones most frequently
deformed. Occasionally one finger will be drawn toward the palm by
gouty inflammation in the sheath of its flexor tendon. If this deformity
be found, always examine the other hand to see if a similar deformity is
not more or less developed on both sides. If so, it is almost a positive
sien of gout.

The diseased condition, called ‘ athetosis” because the fingers do not
maintain a fixed position, is characterized by a continual motion of the
fingers and toes, and an inability on the part of the patient to retain them
in any fixed attitude. These patients cannot keep the hand closed or
open, even for a short period, although the fingers are. to some extent

 

Fic. 47.—AtuHertosis. (After Hammond.)

under the control of the will. The toes are not commonly affected to
the same degree as the fingers. The movements of the fingers and toes
are perpetual, not being entirely arrested during the hours of broken sleep.

The tremor of paralysis agitans, or ‘shaking palsy,” is markedly
aggravated by voluntary muscular effort or mental excitement. Except
in very aggravated cases, it ceases during sleep. During the daytime it
is more or less persistent and uncontrollable.

In imbeciles, rhythmic movements of the hands are commonly met
with. They are in marked contrast to the irregular and spasmodic move-
ments observed in St. Vitus’ dance.

During an attack of acute hydrocephalus, or ‘water on the brain,”
the thumbs are usually flexed upon the palm.

Langdon Down has described the so-called “woolly hand” of the
idiot; the skin being too abundant for its size, and forming wrinkles
upon it.

1
162 LECTURES ON NERVOUS DISEASES.

In all diseases which cut off the nerve fibres from their centres of
nulrilion, or “trophic centres” as they are called, or after injuries to
the nerves, the skin of the hand, as well as of other parts, may become
smooth, shining, and affected with eruptions or ulceration. The nails
and hair may also give evidences of imperfect nutrition.

THE GAIT AND ATTITUDE OF THE PATIENT AS A FACTOR IN
DIAGNOSIS.

Among the symptoms which are brought to the notice of the neu-
rologist by his perceptive faculties, none are more positively diagnostic
than the abnormalities of gait and attitude which are frequently encoun-
tered. It will simplify description to consider first the more common
abnormalities of gait, and subsequently the characteristic attitudes pro-
duced by nervous affections.

Gave or Hemipiecia.—This condition (in which one lateral half of
the body is paralyzed) is evidenced by a characteristic gait, if the paral-
ysis is not so profound as to prevent all attempts at walking. The arm
hangs at first limp, and, in some cases (later on), more or less rigid on

_the affected side. The shoulder droops’upon the paralyzed side. At
each step the paralyzed half of the body is lifted; in order, as it were, to
swine the weak leg forward. This movement causes the shoulder to tilt
toward the healthy side, and the pelvis to be raised; while at the same
time, the leg is not bent at the knee as in health. The shoe of the para-
lyzed leg trails along the ground as it is swune forward, and the toe and
outer part of the sole of the shoe becomes worn off rapidly, a clinical
point not to be overlooked. The back is not arched,as in the spastic
form of paralysis, and the feet do not tend to cross the median line. The
term ‘sickle-walk” is applied by French authors to this variety of gait,
on account of the swinging, semi-circular movement of the paralyzed
foot. The patient usually carries a cane on the healthy side, to aid him
in walking.

Gait or ParapLecta.—Both legs (or, to be more accurate, the lower
half of the body) may be more or less paralyzed, and yet the patient can
walk. How different is the gait, however, from that of health! These
patients shuffle along without raising either foot from the ground to any
appreciable extent, so that they cannot be said to step. The progression
is extremely slow, because the length of the step (if it may be so called)
is very short. The heel of one foot rarely passes the limit of the toe
of its fellow, if the paraplegia is well developed. This gait differs from
that of spastic paraplegia chiefly in the absence of the stiffness of the legs
and the interlocking of the knees, which are both present in the other.
The so-called “hopping gait” is not developed as in the other form. The
back is not arched.
GAIT AND ATTITUDE AS A FACTOR IN DIAGNOSIS. 163

Gar or Spastic on Teranor ParApiecra.—tln the carly stages of
this disease a combination of paresis, muscular rigidity, and occasional
tremor exists. The feet are turned inward and appear to he firmly glued
to the ground during attempts at walking, and are scraped along with a
characteristic noise. They often cross each other in walking, and the
knees are liable to become locked together. These subjects are particu-
larly prone to fall in spite of the use of canes or crutches, becuuse the

 

Fic. 48 —PARALYSIS AGITANS, OR SHAKING Patsy. (Charcot.)

slightest. irregularity in the pavement may catch their shoe as it is slid
along the ground. These patients sometimes exhibit a “hopping gait”
when the muscles of the calf become affected with spasm. The back is
strongly arched and the chest is thrown forward. The patient throws
his weight first on one cane and then on the other, in order to lift his
body so as to move his feet.

Garr or Pararysts AgiTans.—The tottering and trembling gait of
these subjects, with a tendency to trot rather than walk when under full
164 LECTURES ON NERVOUS DISEASES.

headway, is characteristic. The shaking hands sare usually held out in
front of the body, which is bent forward as they run. These subjects are
venerally well advanced in age. The head is projected forward and held
stiffly when walking, and the “vertebra prominens” stands out in bold
relief. Fig. 48 illustrates this point very well.

Garror Pssupo-Hypertropuic PARALYsISs.— These subjects are always
children. The immense ealf muscles are strangely in contrast with their
paralytic symptoms. When they attempt to walk the gait has been aptly
compared to the “waddling of a duck.” The back is excessively curved

 

‘ - 4
Vic. 49.—Artrrune or Pseupo-Hypertropuic PARALYSIS. (Duehenne.)

in the erect posture, so that a line dropped from the shoulders falls behind
the hips. The peculiarities of attitude of these patients will he consid.
ered later.

Garr or Locomoron ATAXIA oR TABes Dorsatis.—These subjects
straddle as they walk. The legs are flung about in an uncertain and ap
parently aimless manner, although the steps are taken with marked de-
liberation, The feet are brought down with the heel projecting, thus
creating a “stamping” and “flopping” gait. These patients keep their
eyes steadily upon the ground when walking. They have no motor paral:

 
ATTITUDES ASSUMED IN NERVOUS DISEASES. 165

ysis, as is shown by testing the various muscles separately; the abnormal
gait being due purely to an inability to properly codrdinate the various
groups of muscles. These patients are frequently subjected to severe
and unexpected falls after marked incodrdination of movement is de-
veloped, and generally resort to the use of strong canes when walking.

Gait or Hysrerican Pausy.—The feet are dragged or shuftled along
in the paraplegia of hysteria, but one foot is usually more attected than
its fellow. There is no ‘sickle-movement” of the leg, as in hemiplegic
subjects. These subjects use a cane or crutch, or cling to articles of fur-
niture as they sluggishly move about a room. It is liable to pass away
suddenly and is usually developed as suddenly.

Gait or Progressive Muscunar AtRopoy.—When the thigh and
calf muscles are attected, or those of the back or abdomen, the gait is
seriously altered. Asa rule, these subjects walk as a sailor does upon
land, only the “roll” is exagecrated, and the trunk is peculiarly poised
upon the legs. The gait is, however, modified by the seat and extent of
the muscular degeneration, as it is produced in each case by the inability
of a certain set of muscles to perform their normal functions.

Garr oF CEREBELLAR Disease.—Like all ataxic subjects, these pa-
tients stand with their feet wide apart, to increase their base of support.
When walking they give evidence of imperfect codrdination of the mus-
cles of the legs. Sometimes they stagger and reel like an intoxicated
person. If the feet are exposed the toes will be seen to be in constant
motion when an effort to stand on one spot is made, as if they were en-
deavoring to bury themselves in the carpet.

Garr or RerLex Paratysis.—This is generally of the “hemiplegic”
variety. One leg is dragged along behind the other, in the large majority
of cases.

Gai’ oF CEREBRO-SPINAL ScLERosIs.—In this disease we meet 2 very
characteristic gait. Slight jerking movements of the head and neck can
be perceived in the early stages. Later in the disease the symptoms of
marked incodrdination of the muscles are apparent. The gait is then
extremely unsteady and irregular, but totally unlike that of locomotor
ataxia, in that the muscles of the trunk as well as those of the legs are
affected. These patients do not walk deliberately and in a straight line,
but shoot suddenly forward or to one side, and are very apt to knock
against articles of furniture in moving about a room and to fall violently.

THE ATTITUDES ASSUMED IN THE MORE SEVERE FORMS OF
NERVOUS DISEASES.

Nervous diseases tend in some instances to produce abnormalities
of attitude. The limits of this chapter will preclude more than a cur-
sory view of this field. A volume would be required to properly exhaust
the headings already touched upon.
166 LECTURES ON NERVOUS DISEASES.

Amone the more common causes of abnormalities of attitude due to
nervous lesions may be mentioned epilepsy, tetanus, hydrophobia, spinal
meningitis, hysteria, catalepsy, hydrocephalus, chorea, athetosis, arthro-
patny, the many forms of cerebral and spinal .paralyses, the different
types of tremor and muscular atrophy, contracture, or reflex spasm.

Of the characteristic attitudes some are observed only in the erect
posture of the patient, and others when the patient moves about. Some
ure recognized when the patient is sitting, while again others are present
in patients confined to bed. Attempts at movement of any kind some-
times increases the deformity, while again walking may gradually limber
up other patients and render the defects of movement less apparent.

In connection with the description of facial evidences of nervous
disease, the characteristic lacial attitudes of Bell’s palsy, Duchenne’s dis-
ease, paresis of the muscles of the eye, paralysis of the third nerve, the
convulsions of epilepsy and tetanus, the condition of catalepsy, and the
facial spasm of St. Vitus’ dance have been alluded to and in part
described.

When the hand was considered, the attitudes of progressive muscular
atrophy, paralysis agitans, and the results of paralysis of the median,
ulnar, and musculo-spinal nerves were described separately. The de-
forinities of the hand in gout, and the attitude of the thum)h and fingers
in hydrocephalus, athetosis, and imbecility, were also mentioned. It is
not necessary, therefore, to again describe them.

It remains for me to touch upon some of the more important atti-
tudes which have as yet been omitted. ‘

In acute Ayprocephalus the tuberculous deposit at the base of the
brain creates a characteristic attitude when the condition is well de-
veloped. These children bore their head into the pillow and roll it from
side to side. The thumbs are flexed upon the palms during sleep, even
hetore the severity of the attack is reached. The pupils are at first con-
tracted, but they become dilated when coma develops from the pressure
of the deposit of tubercle upon the brain. The abdomen is markedly
retracted.

Linked with cerebro-spinal meningitis we notice the rigid contrac-
tion of the muscles of the trunk, resulting in a curvature of the back.
The head is also thrown backward and the muscles of the neck are more
or less rigid. Fever and an eruption are also. present.

Sooner or later after a “stroke” of paralysis, a state of rigidity and
contracture of the paralyzed muscles often develops. It causes, asa rule,
a state of permanent flexion in the upper limbs and that of extension in ,
the lower. This post-paralytic contracture, if developed late, is thought
by some authors to indicate a descending degeneration (?) of those motor
fibres of the spinal cord that have been cut ofl trom their so-called
ATTITUDES ASSUMED IN NERVOUS DISEASES. 167

“trophic centre” by the exciting lesion. It is always associated with a
marked increase of the spinal reflexes, a point of great clinical import-
ance. This condition is known as ‘“tetanoid” or “spastic”? paralysis.
The peculiar gait of these subjects has been previously discussed.

In pseudo-hypertrophie paralysis the child first gives evidence of the
commencement of the disease by a weakness of the legs and a clumsiness
in walking, which is exhibited by frequent stumbling and falls. Gradually
the patient assumes a characteristic attitude and gait.

The attitude is very peculiar. In the standing posture the back is
thrown beyond the proper position, so that a vertical line dropped from
the shoulders frequently falls behind the sacrum; this antero-posterior

 

 

Figs. 50, 61, 52, 53.—AtrtirupEs AssumMED 1n PsevDO-HypERTROPHIC PARALYSIS
URING ATTEMPTS TO Rise. (Gowers. )

curvature entirely disappears, however, when the patient is in the sitting
posture. The feet are placed wide apart so as to increase the base of
support. The heels are usually drawn upward by a contraction of the
tendo-Achillis. In the effort to preserve the balance the arms are held at
the side with the hands extended, and the slightest touch may cause the
patient to fall. Another remarkable feature of the disease is the difli-
culty which is experienced in rising from the recumbent, or even the
sitting posture. The sufferer uses surrounding objects as a means of
rising, drawing the body upward by the hands. When unable to reach
such assistance, the steps which are taken to rise are thus described ly
Gowers: “If laid, for example, on his back upon the floor and told to
168 LECTURES ON NERVOUS DISEASES.

rise, he would first with great difficulty turn on his face; he would next
get on his knees, his head being almost between his thighs; from this
position he would gradually extend himself, so that he stands upon his
feet and hands with all his limbs extended; finally he would extend the
hip-joint by g grasping the thigh with the hand and pushing up the body, as
it were, by the arm.” This movement of “climbing up the thighs,” as it
has been termed, is an indication of weakness in the muscles which
straighten the knee, and also those which extend the trunk upon the
thigh—the extensors of the hip-joint.

 

Fig, 54.—AttTiTupE CREATED BY ATROPHY OF THE Back Musc.es, (Bramwell.)

The gait of these patients is associated with an oscillation of the
body from side to side, or a waddling movement, The advance rade at
each step is very small, and a difliculty seems to be experienced in flexing
the thigh upon the abdomen,

The muscles of the calf exhibit early a firmness and increase in size
which is not proportionate to their motor force—as that is far below
normal. Soon they become excessively dev cloped, as do also those of
the buttock; while the other muscles of the leg commonly grow smaller
from atrophic changes.
ATTITUDES ASSUMED IN NERVOUS DISEASES. 169

The latissimus dorsi and the lower part of the pectoralis major
muscles exhibit marked wasting ina very large percentage of cases. In
some instances all the striated museular fibres of the body, including
even the heart, may become attected,

In spinal meningitis of the acute form the patient lies with the legs
and thighs flexed, and shows evidences of great suffering in the coun-
tenance. The muscles of the neck are attacked by spasms which draw
the head backward. The patient dreads all movements, because they
increase both the pain and the spasms of the muscles.

 

 

Fic, 55.—ATtiruDE CREATED BY ATROPHY OF THE ABDOMINAL Muscies. (Bramwell.)

Children affected with acute poliomyelitis are often delirious and
have febrile symptoms. The paralyzed limbs lie motionless and the
muscles are flaccid. Tremors and twitchings in the facial muscles and
the tendons of the wrist are often observed, but they are the result of a
rapid elevation of the temperature rather than a symptom of this special
disease.

In progressive muscular atrophy the “bird-claw” appearance of the
fingers attracts attention at once (Fig. 43). When the muscles of the
arm and forearm are badly wasted the limb hangs at the side in a help-
170 LECTURES ON NERVOUS DISEASES.

less way, ‘‘as if it were tied to the body by strings.” If the muscles of
the lumbar region be attacked the belly becomes slightly prominent and
tense, und the back is strongly arched in order to balance the trunk
(Fig. 54). A line dropped from the shoulders falls behind the hips as
the patient stands erect. If the abdominal muscles are atrophied the
belly falls forward to a marked extent, and the hack is arched in such
a manner by the healthy lumbar muscles that a vertical line from the
shoulders passes through the sacral region (Fig. 55). The muscles of
the lower limbs are seldom so severely wasted as to prevent the patient
walking. ‘

In hysterical paralysis the patient (usually a young woman) is often
confined to the bed. Todd has described the facial appearance of this
class of patients as characterized by a “remarkable depth and prominent
fullness with more or less thickening of the upper lip, and by a peculiar
drooping of the upper eyelid.” Sometimes the muscles of the limbs are
flaccid, while in others the legs are stiffly extended and the feet are
turned inward. The nutrition of the muscles is generally good, and
marked atrophy is seldom present.

In cerebro-spinal sclerosis the face first attracts attention by a stupid
and vacant expression, the half-open mouth, an oscillation of the eye-
balls (nystagmus) in some instances, and a contracted state of the pupils
in many cases. The speech is liable to be of a ‘drawling”’ character,
and the tone of the voice monotonous. The head is often turned slightly
to one side during attempts at walking, or perhaps is drawn a little back-
ward—a point which is explained by Bramwell as an effort on the part
of the patient to prevent unsteadiness of the head by an artificial stiff-
ness of the neck. The gait has already been described.

SYMPTOMS OF NERVOUS DISEASES REVEALED BY THE
EMPLOYMENT OF VARIOUS TESTS.

We are prepared by what has been said in the preceding pages of
this volume, to consider intelligently the various tests which are em-
ployed (exclusive of the tests of vision which have been already dis-
cussed) as aids in the diagnosis of certain forms of nervous diseases.
The following table may aid the reader in his study of the closing pages
of this section :—

A TABLE OF THE MORE IMPORTANT TESTS OF THE NERVE
OR NERVE CENTRES,

Tests employed to determine the REFLEX EXcITABILITY of the spinal cord:-—
J.) The “superrictAL” or SKIN REFLEXES.
2. The “peer” or TENDON REFLEXES.
3. The “orcanic” REFLEXES.
SYMPTOMS REVEALED BY VARIOUS TESTS. 171

Tests of Motor Pavenvais are employed for the following Purpasen: =
1, To determine its Exacr Limits.

2. To determine its DISTRIBUTION,

3. To determine the TropHre conprrion of the affected muscles.

4. To determine the PowER oF co-onDINATION of muscular movement.
5. To determine the so-called “ muscULAR SENSE.”

6. To determine the irgiraertity of the muscles.

Tests to determine the ‘‘IrrtTaBrLity”’ of the muscles :-—
A. MECHANICAL TESTS—

For “diminished muscular tension.”

For ‘increased musculur tension.”

For fibrillary twitchings.

For tremors.

For contracture of muscles.

ie he

B. BLectric trsts—
1. By the faradie current.
2. By the galvanie current.

Tests for the sensory NERVES cnable us to devide respecting the following conditions:—
A. Abnormalities of TACTILE suNSIBILITY—
1. Anesthesia.

2. Ayperwsthesia.

3, Delayed sensation.
B. Abnormalities of SENSIBILITY TO TEMPERATURE.
C. Abnormalities of SENSIBILITY TO PAIN.

D. Abnormal condition of the ORGANS OF THE SPECIAL SENSES.

THE SPINAL REFLEXES.

“SupERFicIaL” orn “SKin Reruexes.”—These are performed hy dif:
ferent segments of the cord.

Stimulation of the skin of the sole of the foot by a serateh, prick, or
touch with the nail,* for example, induces a contraction of the foot
muscles (plantar reflex) through the lower part of the lumbar enlarge-
ment of the cord.

The skin of the buttock calls into action the glutei muscles (gluteal
reflex) through a segment which corresponds to the escape of the fourth
or fifth lumbar nerve.

The skin upon the inner aspect of the thigh causes the cremaster
muscle to draw the corresponding testicle toward the external abdominal
ring (cremaster reflex), by influencing the cord at the level of the first
or second lumbar nerves.

The skin upon the side of the abdomen creates reflex movements of
the abdominal muscles (abdominal reflea) by affecting a segment of the
cord situated between the levels of the eighth and twelfth dorsal nerves.

4

* A sharp-pointed instrument is best adapted for the excitation of the skin reflexes.
172 LECTURES ON NERVOUS DISEASES.

The skin upon the side of the chest creates a reflex response in the
region of the epigastrium (epigastric reflex), which depends upon a spinal
segment extending from the fourth to the seventh dorsal nerves.

Finally, the skin between the shoulder blades causes the posterior
axillary fold or the teres major muscle to contract (scapular reflex),
by influencing the spinal segment between the levels of the fifth cervical
and third dorsal nerves.

By means of these refleres we are thus enabled to test the various
spinal seements from the neck to the terminal extremity of the cord.
Should any be found to be absent it should be remembered : (1) that the
reflex excitability of the cord varies with individuals, and is always
ereater in youth than old age; (2) that the plantar, cremasteric, ab-
dominal and epigastric reflexes are variable in health but are more con-
stant than the scapular; (3) that cerebral lesions may impair them on
the side of the hemiplegia, for reasons not as yet well understood ;* and
(4) that systematic lesions of Burdach’s or Goll’s columns (see Fig. 32)
tend to diminish or abolish them.

Deep or “Tenpon REFLExes,”—These are also of great value as a
means of determining the condition of excitability of different segments
of the cord. The ones now commonly employed are called the kneeyjerk
or patella reflex; the peroneal reflex; the foot clonus; and the tendo-
Achilles reflec. The method of obtaining these reflexes in the most
satisfactory manner will be described separately. It is important, how-
ever, to remember one fact in connection with them before deciding as
to their clinical significance, viz., that the reflexes should be tested on both
sides and compared with each other, because any perceptible differences
between the two sides are an indication of some pathological lesion of
the cord.

In exceptional cases, the knee-jerk may be absent in health. These
exceptions are not sufficiently common, however, to detract from the
clinical value of the test.

* Gowers advances a theory to explain this fact, which is certainly ingenious and
possibly its true interpretation. He starts with the assumption that the corpora quadri-
gemina, or the optic thalami contain a centre which inhibits or restrains the manifestation
of the skin reflexes in man, as the optic lobes have been proven to do in the frog. He
assumes, in the second place, that, the higher or motor centres of the cerebral cortex are
capable in health of overpowering or controlling in some way this centre.

Now, if the motor centres are prevented from exercising this fuuction (by becoming
themselves diseased or mechanically separated from the fibres that are functionally asso-
ciated with them, as in the case of apoplexy, softening of the brain substance, tumors,
ctc.) the centre which inhibits the skin reflexes is enabled to act without restraint, thus
causing them to hecome abolished. Ou the other hand, when the motor paralysis is due
to some lesion of the spinal cord, the fibres through which the inhibiting centre acts upon
the spinal segments below the seat of the spinal lesion are. severed ; hence the skin reflexes
are no longer coutrolled by the higher centres, and are therefore enabled to respond to even
more delicate tests than in health.
THE SPINAL REFLEXES. 173

The knee-jerk has for years been recognized and employed by
Charcot in diagnosis, although it was first systematically investigated as
a clinical symptom by Westphal and Erb. Gowers remarks in a late
work: “It is not a little curious that this knee-jerk, which for genera-
tions has amused school-boys, should have become an important clinical
symptom.”

To properly test this reflex movement of the limb, the muscles of
the quadriceps extensor tendon must be put upon the stretch to a mod-
erate degree, and the leg be unrestricted in its ability to respond. The
common method employed is to have the patient cross the leg over the
knee and allow it to hang passively at an angle of nearly ninety degrees.
Perhaps a still better way, is that employed by Gowers, viz., to allow it
to hang over the forearm of the physician when his hand is placed upon
the opposite knee of the patient; because in this way the jerk is often
elicited in stout people when it otherwise fails. The space between the
patella and the tibia is then struck with a percussion hammer or the side
of the physician’s hand, upon the bare skin, with sufficient force to slightly
increase the state of muscular tension which has resulted from flexion of
the leg. This will cause a reflex contraction of the quadriceps extensor
muscle and the foot will be jerked upward without the volition of the
patient as a factor in the movement.

The anklejerk. If the muscles of the tendo-Achilles be put upon
the stretch by flexion of the foot, a blow upon that tendon will cause a
similar extension of the foot.

The foot-clonus. When the excitability of the cord is excessive, if
the foot be firmly flexed and held so by the pressure of the hand against
the sole, a series of rhythmical reflex movements of extension follows,
which vary between six and ten per second. They can be traced upon a
revolving drum, by attaching a pencil to the foot, as easily as a sphygmo-
graphic tracing is made. This clonus is more apparent when the knee is
firmly extended than when flexed.

The peroneal reflex, The tendons of the peroneal muscles pass to
the bones of the foot at the outer side of the ankle, A blow made upon
them when the foot is bent inward so as to produce a moderate degree of
tension of these muscles, will elicit a reflex movement, as in the case of
the patella tendon.

The ‘‘front-tap contraction.” Gowers has described a reflex test for
increased spinal irritability that he considers particularly delicate. It
consists in flexing the foot with the hand upon the sole, the knee being
extended, and applying the blow to the muscles on the anterior aspect of
the leg. It is followed by a reflex contraction of the muscles of the
tendo-Achilles, which are not directly affected by the blow.

Although the deep reflexes are commonly tested only in the lower
174 LECTURES ON NERVOUS DISEASES.

extremities, the same phenomena may be elicited in the triceps or biceps
muscle of the arm as in those of the thigh and calf, if subjected to the
necessary position to insure tension of the muscles before the tap is given
over the tendon.

Let us attempt to summarize the more important clinical deductions
pertaining to these deep spinal reflexes.

1. A persistent foot-clonus never occurs in health. It indicates
that the lateral columns of the cord are probably involved by some
spinal lesion. In supposed hysterical affections this symptom will often
decide the question of the existence of organic disease. It must not be
mistaken for the involuntary foot-clonus which sometimes occurs when
an unnatural posture is long maintained, even in health. It is usually
associated with exaggeration of all the other deep reflexes.

2. All reflex tests become abolished when the muscles are separated
from their connection with the spinal cord; hence, severing of a nerve,
posterior spinal sclerosis, compression of the spinal nerve roots, de-
struction of the gray matter of the cord, poisons, etc., are often associ-
ated with their complete abolition.

3. Disease of the lateral columns usually decreases the skin reflexes,
especially those of the trunk. This is particularly true of the so-called
descending degeneration of these columns, which follows the development
of cerebral lesions. ,

4. Sclerosis of the lateral columns always increases the “deep” or
tendon reflexes.

5. When marked incodrdination of movements is present and the
deep reflexes are not abolished, it indicates that sclerosis of the lateral
columns probably co-exists with similar changes in Burdach’s columns.

6. Spasm isa marked symptom in many diseases of the spinal cord.
It commonly indicates an excessive action of the reflex motor centres.
It is particularly common as an acute symptom in spinal meningitis, In
chronic organic diseases of the cord, it assumes the form of contracture
of muscles, especially if the lateral columns of the cord are attacked; this
condition becomes transformed into that of a genuine spasm when the
slightest forms of peripheral impressions are experienced, as in delicately
manipulating the muscles, for example.

Tue Orcanic RerLexes.— The Bladder and Rectum.—The bladder
and rectum are more or less affected, in respect to the performance of
their functions, by those diseases of the spinal cord that tend to impair
or destroy the special nervous mechanism connected with them. The
nocturnal incontinence of children, who “wet the bed” in spite of all pre-
cautions against the accident, is an evidence either of spasm of the
bladder, excessive stimulation of the centripetal nerves connected with
the so-called “vesical centres” of the spinal cord, or atony of the
THE ORGANIC REFLEXES. 175

sphincter muscle. If due to spasm, it may be excited by worms in the
intestine. When the spinal cord is subjected to sudden injury low down,
or is attacked by some disease process that involves the lwmbar region of
the spinal cord, the bladder and the rectum are liable to be paralyzed. In
such cases, if the paralysis be complete, the urine has to be drawn with a
catheter. Sometimes, if not drawn at regular intervals, it overflows,
when the bladder becomes excessively distended. This compels the pa-
tient to wear some form of apparatus to prevent wetting of the clothing.
Urinal overflow should never mislead the physician into the belief that
the bladder is empty.

True incontinence is a rare condition in the adult. The term “in-
continence” is not, however, restricted by many authors to that con-
dition characterized by a continued escape of urine and emptiness of the
bladder.

Bramwell gives the following table, as an aid in the diagnosis of two
forms of incontinence that are commonly recognized :—

 

 

 

 

.
Effect of ef- :
fi - Associated nerve-| Effect of
Occurrence. Ore fOuEh Age. Urine. symptoms, qpeoent:
Ey etc.
SPASMODIC Occasionaland Nil Generally | Sear acids None, unless Good
INCONTINENCE. ) | intermittent. ate young. al hysteria oes
|
. |May be am-| If central, gener-
PaRALYTIC Gbuseat Forces away a oe. | moniacal ally a similar Very often!
INCONTINENCE. : urine. all oft é and puru- affection of rectum able
y geo lent. and paraplegia. :
parapleg,

 

 

 

 

 

 

 

In all cases, where either incontinence or retention of urine is de-
veloped in connection with abnormal nerve symptoms, the urethra and
rectum should always be carefully explored for the purpose of detecting
disease, or of eliminating, if absent, all local causes of these conditions.

Tue SexuaL Rertex.—In the lumbar region of the spinal cord a
centre is situated that governs the acts of erection and seminal ejacula-
tion. It may be called into action either by impressions made upon the
sensory nerves of the skin of certain regions, or by cerebral influences
‘that are exerted upon the sexual centre as the result of some emotional
impulse.

Destructive processes in this centre of the spinal cord cause a loss
of power of erection and ejaculation,—i.e., impotence. General spinal
weakness from any cause may also lessen the duration and degree of erec-
tion or render ejaculation premature.

Linked with some forms of nervous disease comes priapism, or the
state of erection without sexual desire. It may bea result of irritation
or excessive stimulation of the following structures: (1) the sensory
176 LECTURES ON NERVOUS DISEASES.

nerves (as in gonorrhea); (2) the sexual centre itself; (3) the nerves
that convey the emotional impulses from the brain to the sexual centre
through the spinal cord; (4) the parts of the cerebral cortex functionally
associated with sexual emotions. The latter are, as yet, undetermined,
Priapism may be complete and painful, or incomplete and. pain'ess. It
may last for days. It occurs not infrequently in connection with disease
in the lower cervical or upper dorsal regions of the spinal cord.

Tur Pupittary Rertex.—The last two cervical and the three upper
dorsal segments of the spinal cord probably embrace the so-called “ cilio-
spinal centre.” From it sympathetic nerves pass to the muscular fibres
of the iris. Irritation of this centre causes the pupil to dilate; destruc-
tion of it causes the pupil to contract. The tests for the ‘“ Robertson
pupil” have been described already (p. 120). This peculiar condition of
the pupil is one of the most valuable signs of the disease called “ loco-
motor ataxia’ or posterior spinal sclerosis. It is the only condition of
the eye that allows of the movements of the pupil in attempts to focus
near objects and destroys at the same time the response of the pupil to
varying degrees of light.

TESTS FOR MOTOR PARALYSIS.

As mentioned in preceding pages, the physician may be called upon
to recognize five forms of paralysis of motion in the trunk and extremi-
ties viz.: monoplegia, hemiplegia, paraplegia, hemiparaplegia, and com-
plete paralysis. If the paralysis be of an incomplete or partial form in
any type, it is called “paresis.”

Cerebral diseases commonly produce either monoplegia or hemi-
plegia of the epposite side of the body, in case paralysis occurs either
as a result of localized pressure upon the brain or of destruction of some
of its component fibres.

In those cases where the lesion involves both hemispheres, the paral-
ysis may be bilateral. Such lesions are generally present at the base of
the brain.

When “crossed paralysis” is developed, definite information is
afforded respecting the seat and extent of the lesion.

Spinal paralysis ts bilateral in the great majority of cases, and is
limited to the muscles of the legs (paraplegia). This is to be explained
(1) by the fact that the motor tracts of the spinal cord are in a some-
what close relation to each other, and that acute diseases are seldom
confined to one lateral half of the cord; and (2) to the fact that the
muscles below the seat of the lesion are necessarily paralyzed in propor-
tion to the amount of injury sustained by the motor fibres.

In those rare cases, where the spinal lesion is situated above the
point at which the nerves to the upper extremities are given off, bilateral
TESTS FOR MOTOR PARALYSIS. 177

paralysis is apparent in both extremities (arms and legs), constituting
the condition termed “cervical paraplegia” by some authors.

‘The points to be tested in any case of motor paralysis have been
enumerated in a preceding table. Without further explanation, we will
now proceed to consider each separately.

Tue Sear anp Limits of THE PaRALysts.—To ascertain the exact
limits of the paralysis is important as an aid in the determination of the
seat of the exciting lesion, be it cerebral or spinal. The peculiarities of
attitude and gait will often aid, in a rough and imperfect way, in deciding
as to the muscles that are chiefly affected; but a more detailed examina-
tion of the separate muscles, by instructing the patient to perform desig-
nated movements that shall call different sets successively into action, will
be more accurate and scientific. To employ these tests in a skillful
manner, however, the physician must first be thoroughly familiar with
the action of the various muscles, both individually and in conjunction
with others.

 

Fic. 56.—THE DyNAMOMETER OF Martturevu, When taken in the hand and pressed, the two sides
of the elliptical spring, 2, 6, are approximated, and the finger of the dial records the exact
amount of force exerted upon the spring. One advantage’of this instrument over all other
devices of a similar kind is, that the index’ does not return to zero, but remains at the point
indicating the greatest amount of force exerted by the hand of the patient. It is not neces-
sary, therefore, to watch the index while the instrument is being used. Both hands should
be tested separately and the results noted in the record of each case. A modification of this
instrument has been devised ta test the power of the muscles.of the lower extremity.

In some forms of spinal diseases, where great accuracy in the diag-
nosis and localization of the lesion is required, it may become necessary
to test the motor condition of the various spinal segments by means of the
muscles that are governed by them. The investigations of Yeo and
Ferrier upon the monkey tribe, as well as those of Marcacci and Bert
upon dogs and cats, seem to have demonstrated that each pair of spinal
nerves exerts an influence upon definite muscular movements.

Tue Decree or Motor Paratysts.—Complete paralysis, of course,
abolishes all power in the muscles affected, but paresis does not, and
therefore varies in degree. It is often important to decide as to the
Jorce that can be exerted by the partially paralyzed muscles before com-
pleting a diagnosis. This can be best accomplished in the muscles of
the upper extremity, by the employment of an instrument devised by
Matthieu, an instrument-maker of Paris, called the dynamometer. It is
shown in the cut.

12
178 LECTURES ON NERVOUS DISEASES.

When grasped in the hand, the index shows the amount of power
that is exerted upon the spring. The index remains fixed until mechani-
cally replaced after it has been used; this enables the physician to direct
his attention to other points in the case while the patient is trying his
muscles. It is really a test for the “grasping power” of the flexor
muscles of the forearm only. An apparatus for tracing the effects of
muscular contraction is sometimes attached to the dynamometer. It is
called the dynamograph. It shows irregularities of muscular contraction,

 

 

Fic. 57-—Tne Dynamocraru.—This modification of the dynamometer enables the physician
to observe and record the condition of the muscles in respect to their ability to maintain
tonic contractions. In health, the line drawn by the pencil should he perfectly straight
when the elliptical spring is steadily compressed by the hand for a few seconds. If the
grasping power is intermittent or incapable of being maintained continuously for an interval
of several seconds, the line described on the recording tablet will be irregular. The slips of
paper. indicating the deviations of the pencil, can be preserved in the case-book, and by com-
parison they may show improvement or increase of the muscular debility.

The strength of the muscles of the calf can be tested, as Gowers
suggests by requesting the patient to jump on tip-toe. And also by an
ingenious instrument devised by Dr. Birdsall, of this city, called the
“foot-dynamometer.”’

A third method of testing the various muscles is to request the
patient to exercise all possible resistance to some special movements that
the physician creates by manipulation; or, on the other hand, to request
the patient to perform some special movement and estimate the amount
of force required to prevent his doing so.

Bilateral paralysis requires that the power of the muscles should be

compared with that of a healthy individual of about the same muscular
THE TROPHIC CONDITION OF THE MUSCLES. 179

development as the patient, if great accuracy is desired. In unilateral
paralysis, the healthy side can be used as a standard of comparison.

THE TROPHIC CONDITION OF THE MUSCLES.

The amount of atrophy or wasting that ensues simply from disuse
of the muscles must be distinguished from that due to a loss of the so-
called ‘trophic function” in the nerves that supply the muscles.

Rapid wasting of a muscle occurs when the nerve fibres that supply
it are cut off from the so-called “trophic centre” of the spinal cord with
which they are normally connected. The multipolar nerve cells in the
anterior horns of the spinal gray substance are probably the ‘trophic cen-
tres” for the motor fibres found in the anterior roots of each spinal nerve.
When these cells become the seat of disease, the muscles undergo extreme
and rapid atrophy. Similar changes also occur when the nerves are cut
off from the connection with them, as in wounds of a nerve, pressure
upon a nerve, ete.

THE POWER OF COORDINATION OF MUSCULAR MOVEMENTS.

Disease of the cerebellum, the lemniscus or fillet-tract (Fig. 11),
and of the columns of Burdach and Goll in the spinal cord (see Fig. 32)
is commonly associated with a peculiar inability on the part of the
patient to perform certain muscular movements in a proper way,
because the muscles do not act in the sequence necessary to accomplish
them. This is termed “incodrdination of movement.”

Various tests are employed in determining the degree of this ab-
normal state, because one that will answer for the lower limbs will not
for the upper extremities, or vice versa. Besides, it is necessary in these
cases to decide both as to the ability to perform complex movements
with accuracy, and also as to the state of the so-called “ muscular sense.”
Let us consider first the tests of the former.

When so-called “ataxic patients” are requested to follow a designated
line in the floor or carpet as they walk across a room, they invariably
keep their eyes fixed upon the floor, and have extreme difficulty in fol-
lowing the line. Now, ask such a patient to do the same with the eyes
looking straight ahead of him, and the attempt will prove a still more
lamentable failure than before. In advanced stages of the disease, the
patient may fall,

A second manifestation of lack of codrdination in the muscles of the
legs lies in an inability on the part of the patient to stand erect with the
Jeet in close contact, without. swaying or falling. This is rendered still
more difficult when the patient is instructed to close the eyes. It must
be remembered, however, that an inability to stand erect and motion-
less with the eyes closed is not always due to ataxia. I have seen the
180 LECTURES ON NERVOUS DISEASES.

same result produced artificially in a healthy subject ‘by freezing the
soles of the feet to a degree sufficient to destroy the appreciation of its
contact with the floor or carpet. The test is a reliable one only for the
presence of marked anesthesia of the soles of the feet; hence it is common
in ataxic subjects, in whom sensation is always more or less impaired.

Considerable stress may be laid upon this point, because it is stated
by some writers ‘that this symptom or test is to be regarded as a
positive sign of locomotor ataxia. That it is a valuable diagnostic point
m that disease, when associated with other evidences of its existence,
cannot be disputed; but it is by no means a pathognomonic symptom, as
it might exist in any disease (cerebral, spinal, or functional) that could
cause marked anesthesia of both lower extremities.

In order to preserve the equilibrium during an erect posture when the
feet are in close contact, it is necessary that the nerves of sensation allow
the keenest appreciation by the nerve centres of variations in the amount
of pressure exerted by the weight of the subject upon the different
regions of the sole of the feet. When such information is withheld from
any cause (chiefly by sensory paralysis or anesthesia) the nerve centres
can no longer properly govern the muscles to counteract a tendency

‘toward a fall, provided that the sense of sight is prevented from giving
them the necessary information. This explains why it is that ataxic
patients often notice a difficulty in washing the face at a washstand when

. the eyes are closed; why they keep the vision fixed upon the ground as
an aid in governing the movements of walking; and why they keep their
feet well apart when standing still, in order to increase their base of sup-
port. All the other symptoms of ataxia may thus be mechanically in-
terpreted and be employed as tests in diagnosis.

Among these symptoms may be mentioned: a difficulty in climbing
a flight of stairs, on account of the feats of balancing required to do so;
a difficulty in placing the foot rapidly and accurately upon some small
object, as in mounting a horse by means of the stirrup; and many others
of a similar kind.

The tests for incodrdination of the muscles of the upper extremity
have not as yet been described,

The handwriting is sometimes seriously affected in ataxic patients,
by an inability to make continuous curves with accuracy, as in the case
of the capital letters C, D, G, etc. This is because the acts required of
the muscles in making these curves are complicated and must follow each
other in a certain sequence, in order to properly execute them. Again,
the clothes are buttoned and unbuttoned with extreme difficulty, because
these simple acts require codrdinated muscular movements of a complex
character. Food and drink are carried to the mouth with diffienlty in
some cases, especially when the eyes are closed or in the dark. These
THE MUSCULAR SENSE. 181

patients cannot touch designated parts of the face with the finger with
accuracy and rapidity when the incodrdination of the upper extremities
is well developed, or the so-called “ muscular sense” is destroyed. These
tests will be mentioned later.

THE MUSCULAR SENSE.

By this term we mean the power which each individual possesses, in
health, of discriminating in regard to the amount of muscular force re-
quired to accomplish certain ends. Thus, for example, if two objects are
held in the hands, the ditference in weight between them should be esti-
mated with an approach to accuracy. Again, if the eyes be closed, the
fingers can be made to touch rapidly any designated portion of the body
with perfect certainty. Movements of progression should be also per-
formed with the eyes closed nearly as well as when open, if the distance
be short and the location a familiar one. Finally, the handwriting should
not differ materially as regards the formation of letters when made with
the eyes shut or open.

Now in some forms of nervous derangements, the museular sense is
impaired; hence it becomes necessary to sometimes test it before making
a final diagnosis. Several tests are commonly employed. They may be
designated as the ‘weight’ test, the ‘‘movement” test, and the ‘ hand-
writing” test.

In testing the power of discrimination of weights held in the hands,
it is best to have them all of uniform size, in order to avoid the patient
using the sense of sight as a factor in his decision. Hanging different
weights from the foot in a handkerchief will test the muscular sense in
the lower extremity. Metallic balls of different thickness but of uniform
size, either covered or uncovered, answer the purposes of the “weight”
test. The ability on the part of a patient to tell with the eyes closed the
exact position of a limb in reference to other parts of his body, when
different attitudes are assumed, may be interpreted as an exhibition of
the muscular sense.

To test the accuracy of movement, direct the patient to close the
eyes tightly, or blindfold him, and then instruct him to rapidly place the
forefinger of either hand alternately on some spot upon his body which
shall be designated in each instance, as the nose, upper lip, lower lip, ear
of either side, ete. When the lower limbs are to be tested, he may be in-
structed to place his great toe upon the opposite instep, heel, knee-cap,
ete., or to raise the foot to a given height when lying on the back, and
then to slowly lower it till it rests upon some designated spot on the
other foot.

The handwriting of a patient is often of value in diagnosis; es-
pecially when a sentence written with the eyes open is compared with
182 LECTURES ON NERVOUS DISEASES.

the same written with the eyes closed. In health the muscular sense
should enable almost any one to perform both with a fair degree of pre-
cision. In motor paralysis or ataxia the changes are marked, especially
in the latter, because incodrdination of the muscles prevents the forma-
tion of continuous and well-formed curves, even when the eyes are open,
and utterly destroys the legibility of the letters if closed. The exist-
ence of tremor, or the presence of profound motor paralysis, will, of
course, interfere most seriously with the ability of the patient to write
legibly, if at all, irrespective of the aid of vision.

TESTS TO DETERMINE THE IRRITABILITY OF THE MUSCLES.

In some forms of cerebral and spinal disease it becomes necessary
to test the so-called ‘irritability’ of the muscles. Two forms of tests
are employed for this purpose, viz., mechanical and electric.

Mechanical tests enable us to decide (1) as to the existence of dimin-
ished or increased tension of the muscles; (2) the presence of twitchings
of individual muscular fibres in certain regions (as if a live animal were
imprisoned beneath the skin); (8) the presence of tremor; and (4) the
state of muscular rigidity and permanent shortening known as “con-
tracture,”

Electric currents are employed as aids in diagnosis, chiefly in de-
ciding the question of the existence of degenerative changes in the mus-
cles. The increase or decrease of such changes, when they have been
found to exist, can also be scientifically determined by the employment
of electric tests from time to time.

MECHANICAL IRRITABILITY OF THE MUSCLES.

When the muscles are subjected either to manipulation, a light
tapping with the tip of the finger, or a stroke with a percussion hammer,
either an abnormal exaggeration or a diminution of the mechanical ex-
citability of the part struck is sometimes detected in connection with
disease or injury of the brain, the spinal cord, or of the nerves themselves,

The following clinical deductions are offered as a summary of these
tests :—

1. Motor paralysis usually decreases the mechanical excitability of
the muscles affected.

2. When the “galvanic excitability” is markedly increased (reac-
tion of degeneration) the mechanical excitability of the muscles is also
increased.

3. A marked increase in the “deep” or “tendon reflexes” is like-
wise associated with an increase in the mechanical excitability of muscles.
This is particularly characteristic of sclerosis or hardening of the lateral
columns of the spinal cord.
LESIONS OF THE CENTRUM OVALE. 183

4, Atrophy, or wasting of the muscles, as the result of disease-pro-
cesses, Such as functional paralysis, poliomyelitis, etc., usually tends to
diminish the tonicity of the affected muscles (state of flaccidity). An
exception to this rule exists for a time in amyotrophic lateral sclerosis
and other conditions where marked muscular rigidity precedes the
atrophy.

5. Any disease that tends to cause irritation of the motor nerve-
Jibres, or to arrest the control of the brain over the spinal segments, is
liable to be associated with rigidity of the muscles. Twitchings, mus-
cular cramps, tremors, spasms, and contractures, may be associated with
this increase of muscular tension.

The distribution of the muscular rigidity differs if the exciting
cause be confined to the spinal coverings or the substance of the cord
itself. In the former case the flexors are chiefly involved. Hard-
ening or sclerosis of the lateral columns of the cord usually causes the
lower limbs to be firmly extended and closely approximated to each
other. :

6. The disease known as “ progressive muscular atrophy” is the
one most commonly associated with contractions of separate fibres or
bundles of fibres in the muscles,—the so-called “ fibrillary twitchings.”
These twitchings are not confined, however, to this condition. Hypo-
chondriacs and certain functional diseases of the spinal cord may also be
associated with them. A slow destructive process affecting the motor
nerve-cells, or the motor nerves themselves, may also cause them.

7. A permanent shortening of muscles (state of contracture) is a
frequent sequel to extensive atrophy or wasting of the muscular fibres.
It may result also from the prolonged and unrestrained action of certain
muscles whose antagonists are lacking in muscular power, as in the case
of infantile paralysis, lateral sclerosis, etc.

TESTS EMPLOYED IN THE DIAGNOSIS OF LESIONS OF THE WHITE
SUBSTANCE OF THE CEREBRAL HEMISPHERES.

Lesions of the centrum ovale have always been regarded as pecu-
liarly difficult of detection and localization during life. In quite a large
proportion of cases where extensive disease of this portion of the brain
has been discovered after death, the presence of the lesion has been
either unsuspected during life, or, if suspected, imperfectly localized.
The fibres which assist to form the white substance of the brain comprise
the commissural, associating, and peduncular tracts. These have been
described already on page 17. Dr. M. A. Starr has lately written a
very interesting and lucid article upon lesions of the centrum ovale
(Med. Record, Feb., 1886). He explains how a severance of the “com-
missural” and “associating tracts’ of the cerebral hemisphere may be
184 LECTURES ON NERVOUS DISEASES.

recognized during life by a careful examination of the mental faculties of
the patient and by testing the ability of the patient to perform identical
and simultaneous bilateral movements of the face and the extremities.

The tests designated by this author may be summarized as follows :—

To Test THE ComMiIssuRAL Fipres.—If the two hands are moved in
unison, during attempts to draw a circle or write one’s name with each
hand simultaneously, the right hand should move to the right to exactly
the same extent as the left hand does to the left. Therefore, although
the writing of the right hand is legible, that of the left hand will be
backwards and can be easily read only by the aid of a mirror (“ mirror-
writing ” test). Whenever simultaneous bilateral movements are found
to be defective, the “‘commissural” fibres (Fig. 6) will probably be found
to be congenitally imperfect or impaired by a morbid lesion. The history
of the patient would decide which of these two probably existed in any
given case. On this principle, bilateral movements of the upper and
lower limbs ean be tested in a variety of ways.

THE Tests FoR THE ‘ASSOCTATING-TRACTS” are somewhat more com-
plex—although they are by no means difficult to understand. The fol-
lowing suggestions are pertinent to this field :—

1. To test the connection between the hearing centres and Broca’s speech centre
(temporo-frontal tract). Request the patient to repeat promptly words dictated
to him. Notice also if any impairment of spoken language exists during a con-
tinued conversation.

2, To test the tract between the hearing and sight centres (occipito-temporal tract).
Ascertain if the patient can read intelligibly to himsclf and afterwards tell cor-
rectly what he has read.

8. To test the “ occipito-temporo-frontal tract.” Ask the patient to read aloud some
selected paragraphs.

4, To test the tract which unites the sight centres with the motor centres (occipito-
central tract). Ask the patient to write what a selected paragraph contains.

5. To test the tract which unites the hearing centres with the motor centres
(temporo-central tract). Request the patient to write from dictation.

6. To further test the tract uniting the sight and hearing centres with the speech
centres. Ask the patient to name the color of different objects placed in his
field of vision; also their form and general appearance.

7. To test the tract connecting the frontal convolutions and the motor centres
(fronto-central tract). Request the patient to write what he speaks to himself—
preferably in an audible whisper, so that the observer can detect an error.

8. To test the tract connecting the smell and taste centres with the hearing and
speech centres (the hippocampo-temporo-frontal tract). Request the patient to
speak the names of particular odors or tastes, of which he may be made cogni-
zant during the interview by the physician or an attendant.

9. To test the connections between the smell, taste and hearing centres with the
motor centres (the hippocampo-temporo-central tract). Request the patient to
write the names of odors or taste-impressions, of which he may be made cogni-
zant at the time by the observers.
THE PRINCIPLES OF ELECTRO-DIAGNOSIS. 185

After such tests, as those described, have been carefully made, all
forms of impairment of the various tracts observed may be contrasted,
and thus be made a basis for a diagnosis of :a lesion of the white sub-
stance of the hemispheres. Some knowledge of the anatomical relations
of the various associating and commissural tracts is of course necessary
in order to. form the proper deductions respecting an individual case.

It should be remembered :— :

1. That the “ occipito-temporal” tract lies in close relationship with
the fibres of vision; hence, the ‘symptoms of its destruction are liable to
accompany homonymous hemianopsia of the same side as the affected
cerebral hemisphere.

2. That the “occipito-central” tract lies on a higher plane than the
occipito-temporal; hence this bundle of fibres may escape a lesion which
involves the preceding tract; and the patient may retain the power of
writing selected paragraphs, even if he cannot read them correctly. Such
a case as that reported by Charcot (page 8) illustrates this point in
diagnosis.

3. That the “parieto-temporal” tract is probably designed to allow
of the association between memories of sensations of touch, pain and
temperature, with the memories of those sounds by which we express
such sensations in words. Patients in health can thus announce to
others whether an object is hard or soft, cold or warm, rough or smooth,
etc.; and a lesion of this tract may interfere seriously with the proper ex-
pression in words of the patient’s real impressions gained by touch.

4. A perfect connection between the hearing and speech centres
(temporo-frontal tract) is absolutely essential to correct speech ; because
we are enabled to produce any desired sounds only by recalling to
memory and imitating similar sounds whose meaning has been gradually
acquired by the ear and recorded in the cells of the cortical area occupied
by the centres of hearing.

THE PRINCIPLES OF ELECTRO-DIAGNOSIS.*

The various electric tests that are employed as aids in the diagnosis
of nervous affections are too complex to be fully described and explained
without entering somewhat into the domain of physics and physiology.
Erbt+ has lately written an excellent work upon the subject, and most of
the later treatises upon physiology will afford general information re-
specting the reactions of healthy muscle to ‘the faradaic and galvanie
currents. The few practical hints which are given here are offered with
an apology for their incompleteness, although it is hoped that they will
assist you in your studies in this field.

* Portions of this lecture have already deen published.
{ ‘‘Handbook of Electro-Therapeutics,”» New York, 1883.
186 LECTURES ON NERVOUS DISEASES.

Having first moistened the electrodes and connected them with the
battery in action, it is customary to hold them both in one hand (close
together, but not in contact), and apply them to the ball of the thumb of
the opposite hand or the cheek to see if the current is passing properly.
If the current to be employed is a very weak one, touch the electrodes to
the tip of the tongue before it is used upon the patient. The use of a
reliable milliampére-meter will prove of value in determining the exist-
ence as well as the strength of a current.

Next, sponge the part of the patient’s body to be tested with a weak
solution of table-salt in warm water, in order to render the skin a good
conductor of the electric currents. If the wire-brush is to be used, this
step is omitted.

The “polar method” isthe one commonly used. Apply one electrode
of large size, either over the breast-bone of the patient (at about its centre)
or over the back of the neck. The breast-bone is the preferable point on
account of the absence of muscles in the median line.* The other elec-
trode (of small size) is placed over some special nerve-trunk or the muscle
to be tested; in case muscle is to be tested, the electrode is placed usually
at the point where the motor nerve enters its substance,—the so-called
“motor-point” of the muscle. In this way the action of the two poles
can be readily distinguished,

Use both the continuous or galvanic current and the interrupted or
faradaic current in-testing muscular reactions. The former is of the
greatest value in diagnosis.

In studying the muscular reactions to the different currents employed,
remember (1) that the negative pole is called the cathode (C),f and the
positive pole the anode (A); (2) that muscular contractions occur both
when ‘the current is altered in strength and when the circuit is closed or
opened; (3) that the faradaic current produces an apparently continuous
muscular contraction, because its interruptions are so very rapid; (4)
that very weak currents do not produce contractions; (5) that alterations
in the strength of the current cause proportionate variations in the con-
tractions; (6) that the contractions are short, sharp, and sudden in
health; (7) that the effects of applying the electrode over the substance
of the muscle and over its motor point are identical in health, but not in
some diseased conditions; (8) that the galvanic current will not usually
produce muscular contractions while it is constant, but only when its
strength is modified or when the circuit is closed or broken; (9) that the

* This is known as the ‘‘indifferent point,’? when polar effects are being studied at
the other electrode.

} German authors employ different symbols from those given. These are as follows:
0.0. C. = Ka 8. Z., C. 0. C. = Ka O. Z., A.C. C. = An 8. Z., 4.0. C. = AnO.Z. The

symbols Ka = cathode, An = anode, S = closure (Schliessung), O, = opening ( Oeffnung),
Z = contraction (Zuckung).
THE PRINCIPLES OF ELECTRO-DIAGNOSIS. 187

direction of the current can be changed, without altcring the position of
the electrodes, by a simple apparatus that changes the cathode into the
anode, and vice versa (the commutator).

The current passes always from the anode to the cathode. Hence,
when the positive pole is placed on the breast or neck, and the other on
the muscle to be tested, we have a descending current. An ascending
current exists if the cathode is on the same distant or neutral point,

An “automatic interrupter” on an “interrupting electrode” is
necessary in employing the galvanic current in testing muscular reac-
tions.

The descending current (cathode over the nerve or muscle) when
closed and again broken can thus give us :—

1. The cathodal closure contraction :—

Cc. C. C. or Ka 8. Z. of the Germans.
2. The cathodal opening contraction :—

C. O. C. or Ka O. Z. of the Germans.

The ascending current (the poles being now reversed) when closed
and again broken can give us:—

1. The anodal closure contraction :—

An ©. C. or An S. Z. of the Germans.
2. The anodal opening contraction :—

An O. C. or An O. Z. of the Germans.

These four forms of contraction require currents of different
strengths to produce them. They are, therefore, induced by gradually
increasing the number of cells employed. The following order is the
only one commonly observed in healthy muscle :—

pc sestesspardu etal ptm, C. 0. 0. =KaS. Z.
i ss ile ier ae dah Tex oven Cen g An. C.=An6&. Z.
Br eg Bednar hte cence taney An 0.C. = An O.Z.
Das ixc sp actreaes eiceatiantsinaeaee C. O. C.=Ka 0.2.

It will be observed that the cathodal contractions appear first and
last in health, while the anodal contractions follow each other; also, that
the closure contractions precede the opening contractions of both the
cathode and anode. When a nerve-trunk is stimulated by electric cur-
rents the formula of the normal muscular contractions is altered. This
will be spoken of hereafter.

Again, as the strength of the current is gradually increased, the con-
tractions which have successively appeared become intensified propor-
ttonately (as is shown below), and new reactions are added :—

First stage (moderate current), C. C. C.—
Second stage (stronger current), C.’ C.’ C.’ and An C. C.
188

LECTURES ON NERVOUS DISEASES.

Third stage (still stronger current), C.!’ 0.’ C.”” and An’ C.’ C.’ and
A. 0. C,

Fourth stage (very strong current), ©!" ©." C.!" and An!” ©.” C.""
and An’ 0.’ C./ and C, O. C.

C0." 0." 6." is called “cathodal tetanus,” because the contraction
is very violent. Sometimes the anodal contractions both occur
with the same intensity of current, thus merging the second and
third stages into one. Again An O. C, may in some cases appear
before An C. C.

Disease of the nerve-centres or of the nerves themselves may cause

modifications of the normal formula of muscular contractions. This con-
stitutes the key-note to the value of electric currents in diagnosis. Me-
chanical devices may be employed to trace the muscular contractions, as
the sphygmograph does the pulse. Fig. 58.

1.

 

Fic. 58.—Curves or Crosure Contractions 1n Direct (UNIPOLAR) STIMULATION OF THE
Muscres in THE DistRIBUTION OF THE PERONEAL NERVE IN THE Lec. (Erb). Ka=
C.C.C.; An=A.C.C. 1, Curve of health, thirty-three elements; C. C. C. is greater
than A. C. C. ; 2, case of chronic anterior poliomyelitis, showing reaction of degeneration
with thirty-three elements ; 3, same case, with forty elements. In 2 and 3, the excess of A.
C.C. over C. C. C. is apparent ; 3, in the slow character of the contractions is very marked.

If the destructive process is within the brain or spinal cord, and

situated above the “trophic centres” of the nerves supplying the paralyzed
muscles, the electrical reactions of the paralyzed muscles will be normal
in respect to the sequence and character of the muscular contractions.
THE PRINCIPLES OF ELECTRO-DIAGNOSIS. 189

Sometimes, however,a much stronger current (galvanic or faradaic) is
required to produce them over the healthy muscles. This fact is due
to atrophic changes in the muscles. It may be of decided value in
diagnosis.

When disease processes in the brain or spinal cord cause destruction
of the trophic centres of the nerves that supply the paralyzed muscles, or
when the cerebro-spinal nerves themselves are seriously injured, we en-
counter what Erb has described as the “REACTION OF DEGENERATION.”
This will require some explanation.

1. Every nerve degenerates when separated , fe om its trophic centre;
hence, the electric excitability of the nerve, both to the faradaic and
galvanic currents, gradually diminishes and ceases entirely at the end of
about two weeks.

2. The faradaic current ceases to cause muscular contractions when
applied directly over the substance of the muscle. This is explained by
the fact that the so-called ‘‘nerve-plates” within the substance of the
muscle are degenerated, and currents of momentary duration fail to affect
the muscular fibres.

8. The muscular contractions produced by the galvanic current are
diminished for about ten days. Subsequently the excitability of the
muscles to slowly interrupted galvanic currents becomes increased, so that
very weak currents may excite contractions. This may disappear in five
or six months.

4. The polar reactions become altered in their sequence. The anode
contractions appear before those of the cathode, as shown below :—

Dacatetage tin war A. C. C. instead of C. C. C. as in health.
Do fitter sea en enc Cc. C. C. ec A. CoG.
Boon etdacenuhd dee C. O. C. eh A.O.C. “ af
ara cls dant he A.O. C. is c.0.c. * es

5. The character of the muscular contractions becomes altered. In
health, they are sharp, short, and sudden. When degeneration occurs,
they are slow to appear; they are prolonged and continue even during
the passage of the current; and, finally, they assume the character of
“tetanic” contractions, irrespective of the strength of the current em-
ployed,

Finally, in unilateral paralysis the electrical reactions of the muscles
of the paralyzed side should be contrasted with those of homologous
muscles of the unaffected side. When both sides are impaired, the
standard of comparison should be that of a healthy subject of about the
same size, weight, and muscular development.

Now let us suppose that we suspect disease in, and wish to test the
reaction of some special nerve,—the musculo-spiral, for example. We
190 LECTURES ON NERVOUS DISEASES.

place the positive pole (An) of a galvanic battery over the breast-bone
with a large flat electrode attached, and the negative pole (Ka) over the
nerve (where it winds around the humerus below the deltoid muscle) with
an “interrupting ” small electrode attached to the negative rheophore.
We then put into circuit a few cells at a time and press the button of the
interrupting electrode at intervals till we get a contraction of muscles.
When the current is sufliciently strong to excite the nerve-trunk, con-
traction of the extensor muscles of the forearm becomes apparent (the
cathodal closure contraction). Thus we ascertain the number of cells of
the battery in use, or preferably the number of milliamperes required to
produce C. C. C. (Ka 8. Z. of the Germans). Now add a few more cells,
and reverse the poles by means of the commutator. When the circuit is
broken, by releasing the button of the interrupting electrode, we get the
anodal opening contraction (A. O. C., or An O. Z.), and, with a few more
cells, the anodal closure contraction (A. C. C., or An 8. Z). Again re-
verse the current, and add a few more cells. Now, on pressing the button
of the interrupting electrode, we get a very intense cathodal closure con-
traction (C/’. C’’". C’’", or Ka S. Z’’’.), and, on releasing it, the cathodal
opening contraction (C. O. C.,or Ka O. Z.) is developed, thus completing
the chain of polar nerve reactions. ,

You should bear in mind that the polar nerve-reactions differ in their
normal sequence from those of the muscles when the electrode is placed
over the “motor point” of the muscle tested.

NORMAL NERVE-REACTION,.

C. C0. C.> A. 0. Co> aA. C. CC. 0. C.

NORMAL MUSCLE-REACTION.

C. 0. C2>A. C. C25 A. 0. C0. 0. 6.

The final contraction (C. O. C.) of each of these series is seldom seen,
because the current required to produce it is too painful to be endured.
Fewer cells are required to cause muscular formule than those of a
nerve-trunk,

In recording the results of an electrical examination of nerve-trunks
and muscles it is best to arrange the record-page so that the two sides
of the body may be easily contrasted. The number of galvanic cells em-
ployed or the number of milliamperes of current (as shown by a galva-
nometer) should also be specified, and the faradaic reaction of homologous
nerves or muscles should be stated for the purpose of comparison and for
clinical deduction. We may follow with advantage some such plan as the
following :-—
THE PRINCIPLES OF ELECTRO-DIAGNOSIS, 191

NAME.......... DATE scaaunws AGE,
History or Case. See page .... of Caser-Boox.

 

FARADAIC TESTS.

 

2 | Extent of secondary
Right side. Left side. coil employed, (In| Nerve tested.
centimetres, )

Nerve reactionS..cccasscaceeseces

 

Muscle tested.

 

 

 

{
Muscle reactionS.........--+.56-- |

 

GALVANIC TESTS.

 

 

 

 

 

 

 

 

 

 

Right side. cameron pro- Left side. Mews ar anescle
Cells or miliam- Cells or milliam-
péres, péres.
f cee |

Nerve-reactions..... ayainiaeiaks aaa daese 7 a c a nerve,

Cc. 0. C.

c.c. C.
Muscle-reactions....++-.seseeeeeeee - @ muscle:

iG Oz Gs

 

 

Slips of this character may be printed and kept on hand, They can
be pasted into the case-book of the physician when filled out. The tests.
made at different dates can this be compared with each other and the
progress of each case determined.

 

Fic. 59.—Tue Autuor’s Sprinc Erecrrope.—QJ, the binding-post for attaching the rheophore
which connects it with the battery, or with the diagnostic key-board when that instrument is
employed. The motor point of the electrode is represented as enveloped in chamois-skin.
Jt must be thoroughly dampened in salt-and-water before it is applied to the nerve or muscle
to be tested. ‘I'he other end of the electrode is designed to prevent slipping of the instru-
ment after its proper adjustment. z

For the purpose of demonstrating the special action of individual
muscles and nerves before classes of students, as well as the study of
muscle- and nerve-reactions in disease, I have devised small electrodes
which may be made stationary upon any desired part of the head, limbs,
or trunk, by means of straps, strips of adhesive-plaster, or insulated
springs. By means of these I have been enabled to make many points
clear to a large audience which would be extremely difficult to show by any
192 LECTURES ON NERVOUS DISEASES.

other method. Furthermore, it is often desirable to refer from time to
time during an examination ofa patient to the effects of currents of known
intensity upon certain nerves and muscles for the sake of accurate
comparison,etc. Small electrodes of the type described may be accurately
placed upon a patient and allowed to remain upon the spot selected during
the entire examination. To each of these a separate rheophore may be
attached, and, by a simple device of my own, each may be controlled by
touching a key upon a board, without movement of the operator. I can
thus observe simultaneously the reactions of corresponding muscles or
nerves upon the two sides, those of the leg and arm of the same side; and
any other comparisons which may be required in diagnosis. The “ motor-
points” of the body are not always exactly where charts depict them;
hence it is sometimes necessary to hunt for them within a radius of an
inch or two of the normal point. When they are found with exactness,
a small electrode may be fastened over the spot (with moistened ab-
sorbent cotton beneath it) and allowed to remain stationary during the

 

Fic. 60.—THe AutHor’s DiaGnostic Kry-soarv.—A, the rheophore which connects it with
one of the binding-posts of a galvanic battery; B, rheophores connecting its binding-posts
with spring electrodes previously placed upon the body of the patient so as to influence the
“nerves or muscles to be tested; C, buttons and springs which make a circuit to the body of
the patient when the knob on the spring is pressed downward so as to impinge upon the
button. The number of rheophores which may be employed depends upon the necessities
of the case; the cut shows an instrument capable of six.

entire sitting. Whenever it becomes necessary to refer to the reactions
of that point, it can be called into action by touching the key connected
with it by its individual rheophore. The cuts introduced show the ar-
rangement of my device for this purpose. I have given a more com-
plete description of the advantages of this method over others previously
employed, in the New York dMledical Journal of May 9, 1885.

Now, from such a table of record it is apparent that the faradaic
current should first be employed upon the patient (the poles of the sec-
ondary coil being used), The extent of the overlap of this coil (in centi-
metres) necessary to produce muscular contractions when the nerve- and
muscle-reactions are being separately tested should be recorded. In case
no muscular contractions ensue, the extent of the overlap which produces
THE PRINCIPLES OF ELECTRO-DIAGNOSIS. 193

an unbearably painful current should be ascertained and noted. This
may be compared with that necessary to produce contractions upon the
healthy side.

The next step in the examination consists in changing the rheophores
to the binding-posts of a galvanic battery. We can now ascertain the
number of cells or milliamperes (which is preferable) required to produce
the different varieties of contractions (enumerated in the table designed
for record) of muscles in homologous regions of the right and left sides.
Each nerve which is impaired should be tested first; and the muscles

 

ma

err i

Kis ! iy

cg

 

Fic. 61.—Tue AutHor’s Diacnosric Key-soarp aS APpirep in AcTUAL Use.—The spring
electrodes are represented in the cut (for the purpose of illustration) as applied to the facial,
ulnar, and musculo-spiral nerves of each side. Jf he so chooses, the operator can have his
case-book on a stand at his right, for recording his observations as they are made.

supplied by it should be tested afterward. The strength of the current
employed should be ascertained by throwing a galvanometer into the
circuit (when extreme accuracy is desired); by so doing, a comparison
of the nerve- and muscle-reactions of the two sides can be based upon
conditions which are exactly alike.

When we have completed the steps indicated by the chart prepared
for the assistance of the practitioner (page 191) we are in possession of
certain facts which may be of great practical value as regards both diag-
nosis and prognosis :—

18

 
194 LECTURES ON NERVOUS DISEASES.

1. Suppose a case of localized paralysis is examined, and the fara-
daic and galvanic reactions of both a nerve and its muscles are normal
and exactly alike on the two sides. We have reason then to believe that
the exciting cause is either hysteria, a lesion of a higher spinal segment
than that from which the nerve arises, or a lesion within the brain, pro-
vided the possibility of deception on the part of the patient respecting
his paralytic condition can be excluded.

2. If the nerve-reactions of the affected side to both currents are
exaggerated (i.¢., if the contractions occur in their proper sequence, but
under a weaker current than in health), the probability of an existing cen-
tral lesion is heightened, although hysteria may possibly still exist as the
exciting cause of the paralysis.

3. If the faradaic current applied Hinoaglh the nerve fails to pro-
duce contractions of the affected muscles as readily as upon the healthy
side (¢.¢., ifa stronger current is demanded to call any one of the para-
lyzed muscles into action indirectly through the nerve which supplies it,)
then we know that the nerve filaments within the spinal cord or those of
the trunk of the nerve itself are atiected by a lesion which has impaired
but not entirely destroyed their usefulness.

4. If no current from a faradaic machine (which can be endured by
the patient) causes muscular contractions, we know positively that the
motor cells of the anterior horns of that spinal segment which controls
the paralyzed muscles are impaired, or that the nerve itself has been sev-
ered from its connection with the spinal cord, or is undergoing degen-
eration.

5. When the MUSCLE-REACTIONS to the faradaic current have been
tested, the previous deductions (based on the nerve reactions) still hold
good. The electrode should, however, be placed over the “motor point”
' of each muscle thus tested. These are shown in plates at the end of this
volume.

6. If the formule obtained by the galvanic current are normal, all
questions regarding the existence of degenerative changes in the nerve-
or the muscle-plates can be excluded. When the normal order ts altered,
degenerative changes in the nerve- or the motor-cells of the spinal cord
are present.

7. The history of a case in which motility 7s impaired is never
complete without a record of an electrical examination of the nerve- and
muscle-reactions to hoth the faradaic and galvanic current. When doubt
exists respecting the existence of a ccrebral lesion or hysteria, the facts
obtained by other methods of examination (fully described by me in the
preceding pages) will clear up all doubts.

8. Patients afflicted with paralysis from a cerebral lesion generally
exhibit normal electro-nerve and electro-muscular reactions in the para-
lyzed parts, In some instances the reactions may even be exaggerated.
DETECTION OF FEIGNED DISEASES. 195

9. Hysterical patients afflicted with paralysis may exhibit either
normal or exaggerated electro-muscular reactions to faradism or gal-
vanism. The sensitiveness of the muscles to faradism is generally de-
ercased ; in some cases it may be totally wanting (Duchenne).

10. In rheumatic paralysis the electro-muscular contractility is, as
a rule, markedly increased; this may be shown by a comparison of the
reactions of the two sides of the body. In exceptional cases this is not
found to be so,as I have seen the reactions follow only the strongest
currents.

ll. In pertpheral paralysis the faradaic and galvanic reactions are
altered after ten days have elapsed. The muscular contractility to the
faradaic current is lost early to a greater or less extent; and the formula
of degenerative changes is developed later by the employment of the
galvanic current.

12. <A decreased musculo-excitability to the faradaic current in the
musculo-spiral nerve and the extensor muscles of the forearm on both
sides—the flexors being normal and the lower extremities being unaffected
—tells us of the approach of lead-poisoning before the actual symptoms
are well marked.

13. In progressive muscular atrophy a response to the faradaic
current can be obtained as long as any fibres in the muscle tested remain
free from fatty metamorphosis.

14. No alterations in the electro-contractility of muscles is observed
in any of the diseases confined to the posterior part of the spinal cord.

DETECTION OF FEIGNED DISEASES.

In addition to the uses of electricity for the purpose of determining
the presence or absence of nerve- and muscle-degeneration, and the dis-
crimination between cerebral and spinal paralysis and the various types
of peripheral palsies, some other useful purposes in diagnosis have been
published from time to time.

It is stated that muscular contractions produced by the faradaic
current cannot be maintained over four hours in a dead subject.

Malingerers are not uncommon among the applicants for charitable
aid, and they are occasionally encountered among the higher walks of
life. Epilepsy and paralysis are the most common diseases which are
feigned.

Feigned epilepsy can be distinguished by the application of a strong
faradaic current to the forehead or tibia by means of a wire brush. The
intense pain so produced will not be appreciated by a true epileptic, but
will bring the fit to a sudden close, if assumed in order to create sym-
pathy or aid.

Feigned motor paralysis is usually exhibited in some of the vari
196 LECTURES ON NERVOUS DISEASES.

ous forms of peripheral paralysis. Few malingerers know enough to
simulate hemiplegia or paraplegia without detection. If two weeks have
elapsed since the attack, the presence of normal electrical reactions of
nerve and muscle in the affected limb is strong ground for suspicion,
provided a history of some cerebral lesion or of hysteria cannot be
elicited. There are various other tests which a skilled anatomist can
employ in each case that will help to clear up all doubts upon this
subject.

Feigned anesthesia may be told by the use of the faradaic current
with the wire brush attached to the negative rheophore. The opposed
limbs will quickly show how much actual anesthesia exists.

DETECTION OF BULLETS OR BURIED METAL.

An ingenious application of electricity to surgery has been made
which has utility in diagnosis.

The so-called “ electric probe” consists of two wires which are per-
fectly insulated from each other by rubber or ivory. These wires ter-
minate in metal tips which project slightly beyond the insulating medium,
and at the other end of the wires a galvanic cell and an electro-magnet
- acting upon a bell are attached. When the probe is pushed into the
tract made by a metallic missile, and the tips are brought into contact
with it, the circuit is completed and the bell rings. The animal tissues
are not sufficiently good conductors of electricity to form a circuit;
hence the bell will not ring until the metal is touched by the tips of the
probe. ,

Recent experimentation with the so-called “induction balance” goes
to prove this instrument of great value in some cases where buried metal
is suspected to exist beyond the reach of a probe.

ELECTRO-DIAGNOSIS OF AURAL DISEASES.

We owe to Brenner, of St. Petersburg, the first suggestion of this
use for electric currents in diagnosis. From a somewhat limited expe-
rience in its use, I am led to believe that its utility cannot longer be called
into question. Brenner’s formula seems, furthermore, to be in accord
with all that has been proved in respect to nerve-trunks in health, in all
parts of the body. The formula is simply that of the galvanic reaction
of the auditory nerve in health.

1. In place of the C. C. C. observed in muscle, we get, when a gal-
vanic current is sent through the auditory nerve, a ringing noise when
the cathodal closure oceurs. (C. C. 8.)

- 2. The cathodal opening produces no effect.

3. The anodal opening produces a ringing noise when a current of

high intensity is employed,
ELECTRICAL TESTS OF THE SPECIAL SENSES. 197

4, After the cathodal closure (cathodal duration—C. D.), the ring-
ing noise produced at the closure gradually diminishes.

The formula which is indicative of health when a pole is connected
with each ear may be expressed in symbols, as follows :—

Rieut Ear (Anode). Lert Ear (Cathode).

C. (closure) ......00 wee eee eee 8. (loud)
O. (opening) ...... S.(Qweak) s,s
Di (QUvaOn) ecw agiegadercay 5.55

Now, it is maintained by Brenner that any deviation from the normal
reactions of the auditory nerve (shown in the preceding formula) indicates
disease of the acoustic mechanism. The variations produced by the dif
ferent diseased conditions encountered cannot be given here from want
‘of space.

In applying galvanic currents to the ear, it is best to place a medium-
sized electrode over the entire tragus or to fill the external auditory canal
of the ear to be tested with tepid water containing a little salt, aud then
to introduce an electrode of metal inclosed in an aural speculum of hard
rubber into the ear until the metal touches the water. Tf each ear is to
be tested separately, the other electrode should be placed at an indif
ferent-point, preferably the mastoid region of the same side or the middle
of the sternum.

Regarding this test, it is well to state that repeated sittings are often
necessary. The patient has to become accustomed to the disagreeable
effects of the current. It is desirable that you begin with very weak
currents and increase the strength very gradually. As the reaction of
’. cathodal closure (C. C.) is the most important, it can be intensified by
previously allowing cathodal duration (C. D.) to act, or by rapidly fol-
ing C. C. by A. O.

EXAMINATION OF THE EYE, NOSE, AND MOUTH BY ELECTRICITY.

Special effects are produced upon the organs of sight, smell, and
taste by electric currents. Sparks or vivid flashes of light follow electric
stimulation of the eye; and subjective odors and tastes are also produced
when the olfactory and gustatory nerves are excited by this agent. The
“polar method” of examination is employed when any of the special
senses are thus tested. I would caution the reader against employing
too strong currents about any of the organs of special sense. The ex-
amination of the optic, olfactory, and gustatory nerves requires expe-
rience and should not be attempted by novices.

When examining the reactions of the eye, the small electrode is
placed upon the closed eyelid, temple or forehead.. The large electrode
is placed upon the back of the neck. The room should be darkened and
the patient.should. keep both eyes closed.
198 LECTURES ON NERVOUS DISEASES.

When testing the sense of taste, the poles should be in contact with
the cheeks, and the sensations of taste experienced upon both sides by
the patient should be ascertained. A fine electrode can also be placed
upon the tongue, the pharynx, or the inside of the cheek, in case local.
ized polar reactions are to be determined. A double electrode, with two
metal tips which are not in contact, may be employed for this purpose
(Neumann).

ELECTRICAL EXAMINATION OF THE SENSIBILITY OF THE SKIN,

The electrode devised by Erb is, to my mind, the best for this pur-
pose. It consists of four hundred varnished wires in a tube of hard
rubber. The ends of these wires make a perfectly smooth surface. This
electrode is connected with the secondary coil of a faradaic machine and

 

Fic. 62.—Erp’s Evectrope ror THE EXAMINATION OF FARADO-CUTANEOUS SENSIBILITY.—
a, A hard-rubber tube ; 4, the free surface of the electrode.

is then pressed upon the area of the body to be tested—the other pole
being at the sternum. The minimum of the overlap of the secondary
coil which can be felt, and the maximum which can be endured, are both
recorded. Homologous parts of cach side should be compared with each
other.

Regarding this test Erb wisely remarks: “The skin, regarded as a
sensory organ, cannot be tested with irritants other than those adequate
to it,—viz., touch, pressure, various temperatures, and the higher grades
of those irritants which produce pain. It may be disputed whether elec-
tricity should be included among these ‘adequate’ irritants of the skin.
The electric sensation is a specific, distinct, quality of tegumentary sen-

sibility, whose careful examination, however, is of value in many morbid
conditions.”
TESTS OF THE SENSORY NERVES. 199

TESTS TO DETERMINE THE CONDITION OF THE SENSORY NERVES.

Before completing a diagnosis of some forms of nervous disease, it
is necessary to investigate the following functions: 1, The condition of
the sensory nerves of the skin in respect to the sense of touch; 2, the
appreciation by these nerves of varying degrees of tempcrature; 3, the
appreciation by the patient of painful impressions transmitted to the
brain by the nerves; and 4, the condition of the special senses of sight,
smell, hearing, and taste.

TESTS FOR TACTILE SENSIBILITY.

In this series of tests, as also in those employed to detect abnor-
malities of appreciation of different degrees of temperature, the following
precautions must be taken against error in the results obtained :—

1. The nature of the tests to be employed must be clearly explained
to the patient, as well as the importance of accuracy in his decision re-
specting the sensations perceived. This insures his intelligent codpera-
tion, and makes the patient more earnest in his endeavors to answer
correctly. ,

 

Fic, 63,—Brarpv’s PresMETER,—This instrument consists of a’spring in a tube that resists press-
ure made upon the piston. A scale indicates the amount of pressure upon the spring. It
is employed to determine the degree of sensitiveness to pressure in different parts of the
body The forehead, tongue, and cheek are the most sensitive to pressure; the least so are
the backs of the thighs and legs.

2. Itis preferable that the patient be blindfolded, in order to avoid
any information respecting the tests used reaching him by sight.

3: To make the patient keenly alert to avoid errors of statement, it
is well to employ blank experiments from time to time. Thus, when the
skin has not been touched with any instrument or foreign substance, it
is well to ask “where the object is now felt,” “how many points are now
in contact with the skin,” ete.

Having explained the objects of the tests about to be employed and
then blindfolded the patient, the tactile sensibility of the skin should be
first determined by the following methods :—

(1) Consciousness of simple contact impressions. When the skin
is brushed by a hair or a fine feather, notice, first, if the patient perceives
the contact immediately, and, secondly, if he can describe the sensation
correctly.

(2) The ability to locate contact impressions. With tests of de-
creasing delicacy (the touch of a hair being the most delicate, and painful
impressions the least so), notice to what extent the patient is able to
200 LECTURES ON NERVOUS DISEASES.

correctly designate the point of contact of the body employed with the
skin of different localities.

(3) The degree of sensibility of different regions. This has to be
investigated with great care in some cases. Several methods are em-
ployed to determine it with accuracy. These are as follows :—

(a) Objects of different shapes may be laid upon the skin and the
patient requested to describe their form and character. Coins, keys, and
weights may be employed for this purpose, as they are always to be had.
This test should be used over many parts of the body, and the results
obtained compared with those of similar experiments made by the phy-
sician upon himself or some healthy person.

wit epi Ne ag

     
 

 

Tyee tpi tyne yt!

—>.
Orie mot

 

©

Fre, 64.—Hammonp’s AEsTHESIOMETER.— When closed it can be conveniently carried in the pocket.

(b) The appreciation of pressure, as suggested by Weber, may be
tested by placing weights of varying sizes upon the skin of some part,
that has previously been supported in order to avoid the so-called “ mus-
cular sense” being a factor in the patient’s decision. Dr. Beard has de-
vised an instrument for this test that answers all purposes very well.

(ec) Again, the various forms of esthesiometers are used to detect
the minimum distance which can exist between two points of simple
contact with the skin without destroying the distinct perception of both
points by the patient. This distance varies in health between extremely
wide limits, because some regions are abundantly supplied with sensory
TESTS FOR TACTILE SENSIBILITY. 201

nerves and tactile corpuscles, while others are not. For this reason, the
following measures* can be used as the healthy standard for comparison
in any given case. They are given in inches, lines, and millimetres so
as to meet the requirements of any scale:—

1. Pointof tongue ...... gyinch = $line = llm
2. Palmar surface of finger tips. py “ = 1“ = 22 %
3. Mucous surface of ips. ... § “ = 2lins= 42 *
4. Palm of hand and tip of nose. }$ “ = 3 “ = 63 “
5. White partof lips ..... 3% = 4 “ = 84 *
6. Lower part of forehead ... 8 “ =10 “ =211 *
7. Backofhand ....... 18 “ =14 “ =202 *
8. Dorsumof foot. ...... 1) * =18 " = 375 *
9. Forearm. ......... 18% =19 “ =396 «
10) (Stemant ¢a 2a Goaweee de s2b ety
ll. Middle of thigh ...... 2hinches=30 “ =62.5 “
V2 Baths ogee ead eee 2E- 8h e660. *

 

Fic. 63.—Carroi’s AisTHESIOMETER —The instrument has two points upon each leg of the
compass, one blunt and the other sharp. It is a convenient instrument to determine the con-
dition of the sensory nerves in respect to contact sensations and those of pain. This is ac-
complished by simply substituting the blunt for the sharp points, of vice versa.

Various forms of esthesiometers have been devised, but a simple
pair of compasses, such as are used by artists, will answer all purposes.

 

Fig. 66.—Srevexine’s Aistuestomrter.—A modification of the ordinary beam compass ems
ployed vy carpenters, but graded in inches and tenths of an inch. Its points are not sharp.
The distance between the points can be ascertained by a rule graded in
inches, lines, or millimétres. The points should not be sharp, as they will
cause pain if so, and thus defeat the object of this test.

* More complete tables than the one offered may be found in many of the later works
on physiology and nervous diseases,
202 LECTURES ON NERVOUS DISEASES.

The suggestions previously made respecting the definite instructions
to the patient, the use of blank experiments, and the employment of a
bandage over the patient’s eyes, apply to this test as well as to those pre-
viously described.

The following rules must be observed in case the xsthesiometer is
to be used :—

1. The two points of the instrument must be made to touch the skin
simultaneously; otherwise the patient will detect the two points of con-
tact more readily than if both meet the skin at the same moment,

2. The contact should be a gentle one; otherwise the impression
upon the skin becomes a painful sensation.

3. The relative position of the two points should always bear the
same relation to the axts of the limb or median line of the body, because
the sensibility of a part is affected differently when the points are directed
transversely or longitudinally. This is essential to the accurate com-
parison of the sensibility of different regions of the body, or of corre-
sponding regions of either side.

4. The table which has been previously given should be employed
asa standard of comparison only when the sensory functions of the skin
are impaired upon both sides. When the derangement is one-sided, the
healthy side will be the satest guide for comparison.

ABNORMAL CONDITIONS OF SENSATION.

We are now prepared to consider the significance of the disorders
of cutaneous sensibility, viz., anesthesia or loss of sensibility; hyper-
zesthesia, or increased sensibility; the existence of pain; and the lack of
appreciation of varying degrees of temperature.

ANZSTHESIA.—Certain regions of the body may be deprived of
cutaneous sensibility (either totally or partially) (1) by diseased con-
ditions of the brain or spinal cord, and (2) by any abnormal state of the
nerves themselves that tends to impair or destroy their ability to conduct
sensations to the nerve centres.

In the latter case, the loss of sensation is liable to be associated
with an impairment also of motion, because the cerebro-spinal nerves are
composed, as a rule, of both motor and sensory fibres. The fact that
sympathetic nerve fibres are also present in the majority of nerves, helps
us to explain certain disorders in the nutrition of the skin that some-
times accompany motor or sensory paralysis dependent on injury or de-
struction of some individual nerve.

The regions of the spinal cord and brain that are functionally asso-
ciated with sensation, have been already touched upon in Section lL. It
may be stated in a general way that the nerve fibres that conduct sensory
impressions from the peripheral parts of the body to the brain travel
ABNORMAL CONDITIONS OF SENSATION. 2903

chiefly through the posterior columns of the spinal cord and tts gray matter
in order to reach the brain—the seat of intelligent perception of such
sensations. Within the substance of the brain itself, these fibres pass
through the outer part of the formatio reticularis and the posterior part
of the so-called “internal capsule” of that organ. We are justified, I
think, in drawing the following clinical deductions as regards the exist-
ence of cutaneous anesthesia :—

1. Lesions of the cerebral hemispheres produce anesthesia when
they involve the posterior one-third of the internal capsule.

If the sensory cranial nerves are affected by such a lesion, the loss
of sensation is commonly on the same side as the lesion, except in case
of the optic nerve (the condition known as hemianopsia). The anzs-
thesia of parts below the head, if due to cerebral causes, is confined to
the side opposite to the hemisphere in which the lesion exists.

2. Anzesthesia from lesions of one lateral half of the substance of
the spinal cord exists, as a rule, on the side opposite to the spinal
lesion.

3. Lesions which involve both lateral halves of the spinal cord
create anesthesia on both sides of the body, provided the destructive
process affects the so-called “sensory tract” of the cord, viz., the pos-
terior columns, or the gray matter around its central canal.

4. Anzsthesia may exist on the same side as a spinal lesion, pro-
vided the posterior roots of the spinal nerves be pressed upon or de-
stroyed by it, or in case the sensory nerves be affected by the spinal
lesion before they cross to the opposite side of the cord.

5. Anesthesia, unlike motor paralysis, is not necessarily present in
parts of the body supplied by those nerves that are given off from the
cord below the seat of the lesion. Anesthesia is often associated with a

_ condition of increased sensibility or “hypersesthesia” of parts below the
seat of the spinal lesion, and on the side opposite to it.

6. Anzesthesia may often co-exist with other sensory symptoms,
such as pain, incodrdination of movement, the peculiar sensation known
as “formication,” numbness, tingling, and other subjective sensations.

7. Anesthesia of spinal origin is generally bilateral and symmet-
rical, because lesions of the cord commonly affect both lateral halves.

8 Tactile sensibility may be destroyed by spinal lesions, and yet
the sensibility to pain and temperature may occasionally be retained.

9. Unilateral anesthesia of the face and of the opposed arm and
leg indicates a unilateral lesion of the formatio reticularis.

In rare cases, sensibility to temperature may be lost, and the sensi-
bility to pain and touch may be normal. It is not extremely infrequent
for the neurologist to record an absence of sensibility to pain, when
tactile sensibility remains unaffected, and accurate perceptions of tem-
204 LECTURES ON NERVOUS. DISEASES.

perature are still experienced by the patient. These subjects can detect
a needle thrust into the muscles from a simple sensation of touch. These
clinical facts seem to confirm the view that has been advanced by late
physiologists,* viz., that the paths of conduction of sensations of touch,
pain, and temperature probably lie in different parts of the spinal cord.

Hyrenastures1a.—The skin may be rendered extremely sensitive in
certain diseased conditions. This abnormal state of the nerves is termed
“hyperesthesia” in contradistinction to ‘“‘anmwsthesia” or a loss of sen-
sation.

When the “sensory tracts” of the spinal cord are involved by a
localized lesion, the parts below the regions that are rendered anesthetic
by the cutting of the sensory nerves are sometimes affected with hyper-
zsthesia. The cause of this is not yet definitely known.

A narrow band of hyperesthesia is also developed, as a rule, at the
upper level of the spinal lesion. If in the dorsal region, this zone of
hypereesthesia generally encircles the body. When in the lambar region,
it is more or less vertical over the limbs in accordance with the particular
spinal segment which happens to be affected.

Hyperesthesia probably indicates, according to our present knowl.
edge, some irritation of the nerve fibres distributed to the regions so
affected. The cut introduced is admirably adapted to illustrate the
effects of a one-sided spinal lesion upon the sensory functions of the skin.

In the disease known as locomotor ataxia, after a paroxysm of
“stabbing pains” has subsided, the seat of previous pain becomes
markedly sensitive to the touch, while the rest of the body is not simi-
larly affected.

Hyperesthesia may be of service in diagnosis. It may afford valu-

able information respecting the spinal segments that are irvztated by some

destructive process within adjacent regions of the spinal cord. Again,

*The lateral columns (Fig. 84) and the posterior columns are probably concerned
(as well as the gray substance of the cord in the region of its central canal) in the trans-
mission of sensory impressions to the brain.

Woroschiloff, Ludwig, and Ott have apparently demonstrated by careful and appar-
ently conclusive experiments that, in the lower animals, the lateral columns in the dorsal
region ‘of the spinal cord are physiologically associated with the transmission of sensations
from the legs. Whether this is true of man is not yet determined, although Gower’s re-
ported case of a crushed cord in man gave evidence of ascending degeneration, both in
the postero-internal columns (Goll’s columns) and also in the lateral columns in front of
the ‘‘ crossed pyramidal tract” (Fig. 29), Unfortunately, this case stands alone as yet.

This view is directly opposed to the older one that has been generally accepted by
standard authors, viz., that sensations of pain travel along the gray matter of the cord,
and those of touch, and perhaps of temperature, pass up the posterior columns of the
spinal cord.

The late researches of Starr seem to prove that impressions of muscular sense from
the upper limbs are transmitted by Burdach’s column, and from the lower limbs by Goll’s
column of the corresponding side of the cord,
 

ABNORMAL CONDITIONS OF SENSATION. 205

if limited to the area of distribution of some individual nerve, it may
point most suggestively toward the existence of some local cause of irri-
tation of that nerve itself. Finally, Valleix has pointed out the situation
of certain regions in the course of the more important nerves of the
hody where extreme sensitiveness to pressure or touch exists in con-

 

Fic. 67.—D1aGRamMaTiIc REPRESENTATION OF THE SKIN SYMPTOMS IN UNILATERAL LESION
OF THE Dorsat Portion OF THE SrrnaL Corp on THE Lert Sipr. (After Erb.) The
diagonal shading (a) signifies motor and vaso-motor paralysis; the vertical shading (¢@ and

o signifies anesthesia of the skin; the dotted shading (c) indicates the hyperzsthesia of
the skin.

nection with neuralgic attacks. These are known as the “puncta dolo

rosa.” They have been separately described by the author in his work

entitled “The Applied Anatomy of the Nervous System.”
Hyperesthesia may be functional or organic. If functional, it is

often due to some form of general spinal irritation; if organic, it is com-
206 LECTURES ON NERVOUS DISEASES.

monly associated with more or less anesthesia. We meet the organic
variety chiefly in connection with spinal meningitis, compressa of the
sensory nerve roots, and locomotor ataxia.

DELAYED SENSATION.—To the beginner in medicine as well as to the
laity, nothing strikes the intelligence so forcibly as this symptom when
well marked. Imagine a patient stuck with a pin, when unaware of its
occurrence, and an interval of time (varying from one to thirty seconds)
to elapse without any consciousness of the wound. Imagine the patient
then suddenly becoming conscious of the injury with all the evidences
of pain that should have occurred without any perceptible interval of
time in a healthy subject. This is delayed sensation. It occurs chiefly
in connection with the disease known as “locomotor ataxia.”

This symptom is to be interpreted as an evidence of imperfect con-
duction of sensation to the brain by means of the sensory nerves and the
so-called ‘sensory tracts” of the spinal cord. The sensation is not ar-
rested “in toto;” it is simply delayed. Complete abolition of sensation
or “anesthesia” is liable to be developed later—when the nerves or sen-
sory tracts are so extensively involved as to be no longer able to perform
the functions.

SENSIBILITY TO TEMPERATURE.

In testing this variety of sensibility, the precautionary steps pre-
viously mentioned in connection with sensory disturbances must be
carefully observed.

Test-tubes holding water of different degrees of temperature are then
applied to the different regions of the body which have given previous
evidences of sensory disturbances, and the patieut’s ability to discrimi-
nate between them with accuracy should be noted. The temperature of
the test-tubes should be greater or less than that of the skin (983°) and
of a uniform size. This prevents the confusion of simple “tactile” sen-
sations with those of temperature. Breathing upon the surface of the
patient answers as a rough test for the appreciation of heat.

SENSIBILITY TO PAIN.

The tests for this variety of sensibility comprise (1) pinching or
pricking of the skin; (2) the application of extreme heat to the skin;
and (3) the use of a powerful faradaic current upon the skin with dry
electrodes. The patient should never be prepared for this test,as he may
fail to give external evidences of pain from an assumed fortitude. Sen-
sitiveness to pain and temperature may sometimes be affected when
tactile sensations are not impaired.
THE SPECIAL SENSES. 207

THE SPECIAL SENSES.

These comprise smell, sight, hearing, taste, and touch, The latter
has already been discussed, and the tests employed to detect abnormalities
of the eve or its muscles have been quite fully described.

SmeLLt.—The abolition of smell, or “anosmia,” is to be detected Wy
the following methods: (1) Use the same test upon the nostrils alter-
nately; (2) avoid all irritating substances, such as ammonia, acetic acid,
snuff, etc.; (8) employ both agreeable and disagreeable odors (cologne,
camphor, musk, etc.,on the one hand, and valerian, turpentine, asafcetida,
sulphuretted hydrogen, etc., on the other); (4) employ odoriferous sub-

R e

   

Fic. 68.—A Diacram DeEsiGNepD BY THE AUTHOR TO SHOW -SOME OF THE RELATIONS OF
THE Optic AND OLeacrory Nerve Fisres ro SurrounpinG Parts, F, Frontal lobes
of cerebrum; P, parietal lobe; ‘I’, temporo sphenoidal lobe; 5, fissure of Sylvius; R,
fissure of Kolando; O, occipital lobe; C, cerebellum; M, ‘medulla oblongata; 1, corpora
quadrigemina; 2, optic tracts; 3, optic chiasm; 4, optic nerves; 5, olfactory nerve; 6,
motor-oculi nerve; 7,trigeminus nerve ; @, basis cruris ; 6,tegmentum cruris. ‘The diamonds
in the occipital lobe represent the cortical visual centres of Munk, ‘he cerebellum and
‘pons Varolii are shown as if separated from the cerebrum, in order to make the relations of
the crus to the optic tracts apparent.

stances on the tongue (coffee, wines, cheese, etc.), so that the nose may
perceive them by means of the throat, rather as imaginary taste percep-
tions than as true olfactory impressions.

The abnormal acuteness of smell, or ‘“hyperosmia,” may indicate
brain disease that creates irritation of the olfactory nerve. Nauseating
208 LECTURES ON NERVOUS DISEASES.

odors to the healthy subject may become agreeable to such patients.
Pleasant odors, such as those of flowers, may cause nausea, headache, or
possibly convulsions.

Anosnvia has been observed to accompany a congenital defect in the
olfactory nerve, Bell’s paralysis, tumors at the base of the brain, absence
of the pituitary body, syphilitic disease of the nose, hysteria, insanity,
paralysis of the fifth cranial nerve, meningitis, typhoid fever, injuries to
the nose or skull, and nasal catarrh.

Hyperosmia is commonly met with during convalescence from some
exhausting disease, and in connection with hysteria, insanity, meningitis,
tumors of the frontal lobes, softening of the brain, epilepsy, and adhesions
of the olfactory bulbs to the dura mater.

Siaur.—In connection with vision, in addition to errors of refraction
and accommodation, and the condition known as “ ocular insufficiency ”
(which have been already discussed at some length), the neurologist is
chiefly called upon to detect the following conditions: (1) Paralysis of the
eye muscles; (2) the Robertson pupil; (3) the condition known as “ hemi-
anopsia,” or, less correctly, “‘hemiopia;” (4) the condition of the retina
known as “choked disk;” (5) the conditions known as “amblyopia” and
“amaurosis.”

Paralysis of the Eye JMuscles.—The attitudes assumed by the
patient as a result of defective power in some of its muscles have been
discussed in the second portion of this chapter.

Hemianopsia.—This condition is characterized by a blindness of one
lateral half of each eye; the unaffected half of each eye retains its power
of sight. The forms of this condition that are observed, and the tests
employed to detect it, have been referred to already.

Choked disk.—This condition is also known as “neuro-retinitis,”
because the optic nerve and retina both participate in the changes that
ensue. It has been discussed already (page 150).

Robertson’s Pupil—This condition is characterized by extremely
small pupils that contract for the focusing of vision upon near objects
(within a radius of twenty feet), but do not respond to varying degrees
of light. The tests employed to determine this point have been pre-
viously mentioned in the second section of this chapter.

Amblyopia and Amaurosis.—These terms are commonly used to
cover all the various conditions of blindness where no organic changes
in the cye itself can be seen to account for them. The term “amblyopia”
is frequently used to denote a mild degree of “amaurosis.”

The more common causes of these two conditions comprise (1)
poisons, such as lead, tobacco, and urea; (2) exposure to a prolonged
glare, 1s in snow-blindness; (3) concussion of the eye; (4) irritation of
the fifth cranial nerve, as in severe neuralgia; (5) certain brain diseases.
THE SPECIAL SENSES. 209

The latter are of special interest in this connection. Several diagrams
incorporated in this work may prove of aid in explaining certain ana-
tomical points that bear directly upon the subject.

The following diagram (Fig. 69) shows that the optic nerve fibres
eventually pass to those regions of the gray matter on the surface of the
brain (the cerebral cortex) that are associated with the intelligent percep-
tion of the images focused upon the retina. But-it will be also observed that
the optic nerve fibres (a and 5) first pass through certain collections of
gray matter or “centres”? within the optic thalami and the corpora quad-
rigemina before they radiate to the so-called ‘visual area” of the con-
yolutions,

Let us now compare this diagram with another (Fig. 21), which will
make some of these statements more intelligible to the general reader.

VISUAL vei \

 
     

MEDULLA.

Fic. 69.—A DiaGram DESIGNED BY THE AUTHOR TO SHOW THE GENERAL COUKSE OF
Fisres IN THE ‘SENSORY’? AND “ Moron TRACTS’’ AND THEIR RELATION TO CERTAIN
Fascicuti OF THE Optic Nerve Tracts, (Modified from Seguin.) 5, Sensory tract in
posterior region of mesocephalon, extending to O and T, occipital and temporal lobes of
‘hemispheres: M, motor tract in basis cruris, extending to P and F, parietal and (part of)
frontal lobes of hemispheres; C Q, corpus quadrigeminum; O T, optic thalamus; N L,
nucleus lenticularis ; N C, nucleus caudatus; 1, the fibres forming the ‘tegmentum cruris’’
(Meynert); 2, the fibres forming the ‘basis cruris'’ (Meynert); @, fibres of the optic nerve
which become associated with the ‘‘ optic centre’ in the optic thalamus, and are subsequently
prolonged to the ‘visual area’ of the convolutions of the cerebrum ; 4, optic fibres which
join the cells of the “ corpora quadrigemina,”’ and are then prolonged to the visual area of the
‘cerebral cortex.

It will help to explain why it is that pressure upon the optic tracts, as
they are called, causes hemianopsia or blindness of one lateral balf of
each retina.

Tasre.—This special sense is presided over by the gustatory branch
of the fifth cranial nerve, the glosso-pharyngeal nerve, and the cherda
tympani branch of the facial nerve. Taste may be affected, therefore, by
any diseased condition that can cause either irritation or destruction of

14
210 LECTURES ON NERVOUS DISEASES,

the fibres of these nerves. Certain functional diseases, in contradis-
tinction to organic lesions of the brain, may also cause modifications of
taste.

An abnormal sensitiveness of taste is known as “hyperquesia.” It
may be developed in connection with hysteria; with melancholia and
some other types of insanity; and with facial paralysis of rheumatic
origin. Such subjects can often detect extremely small quantities of
sapid substances in solution, which in health would be unperceived.
They may perceive gustatory sensations when the electric current is
applied over the spine in the region of the neck or upper dorsal verte-
Inve. They may develop a loathing of certain dishes which have pre-
viously been their delight, from some imaginary taste of a disagreeable
character. Again, this condition may express itself in an unnatural
enjoyment of food. Finally, sweetish, sapid, or sour tastes within the
mouth may be constantly present.

A loss of the sense of taste is known as “aguesia.” It may be com-
plete or partial. Some regions of the tongue may be affected, and others
‘retain the sense of taste. In some instances, the tongue may be sensible
to certain substances, and insensible to others. -It may be associated

 

Fic. 70 —SEGUIN’s SURFACE THERMOMETER.

with a sense of burning and bitterness within the mouth, as in a case
reported by Béttcher, where a tumor at the base of the brain was its
exciting cause,

This abnormal state has, been observed to follow the development of
tumors of the brain or its coverings; paralysis of the fifth cranial nerve;
sclerosis of the medulla oblongata; injuries to the glosso-pharyngeal
nerves; atrophy of the nerves associated with taste; and ear disease
causing pressure upon the chorda tympani branch of the facial nerve.

Hearinc.—The mechanism of the ear is so complicated that defects
in hearing are commonly due to some abnormal condition of the ap-
paratus itself, rather than of the nerve of hearing or the brain. Perhaps
the most reliable test to determine the presence of the latter condition is
the employment of the tuning-fork. If this instrument be set in vibration
and applied to the teeth, or the bones of the skull, the transmission of
the sound-waves through the bones will enable them to reach the nerve
filaments of the internal ear, and afford the patient perceptions of sound.
If the patient is unable to perecive sound when thus conducted to the
verve filaments, it is strongly suggestive of some diseased condition
within the eavity of the skull.
CEREBRAL THERMOMETRY. 211

CEREBRAL THERMOMETRY.

Within a few years much attention has been given to the temperature
of limited portions of the skull in health and disease (Broca, Hammond,
Seguin, Amidon, Gray, and others). Many forms of instruments may be
employed for this purpose. Probably the simplest and least expensive is
the surface thermometer devised by Seguin, which has « large flattened
bulb well adapted to insure close contact with the scalp. Any number
of such thermometers may be fastened to a shaven scalp by means of per-
forated straps (Gray) or an India-rubber cap similarly perforated. The
effect of the temperature of the air upon the mercury may be avoided
by coating the parts not in contact with the scalp with shellac.

 

Fic. 71.—THERMOo-xLECTRIC DIFFERENTIAL CALORIMETER.—Connect the two thermostats as
shown in figure, viz.: connect by means of one of the metal tipped cords one binding-post of
each of the thermo-piles to the two binding-posts on base of the galvanometer. Then con-
nect the two remaining posts, one on each of the thermo-piles with each other, After so
doing, place the thumb on the face of one of the thermo-piles and observe the direction of the
deflection of the galvanometer needle, then place thumb on face of the other thermo-pile,
leaving the first uncovered, and, if the deflection is in the opposite direction to that first ob-
tained, the instruments are properly connected. If, however, the second deflection is in
same direction as obtained by pressing thumb on first thermo-pile, disconnect the two cords
from either thermo-pile and interchange them, viz.: take cord from right-hand post and
place in left, and cord from left post and place in right-hand post; the deflections will then
be as first alluded to, one pile turning needle in one direction and the other in the opposite
direction.

More delicate tests of temperature may be obtained by the thermo-
electric calorimeter devised hy Lombard. One or two minutes is only
required by this instrument to detect variations in the temperature of
homologous regions of the scalp, but it is expensive and only available
for use in the office.
212 LECTURES ON NERVOUS DISEASES.

It is essential that two thermometers at least be employed when the
thermometry of the scalp is being tested, in order that the temperature
of homologous parts of the two hemispheres may be simultaneously taken,
thus insurine the same conditions of vascular supply. A comparison
should always be made between the results so obtained, before any
clinical deductions can be drawn from them.

The temperature of the scalp seems to be somewhat below the
normal standard of health (98.5° Fahr.) in all of its parts.

Amidon has shown that willed muscular movements if continued for
some time are associated with an increase of heat over the cortical centres
which are called into action. He has thus confirmed some of the dedue-
tions obtained by physiological experiments upon animals. Gray and
Mills report the diagnosis of a tumor of the brain by the detection of a
localized elevation of temperature over the area involved. The differ-
ence between the healthy and unhealthy side was about one degree and a
half. Hamilton reports a case where a difference of three degrees ex-
isted, and persisted at repeated examinations; the case was living at the
date of this statement, so that the diagnosis of tumor had not been posi-

 

Fic, 72.—Ducuenne’s TROCHAR. a, Open; 4, closed.

tively verified, From my own experience, I am led to believe that an
unilateral deviation of one and a half or two degrees above or below the
normal point, within a circumscribed area of the scalp, which is per-
sistent and unattended with as marked a rise or fall in temperature in
adjacent areas, must be regarded asa valuable diagnostic symptom of
disease within that area. If it be a cerebral tumor, I should expect to
find by the ophthalmoscope the characteristic evidences of nenro-retinitis,
known as the “choked disk.”

Sometimes it is very important to decide as to the existence of or-
ganic changes in the muscular tissue of different parts of the body. By
means of this very ingenious and useful instrument we are enabled to
extract with little pain, and no danger, small pieces of any muscle which

can be examined microscopically at your leisure. This instrument is
introduced (with the slide open) into the substance of the muscle; sub-
sequently the slide is closed and the instrument is then withdrawn, A
small piece of the muscle will be found to have been removed and re-
tained within the instrument.
CEREBRAL THERMOMETRY. 213

In closing this chapter, the author feels that he has perhaps over-
taxed the patience of his readers. If he has erred in this direction, it is
because he has endeavored to cover a large field within the limited com-
pass of a single chapter, and to so interpret the symptoms of nervous
diseases as to bring them within the grasp of the general practitioner of
medicine. It must not be inferred that all of the tests described are of
necessity demanded in each individual case that is brought to the notice
of the neurologist. As Gower happily remarks, ‘To know our enemy is,
if not ‘half the battle,’ at least an important part of it.” When once the
symptoms of nervous <liseases have been thoroughly mastered, the special
lines of investigation demanded in each case become as clearly defined
as does the course of his vessel to the mariner, to reach the harbor for
which he steers. This chapter gives but the rough outlines of a chart in
which the short cuts to valuable information in diagnosis are imperfectly
jotted. Arduous and persistent labor on the part of cach of its followers
can alone fill in its details and render it complete.
SECTION II.

DISEASES OF THE BRAIN AND ITS
ENVELOPES.
SECTION ITI.

DISEASES OF THE BRAIN AND ITS ENVELOPES.

DisEAseEs of the brain are, perhaps, in many cases, the most difficult
to recognize with certainty during life of any that the physician encoun-
ters. The results of autopsies go to prove that serious errors in diagnosis
are too often made in connection with cerebral affections, In occasional
instances, such errors are, perhaps, unavoidable; but many that are con-
stantly made might unquestionably have been avoided had more study
been given to the peculiar features of each disease, and greater care
exercised in the clinical examination of the patient.

In the two preceding sections we have discussed at considerable
length the anatomical and physiological bases of cerebral localization ;
and also the various tests which may be demanded from time to time
during the clinical examination of a patient. Weare now prepared to
intelligently discuss separate diseases of the nervous system from the
clinical aspect.

Too great stress cannot be laid upon the necessity of a,thorough
familiarity with the two preliminary sections of this work. Constant
reference will be made by me to many facts and deductions incorporated
and interpreted in those chapters.

The following table may aid the reader in classifying the more
important diseases of the brain and its envelopes :—

ABNORMAL Conpitions oF THE Brain AND ITS ENVELOPES.

{ Double-head.

Fusion of two heads.

Absence of brain or head.

Cyclocephalic deformity.

Abnormalities of the cerebral envelopes. |
Incomplete development of special ganglia.
Hydrocephalus.

| He gashalsoale,

( Aneurisms.

Atheroma.

1. ConGENITAL
DEFECTS OR
MALFORMATIONS 4
oF THE Bratn
AND CRANIUM.

vessels.
Capillary variety

Affecting sinuses and large
Arterial thrombosis, {

2. Diskases ar- | Venous thrombosis. ,
FECTING THE | Embolism.
_ VESSELS OF THE Aphasia.

Brain.

Cerebral hyperemia, . ; Active variety.

Passive variety.

Localized variety.

Cerebral anemia, .. : a f 4
General variety.

 

Apoplexy—erebral hemorrhage.

(217)
218 LECTURES ON NERVOUS DISEASES.

ArpyorMaAL Conpitioss OF THE Brain anv irs ENvELopes (continues).

\ Suppurative variety.

Be 7 ss ‘oie
Faoh phasing an, Non-suppur. variety.
3. INFLAMMA- Acute.
tory Conpt- | Meningitis, puede a <5 SUbsacute,
TIONS OF THE? Chronic.
Brain. este Acute.
Hydrocephalus (tubercular meningitis).. 9 Chronic.
\ kneephalitis.
Red.
Softening, White.
Yellow.
4. STRUCTURAL | Abscess, 7 Acute.
CHANGES OF Chronic.
THE Brarn- General variety.
TISSUES. Sclerosis, . . 4 Multiple variety.
Miltary variety.
; Infantile variety.
SNR « Senile variety.
Carcinoma.
Lipoma.
(homa.
Myxoma.
Papilloma.
Melanoma.
5. CEREBRAL | Sarcoma.
Tumors. vummata.
Psammoma.
Cholesteatoma.
Tubercle.
Fibrous.
Fibro-plastic.
| Parasitic.

 

CONGENITAL MALFORMATIONS OR DEFECTS OF DEVELOPMENT.*

Detects in development of the central nervous system (which are
occasionally observed in connection with congenital malformations) are
being studied to-day with great interest, both by anatomists and physi-
ologists. Sections of such brains, when properiy prepared and stained,
are often very instructive, because they shed more or less light upon the
course and connections of tracts of fibres whose functions are in many
cases more or less imperfectly understood.

The following paragraphs relate to those defects which may be
observed in the human brain as a result of imperfect development :—

Two heads have heen repeatedly met with upon the same body.
They may he either distinct or joined laterally or anteriorly. They

* Portions of this chapter have been incorporated by the author in the third edition
of his work, entitled, ‘‘ A Practical Treatise on Surgical. Diagnosis,’ N. Y., 1884.
DISEASED CONDITIONS OF THE CEREBRAL VESSELS. 219

may assume different sizes and shapes, and may exhibit different
degrees of development.

An entire absence of the brain at birth, and, in some instances, of
the spinal cord in part, has not infrequently been recorded.

The cerebrum, cerebellum, pons Varolii, medulla oblongata, and
even a part of the spinal cord, may be occasionally wanting, and yet the
cranial nerves may be perfectly developed.

In rare instances, the base of the skull has been exposed to view.
In others, the upper cranial bones have been wanting, and the integu-
mentary covering of the head has been found to be distended by a fluid
accumulation beneath it. In some cases reported, only parts of the
brain have been absent, the remaining ganglia being normally developed.

The condition termed “ Cyclocephalous ”—due to a fusion of the two
orbits into one cavity—is sometimes encountered.

The’ meninges may be occasionally found to be incomplete. The
falx and tentorium may be wholly or partially absent, or may be perfo-
rated with holes. The dura is sometimes wanting at the base of the
skull.

The corpus callosum, fornix, and septum lucidum have been found
wanting in the brains of some idiots. The optic nerves have sometimes
no commissure.

The whole brain may be occasionally so small as to constitute
the “microcephalous state.” Again, only certain convolutions may
exhibit arrested development, and «a cyst filled with serum is then
found to commonly spring from the meninges and fill the space thus left
vacant.

The two hemispheres of the cerebrum may present extreme variation
in point of size and weight. The thalami and corpora striata may
occasionally exhibit atrophy.

The brain may occasionally protrude from the cavity of the cranium
at the various sutures or fontanelles,—constituting ‘‘ encephalocele.”

Finally, the “hydrocephalie condition” may exist (characterized by
excessive fluid outside of or within the ventricles of the brain). It
usually tends to increase after birth.

The various types of congenital malformations of the nerve centres
which are encountered seem, as a rule, to depend either upon some
violence to the uterus or some mental shock to the mother during
pregnancy.

DISEASED CONDITIONS OF THE CEREBRAL VESSELS.

Under this heading may be included the following conditions:
Aneurismal dilatations ; atheromatous and calcareous changes ; rupture
or spontaneous perforation of blood-vessels ; thrombosis of the arteries
220 LECTURES ON NERVOUS DISEASES.

or sinuses of the brain or its coverings; embolism ; fibroid degeneration ;
hyperemia; anemia; and to inflammatory changes in the coats of
blood-vessels.

ANEURISMAL DILATATIONS.

The vessels within the skull most frequently affected are the in-
ternal carotid, basilar, and middle cerebral. Within the cavernous sinus,
large aneurismal tumors are not uncommon. It must not be supposed,
however, that the smaller vessels of the brain are exempt. Miliary
aneurisms, which sometimes give to an artery and its branches an
appearance resembling a bunch of grapes, frequently affect the vessels
that form the cirele of Willis, and even those of the pia-mater, within

 

Fic, 73.—A MrtiARY ANEURISM OF THE CEREBRAL CORTEX—ANTERIOR TO ROoLanp's
Fissure (350 diameters). This beautiful drawing was kindly made from a microscopic
slide by my friend Dr. G. Van Schaick, of New York. (/, proximal end; J, distal end.)

the substance of the brain and in the ventricles. The small vessels
which nourish the corpora striata and the optic thalami are sometimes
affected.

Miliary aneurisms of the brain frequently coexist with aneutismal
tumors of larger vessels outside of the cranium ; but they seem to exhibit
an independence of atheroma which is quite remarkable.

Morbid Anatomy.—Those who have devoted special attention to this
subject—Charcot, Zenker, Bouchard, Meynert, Hammond, and others—
differ regarding the cause of these dilatations. Some regard them as due
to a “sclerosis of the tunica intima ” of the arterioles. Others believe
that small “dissecting aneurisms” (this term covers all those types of
ATHEROMA. 294

aneurism where the blood escapes between the coats of an artery fora
greater or less distance) first form, because of a rupture of the inner coat.
When the external coat of such an aneurisin ruptures, a cerebral hemor-
rhage ensues. The fact that miliary aneurisms affect allages (since even
children are not exempt) seems to me to point to an“ ancurismal dia-
thesis” as an exciting cause in some instances, If such be the case, the
arterial coats would exhibit under a microscopic lens marked congenital
defects in their construction.

Etiology.— Among the other exciting causes of cerebral aneurism
_ may be mentioned the cachexia of cancer; tuberculosis; urwmic poison-
ing; chronic alcoholism; lead poisoning; leucocythemia; rheumatism;
gout; syphilis; and general paralysis. The remarkable tendency of
alcohol to excite aneurismal tendencies (not only in the brain and retina,
but in other parts as well) is adduced by some authors as an argument
in favor of the view that arterio-sclerosis precedes and causes the altera-
tions in the calibre of the vessels.

In case cerebral aneurisms be of large size, atheromatous or cal-
careous changes within the arterial coats are seldom absent.

Symptoms.—Miliary cerebral aneurisms give rise not infrequently to
headache and vertigo. Attacks of paralysis which follow one another
rapidly, and from which the patient quickly recovers, may be regarded
as almost a positive proof of their existence.

These small aneurisms produced their motor effects only by rupture.
Minute extravasations into the brain-tissue commonly occur at first ; but
later on large apoplectic clots may be formed. The discussion of the
symptomatology of cerebral hemorrhage will occupy subsequent pages
of this volume. <A previous section of this work also covers many sug-
gestions of an anatomical and clinical nature that bear upon cerebral
localization.

ATHEROMA.

The cerebral vessels may participate in a peculiar form of degenera-
tive change, termed atheroma. When this condition is developed, ves-
sels in other parts of the body are usually affected simultaneously.

Morbid Anatomy.—The changes observed in the cerebral vessels,
when atheromatous, seem to be produced slowly.

The extent to which it affects the blood-vessels admits of large vari-
ation. In some instances every vessel named by anatomists is thus dis-
eased, while, in others, only certain vessels, and even parts of vessels, are
found to he affected. In extensively developed atheroma, a symmetrical
condition is usually present on the two sides. This fact is of importance
in some cases, since a guide to diagnosis may be thus afforded. Cases,
which have often been reported, of parallel and contemporaneous popli-
222 LECTURES ON NERVOUS DISEASES.

teal aneurisms in the same person illustrate well the tendency toward a
symmetrical development in the limbs.

Atheroma develops more often in the lower limbs than in the upper,
and the extent of its progress seems to be greater when situated below
the diaphragm than when above it.

It is a direct result of an existing chronic endarteritis, the lining
membrane of the vessels being invariably involved to a greater or less
degree. It is most frequently found in the arteries, although the veins
may develop an atheromatous condition when exposed to any source of

prolonged irritation. It is also developed in the male sex in far greater _

proportion than in females, and is apparently influenced to some extent
by climate.

Asa result of this condition the affected vessel becomes impaired
in its contractile power, loses its natural tone, and, in consequence of its
inability to sustain its accustomed internal pressure, undergoes, in many
cases, dilatation at the seat of the disease.

Etiology.—This condition may be produced by age, chronic alcohol-
ism, gout, rheumatism, lead poisoning, syphilis, chronic diseases of the
kidney, exposure, or traumatism.

Symptoms.—When the condition of atheroma is once developed,
rings of ossification are often perceptible along the course of the
superficial vessels. An abnormal tortuosity of the artery is not in-
frequently present, if the atheromatous condition is diffused for some
distance.

The existence of atheromatous changes is not always to be detected,
however, even in the superficial vessels of the extremities, by the sense
of touch. Diminished arterial volume, and an impaired nutrition to
tissues when an excessive arterial supply is demanded (as occurs in
inflammatory processes) are frequently points of value in the diagnosis
of an atheromatous condition. Atheroma has especial medical import-
ance on account of a tendency which it creates toward rupture of
the affected vessels, either from an ulcerative destruction of their coats
or from the rigid and brittle condition of the walls of the vessel pro-
duced by the calcareous deposits.

The dangers which result from atheromatous changes within the
coats of the cerebral vessels render the detection of these changes im-
portant, even if the disease be unassociated with marked external evi-
dences of its existence.

Tt must be remembered that the process of repair cannot be per-
fected in an artery whose lining membrane is tough or osseous, or in a
state of fatty degeneration, whose middle coat has atrophied, and whose
contractility is destroyed.

One important point in diagnosis in this connection has lately been
CEREBRAL THROMBOSIS. 223

brought to professional notice, viz., that bi-temporal hemianopsia indi-
cates in most cases an atheromatous change in the vessels composing
the circle of Willis. This subject has been discussed lately, under the
head of “ Lesions affecting the Optic Nerve.”

CEREBRAL THROMBOSIS.

A coagulum of blood may form in either the sinuses, veins, or
arteries of the brain. Some changes in the coats of the vessels, however,
usually precede and cause the development of sucha coagulum. The
vessels are therefore occluded gradually. This is in marked contrast
to embolism, which causes a sudden occlusion of a vessel whose coats
may be perfectly healthy.

Morbid Anatomy.-—Thrombosis is much less common in arteries
than in venous channels ; but it is not uncommon in the internal, carotid,
the vertebral, the basilar, and the middle cerebral arteries. In the
superior longitudinal and lateral sinuses thrombosis is frequently found;
chiefly in connection with pachymeningitis. Old age seems to predis-
pose to the development of cerebral thrombosis;and males are more
commonly affected than females. Cerebral thrombosis in children may
develop in connection with exhausting diarrhcea.

The effect of thrombosis of arteries or veins within the cavity of
the cranium is to render the nutrition of surrounding parts more or less
imperfect, and thus to impair the function of those parts. If it be of
pyemic origin the thrombosis may cause suppuration of the adjacent
structures; and, by its disintegration, other vessels more or less distant
from the seat of the original thrombus may become plugged by the
detritus. Metastatic abscesses in the viscera are produced in this
way.

Etiology. —The causes which chiefly tend to produce thrombosis
include (1) atheroma, which produces a roughened condition of the
internal coat of the blood-vessels ; (2) hyperinosis, or that condition of
the blood in which a marked excess of fibrine is present, as in some acute
diseases, of which inflammatory rheumatism stands foremost; (3) pres-
sure upon some large vessel or sinus, so that the circulation within it is
rendered extremely slow ; (4) chronic interstitial nephritis ; (5) syphilis ;
and (6) pyemia, which seems to be associated with a special tendency
toward spontaneous coagulation of blood within the vessels, when the
rapidity of the current is slowed.

Symptoms.—The symptoms produced by cerebral thrombosis must,
of necessity, be modified by the situation of the clot and the vessel
occluded by it. A knowledge of the functions of different portions of
the brain can alone decide questions which may arise in any indi-
294. LECTURES ON NERVOUS DISEASES.

vidual case respecting the situation and the probable termination of the
lesion, Wither coma or paralysis (in any of its forms) is apt to be
one of the results. It is liable to be confounded chiefly with cerebral
embolism or cerebral hemorrhage. Cerebral softening, which may be
one of its sequel, will be treated of as a separate affection in this
volume.

It must be remembered that syphilis and chronic nephritis are
among the most frequent of the causes of arterial thrombosis. This fact
is explained by the development of an inflammatory condition of the
internal coat of the vessel,—the so-called “ endarteritis obliterans.” For
this reason the history of the patient may prove an important factor in
the differentiation between cerebral thrombosis and some other conditions
of the brain which might be mistaken for it.

Cases where cerebral thrombosis has existed during life and yet been
unrecognized by many medical men of note confirm the statement that an
accurate diagnosis of this condition is a matter of extreme uncertainty
in some instances.

The symptoms of the conditions are modified in every case (1) by
the seat of the blood-clot, and (2) by the amount of interference with the
circulation that ensues in surrounding parts. Furthermore, serious effu-
sion may occur (in some cases) from neighboring vessels, provided the
circulation in adjacent parts is rendered imperfect. This may tend to
mask the symptoms of the primary condition.

To enter into detail respecting all the phenomena that may be
encountered in connection with cerebral thrombosis would necessitate
the discussion of the entire subject of cerebral localization.* Hints may
be given, however, that may shed some light upon cases of this character.
None of these suggestions are to be considered, however, as pathogno-
monic of this condition.

Thrombosis of the lateral sinuses may be attended, according to the
observations of Gerhardt, with a difference in the size of the external
jugular veins.

If thrombosis oceurs in the transverse sinus a circumscribed edema
of a painful character may develop behind the ear, provided the veins
leading to the sigmoid fossa are implicated.

Epistaxis may occur when the superior longitudinal sinus is thus
plugged. A complicating cedema of the forehead and the development
of exophthalmus has been reported from the same cause.

Suppuration of the ear not unfrequently occurs when the petrosal or
cavernous sinuses are implicated.

A thrombus of one of the larger arteries of the brain may produce
sudden anzmia of the parts nourished by its branches, and thus induce

* See closing pages of Section I.
CEREBRAL THROMBOSIS. 225

paralysis of motion or sensation, or both. Convulsions, disturbances of
the special senses, and coma may also follow. The ocular muscles may
be rendered paretic, thus causing strabismus and diplopia.

Localized passive hyperemia may be one of the effects of cerebral
thrombosis, and thus give rise to a train of symptoms indicative of that
condition. (See subsequent pages.)

Thrombosis may go on to suppuration. In such a case the symp-
toms of cerebral abscess or of general pywinia may develop. In a
brochure upon this subject * I reported two cases which came under my

se

oe

 

Fic. 74.—4 DraGRAM DESIGNED BY THE AUTHOR TO SHOW THE CEREBRAL SINUSESIN PRroriLe.

1, superior longitudinal sinus ; 2, inferior longitudinal sinus ; 3, straight sinus, deriving blood
from 1 and also from the veins of Galen (11); Nos 1, 2 and 3 bound the falx cerebri:
4, the torcular Herophili, where four sinuses meet; 5, lateral sinus; 6, superior petrosal
sinus, joining the Jateral sinus (5) with the cavernous sinus (5); 7, inferior petrosa! sinus,
joining the cavernous sinus (8) with the jugular vein (9) ; 5, cavernous sinus; 9, internal
jugular vein formed by two sinuses (5 and 7); 10, occipital sinus; 11, vena Galeni; 12, vein
passing to nasal cavity; 13, foramen cecum.

personal observation, where a trivial contusion of the scalp which failed
to break the skin had induced thrombosis of the diplée and cansed death
by pyemia. The autopsies showed extensive secondary thrombosis of
the cerebral sinuses and metastatic abscesses in nearly every organ of
the body.

In children exhaustive diarrhcea may induce thrombosis of the cere-
bral sinuses. We may expect to encounter in such a case rigidity of
muscles of the neck, and sometimes of the back and limbs; the develop-

* Pyemia and Septicemia, Annals of Anatomy and ‘Surgery, Nov., 1881. A lecture
delivered by the Author before the Anatomical and Surgical Society of Brooklyn, N.Y.

15
226 LECTURES ON NERVOUS DISEASES.

ment of nystagmus, ptosis, or strabismus, facial paresis (in some cases),
and somnolence, coma and collapse. It is well to state, however, that
these symptoms are not pathognomonic of cerebral thrombosis in a child.
They may indicate only a state of general cerebral anxmia.

Differential Diagnosis.—The probable cause of the thrombosis must
be taken into consideration in connection with the symptoms presented
by each case. Both may assist greatly in the diagnosis. If the throm-

woeeee
s.

 

See -*
Smeamnee*

Fic. 75.—A DraGcram Desicnep sy THe AuTHOR To SHOW THE VENOUS SINUSES OF THE
Dura-Mater, aS SEEN AFTER A HORIZONTAL SECTION THROUGH THE CRANIUM. A,
anterior fossa of skull; 2, middle fossa; C, posterior fossa; /S, frontal sinus; 1, torcular
Herophili ; 2, 2, lateral sinuses; 3, 3, occipital sinuses ; 4,4, superior petrosal sinuses; 5, 9,
inferior petrosal sinuses; 6, transverse sinus; 7, 7, cavernous sinuses; 8, circular sinus; 9,
opening into internal jugular vein; 10. ophthalmic vein, communicating with cavernous
sinus (7) ; 11,a branch joining the occipital and inferior petrosal sinuses; 12, veins from
posterior condyloid foramen to lateral sinus.

bus be due to a tumor within the cranium it will perhaps be impossible
to separate the symptoms of each. It is well to know that thrombosis
has been known to follow rheumatism, erysipelas, a carbuncle of the
neck, some of the fevers, injuries to the head, and surgical operations, in
addition to the other causes mentioned on a previous page.

The following differential diagnosis is quoted with slight modifica-
tions from the author’s work on “ Surgical Diagnosis :”-—
 

CEREBRAL THROMBOSIS.

CEREBRAL EMBOLISM.

207
CEREBRAL THROMBOSIS,

Sex AFFECTED,

Most frequent in females,

Equally frequent in the sexes.

ONSET.
Sudden. No prodromal symptoms. Gradual. Prodromal symptoms.
CausEs,
A history of heart-disease and the phys- Chronic nephritis.
ical evidences of a valvular lesion are usu- Atheroma.
ally to be discovered. Syphilis,
The embolus may spring, however, from Pachy meningitis.
an aneurism or a suppurating thrombus and Hyperinosis.
be carried into the circulation to the brain. Pyemia.

Pressure upen the veins or arteries.

These morbid conditions all tend to cause
a coagulation of blood within the vessels
affected.

CHANGES IN THE Exterior or SKULL.

No changes in the vessels of the exterior
of the skull are to be detected.

The veins of the neck are symmetrical in
point of size.

\

Epistaxis, cedema of the frontal veins,
and exophthalmus may occur if the superior
longitudinal sinus is eblitersted.

The external jugular veins may not be
of the same size—the one on the clei wuten
side being the smaller—if the lateral sinus
be occluded.

Painful cireumscribed cedema behind the
ear may arise from a thrombus of the
transverse sinus.

SuppuRaTIVE CHANGES.

ee effects are sometimes pro-
duced within the brain-substance (embolic
abscess), but seldom in distant parts.

Suppuration of the ear is very common in
connection with thrombosis of the cerebral
sinuses.

Abscesses in distant parts are liable to
form on account of a suppurative disinte-
gration of the thrombi.

ConrvuLsiIons,

Convulsions are rare.

Convulsive attacks are common and may

exist for months in attacks of venous throm-

bosis.

PARALYSIS.

A sudden hemiplegia usually occurs—
generally of the right side
Aphasia exists in the majority of cases.

Comes on gradually, if at all, in the
venous variety. It may be absent.

May occur suddenly in arterial thrombosis.

Aphasia may be developed, but is not
the rule.

Coma.

The patient seldom loses consciousness
completely during the attack or after it.

Profound coma often follows the paraly-
sis or accompanies the attack.

In venous thrombosis it may occur with-
out paralysis having preceded it.

Symptoms in Common.

Both commonly affect the young and early adult life.
Both may cause aphasia, and coma. : _
Both may cause hemiplegia, local paralysis, convulsions, etc.
228 LECTURES ON NERVOUS DISEASES.

Prognosis. —This disease is liable to prove fatal sooner or later. It
is possible that pysemia may be induced by it, provided the thrombus
becomes disintegrated by suppuration. Emboli are thus formed. These
are subsequently carried to other organs by means of the circulation.
Infarctions and embolic abscesses of the lungs, liver, spleen, kidneys,
etc., may be produced in this way. Softening of the brain is a frequent
sequel to thrombosis. Death may occur in a few days if the cerebral
anemia is very profound.

Treatment.—No remedial measures can affect an existing thrombus.
When the exciting cause can be discovered it should be removed if pos-
sible. The symptoms should be treated as they develop, with the hope
that the more serious complications of the disease may not occur and the
patient survive the attack.

THROMBOSIS OF THE CEREBRAL CAPILLARIES.

The capillaries of the brain may be extensively affected by small
thrombi or emboli. This condition is distinct from that comprised
under the common acceptation of the terms “cerebral embolism” or
“ cerebral thrombosis,”

Morbid Anatomy.—The microscope alone can detect the points of
occlusion. Atheroma may be detected. The capillary vessels will he
found to contain pigment-granules, fatty masses, crystals of lime-salts,
etc. The larger vessels are not atheromatous, nor are they occluded.

The brain may exhibit spots of softening or of suppuration, and the
cortex of the organ is gencrally ansemic.

Etiology.—-Pigmentary embolic occlusion of the cerebral capillaries
may be induced by malarial diseases. Fatty masses may be formed at the
seat of occlusion as a result of a fatty degeneration of the capillaries,
or they may be swept along in the blood-current from distant foci of
fatty metamorphoses in the bones, viscera, heart-cavities, etc. Pus-cells
or the white blood-corpuscles may also occlude the cerebral capillaries,
chiefly in connection with acute diseases, causing a marked elevation of
temperature, and with leucocythemia, Fibrinous masses may be pres-
ent in the blood-vessels of the brain, especially in rheumatism and
inflammatory diseases; and cancerous material may act as emboli.
Finally, lime-salts may be absorbed from diseased bones (Virchow) and
be carried to the brain.

Symptoms.—These are vague and not well understood. Mental
disturbances are prominent, such as delirium, loss of memory, loss of
emotional control, and hallucinations. Headache, nausea, dizziness,
trembling of the extremities, and paresis may develop. Bastian advances
the view that disturbances of the sensorium, when occurring in acute
CEREBRAL EMBOLISM. 229

diseases attendant with high fever, may be due to capillary occlusion
and consequent anzmia of the cerebral cortex.

CEREBRAL EMBOLISM.

The term “embolus” is commonly used to designate any foreign
body in a blood-vessel which floats in the blood-current, or, in case it
be stationary, that has been transported by the blood from some situation
more or less distant from the seat of lodgment. The term “embolism”
must not be employed synonymously, therefore, with “thrombus ;”
because the latter term applies only to a blood-coagulum within a blood-
vessel (unhealthy as a rule), which has been formed at the site of
occlusion of the vessel, and not transported there by the blood.

Morbid Anatomy.—The most frequent seat of cerebral embolism is
in the middle cerebral artery of the left side. This is because that artery
forms the termination of the most direct channel from the heart. The
axis of the left carotid is so situated in reference to the curve of the
aorta as to assist the passage of floating particles in the blood into
its mouth. The internal carotid is, moreover, the direct continuation
.of the common carotid of each side; and the middle cerebral artery
is similarly placed in reference to the internal carotid after that vessel
enters the skull. u

Next in point of frequency comes the right Sylvian artery. This
is because the innominate artery, although much larger than the left
carotid, leaves the aorta at an angle opposed to the current of blood in
that vessel. The middle cerebral artery nourishes, in addition to other
convolutions, the so-called “speech area” of the cerebral cortex; hence
plugging of the main trunk of that vessel deprives those convolutions of
blood that are physiologically concerned in the codrdinated movements
of articulate speech. The motor speech area is shown in Fig, 5,

Cerebral embolism is a frequent cause of extravasation of blood,
because it tends to induce infarction. Again, it may result in localized
softening of the parts that are imperfectly nourished, provided the
embolus is large. If the embolus is of suppurative origin the parts in
which the nutrition is impaired by the embolus suppurate, and a so-called
“embolic abscess” results.

An infarction is a wedge-shaped spot of consolidation and discolor-
ation within an organ dependent upon occlusion of a blood-vessel and
the subsequent rupture of neighboring capillaries. Whenever a vessel
of an organ becomes occluded, the parts nourished by the occluded vessel
are deprived of blood until a collateral circulation is established. Now,
it is found that, after such occlusion, those parts which are at first
deprived of blood become subsequently the seat of a rupture of the
capillary blood-vessels (as the result of an excessive pressure produced by
230 LECTURES ON NERVOUS DISEASES.

the collateral fluxion). Hence the infarction is wedge-shaped, as a rule,
owing to the distribution of the blood-vessels. Its apex (corresponding
to the seat of the plug) usually points toward the centre of the organ in
which it is detected. If the circulation is not speedily restored, the re-
sult of defective nutrition caused by the embolus is evidenced in one of
three ways: either in gangrene—if the part be totally cut off from its
blood-supply ; fatty degeneration and absorption of the embolus and
blood-coagula—if the nutrition be only partially cut off; or more or
less extensive suppuration—if the plug in the vessel be derived from a
suppurative focus or be septic in its origin. We usually find, therefore,
that old infarctions are liable to appear pale, and to be firm and incom-
pletely organized, provided that the character of the plug (an embolus
or thrombus) does not create suppuration ; in which case disintegration

 

aw

Fic. 76 —A DiAGRAM or AN EmBoLic INFARCTION, .(After Weber.) a, artery obliterated by
anembolus (e); v, vein filled with a secondary thrombus (¢/4); 1, centre of the infarction,
which is becoming disintegrated; 2, area of extravasation of blood into the tissues ; 3, area
of collateral hy peramia.

takes place rapidly in the centre of the infarction, and an abscess
results,— embolic abscess.”

The more complete the obstruction, the more vascular the tissue,
and the less the vessels are supported, the greater is the amount of in-
farction and the more rapid the softening and disintegration that ensues.
The development of ‘ metastatic” or ‘embolic abscesses” is one of the dis-
tinctive pathological features of pyzemia, and no case can be properly so
called when these abscesses are not found after death.

Etiology.—For some unexplained reason the female sex is more
frequeitly affected with cerebral embolism than the male sex. It is also
more common in youth and adult life than in old age.

Floating particles in the circulation (which become emboli within
the vessels of the brain) may spring (1) from the heart-cavities or from
the mitral and aortic valves; (2) from the walls of the aorta; (3) from
CEREBRAL EMBOLISM. 231

the cavity of some aneurism; (4) from the disintegration of some thrombus
in other parts of the body (the loosened particles being swept into the
circulation); (5) from particles of connective-tissue growths which affect
the vascular system; (6) from chalky concretions; and (7) from foreiyn
bodies introduced into the circulation from without,

Affections of the heart, especially endocarditis, are liable to be
followed by attacks of cerebral embolism. Aneurisms of the aorta or
carotids are the next most common source of emboli. Pyzmia or sup-
purative phlebitis may induce emboli by disintegration of blood-clots.
Oppolzer records a case where a syphilitic gumma, of the cardiac wall
broke through the sinus of Valsalva and caused embolism. A rheumatic
history should point you to an examination of the heart for valvular
defect. Cardiac thrombosis has been known to excite embolism. Car-
cinoma, tuberculosis, and empyema may also act as etiological factors
of this condition.

The size and number of the floating particles modify the seat and
number of the emboli. If small, the capillaries of the brain alone may
be occluded; if large, one or more of the main trunks are liable to be
plugged, and a much larger area of brain-substance is thus deprived
of blood. Not infrequently many vessels are simultaneously obstructed
at the same time. Sometimes all the main vessels on one side, and at
other times vessels of both sides, are more or less occluded.

Symptoms.—The common effects of occlusion of a large trunk are
sudden aphasia and hemiplegia (usually of the right side of the body).
When the capillaries alone are involved and the main trunks escape, the
effects and symptoms vary with the seat of the embolus, because only
certain limited portions of the brain are then deprived of their nutrition.
The collateral circulation of the brain takes place almost entirely through
the larger arteries. It forms, therefore, an exception to the other
tissues,

There are usually no premonitory symptoms that indicate the ap-
proach of the attack. The patient does not (as a rule, at least) lose
consciousness; although there may be a slight confusion of the mental
faculties for a time. In some instances, however, coma accompanies the
attack of paralysis. Although so eminent an authority as Nothnagel
states that embolic attacks are, as a rule, accompanied by profound coma,
my experience does not confirm that view. I regard such cases as ex-
ceptions to the general history of embolism; although it cannot be denied
that they are frequent exceptions. Even then the patient recovers con-
sciousness gradually within a few hours. Ptosis,a squint of one eye,
and even blindness have been known to accompany the attack; but these
complications are rather infrequent. In still rarer cases, paralysis may
not be developed in any part of the body. The paralysis tends to exhibit
232 LECTURES ON NERVOUS DISEASES.

a marked improvement within forty-eight hours, if collateral circulation
is established.

The difliculty in speech which commonly results from cerebral em-
bolism is not, as a rule, due to paralysis of the hypoglossal nerve, as it
is present in cases where the movements of the tongue are normal. It is
to be attributed to sudden anemia of the ‘speech centre” of Broca. This
is situated chiefly in the base of the third frontal convolution and the
adjacent “island of Reil.” There are cases reported where both the
hypoglossal and facial nerves have been simultaneously paralyzed as a
result of embolism, but they are exceptional.

The pupils are not often affected in embolism. The pulse is com-
monly small in volume and somewhat weak. The temperature may fall
slightly below the normal point. A valvular heart-lesion will frequently
be discovered. Vegetations upon the aortic and mitral valves are a
prolific source of emboli. The arteries of the retina are frequently en-
larged at the onset of the attack, because the ophthalmic arteries arise
below the middle cerebral.

Emboli are so rarely conveyed to the brain by means of the ver-
tebral arteries that the symptoms produced by occlusion of the branches
supplied by that vessel may be clinically disregarded.

Aneurism of the arch of the aorta, or of ‘the innominate and carotid
arteries may prove an exciting cause of cerebral embolism. In these
cases, portions of the laminated fibrin or blood-coagulum which line the
interior of these sacs become detached and are swept into the circulation.
It is well to remember this fact, as symptoms referable to- aneurismal
tumor may occasionally coexist with those produced by the cerebral
embolus.

Convulsions may accompany the development of cerebral embolism.
The form of convulsion may be of the typical epileptic attack, or it
may be only a slight twitching of the muscles, one of the limbs, or the
face. The convulsive attack may precede the paralysis, if of the mild
type. With bilateral embolism, convulsions are rarely absent. They
are due to the extensive anemia that is suddenly induced. Transient
delirium may accompany an attack of embolism.

Differential Diagnosis.—From cerebral apoplexy the diagnosis is
often diflicult. Embolism is to be diagnosed chiefly by the absence of
profound coma (although there are frequent exceptions to this rule), the
absence of premonitory symptoms, the fact that any age may be attacked,
the frequent coexistence of a valvular lesion of the heart, or possibly
of an aneurism of the aorta or the carotid artery, the predisposition of
the right side of the body to paralysis, the simultaneous development
of aphasia, and the slow improvement in the paralysis, provided it re-
mains well established on the fourth day after the attack.
APHASIA. 233

From cerebral thrombosis the diagnosis is less difficult. ‘The sudden-
ness of the onset, the rapid development of aplasia and right hemiplegia,
the absence of prodromal symptoms, the presence of valvular defect of
the heart, the absence of atheromatous changes in the vessels, or of any
of the well-known exciting causes of thrombosis, the retention of con-
sciousness (more or less complete) during the attack of paralysis, and
the absence of suppuration of the ear, epistaxis, circumscribed oedema
of the frontal or mastoid revions, are the chief diagnostic points of
embolism These points are contrasted on page 227.

Prognosis.—The danger of rapid cerebral softening and possibly of
abscess renders the prognosis somewhat grave as regards complete
recovery, provided the paralysis does not disappear to a great extent
within forty-eight hours after the attack. If a large vessel be occluded,
collateral circulation may be established rapidly. The persistence of
head symptoms is another omen of evil import. It must not be for-
gotten that the exciting cause remains and subsequent attacks may be
expected.

Treatment.—The symptoms must be treated as they arise. The
patient must be kept quiet, and all mental activity avoided for several
weeks. Stimulants and digitalis are only indicated when collapse
threatens. The faradic current will usually tend to partially relieve the
paralysis, in case it persists after the third week.

APHASIA.

This subject has been discussed at some length in a previous chapter
(p. 66). The reader is referred to the remarks already made rela-
tive to the significance of this symptom, and its bearing upon cerebral
localization.

Motor Aphasia is one of the most common symptoms of cerebral
embolism, although it occurs often in connection with anemia from other
causes, and also from lesions of a destructive character. It seems proper
therefore to consider its clinical significance again in this connection.
Too great stress cannot be laid upon the fact that motor aphasia is not
pathognomonic of embolism. It may occur in connection with cerebral
hemorrhage and many other diseases of the brain.

It should be remembered also that aphasia may be due either to an
inability to properly codrdinate the muscles of articulation (which are
‘governed to a marked degree by the centre of Broca), or to a loss of
memory of articulate sounds or their symbols. Should the meaning of
spoken language be lost, the lesion is probably situated in the first
temporal convolution, and not in the centre of Broca; provided the
patient can articulate perfectly, as can be determined by having the
patient repeat single test-words, and in other ways. (See page 64.)
234 LECTURES ON NERVOUS DISEASES.

Among the aphasic-symptom group may be mentioned the conditions
known as “aphasia,” “alexia,” “ ainimia,” “apraxia,” “ asymbolia,”
“agraphia,” and “paraphasia.” Thus, disturbances of speech (true
aphasia) may be associated with an inability to read (alexia), to make
appropriate gestures (amimia), to recognize objects in common use
(apraxia), to sign the name (usymbolia), to write or copy (agraphia),
and to properly select words (paruphasia).

The term “e@praxia” has been employed by some authcrs to cover
a class of cases where by disease of the cortical centres of sight the
patient has been rendered psychically blind, not to the meaning of words,
but to the most familiar objects and their uses. Such patients, after
being disrobed and having their clothing returned to them, have been
known to require instruction as to what uses to put each garment to.
The most common objects about them are apt to be regarded as things
unknown by such subjects.

The lack of power to express the psychical states by means of
gestures has been designated “ amémia.” The power of appreciating the
meaning of gestures made by others may coexist with the loss of power
on the part of the patient to personally execute appropriate mimic
interpretations of thought.

Whenever motor aphasia is clearly dependent upon cerebral embo-
lism or general cerebral anemia, efforts should be made to relieve the
vascular disturbance (as far as is possible), and to treat the coexisting
symptoms. Such steps will be discussed in connection with cerebral
anemia.

Clinically, however, we often encounter motor or sensory aphasia
in connection with circumscribed lesions, such as depressed bone, menin-
geal or cerebral hemorrhage, suppuration after an injury to the skull,
cerebral softening, tumors, etc., as well as a symptom of embolism.

Under such circumstances the question ot’ mechanical relief by the
trephine has to be considered.

There is a safe rule to follow whenever the use of the trephine is
suggested, viz., never to employ it when sensory paralysis coexists with
motor paralysis, or when the motor paralysis exists on the side of the body
corresponding to the probable seat of thé cerebral lesion,

The reasons for this rule arc self-evident. The coexistence of motor
and sensory paralysis indicates a lesion that is either too extensive or
deeply seated (although it may possibly be cortical in character) to be
benefited by the removal of a small button of bone. Again, the develop-
ment of paralysis upon the same side as a cerebral lesion justifies a
doubt, to say the least, regarding the hemisphere of the brain which has
been injured.

Those cases known as word-deafness and word-blindness, where the
 

APHASIA. 235

memory of spoken words or of written characters has been effaced by a
cerebral lesion, are now better understood than in the past. We have
reason to believe that the memories of sounds are stored in the cells of
the first temporal convolutions, and those of sight in those of the occipi-
tal lobes. We also know that after a lesion of these gyri has effaced past
memories new ones may be often acquired and retained, provided that
all of the cells of the affected gyrus are not actually destroyed. Hence
we have come to learn that patients afilicted with aphasia of the amnesic
type (p. 63) can be slowly taught in some cases the meaning of sounds,
and cases of word-blindness those of symbols, in spite of the fact that

     
    
    
 

ASSOCIATING TRACT

THE SO-CALLED —-
°SPEECH TRACT”

-SWUCLE! OF ORIGIN
OF NERVES
“EMPLOYED J SPEECH

Fic. 77,—A Diacram DegsiGNep BY THE AUTHOR TO ILLUSTRATE THE MECHANISM OF TJE

Arraratus Requrrep In SpEECH.—The reader must not regard this diagram as intended

to accurately portray the anatomical relations of the various centres and tracts to each other.

The physiological interpretation of this diagram has been given on page 67.
the memories of such have been mechanically effaced. The cortical cells
associated with the auditory nerves or with the eyes must be developed
anew in respect to their functional attainments, as if the patient were an
infant. Words must be repeated again and again, until the patient can
retain them in memory and pronounce them properly, in case of “ word-
deafness,” and after the development of “ word-blindness” the patient
must sometimes be taught the letters and numerals in the same way as
a child is instructed. The tests for these conditions have been given in
the preceding section (p. 183).
236 LECTURES ON NERVOUS DISEASES.

In cases where word-deafness is suspected to exist it is well to test
the patient by instructing him to do certain simple things, such, for
example, as putting out the tongue, pointing to selected objects in the
room, shaking hands, passing common objects to some third party, ete.
It is particularly important that no sign or gesture should be employed
while making such tests as will serve to aid the patient in discerning
the meaning of any of the requests made as a means of determining
the integrity of the cortical centres of hearing.

Embolism of the left middle cerebral artery is perhaps the most
frequent cause of true motor aphasia, because the same vessels which
nourish the motor speech-centre supply also most of the motor centres
in the two central convolutions. A right hemiplegia is commonly
observed in connection with aphasia (when due to embolism).

Agraphia, like aphasia, may be of the ataxic or amnesic types. When-
ever the sight and hearing centres are impaired, copying from sight or
dictation will be rendered impossible, because centres which control the
muscles employed in writing lack the necessary stimulus to perform such
cobrdinated movements.

When the codrdinating centre of the muscles of speech is perma-
nently impaired by a lesion of the vessels or brain-tissue, the prospect
of a return of the normal power of articulation is not, in my experience,
encouraging, although great improvement may sometimes occur (pos-
sibly by the aid of the homologous centre in the uninjured hemisphere).

The guides that are employed to-day in trephining for the special
centres of the cerebral cortex have been given elsewhere (p. 49).

My friend and late colleague Prof. Wm. H. Thompson, of New
York, has lately published a very interesting case of word-blindness
which came under his personal observation. I take the liberty of
quoting his record of this case in full :—

“On May 1, 1884, I was called to one of my stated patients, a lady of about sixty
years of age, whom I found naturally anxious about a peculiar experience which had
befallen her. The previous afternoon she had taken a long ride in her carriage to Green-
wood Cemetery, to visit the grave of her only son, who died three years before, of phthisis.
She said that she had enjoyed the ride, and did not feel particularly fatigued by it, but on
returning home began to experience a sensation of unusual weariness. She exerted her-
self, however, then, before going down to dinner, to write au advertisement to come out in
the morning paper for a servant-girl. She was surprised, however, to find that for some
unaccountable reason she could not word the advertisement to suit her, and after tearing
tp some five or six such written attempts she was obliged to ask her sister to write the
notice for her. Soon afterward, while at the dinner-table, a severe pain set in at the
upper portion of the left temple, which continued to increase until it obliged her to retire
to her room, and not long afterward, to bed. This pain persisted through the night, but
did not prevent her from haying a fair amount of sleep. She rose at her customary hour
in the morning, and but for the persistence of the same pain, though in less degree than on
the evening before, she would not have noticed anything unusual about herself, had it not
APHASIA, 237

been for the arrival, soon after breakfast, of an applicant in answer to her advertisement.
Upon the girl handing her some written recommendations the lady found herself unable
to make anything out of either one of them, and had to call her sister in, who then read
them without difficulty. Soon another girl came in, and my patient experienced just the
same difficulty in attempting to read her references. She said that her first thought was
that something was wrong with her eyes, but on looking around the room and inspecting
a number of small articles minutely she was satisfied that she could see and distinguish
objects as well as ever. The moment, however, that she turned to the writing, while she
knew that she could see the written characters as well as she could see worsted work, yet
not a single letter conveyed any idea to her mind of its character or meaning. She there-
upon took up a newspaper, and at once recognized that something peculiar had happened
to her, for she was totally unable to read a word in it. The separate letters could be seen,
but an indescribable blur, as she thought, rendered it all indistinguishable; whereupon I
was sent for to explain the difficulty.

“T was much interested, of course, in the patient’s story, for nothing could have been
better described or expressed in words. There was neither hesitancy nor thickness in her
articulation, nor confusion in diction or thought, but, on the contrary, she detailed her case
with a peculiarly good choice of terms. ‘ What is it, doctor, that makes that newspaper so
illegible to me? I sec that there are words there, but I am wholly unable to tell what
they are,’ were some of her remarks. At first I directed my questions so as to avoid
increasing her alarm and excitement, and in time found that she had not experienced
another symptom except the above-mentioned pain and her inability to read or write.
She felt. no numbness or tingling, either in the face or extremities, nor any loss of power;
her grasp being the same as usual in each hand, while no difference was perceptible to her
between either of the lower extremities in walking. The use of the hands for sewing,
buttoning, or tying, and for holding a pencil for writing seemed as good as ever. There
was no difference observable in the vision of the two eyes,—no specks, nor mists, nor
colored images; no marked difference in hearing on either side, nor any other symptoms
referable to the ears; and there was no dizziness whatever. The face showed no distor-
tion, either when the patient was speaking or laughing. Examination of the radials
showed them to be hard and tortuous, and the pulse was of high tension and slightly
quickened. I may remark here that a brother of the patient, a few years her senior, had
aslight hemiplegic attack, with aphasia, some seven years ago, from which, however, he
has quite recovered.”

“At my first visit I was soon obliged to desist from experimenting with my patient's
inability to recognize written or printed words or figures; for the plainer this strange dis-
abilty became to her by my tests the more she was inclined to become distressed by it
and to press for an explanation, so that I feared the effects of excitement upon her cere-
bral circulation. At my visit the next day the pain in the temple still persisted, and was
uniformly described as running along a line which corresponded to the temporo-parictal
suture. Some days afterward it was noticeable that she occasionally miscalled words, of
which, however, she immediately corrected herself. On cautiously testing her again, I
found that her word-blindness at the end of the week was complete. The largest letters,
like the heading of the New York Herald, and figures were as unrecognized by her, when
separately pointed out, as the smallest. With the exception, however, just mentioned, her
spoken language was that of a well-educated woman who had learned to express herself
fluently and well.

“Her recovery from this condition began in about two weeks and progregsed gradu-
ally until in three months she could both read and write, especially the latter, with
tolerable facility. When she began to write again, however, it was in a very small hand;
238 LECTURES ON NERVOUS DISEASES.

but in time she quite recovered her ordinary handwriting. Since then she has shown
little or no change, except a marked increase of restlessness and impatience. She now
writes all her own letters, but says that, whereas she used to be a'good correspondent, the
task of answering letters has become very irksome. Reading, however, she finds more
difficult than writing, for she can read aloud only slowly; while reading to herself, she
says, soon fatigues her.”

Differential Diagnosis.—The following table is quoted with some
modifications in this connection from the third edition of the author's
work upon “ Surgical Diagnosis ”:—

GLOSSO-LABIO-LARYNGEAL

APHASIA, PARALYSIS. .
(DucHEnve’s Disease.)

EarLy Symptoms.

The loss of speech is usually sudden and Patient notices a slight impediment in
only partially complete. speech early in the disease, or a tendency
The lips are under perfect control and in the lips to separate and remain apart.

do not tend to separate. ;
DEGLUTITION.

Swallowing is not interfered with. Swallowing is imperfectly performed later
on in the disease,
The palate becomes affected, and attempts
at swallowing induce symptoms of strangu-
lation.

Face.

‘The face is normal in expression. Saliva dribbles constantly from the mouth,
in the advanced stages of the disease; and
the face is altered by the attitude of the jaw
and the separation of the lips,

SPEECH.

In the atawie or “ motor” varrety, speech The lingual and dental consonants are
is impaired in a variety of ways (page 64). first pronounced with difficulty, and, later
In the amnesic or “sensory” variety, some on the labials.
form of memory of words or symbols is lost.

MAastIcaTIon.

Mastication is performed as in health. The food accumulates in the cheek during
eating, as the tongue cannot control the
bolus properly.

RESPIRATION,

Respiration is not affected. Respiration becomes impaired, from paral-
ysis of the muscles necessary to that act.’
The patient often cannot cough or breathe
deeply.

VoIceE,

The voice is normal. Phonation becomes impossible when the
larynx is paralyzed.

AvROPHIC CHANGES.

No atrophic changes in muscles occur As the disease tends to extend into the
throughout the disease. spinal cord and involve the cells of its gray
matter, symptoms of muscular atrophy de-

velop.
HYPEREMIA OF THE BRAIN AND ITS COVERINGS. 239

Motor PARALysis.

The right side of the body is usually ren- Motor ‘paralysis is not developed as a
dered hemiplegic, when the aphasia is of — result of the spinal changes. The patient
the motor variety. This is especially true becomes unable to walk, however, as a
if an embolus exists as its cause. result of general debility and the atrophy

of the muscles,
Memory.

The memory may be impaired, in the am- The memory of words is intact, but the
nesic variety, im respect to words, figures, ability to use the tongue and lips interferes
foreign tongues, familiar objects and their with articulate speech.
uses, gestures, etc.

Dementia.

Dementia scldom, if ever, occurs. In exceptional cases, dementia develops
late in the disease.
- Symptoms in Common.

Both may be associated with impairment of the normal use of the tongue.

Both may be associated with defects of speech.

Prognosis and Treatment.—The duration, course, and severity of
the abnormal conditions described under the general head of aphasia
depend to a great extent upon the exciting cause and its exact seat. In
the first section of this work, the localization of the lesion and the com-
plications most frequently encountered in connection with aphasia have
been quite fully discussed. To these pages the reader is referred.

The treatment of the various lesions which may induce aphasia
will be discussed later, under the heads of cerebral hemorrhage, tumors,
softening, abscess, etc. Some points relative to the treatment of cere-
bral embolism and thrombosis have already been given.

HYPERZMIA OF THE BRAIN AND ITS COVERINGS.

Contrary to opinions of the past,* it is now quite well determined
that the quantity of blood within the cavity of the skull may admit of
variation and be increased under certain circumstances to an abnormal
extent, constituting the cqndition known as cerebral hypersemia.t

Two forms are commonly recognized,—-the active and passive. Both
may be general or localized.

*The experiments of Kellie led him to deny that the cerebral circulation could be
affected by bleeding, the ligation of veins, etc. “

t Burrows, Donders, Kussmaul and Tenner, Jolly, Leyden, Ackermann, and Frmann .
have demonstrated that the view of Kellie was untenable.

The functions of the cerebro-spinal fluid were imperfectly understood untfl Magendie,
Longet, and Ecker brought them to light. The perivascular lymph spaces unquestionably
assist also in the imperfectly understood mechanism by which the cerebral circulation is
regulated. Maingien believes that the thyroid gland plays an important part in preventing
over-distention of the cerebral vessels,—a conclusion that is sustained by as high an
authority as Guyon. The thyroid lobes become turgid and swollen during excessive mus-
cular exercise, and overcomes (by compressing the carotid arteries) the danger of venous
congestion of the brain.
240 LECTURES ON NERVOUS DISEASES.

In the active variety, the blood-vessels are dilated and (although the
amount of blood is proportionately increased) the current is very rapid.
In the passive form, the blood-vessels are dilated and the amount of blood
is also proportionately increased, but the current is slower than normal.

The term “cerebral congestion” is properly applied to the latter
variety only, in spite of the fact that authorities of notc sometimes
employ it when speaking of both forms.

Some neurologists have attempted to classify cerebral hypereemia on
a basis of its symptomatology. Andral speaks of eight varieties, and
Hammond of six. These have been designated by the terms “ apoplectic,”
“naralytic,” “convulsive,” “maniacal,” etc., in accord with the most
prominent of the symptoms exhibited.

Morbid Anatomy.—Great variations in the intensity of cerebral and
meningeal hyperemia are observed.

If the condition be of the general variety, in contradistinction to
local hyperemia, the vessels will be found to be engorged and the mem-
branes altered in their color. Some of the cerebral convolutions may be
slightly compressed and flattened. Finally, hemorrhagic points may be
detected both in the gray and white substance of the brain on section.
In some cases, coagula of blood may be detected in both the arteries and
sinuses.

Chronic hyperemia is recognized chiefly by a thickening and opacity
of the membranes and marked dilatation of the vessels. The cerebellar
meninges are commonly more vascular than those of the anterior por-
tions of the brain. In some insane patients, the cortex may assume a
brownish and pigmented condition.

Localized areas of hyperemia are occasionally observed. These
sometimes coexist with embolism or thrombosis. The basal ganglia
(corpus striatum and optic thalamus) occasionally exhibit isolated con-
gestions.

It is not uncommon to meet an increase in the subarachnoidean fluid
and distension of the choroid plexuses, in connection with cerebral con-
gestion. Moreover, particles of hematin may often be found in contact
with the blood-vessels, and miliary aneurisms are liable to be found.

. Etiology.—In a general way it may be stated that the so-called
“active” form of cerebral hyperemia is dependent upon any cause that
tends to increase the arterial supply of the brain or its coverings without
interfering with the venous return from the vessels within the skull, and
that the “ passive’ variety results from defective venous return, irre-
spective of the arterial supply This axiom is not strictly true in all
cases, because the passive form may develop as a secondary result of the
active; but it will hold good in the majority of cases and prove of assist-
ance often in diagnosis.
HYPERZMIA OF THE BRAIN AND ITS COVERINGS. 241

Tue Active Variety (cerebral jlurion)—A heated atmosphere is
often a factor in the development of the active variety. The passive
form, on the other hand, is more frequent in extremely cold weather, as
sustained by the observations of Andral and Hammond; but cold may
induce either variety.

An increased heart’s action (as in the case of fevers, mental excite-
ment, severe physical exertion, and cardiac hypertrophy) may be an
important factor in producing the active or “fluxionary ” type.

Again, the cerebral arteries may possess weak: walls; so that they
yield to an increased pressure of blood sooner than the rest of the
arterial system, thus causing what is termed a ‘‘rush of blood to the
head.”

As a fourth factor, tnereased lateral pressure within the carotids
may be mentioned. This occurs in connection with constriction of the
thoracic or abdominal aorta, or compression of the abdominal aorta by
distended intestines or abdominal tumors, and of the thoracic portion
of that vessel by mediastinal growths, emphysema, etc. The effect of
cold upon the surface of the body, which checks the determination of
blood to the skin and drives an excess of blood to the viscera, may also
be evidenced in the cerebral vessels.

Again, vaso-motor paralysis may induce active cerebral hy peramia.
An excess of alcohol, indulgence in some drugs, malarial poisoning, pro-
longed mental labor, and emotional excitement may also lead to this
condition. Opium-eaters and drunkards have chronic cerebral hyper-
einia, as a rule.

Finally, cerebral atrophy may possibly be associated with that form
of cerebral hyperemia which is occasionally encountered during con-
valescence from severe attacks of illness.

Tus Passive Variety (cerebral congestion) must of necessity depend
to a great extent upon causes that interfere with the return of blood from
the cerebral sinuses. Among these conditions the following may be
prominently mentioned :—

1. Compression of the Jugulars.—This may be induced by wearing
of tight clothing around the neck, enlargement of the thyroid or the
lymphatic glands, new growths in the neck, or by strangulation, etc.

2. A Dependent Position of the Head.-—Acrobats are not infrequently
attacked with cerebral congestion. Any labor performed with the head
down, or with the body in a stooping posture, may induce it. Attacks
_ have been brought about by straining at stool or the buttoning of the shoes.
3. Violent Expiratory Efforts——Playing upon wind instruments,
severe paroxysms of coughing, etc., tend to prevent the entrance of blood
into the chest, and thus to force too much blood into the general circula-
tion. Such acts may prove an exciting cause of this condition.

16,
2A2, LECTURES ON NERVOUS DISEASES.

4. Valvular Disease of the Heart.--When valvular defect exists at
the mitral or aortic orifices, sufficient hypertrophy of the auricle or
ventricle may be developed te compensate for the deficiency. In this
case the organ exhibits no marked impairment of its function; but,
when the compensation is disproportionate to the valvular lesion, the
return of blood from the head is seriously interfered with. Under such
circumstances anything that tends to over-excite or weaken the heart’s
action produces marked cerebral disturbances.

5. Symptoms of cerebral congestion are occasionally developed as

 

 

Fic. 78.—DIAGRAM OF A TRANSVERSE VERTICAL SECTION OF THE Lerr CEREBKAL HemI-
SPHERE, SHOWING THE ARTERIAL DistriguTion. (Modified slightly from Westbrook.)
1, arteries ramifying in the pia, and sending off cortical and medullary branches ; 2, gray
matter of cortex; 3, corpus callosum; 4, cavity of the ventricle; 5, caudate nucleus;
6, 6’, 6/7, members of lenticular nucleus (Glieder) ; 7, internal capsule; 8, septum ; 9, optic
chiasm ; 10, arteries from circle of Willis, sending branches to basal ganglia ; 11, convolu-
tions of Island of Reil; 12, claustrum.
the result of plethora, caused by excess in eating or drinking. It is
questionable to my mind if this form is not always associated with some
organic changes in the arteries —prolably of the atheromatous type.

6. Persistent Anriely or Emotional Barcitement.—This is perhaps the
most common and potent of all the etiological factors of cerebral conges-
tion. The prolonged activity of the brain protracts the determination.
of blood to the head (which is requisite to maintain that activity) beyond
its proper limits. The continued over-distension of the cerebral vessels
causes the coats to lose their contractility, and thus active hyperamia
(which at first existed) becomes passive. Examples of the marked
HYPERZEMIA OF THE BRAIN AND ITS COVERINGS. 243

effect of emotions upon the circulation of the head are well exhibited in
the turgid face of unger, the blush of shame, and the pallor of fear.

1, Hye-strain (from an uncorrected refractive error or imperfect
adjustment of the ocular muscles) often tends to excite and to maintain
passive cerebral hyperemin, This, in my experience, is 2 very common
cause.

Symptoms.—The manifestations of the active and passive varieties
ditfer markedly. Some authors describe the symptomatology of cerebral
congestion as capable of being divided into two stages,—those of active
hyperemia constituting the first, and those of passive hypersmia the
second. It seems to me illogical, although perhaps it is clinically true in
a certain proportion of cases.

The active form is an independent condition. It muy be transient ;
and is not invariably followed by the passive variety. It is, moreover,
chiefly if not exclusively encountered in those subjects that have suffered
from prolonged anxiety, emotional excitement, or mental strain that we
meet the two as consecutive stages.

Galton first called attention to the utility of an examination of the
drum of the ear asa means of determining the existence of cerebral con-
gestion, and Hammond and Roosa have used it as a guide to the con-
dition of the intracranial circulation in. their experiments with the
internal administration of quinine. I have had reason in several
instances to acknowledge the utility of this step. It is necessary in
many cases to clear the ear of wax before the drum can be utilized for
this purpose. The tympanum will be congested over the handle of the
malleus and be pink in color when cerebral hyperemia exists,

Symptoms or tHE Active Variety.—The cause of the hyperemia
will modify the symptoms in each individual case. There is a wide-
spread error (often injurious to the patient) that all cerebral disturbances
which cannot be traced to some definite cause must be dependent upon
hyperemia or anemia of the brain or its coverings. That this is an
error is proven conclusively by the fact that the quality of the blood as
well as its quantity may exert an influence upon the cerebral functions
(as clinically observed in fevers, poisoning by alcohol, drugs, etc.), and
that a general overheating of the body may produce the symptoms of
sunstroke without actual exposure to the sun’s rays. The cerebral
hyperemia which accompanies alcoholism, for example, plays probably
but an insignificant part in the development of the symptoms of that
condition, provided the use of alcohol has been long continued.

_ The symptoms of cerebral hyperemia may be classified under two
heads, viz., those dependent upon cerebral irritation and those indicative
of cerebral depression.

Under the former, the following may be prominently mentioned:
244 LECTURES ON NERVOUS DISEASES.

1, headache, which may be more or less severe and sioonmesied by
dyobbing: ; 2, an increased sensitiveness to light or sound ; 8, abnormal
phenomena connected with the special senses, such as spare before the
eyes, buzzing in the ears, formication in the limbs, and ill-defined pains;
4, motory symptoms, such as restlessness, vertigo, muscular startings,
saan of the teeth, vomiting, convulsions, etc.; 5, disturbance of the
psychical functions, such as hallucinations, Hluaians, delusions, melan-
cholia, etc.; 6, persistent insomnia, which is perhaps more marked than
any symptom in most cases; and 7, loss of control over the emotions.
These patients are apt to talk a great deal, and to exhibit other mani-
festations of mental exaltation.

The effects of cerebral depression may be indicated by any of the
following symptoms: 1, insensitiveness to external irritation, such as a
bright light, loud noises, etc.; 2, an altered condition of the pupils; 3,
sluggishness of the intellectual faculties; 4, slowness of muscular
movements, which may go on to paresis or paralysis; 5, marked somno-
lence, possibly deepening into coma; and 6, slowing and deepening of
the breathing, which muy become stertorous.

In all cases, the symptoms are increased by the recumbent posture,
by deep inspirations, and by stimulants.

All possible combinations of the symptoms of either of the two
varieties described may be encountered in any individual case. Some of
the more important deserve special mention.

Tnsomaia isa very common symptom of cerebral irritation. If sleep
is not actually prevented, it is liable to be markedly disturbed by bad
dreams and fails to refresh the patient.

Headache and throbbing in the head is a very constant symptom.
The pain may be either of a dull, aching character, or extremely severe.
It is greatly aggravated by stooping, deep inspirations, or muscular and
mental exertion. Stimulants usually increase it. In many cases com-
pression of the carotids relieves it.

Prolonged mental efforts bring about a confusion of intellect early,
in many cases. This is particularly noticeable when mental exercises
requiring concentration, such as adding up columns of’ figures, solving
of mathematical problems, reading of philosophical works, etc., are
attempted. To this symptom may sometimes be superadded delusions,
illusions, hallucinations, melancholia, morbid fears, and « loss of emo-
tional control.

Vertigo is a very constant and important symptom. It may be se
severe as to prevent the patient from attending to his business. It may,
furthermore, be associated with unnatural sensations in the head, such as
a sense of constriction, a snapping noise, an encircling band, a burning
sensation, ete.
 

HYPERHEMIA OF THE BRAIN AND ITS COVERINGS. 245

The motory symploms are sometimes contined to one side, but this is
not always the case. Paresis or actual paralysis sometimes develops
suddenly in an arm or leg, or both. All of the limbs are simultaneously
atfected in rare cases. Convulsive twitchings may develop in the muscles
of the face and limbs. The heart is lable to exhibit a marked accelera-
tion in the frequency of its beats after slight exertion, and to develop
paroxysms of palpitation. This is independent of any organic lesion,
and is to be attributed to cerebral disturbance. Respiration may become
similarly disturbed when the heart becomes unduly excited. Aphasia
is sometimes developed, either independently of or in conjunction with
paralysis of the limbs. It is usually transient. Convulsions may occur
in the advanced stages of cerebral hyperawmia. They differ from those
of epilepsy in the absence of sn aura and the epileptic ery.

The psychical symptoms are sometimes prominent. A gradual
stupor may develop in some cases, accompanied with pain in the bead and
dilated pupils. Again, mania may occur, with active deliriuin and a
tendency to acts of violence. These states, however, are preceded in
every case by some of the premonitory symptoms that have been pre-
viously enumerated.

SYMPruMs OF THE PasstvE Varrery._The symptoms of irritation
are less marked in this form than those of cerebral depression. Although
all of those enumerated in previous pages may occur in the passive
variety as well as in the active, it is more common to meet with somno-
lence early instead of insomnia, and to find all the irritative symptoms
subordinate.

Whenever the congestion is attended with an exudation of serum
we are liable to encounter paralysis, convulsions, deep coma, maniacal
attacks, or aphasia. This form of hyperemia is more liable to serous
effusion than the active, and is therefore a more serious disease.

Passive cerebral hyperemia is particularly prone to pass into that
stage where alarming symptoms appear. It is not. uncommonly fatal.
In some cases it induces a condition of body that is diagnosed with diffi-
culty from apoplexy.

If convulsions develop, they are generally of longer duration than
if due to active hyperemia, and are followed by a more profound stupor.
The tongue may be severely bitten. The fit may be followed by paralysis.
The mind appears to suffer rapid deterioration after the convulsive
attacks develop.

Whenever mania ensues the patient seldom exhibits as active
delirium as in the previous form of cerebral hyperemia, nor are acts of
violence as common.

The ophthalmoscope will usually show a marked turgescence of the
retinal veins in this form of cerebral hy perzmia.
246 LECTURES ON NERVOUS DISEASES.

Differential Diagnosis.—The history and examination of the patient
is an important factor, because it aids in deciding as to the existence of
hysteria, chlorosis, alcoholism, venereal excesses, seminal weakness, dis-
vuses of the heart, lungs, or abdominal viscera, and many other conditions
that often tend toward the development of cerebral hyperaainia,

From cerebral hemorrhage this condition differs in that conscious-
ness is seldom completely abolished; that the paralysis is not unilateral
asarule; that sensation and motion are seldom simultaneously impaired
or lost; and that the symptoms are of shorter duration.

From embolism, it differs in that premonitory symptoms have existed ;
that the paralysis is of shortcr duration; that the pulse is slowed rather
than accelerated at the time of the attack; that the temperature of the
head is elevated; and that cardiac disease is usually present in embolism.

From epilepsy it is to be told by the absence of an aura and of the
epileptic cry; the existence of premonitory;symptoms; the staggering
before an attack; the absence of facial pallor before the fit; and the in-
frequent biting of the tongue.

From uremia the diagnosis is made by the waxy pallor of the face
in renal disease; also the absence of albumen and casts in the urine;
the infrequency of nausea or vomiting; the absence of cedema of the
eyelids and possibly of the extremities, and the infrequent convulsions.

From cerebral softening it is distinguished by the aggravated char-
acter of mental impairment of that malady, together with the progressive
interference with articulate speech. The gradual onset of paralysis pre-
ceded by feebleness of gait in some cases, and the development of a
persistent hemiplegia with a sudden loss of consciousness would point
to the more grievous malady.

From stomachic vertigo, the presence of marked gastric derange-
ment in connection with such attacks of dizziness (which is often
wanting in congestive vertigo) aids in the, diagnosis.

Treatment.—The multiplicity of causes of this affection would nat-
urally suggest that the treatment must be modified by the history of the
patient. It is important, furthermore, that the dinenosis be carefully
made before any line of treatment is commenced. This is not always an
easy matter. It is especially difficult in some cases to decide between
cerebral hyperemia and anemia.

The AcTIVE VARIETY requires neasures that will tend to lessen the
action of the heart and diminish the quantity of blood in the cerebral
vessels, Leeches to the temporal region or within the nostril, or at the
neck close to the skull, will often prove of immediate benefit. The actual
cautery applied to the neck near to the base of the brain, and the gal-
vanic current so used as to stimulate the main sympathetic nerves in
the neck, both tend to cause 2 diminution in the calibre of the cerebral
HYPEREMIA OF THE BRAIN AND ITS COVERINGS. 247

vessels, and are therefore useful. My experience with the cautery has
led me to believe that it is more prompt in its effects than any other
single remedial measure. It is comparatively painless when properly
used. Heavy static sparks from Leyden-jars applied to the neck are
sometimes of great benefit.

Sleeping with the head raised (especially with the arms placed above
the head) will help to decrease the amount of blood in the brain. Stooping
should be avoided. Severe muscular exercise increases the heart's
action; hence it should be prohibited in this class of cases. The clothes
should not press tightly upon the neck, as it tends to impede the venous
return from the head.

Warm baths to the feet, mustard plasters over the stomach, and
cold effusions to the head and neck are valuable adjuncts to treatment
in some instances, since they all tend to decrease the amount of blood in
the cranial vessels,

Among the internal remedies employed by me in this allection (after
all recognizable causes have been removed without a cessation of the
symptoms) are the bromides of sodium and potussium, ergot, oxide of

- zine, phosphorus, strychnia, and arsenic. The internal administration of
hot water, according to the rules given in my paper upon this agent,*
is often attended with great benefit.

The bromides and the ergot exert an immediate effect upon the
amount of blood within the cerebral vessels, causing a very marked
decrease, as was first proven experimentally by Hammond. I have found
ergot a very valuable adjunct to the bromides. They are best given by
dissolving the bromide in a fluid extract of ergot. The following formula
is an excellent one :—

BR. Potasii bromidi ped DR Oty ag te & BQ
Ergote ext. fluidi 2... ..........2.. $iv.
M. Ft. sol.

Sig.—Dose, a teaspoonful after each meal.

In place of ergot, ergotin may be substituted (in doses of five grains)
in pill three times a day, where the taste of the fluid extract is disa-
greeable to the patient.

Iam inclined to lay stress upon the beneficial effect of the oxide of
zinc, When given in connection with ergot, the bromides, and the hot-
water treatment, which will be described later. It should be given three
times a day (in doses of two grains) in pill after eating, as it is less liable
then to cause nausea. By the use of these three drugs and hot water as
a beverage the symptoms will usually disappear inside of two weeks.
It is then advisable to begin a course of tonic treatment.

The tonics that are commonly employed are quinine, strychnia,
arsenious acid and other arsenic preparations, hydrobromic acid, and

* N.Y. Med. Jour., October 17, 1884.
248 LECTURES ON NERVOUS DISEASES.

phosphorus. I have used Warburg’s tincture with exccllent effects in
doses. of from one to two drachms after each meal.

In regard to quinine, I have tried the hydrobromic acid with good
results in combination. It undoubtedly relieves the unpleasant head-
symptoms of the quinine.

Phosphorus should be given, when indicated, in doses varying from
one-fiftieth to one-hundredth of a grain. It may be administered either
in an emulsion, a capsule, a pill (by the aid of resin), or in the form of
the phosphide of zinc.

Arsenious acid is highly recommended, in doses of one-fiftieth of a
grain, as a substitute for other arsenical preparations. My experience
with it is too limited as yet to enable me to furm any positive conclusion
regarding it.

Dyspeptic symptoms should be treated by keeping the bowels open
and the continued use of hot water as a beveraye, a gobletful being
drank one hour and a-half before each meal, with the temperature as
high as it ean be borne (110°-150°). Twenty minutes may be consumed
in sipping a goblet-full when necessary.

Irrespective of dyspeptic symptoms, I have been in the habit, how-
ever, of recommending this treatment to nearly all of my nervous
patients. Its effects have proven quite remarkable in my hands. It
increases downward peristalsis, which warm water does not (as the latter
is an emetic); it stimulates the secretion of urine, and alters its character
with great rapidity; it produces a gentle perspiration after drinking it,
and a sense of warmth in the skin; it relieves dyspeptic symptoms better
than chareoal and bismuth, if continued long enough; finally, it seems
to act upon the sympathetic system (probably by affecting the solar
plexus), as is shown by the relief of most forms of local hyperemia. It
must be taken, however, with absolute regularity, one hour and a-half
before every meal, so as to get the effect of the heat and to wash out the
stomach before the ingestion of food. A little lemon or flavoring of any
kind may be added, if the taste is disagreeable; although patients soon
learn to crave it without such additions. Carlshad salts may be added
to the morning dose, if constipation exists. In some cases it becomes
necessary to restrict certain articles of food during the hot-water treat-
ment. I have published the methods employed by me in full in a
brochure* upon the subject, to which the reader is referred.

In the PAsstVE VARIETY of cerebral hyperemia the indications for
treatment are to increase the heart's power and assist the venous retum
from the cerebral sinuses.

Stimulants are strongly indicated, therefore, in many cases, in con-
junction with the other methods of treatment previously suggested to

* N.Y. lcd. Jour., October 16, 1884.
ANEMIA OF THE BRAIN AND IVS MEMBRANES. 2A9

relieve the congestion of the vessels. Alcohol, sulphuric ether (hy
inhalation or the stomach), carbonate of ammonia, and digitalis uny be
employed often with marked benctit.

The habits of the patient should be controlled, provided that excesses
of any kind exist, and are thought to be injurious, Tobacco, ten, coffee,
opium, etc., may be factors both in the causation and persistence of the
cerebral congestion.

Success in treatment of passive cerebral hyperemia will depend
chiefly upon the removal of the exciting cause of the condition. It
should be coupled with such advice as to exercise, mental work, bathing,
eating, drinking, etc., as will tend to prevent its return by promoting a
general improvement in health.

Static insulation and a fusillade of sparks to the spine seem to give
these patients relief. I often employ the umbrella-head-electrode in these
cases with satisfactory results. The static machine used must be sufli-
ciently powerful (when this is employed) to generate large quantities of
electricity.

ANEMIA OF THE BRAIN AND ITS MEMBRANES.

Kussmaul, Donders, and Tenner have observed the phenomena of
marked cerebral anemia through a glass plate inserted in the skull of
animals; and Nothnagel, Loven, Mayer, and Pribam, and many others
have proven the possibility of artificially producing it. These facts are
mentioned because, for a time, the existence of this condition asa dis-
tinct disease was denied. Cerebral anseemia may be localized or general.
The latter is the most common variety. The symptoms of this condition
are modified (1) by the variety and (2) by the method of its development
(whether sudden or gradual), irrespective of its intensity.

Morbid Anatomy.—The meningeal vessels are usually nearly empty ;
although, in some cases, meningeal hyperzemia may coexist with cerebral
anemia, The pia usually contains some serum in its meshes. The
medullary substance of the brain is of a dull, white color, and presents on
section few, if any, vascular spots. The masses of gray substance are
poorly defined in their outline, in sagittal or transverse sections of the
brain. They are dryer and firmer than normal, in case the anemia has
persisted for some time, or when it exists in connection with general
anemia or chlorosis.

In connection with partial cerebral aneemia it is common to find the
adjacent areas markedly hyperemic. This hyperemia may occasionally
exist also in parts somewhat removed from the anemic territory. It is
due to excessive arterial tension in the vessels whose supply is not inter-
fered with.

If the condition of cerebral anemia has been developed as 4 result
250 LECTURES ON NERVOUS DISEASES.

vf localized pressure (as in the case of cerebral tumors, large extravasa-
tions of blood, encephalitis, etc.) the conyolutions of the brain may be
flattened or otherwise distorted.

According to the researches of Golgi, in all forms of cerebral anemia
the perivascular spaces are enlarged, even if adeima le present.

Etiology.-—‘The causes of this condition, when widely diffused or
partial, can be classified under several heads, as follow :—

1. Those Causing a Diminution of the Space Within the Skull.—Under
this head may be mentioned all forms of exudation, new growths, and
blood extravasations. Tumors and blood extravasations tend to produce
definitely localized pressure upon the adjacent areas of the brain. Exu-
dations (when very extensive) may result in a more diffused pressure.
The brain may be more or less distorted in its outlines from all of these
causes.

9, Compression or Obstruction of the Arteries that Supply the Brain
with Blood.—_Under this head come embolism, thrombosis, ligation, aneu-
rism, pressure of new growths upon the vessels, ete. Fortunately for life,
the “circle of Willis” allows of a collateral circulation in case of ligation
or other causes of obstruction to the vessels of one side of the neck.
Ligation of both carotids or a severe loss of blood from any large artery or
vein is followed invariably by the symptoms of general cerebral anemia.

The circle of Willis unquestionably prevents in the majority of sub-
jects general cortical anzemia of one hemisphere, in case of ligation of
the carotid or other obstruction to its calibre. But it is questionable if
the basal ganglia are not more liable to ischaimia from such causes than
the cortex. The anastomoses are less frequent in these gray nuclei than
upon the surface of the cerebrum, and sometimes the branches of the
circle of Willis are impervious or imperfectly developed. Ehrmann
found about 20 per cent. of cases (selected at random) to exhibit defects
in the vessels mentioned.

3. Overloadiny of Other Organs with Blood.—Scvere catharsis, eXx-
tensive dry cupping, an enfeebled heart’s action, and simple gravity may
induce cerebral anemia. As an illustration of the last cnuse, conva-
lescents from protracted fevers or dclilitating diseases often faint when
they attempt to sit up.

4. Direct Abstraction of Blood from the Brain.—In case of a severe
hemorrhage from some vessel of the trunk or extremities, the brain is
rendered anemic early,

I have witnessed in a few instances the must profound symptoms of
cerebral anvemia in connection with severe epistaxis, metrorrhagia, intes-
tinal hemorrhage, and after an operation for hemorrhoids. The applica-
tion of Junod’s boot may deprive the brain of its blood, and thus induce
cerebral anemia mechanically.
ANAMIA OF THE BRAIN AND ITS MEMBRANES. 201

5. Poverty of the Blood.—In this case the amount of the blood
within the cerebral vessels may be normal, and still the brain be anemic
because the quality of the blood fails to properly nourish it. Examples
of this are encountered in bottle-fed babies, and in connection with the
fevers, leukemia, chlorosis, tuberculosis, malarial cachexia, prolonged
lactation, chronic suppuration, starvation, ete.

6. Vasu-motor Disturbance.—Stroug and sudden emotions, shock,
cerebral concussion, electric stimulation of the sympathetic cords, ete.,
are not infrequently followed by symptoms of cerebral wuewinia, such as
pallor, vertigo, insensibility of some of the special senses, and a weak-
ness of the action of the heart.

Symptoms.—It is important but not always an easy matter to diag-
nose cerebral anemia from the condition of ‘cerebral hyperemia. Not
only is this discrimination important from a scientific standpoint, but the
life of the patient may be imperilled by an error in diagnosis (especially
in infancy) because the treatment of the two conditions is directly opposed.

Sudden cerebral anemia produces symptoms that differ from those
of the form which is gradually developed. In the former a “ fainting
fit” is produced. An attack of this character usually begins with dizzi-
ness, 4 sense of impaired vision, and a loss of the normal appreciation of
sensory impressions. The patient becomes incapable of voluntary move-
ment, gradually sinks to the ground and loses consciousness. The pupils
dilate, the face becomes pale, the respirations are slow and shallow, and
slight spasms of the muscles occur. Gradually the patient regains con-
sciousness, and the other symptoms slowly disappear. In rare cases,
however, death ensues without a return of consciousness.

In infants, cerebral anemia is liable to be confounded with acute
hydrocephalus. The child is restless and capricious; tosses about,
gnashes the teeth, and cries out in sleep. The face is often flushed in the
early stages, but tends to become pale. The temperature and pulse may
be increased. Sleep is interrupted by attacks of crying in many in-
stances. Twitchings of the limbs and even convulsions are liable to be
developed. The fontanelle is depressed. Later in the attack the patient
becomes insensible to light, noises, or objects held before the eyes; the
eyelids remain half closed; the pupils, which were contracted in the early
stage, now become dilated ; the pulse flutters and is irregular; the respira-
tion grows shallow, noisy, and infrequent; the sphincters are not con-
trolled; and death comes at last, preceded by complete coma. Stralvis-
mus and rigidity of the muscles at the nape of the neck may occasionally
be observed during the attack.

In older patients the symptoms of gradual development of cerebral
anemia differ (1) with the variety present—general or partial—and (2)
with the severity (so to speak) of the anemia,
259 LECTURES ON NERVOUS DISEASES.

The more prominent signs of the general variety are headache, ver-
tigo, nausea, dimness of vision, and fainting or convulsive attacks.
Muscular weakness, drowsiness, flashes of light before the eyes, roarings
in the ears, a dread of mental or physical effort, tremor after exercise,
and mental confusion may precede the attacks of syncope or convulsions,

The partial variety is commonly due to tumors, edema, embolism,
or thrombosis. The symptoms will vary with the area of the brain that
is rendered anwmic. Motor paralysis (monoplegia or hemiplegia) may
follow if the cortex of the “motor area” of the cerebrum is deprived of its
nutrition. Again, aphasia may be the result of anwmia of the base of the
third frontal convolution, the island of Reil, or the adjacent medullary
substance. Vision may be impaired if the cortex of the occipital convo-
lutions are affected or the other mass of gray matter with which the
optic fibres are known to be associated. Finally hearing or smell may be
impaired by anzemia of the temporal lobes, and tactile sensibility may be
impaired if the parietal cortex be deprived of its normal blood-supply.
Fig. 5 will enable the resder to appreciave the grounds for these state-
ments. Some of the more important points in cerebral localization will
be discussed later, chiefly in connection with cerebral hemorrhage.

Delirium and hallucinations are not infrequently observed in con-
nection with cerebral anemia. Occasionally the delirium may assume a
maniacal type. In other instances melancholia may be a prominent
symptom.

Nothnagel states that smell and taste are never affected in cases of
cerebral anemia, My own experience leads me to doubt the accuracy
of this statement. It is more common to observe symptoms referable
to the optic and acoustic apparatus, but hyperosmia and hypergeusia
have been present in some cases that have fallen under my observation.

Differential Diagnosis.—The diseases most lialle to be confounded
with general cerebral anzemia are cerebral hyperemia and hydrocephalus.

From cerebral hyperemia the diagnosis is often difficult. The ap-
parent cause is an important fictor in the discrimination. Moreover, the
pallor of the face, the fainting attacks, the dimness of vision, and drow-
siness are characteristic of anemia. The ophthalmoscope may enable
the physician to detect anemia of the retinal vessels. The vertigo of
anemia is diminished by a reeumbent posture, and increased by stand-
ing. Finally, the effects of stimulants and the inhalation of a few drops
of the nitrite of amyl will be markedly beneficial in anzemia, while such
agents will increase the symptoms of congestion.

From hydrocephalus the diagnosis is to be made hy the absence of a
history of tuberculosis in the parents, the presence of some of the ex-
citing causes of anemia, and the age of the subject. There is probably
little difference in the two diseases, as far as the condition of the cere-
ANAIMIA OF THE BRAIN AND ITS MEMBRANES. 253

bral vessels is concerned. The tubercular deposit at the base of the
brain in hydrocephalus undoubtedly produces most of its effects by
pressure upon the cerebral vessels,

Prognosis.—In adults, the prognosis in cerebral aniinia is favorable
if we are able to relieve the exciting cause. In children, cerebral anaemia
may prove fatal if following an exhausting diarrhoea, marasmus, or
debility. Kussmaul states that when the pupils have become dilated
areturn of the mobility is a favorable omen.

Treatment.—The indications for treatment vary with the exciting
cause. Stimulants and the inhalation of from four to eight drops of the
nitrite of amyl three times a day by an adult will generally cause a rapid
improvement in the symptoms after the cause has been removed. Alco-
holic liquors should be given in small doses, and repeated frequently till
the heart-power is increased and the symptoms show improvement.
They should not be pushed beyond reasonable limits. he diffusible
stimulants are only advisable when a rapid effect is sought for, or when
alcohol disagrecs with the patient. Opium tends to increase the flow of
blood toe the head; hence it is sometimes very happy in its effects when
administered in one-quarter-grain doses three times a day for a few weeks,

When anemia of the blood exists, iron and some of the bitter tonics
are of great benefit. If hemorrhage has been a factor in the case, the
recumbent posture should be maintained rigorously until the pstient has
regained strength and manufactured blood to fill the depleted vessels.

 

Tying the arms and legs after a serious hemorrhage, in order to force
the blood to the head, may sometimes be demanded. Raising the foot
of the bed, upon which the patient is lying, upon two chairs will also
help to detemnine blood to the brain. In obstetric practice, this
manceuvre is often employed to arrest the brain symptoms after flooding.

During convalescence, restrictions regarding excessive physical or
mental exercise should be placed upon the patient. All forms of excite-
ment should be avoided. J have twice known insanity to follow emotional
excitement, after.this condition of cerebral anwmia has existed to marked
degree.

The advisability of employing galvanism, although sustained by
Hammond and other authorities of note, is to my mind questionable.
Personally, I have seldom observed any decidedly bencficial ettects
from its use. Whenever it is employed, the current should. as a rule, be
an extremely mild one, and the duration of its employment short. I
greatly prefer static insulation, followed by sparks to the nape of the
neck, when such applications are feasible.

Finally, care in regulating the dict and the functions of the abdominal
organs is very essential to a complete recovery. I would again urge
here the use of the hot-water treatment, which I have described on a
254 LECTURES ON NERVOUS DISEASES.

previous page in discussing cerebral hyperemia. Any form of disturb-
ance of the circulatory apparatus scems to be modified and generally.
improved by the action of heat upon the solar plexus. The treatment
of the most important symptom of partial cerebral anemia (aphasia) has
been considered under the treatment of cerebral embolism.

CEREBRAL HEMORRHAGE,

The blood-vessels of the meninges or of the brain sometimes rupture,
and thus allow of an escape of blood into adjacent structure.

If the extravasation be meningeal, its effects are exerted chiefly
upon the gray matter of the convolutions (the cerebral cortex). If
within the substance of the cerebrum, tracts of fibres are torn across by
the escaping blood, and are thus separated from their connection with
the cortical cells,

Intra-cerebral hemorrhages may exert pressure-etfects upon the
ventricles, in case the blood fails to enter these cavities, and thus create
a more or less complete obstruction to the ingress and egress of the
cerebro-spinal fluid.

Because the symptoms of pressure upon the different parts of the
brain are observed in patients atiicted with tumors, depressed bone,
abscess, and extensive exudation, as well as in connection with hemor-
rhage, any remarks made in reference to the localization of blood-clots
applies as well to many of these conditions.

Morbid Anatomy.-—The middle meningeal artery is the most
frequent source of surface hemorrhage—the extravasation that occurs
in connection with pachymeningitis being excluded from this head, as it
is of inflammatory origin. This vessel of the brain is particularly liable
to be involved in direct injuries to the cranial vault. Its area of distri-
bution to the meninges corresponds approximately to that portion of the
cerebral cortex which contains the motor centres (see Fig. 5). For this
reason the blood extravasated from that vessel is particularly prone to
press upon the motor convolutions beneath. Actual damage may be
done to these cortical centres if the blood escapes in suflicient quantities
to impair the structural integrity of parts beneath the clot. Otherwise
the cortex is rendered simply anemic at the seat of pressure. It may
regain its function, in such x case, when the pressure is relieved by the
use of trephine or the gradual absorption of the clot.

Structural changes in the motor convolution are abnost invariably
followed by a descending sclerosis of those fibres that are anatomically
associated with the cortical cells destroyed. This sclerosis can often be
traced into the substance of the spinal cord. In this way the motor
function of Tureck’s columns and of the crossed pyramidal tracts in the
spinal cord (Fig. 2%) has been established beyond dispute.
CEREBRAL HEMORRHAGE. 255

The following simple diagram will possibly aid the reader in master-
ing the more essential anatomical facts that pertain to motor paralysis
of cerebral origin. It is designed purely for the purpose of teaching,
and must not be construed as a representation of the parts in their
proper relations to each other :—

motor COM Tn RB Ry,

  

 
 

 

5 LEVEL OF BRSE
-~4 OF CEREBRAL
(HEMISPHERES

REGION OF
THE CRUS

REGION OF
THE PONS

REGION OF
THE

MEDULLA

 

 

 

 

 

 

 

 

 

 

REGION OF
THE
SPINAL CORD

 

 

 

 

 

 

DIRECT PYRAMIDAL CROSSED PYRAMIDAL
FIBRES FIBRES

Fic. 79.—A DiaAGRaM DESIGNED BY THE AUTHOR TO ILLUSTRATE THE EFFECTS OF CORTICAL
AND Non-corticaL Lesions OF tHE CEREBRUM.

It, will be perceived that the motor convolutions of the cortex
contain special centres of motion (C.). From these centres fibres of the
so-called “pyramidal tracts ” can he traced through the medullary centre
ofeach hemisphere (the white matter of the cerebruin) to enter the posterior
half of the internal capsule that passes between the corpus striatum
(C. 8.) and the optic thalamus (O. 7.). At the level of the base of the
cerebrum these fibres are continued downward successively through the
crus cerebri, the pons varolii, the medulla, and into the spinal cord. At
26 LECTURES ON NERVOUS DISEASES,

the lower part of the medulla the pyramidal tracts undergo a change.
Some of the fibres (usually about 10 per cent.) pass down the same side
of the cord in Turck’s columns (sce Fig. 29). The remainder cross to
the opposite side of the cord and compose the so-called crossed pyramidal
columns of the cord (see Fig. 32).

Flechsig has shown that the percentage of crossed to direct pyra-
midal fibres varies in diflerent individuals, In a few cases all have been
observed to cross, and in other instances all have been seen to pass
directly into the cord without decussation. Both of these conditions,
however, must be regarded as exceptions to the rule. Cerebral lesions
that induce hemiplegia of the opposite side are commonly associated
with a more or less extensive paresis of the same side,* on account of the
direct pyramidal fibres. This paresis is, nevertheless, overshadowed by
the hemiplegia, and is often unrecognized for that reason. In those rare
cases where the hemiplegia is upon the same-side as the cerebral lesion
the direct pyramidal fibres are in excess of the crossed, if not exclusively
present.

Surface hemorrhages are sometimes observed in connection with
miliary aneurisms and thrombosis of the cerebral sinuses and_ the
meningeal veins; also as a result of a collateral circulation following
embolic occlusion of the middle cerebral artery. They may exist,
furthermore, around localized morbid processes, such as foci of soften-
ing, tumors, abscess, etc.

[ntra-cerebral hemorrhages may appear as small spots of discolora-
tion if due to a rupture of the capillary vessels; or, if the ruptured vessel
be a large one,as clotted masses within the white substance of the hemis-
pheres, the basal ganglia, the crnra cerebri, the pons, the cerebellum, and
the medulla. In some cases the ventricles are more or less filled with
blood. This is more liable to oeeur when ‘the caudate nuclei or the
thalami are involved.

The most common seat of intra-cerebral hemorrhage is within the
substance of the caudate and lenticular nuclei of the corpus striatum
and the thalamus of either hemispheres. The right side appears to be
more frequently affected than the lett, but the relative proportion is
nearly equal as regards the ganglia. The pons Varolii and cerebellum
are often the seat of clots.

The basal gangliaf of the cerebrum are nourished by vessels that pass

*The “direct pyramidal fibres? (Fig. 19) usually disappear in the middle dorsal seg-
ments. According to some observers a certain proportion of these fibres cross in the white
commissure of the cord, and after crossing become assoc iated with the cells of the anterior
horn. Ferrier seers to incline toward the view that ‘this is the rule rather than the
exception,—a deduction which I cannot fully accept as proven.

} A term applied to the corpora striata and the optic thalami because they are situated
ucur to the base of the cerebrum.
CEREBRAL HEMORRHAGE, 257

frem the circle of Willis through the anterior and posterior perforated
spaces. These ganglia lie in intimate relation with the paths of conduc-
tion of motor and sensory impulses. Whether any of the fibres of the
internal capsule are structurally related with the cells that compose these
ganglia is still a disputed point. The later investigations of Flechsig
seem to disprove it.

Clinically the question in dispute is of no umportance, because any
increase in size of these gray masses (as would oceur from a clot within
them) would inevitably cause pressure to a greater or less extent upon
the motor or sensory tracts of the internal capsule. Fig. 79 will make
this apparent.

Again the caudate nucleus of the corpus strintwuin and the thalamus
of each hemisphere enter into the formation of the ventricles ;* hence
any lesion of these ganglia would be liable to displace cerebro-spinal
fluid, Such a displacement is believed by Duret to account for the loss
of consciousness that usually uccompanies attacks of intracerebral
hemorrhage.

Again, certain fibres associated with the special senses of smell,
sight, hearing, taste, and tactile sensibility run in the internal capsule
and are liable to be destroyed by clots within the basal ganglia of the
cerebrum.

The method of recovery from an extravasation of blood into the
brain-substance is as follows: 1, the clot generally becomes encapsu-
lated. by the formation of a false membrane; 2, a serous exudation com-
bined with fatty metamorphosis softens and ‘dissolves the clot and the
débris of brain-tissue, and changes them into a.yellowish fluid ; 3, bands of
connective tissue form from the sides of the cyst so produced and traverse
it in all directions; +4, after a lapse of time these connective-tissue bands
contract and draw the sides of the cyst in apposition, the fluid contents
becoming absorbed to a greater or less extent; 5, a stellate and pig-
mented cicatrix often forms. Apoplectic cysts are formed, as a rule, in
about two months after tlie hemorrhage, in favorable cases.

I have already referred to the fact that secondary changes in nutri-
tion are observed, in the case of destruction of the cortical cells, when
the motor fibres are destroyed by intra-cerebral clots. We owe to Tiirek
our first intimation of these secondary sclerotic and degenerative changes
in nerve‘fibres. His discovery,f which was for a time buried in the
archives of the Vienna Academy of Sciences, has proved of inestimable
benefit to anatomists, since it enables them to trace the course of special

* Wilder doubts if the thalamus actually forms a part of the floor of the corresponding
. Jateral ventricle. i :

{A paper read in 1851 upon the results of pathological observation respecting the
results of old cerebral lesions.

17
BOS LECTURES ON NERVOUS DISEASES,

bundles of fibres within the substance of the brain and spinal cord. The
degenerated fibres become very distinctly outlined from the healthy
fibres in all transverse sections of the nerve-centres, and thus Nature

“3 <
<lo% <6",

2 So
CF Peorse?

    
 

va
LEFT \ Cf RIGHT
CAUS : : CRUS

PONS

eae . | ee i
EN elo aN,
: 22M,

12224. : MEDULLA

SPINAL CORD

  
 

i
|
©

S.C,
aes i.
is 8.¢ SPINAL
Or NERVES

Fic. 80.—A DiAGramMatic REPRESENTATION DESIGNED TO SHOW THE COURSE OF THE
Moror TRACTS AND THE EFFECTS OF LESIONS OF THE CRUS CEREBRI, Pons VAROLI, AND
MepuLtaA OsLonGaAra upon Moticiry. (Modified from Starr by the Author.) The
red fibres represent the motor fibres which govern facial movements. These decussate in
the middle of the pons. ‘The dZwe Adres ave connected with tongue movements. ‘These
decussate at a lower level in the pons. The Aurf/e fidres arethe motor tracts, which preside
over voluntary movements of the arms and legs. Some of these decussate at the lower level
of the medulla (the ‘‘ crossed pyramidal tracts’’), while.others do not decussate (the “direct
pyramidal tracts’’).

Each of these three bundles of fibres are associated with a group of motor cells atier
leaving the crus. he facial fibres terminate in the facial nuclei (/ #.); the tongue fibres
in the hypoglossal nuciei (%, 2.); the pyramidal tracts-in the cells of the anterior horns of
the spinal gray matter (s, ¢.).

A lesion at land 2 might affect any of these tracts separately, or various combinations of
the three might exist, and manifest its presence by a disturbance of motility without affect-
ing the sensibility of any part to imoressions of touch, pain or temperature. _ If the tongue,
face or limbs were paralyzed by such a lesion the parts would be deprived of motility upon
the same side,—that opposed to the seat of the lesion.

A lesion at 3 would cause facta diplegia. ‘This is at the middle level of the pons,—at
the rapha.

A lesion at 4 would cause Aypoglossal paralysis and hemiplegia af the opposed side.

A lesion at 5 would cause ézlateral paralysis of the tongue.

A lesion at 6 would cause wrotor paresis of both arms and legs, rather than a complete
paralysis of motion, The non-decussating pyramidal fibres would still be unimpaired ; °
hence some voluntary movements would be unaffected by the lesion.

Paralysis of the tongue, if unilateral, causes the tongue to deflect toward the paralyzed
side when protruded, if bilateral protrusion of the tongue becomes impossible, and chewing,
swallowing, and talking become very difhcult.

 
CEREBRAL HEMORRHAGE. 25Y

perfects a dissection that no human hand could possibly make. We
have been enabled to acquire of late many facts in anatomy which aid

RIGHT
CRUS

 

S2N | | SN

 

 

MEDULLE

SPINAL CORD

 

 

 

Fic. s1.—A Diacrammatic REPRESENTATION OF THE Course OF THE SENSORY TRACTS, AND
THE Errrcts of LESIONS INVOLVING THE SAME WITHIN THE CRUS CEREBRI AND THE
Meputta QOsroncata. (Modified from Starr by the Author, ) The red fibres represent
the sensory fibres of the face which pass to thecerebral hemispheres by means of the
pons and crus. They spring from two sets of nuclei (Vn and Vn’). The purple fibres repre-
sent the tracts for the ‘‘ muscular sense.’’ The blue fibres represent the tracts for the trans-
mission of impressions of touch, pain, and temperature. ‘he arrows indicate the direction
of the impulses carried by each set. -

Alesion at 1 (tegmentum of the crus orupper part of the pons Varolii) would cause 4ev22-
anesthesia of the opposite sidv of the face,and also of the opposed limbs, and the opposed
ee trunk, ‘The muscular sense might also be disturbed on the opposed lateral half
of the body.

A lesion at 2 or 3 (the lower part of pons in the formatio-reticularis or in the medulla)
would cause crossed hemianesthesia, the face being affected upon the side corresponding
to the seat of the lesion, and the body and limbs upon the side opposed to the lesion. -This
statement holds true to all lesions which affect the tract below the point of decussation of the
trigeminal fibres, viz., at the middle level of the pons.

us directly in determining the seat of localized lesions during life. Many
of these haye been mentioned in the first section of this volume. The
260 LECTURES ON NERVOUS DISEASES.

methods of research brought to professional notice by Turck, Flechsig,
Gudden, Fritsch, Witsig, and others have been of inestimable value in
the study of neuro-anatomy and neuro-physiology.

Apoplectic clots may assume two forms: (1) those where the blood
is collected into a circumscribed mass, a so-called “ apoplectic focus,”
and (2) those where minute points of capillary extravasation are slone
detected. :

Apoplectie foci vary in size from that of a small pea to that of a
large orange. They are commonly of the size of a hazel-nut, and are
usually more or less globular in form. When blood is extravasated
upon the surface of the cerebral hemispheres or into the substance of
the pons, the clot generally assumes the form of a disseminated layer
rather than a circumscribed mass. The number of foci that develop
simultaneously is apt to vary. Not infrequently homologous regions in
each hemisphere are attacked at the same time. Although it is the rule
to encounter a single focus, several may exist in different parts of a brain
and give unmistakable evidences of a simultaneaus formation.

Respecting the relative frequency of clots in different parts of the
cerebrum, Andral reports 386 cases, in which he found that the corpus
striatum was involved in 61, the optic thalamus in 35, the centrum ovale in
2T, and the centrum ovale and basal ganglia combined in 202.  Rosen-
thal gives the statistics of 103 autopsies at the Vienna General Hospital,
which show that the caudate nucleus ulone was involved in 32 cases,
the lenticular in 20, both nuclei of the corpus striatum in 8, the caudate
nucleus and the thalamus in 7, the optic thalamus alone in 20, eentrum
ovale in 3, parietal lobe in 2, lenticular nucleus and other parts in 6, the
basal vanglia of the two sides in 2. It thus appears that the lenticular
and caudate nuclei of the corpus striatum were attacked in a very large
percentage of all the cases, and that the thalamus ranks as the next most
frequent seat of apoplectic foci.

Etiology.— Vascular changes, in the vast majority of subjects, have
preceded a rupture of the cerebral vessels, unless it be dependent upon
traumatism. Among the conditions that tend toward rupture, miliary
aneurisms, atheroma, and fatty degeneration of the vessels stand fore-
most. ‘The various causes of cerebral thrombosis and embolism may
also indirectly produce a hemorrhaee. These have heen discussed in
previous paves,

Degenerations of the brain-substance may have preceded the rupture
of vessels. We not infrequently eucounter sudden paralytic symptoms
in connection with softening of the brain. In such cases, the softening
is accompanied by secondary hemorrhave.

Certain diseased conditions of the organs and tissues may be factors
in producing apoplectic extravasations. Among these may be mentioned
CEREBRAL HEMORRHAGE. 261

(1) simple hypertrophy of the left veutricle; (2) valvular lesions of the
heart; (3) chronic nephritis, which induces changes in the coats of blood-
vessels; (4) a congenital defect in the construction of the arterial coats
or miliary aneurisms; (5) compression of the jugular veins or the supe-
rior cava from tumors, aneurisim, cte.; (6) certain abnormal blood-con-
ditions (chlorosis, scurvy, syphilis, typhus, gout, chronic alcoholism,
Bright's disease, rheumatism, etc.).

Statistics show that age exerts a wnurked influence upon the develop-
ment of apoplexy. ‘The percentage increases gradually from the ave of
twenty to sixty.* It is rare before twenty except in infancy. After the
fiftieth year the relative percentage becomes very luree.

For some unexplained reason, a large proportion of cases are attacked
between the hours of three to five in the afternoon, and two to four in
the morning. Males are more commonly attacked than females. The
cold seasons of the year seem to be especially liable to induce cerebral
hemorrhage. The so-called plethoric habit bas little, if anything, to do
with apoplectic seizures.

Among the ereitiny causes of cerebral apoplexy may be mentioned
all mental or physical conditions which tend to increase the heart's
action or to suddenly intensify the blood-pressure.

Attacks of coughing or laughing; severe physical exercise; straining
at stool; over-indulgence in alcohol; sudden rage, vrief, or mental excite-
ment; the sexual act; a recumbent position of the head; the eating of a
hearty meal; the use of opium; a cold bath; and many other similar
occurrences have been reported factors in producing a rupture of an
artery whose walls haye been impaired by the predisposing causes
mentioned.

Symptoms.—Prodromal symptoms indicative of cerebral irritation
are frequent in subjects inclined toward apoplectic attacks.

A headache of a dull and ill-defined character is often present on
rising. Insomnia may have existed for some time. Vertigo may lave
been often noticed. The intellectual faculties are sometimes impaired to
a greater or less extent. There may be flushing or pallor of the face,
bleeding from the nose, ringing in the ears, persistent specks before the
eyes,t nausea or vomiting, irritability of temper, a sense of weight or of
numbness in the limbs, transient disturbance of speech, tremor of the
muscles, and disseminated pains of a neuralgic type. I regard epistaxis
in old subjects as a symptom of evil import,as arule. Ifit accompanies
the other prodromal phenomena of apoplexy it is particularly ominous.

* Loomis states that the increase of percentage never stops, and that the small number
of persons who live after seventy years is not taken into the computation by those who
limit the danger.

} These may be due to small extravasations into the retina.
962 LECTURES ON NERVOUS DISEASES.

It should be borne in mind that apoplectic attacks may often occur
without any of the prodromal symptoms enumerated. On the other
hand, it often happens that some of them have been persistent for a
greater or less period of time. The evidence drawn from statistics
regarding the prodromata of apoplexy are, to my mind, of little value as
a basis of diagnosis. Vertigo, epistaxis, headache, musce volitantes,
change in the disposition, a sense of weight or numbness in the limbs,
drowsiness, lethargy, ete., do not justify in every case the alarm which a
diagnosis of a liability to an apoplectic attack would necessarily create
in a patient. I regard attacks of thickness of speech, slight paralyses
of short duration, double vision from paresis .of the ocular muscles, ete.,
as possessing ereater clinical significance than the others; but even these
may be due to vascular disturbances which are not always followed by
cerebral hemorrhage. A physician cannot be too careful in expressing
un opinion calculated to excite anxicty and alarm either in the mind of a
patient or interested friends until the examination warrants a positive
diagnosis,

The actual symptoms of “apoplectic stroke,” as it is commonly

called, will be modified (1) hy the amount of blood that escapes. (2) by
the damage that it causes to the brain-cells or nerve-fibres, and (3) by the
seat of the clot.

The onset of an apoplectic attack may be sudden or gradual. The
situation of the clot and its size will determine the character of the
initial symptoms. Clots in the medulla, pons, or cerebellum are liable
to fell the patient to the ground without warning, as if struck by a blow,
even if the hemorrhage be small. A hemorrhage into the ventricles may
do the same, and, if extensive, may sometimes produce instantaneous
death. These cases do not produce the typical form of attack, however,
because they are less frequent than those where the hemorrhage occurs
in or upon the cerebral hemispheres. In many instances the coma comes
on gradually, and is preceded by pain in the head, nausea, confusion of
the intellect, dizziness, incoherent speech, and other of the prodromata
enumerated in preceding pages. Occasionally the attack is ushered in by
clonic convulsions, or by a paralysis of the arm, leg, face, eve. or some
other part. I recall a case where one of my patients was seized with a
weakness of the leg, which was followed hy paresis of the arm, then by
complete paralysis of that side, then by stupor which deepened rapidly
into Goma, and finally by convulsions before death ensued. I have met
cases where coma did not occur throughout the attack. Trousseau,
Andral, and others report similar instances.

The coma of apoplexy generally becomes profound, aad lasts for
hours or even days. The muscles are relaxed, the face is usually red or
cyanotic, the abolition of consciousness is complete, the head and eves
CEREBRAL HEMORRHAGE. 263

may be rotated to one side, the pupils are apt to be irregular, the tem-
peratare of the body falls to about 96.5°, the breathing may be regular
and quiet, or it may be RVENOEDUE finvlly, the urine and feces may he
passed involuntarily.

Although many theories have been advanced to explain the mechan-
ism of apoplectic attacks, I believe that all may be interpreted as result-
ing from the following conditions: (1) from the disturbance that the
lesion has created upon the intracranial circulation directly hy pressure;
(2) from the displacement of cerebro-spinal fluid from the ventricles or
the cranial cavity, thus disturbing the circulation of the organ in an indi-
rect way; (3) from an increase of intra-cerebral pressure; and (4) from
direct injury done to the nervous elements, and the irritation of sur-
rounding parts.

Respecting the duration of life in severe cases, Abercrombie reports
an instance where death occurred in five minutes after the attack; but,
asa rule, it seldom occurs before two or three hours, and it may he de-
layed for one or two days. Prolonged coma may induce pulmonary
cedema, and lesions of the medulla or pons may interfere with the vagus
nerve,and thus produce death. I have never observed a case of recovery
where the coma has lasted more than two days. A very marked rise in
temperature above the normal point is a very serious omen.

In favorable cases, consciousness is regained gradually after a short
interval of coma, which has lasted for only a few hours. The reflex ex-
citability of the limbs usually returns before consciousness, as detected
by irritating the skin with a pin or by tickling the soles of the feet. The
temperature of the body returns to the uormal standard. After the pa-
tient begins to exhibit evidences of consciousness, a sense of pain in the
head and of general discomfort is complained of; the answers to ques-
tions are inappropriate, or badly articulated; a drowsy condition per-
sists; the patient is apt to be apathetic, peevish, or surly; the movements
of the muscles not paralyzed are feeble; and, in some cases, delirium may
be developed. We are apt to encounter a rise of temperature on the
second, third, or fourth day, and other febrile manifestations. Pain in
the paralyzed limbs is frequently complained of by these patients. The
emotions are not well controlled. The appetite and the habit of normal
sleep: is not usually regained for some months. Whenever cerebritis is to
follow, the symptoms of that affection will usually be developed by the
beginning of the second week.

In order to interpret the more common symptoms, some knowledge
must be had of the functions of the component parts of the brain and
the course of the more important tracts of fibres. A close study of
Figs. 3 and 5 will aid the reader in appreciating the results of cortical
lesions. Subsequent diagrams will help to interpret the results of
264 LECTURES ON NERVOUS DISEASES.

pressure upon the fibres of the internal capsule. Lesions of the basal
ganglia, the crus cerebri, the pons, the cerebellum, and the medulla have
already been considered separately in this volume.
It may assist the reader if we start with the statement that the ex-
istence of suddenly-developed lesions within the cranial cavity may be
indicated by some or all of the following symptoms :—

Moror Pararysis, which will vary in its extent, duration, and

degree.
2. SENSORY PARALYsIS, Which will vary in its extent, duration, and
degree. :
3. DISTURBANCES OF CONSCIOUSNESS.
4. DistuRBANCES OF THE SPECTAL SENSES.
5. ABNORMAL ATTITUDE OF THE IT eaD AND HYEs.
6. TREMOR, which may present one of several forms.
7. CUANGES IN THE PUPits, PULSE, TEMPERATURE, AND RESPIRATION,
8. ABNORMAL PHENOMENA OF THE BuapperR, RecrumM, KipNey, ETc.
9. Menran IMPAIRMEN’.

In the first section of this work, attention has been called to some
of these symptoms. It is not necessary to repeat them here. A few of
the more important facts may, however, be summarized.

Cerebral lesions which affect the motor convolutions or the fibres
that spring from them induce either a monoplegia or a hemiplegia of the
opposite side.

The duration and degree of the paralysis will aid in determining the
severity of the structural chanues that the lesion has produced. Paraly-
sis of motion may be recognized, even when profound coma exists, by
tests that have been mentioned in previous pages.

Ifalimb is paralyzed it will drop inertly if raised. Tickling the
soles of the feet will often cause the patient, even when partially coma-
tose, to draw up the lower limbs when not paralyzed. If this fail, painful
impressions, as a pin thrust, will usually create sluggish movements in
comatose subjects if paralysis be absent,

MonopLecta, or that form of paralysis in which a distinct group of
muscles is paralyzed, indicates a circumscribed lesion that ¢mputrs the
free action of those cortical motor centres which preside over the mus-
cles affected, The type is n guide to the seat and extent of the lesion

g. 3).

A monoplegia may usually be diagnosed from paralysis of a spinal
nerve by the fact that the muscles paralyzed are not supplied by oue
nerve.

We encounter the ervwral type of monoplegia when the superior
parietal convolution of the opposite cerebral hemisphere is the seat of the
CEREBRAL HEMORRHAGE, P65

lesion, the brachial type in lesions of the upper part of the ascending
frontal and the base of the first and second froutal gyri,* and the fucial
type when the middle of the ascending frontal convolution is involved.
Lesions of the ascending parietal convolution are apt to produce a mono-
plegia of the hand, The covdrdinated movements of speech become
affected (aphasia of the motor type) when the base of third frontal gyrus,
the island of Reil, or the medullary substance which carries the fibres
connected with the cells of these regions, are affected by the lesion.
Figs. 3 and 24 will explain these deductions, and pages 50 and 51 relate
to this subject more fully than is deemed wise here. The late views of
Horsley are there reviewed.

HEMIPLEGIA, or paralysis of one lateral half of the body, may indi-
‘ate a lesion either of the brain or of the spinal cord.

If of cerebral origin, the lesion must affect the greater part of the
fibres which compose the pyramidal tract of the opposite side (Fig. 29);
hence it is seldom cortical, as it would have to be sufficiently large to
destroy the function of the entire motor area. As a rule the lesion is
confined either to the white substance of one cerebral hemisphere, the
basal ganglia, the internal capsule, the motor bundles of the crus and
pons, or the anterior pyramids of the medulla.

If the hemiplegia be of spinal origin, the lesion must be situated
high up in the cord (above the origin of the nerves to the upper ex-
tremity) and exert its effects upon the lateral half of the cord that cor-
responds to the motor paralysis.

In the first section of this work the varieties of motor paralysis
have already been discussed in a general way. Later in this volume, the
special types will be given further consideration. It may be well to give
here, as an aid to the study of the various types, a few of the clinical facts
that will prove of aid in diagnosis :—

1. Cerebral paralyses occur chiefly on the opposed side of the body
below the head. This is true of both motor and sensory paralyses.

2. Motor paralysis of cerebral origin is (able to be assvciated with
more or less disturbance of sensation when the lesion is non-cortical.
This is not the case, as a rule, when the lesion is situated upon the sur-
face of the brain.

3. When sensory and motor paralyses coexist, as a result of a cerebral
lesion, they are upon the same side; the reverse is true of spinal lesions.

4, Lesions within the cranium, which cross the mesial line, are liable
to produce paralysis upon both sides of the body.

5. Lesions of the base of the brain are more liable to produce paral-
yses of cranial nerves than are those of the hemispheres or basal ganglia.
Vomiting and choked disk are also frequently observed in these cases.

* The term “gyrus” is synonymous with “ convolution,”
266 LECTURES ON NERVOUS DISEASES.

6. The sensory areas of the cortex commonly give rise (when circum-
seribed lesions tend to impair or destroy their functions) to disturbances
of vision, hearing, smell, or touch. If the lesion be very extensive, hemi-
anesthesia may be produced. Munk, Tripier, and Moeli have lately
shown that the cortex of the entire motor area, as well as the remaining
parictal convolutions, must be destroyed in animals to produce complete
heminnwsthesia, Hence it is seldom of cortical origin.

7. Consciousness is not usually lost, at the time of the attack, with
purely cortical lesions. Apparent exceptions to this statement occur; but
they are to be attributed to effects exerted by the lesion upon deeper parts.

8. Epileptic attacks (which are characterized by the development
of paralysis of a transient character after the fit) indicate an ¢rrdtation
of the cortical motor centres by the lesion. This symptom is often spoken
of as “ Jacksonian epilepsy,” being named after the author who first inter-
preted its phenomena correctly (Hughlings-Jackson).

CorvicAL CEREBRAL Lesions may be indicated (1) by monoplegia
of the opposite side; (2) by disturbances of some special sense; (8) by
the presence of consciousness at the time of the attack; (4) by an
early rigidity of the paralyzed muscles; (5) by circumscribed pain at the
seat of the lesion, which may be elicited or increased by percussion over
the lesion; and (6) possibly by Jacksonian epilepsy, if the lesion creates
simply an irritation of the cells of the cortex.

When sensory and motor disturbances coexist with 2 purely cortical
lesion it indicates that the lesion involves both the motor and sensory
arers of the cortex. Trephining would be contra-indicated in such a
case, because the lesion is of necessity diffused over a large area. The
existence of a well-defined traumatic monoplegia without sensory com-
plientions is an indication for immediate surgical interference, provided
that the paralysis is on the side opposed to the injury. The situation
of the cortical motor centres are of assistance also in determining the
seat at which to trephine for circumscribed lesions within the skull that
are not of a traumatic character.

The convolutions of the frontal lobes are not associated with motion,
excepting the ascending, and the bases of the first, second, and third
frontal convolutions. Outside of this area lesions of the frontal lobe
apparently produce no symptoms. If Broea’s centre be destroyed, motor
aphasia follows.

Trritative lesions of the occipital convolutions sometimes tend to
produce colored perception of objects and other ocular spectra. The
power of vision, as well as the memory of past visual impressions, seems
to be markedly impaired by lesions of this lobe.

The convolutions of the temporal lobe are associated with the
special senses of smell and hearing. Some cases of aphasia have been
CEREBRAL HEMORRHAGE. 267

induced also by lesions of this lobe,—the so-called cases of “word.
deafness.”

Our ability to localize lesions of the sensory regions of the brain is
less positive than of the motor area.

The paricial lobe is physiologically associated with the tactile sense,
as far as we are able to judge hy well-reported cases.

Cortical paralysis may often be ¢ransitory, if the lesion be sheht and
superficial; or it may be permanent, if deep and impinging upon the me-
dulla oblongata. :

Secondary degeneration appears to follow destruction only of the
conyolutions of the motor area and the para-central lobule.

INTRA-CEREBRAL Lestons.—We are now prepared to discuss the
effects of intra-cerebral hemorrhage.

It may be well to preface our remark upon this head by the veneral
statement that such lesions may be accompanied by profound motor
paralysis (usually of the hemiplegic type) ; a loss of consciousness, as 2
rule, at the time of the attack; simultaneous paralysis of sensation Gmore
or less marked); marked disturbances of some or all of the special
senses, and late rigidity of the paralyzed muscles. These symptoms ure
indicative of lesions within the substance of the cerebrum rather than
upon its surface.

Some of these symptoms (especially hemiplegia, hemianesthesia,
hemianopsia, loss of consciousness, and impairment of the special senses)
have been discussed in the first section of this volume. The reader will
find Figs. 6, 21, and 36 of assistance in following the deductions given.

A few facts may be given here as a summary of previous pages with
possible advantage.

Hemiplegia.—A paralysis of the lateral half of the body may occur
in connection with lesions of the cerebral hemisphere. If this form of
motor disturbance coexist with a slight or severe impairment of sensation
upon the same side, the existence of an intra-cerebral lesion may be
strongly suspected.

This combination is to be attributed to pressure upon the tract of
fibres known as the “internal capsule” of .the cerebrum; because the
fibres of the middle part of this tract are motor, while those of the pos-
terior one-third are sensory in function. Both the motor and sensory
fibres of this tract decussate in order to supply that lateral half of the
body which is opposed to the cerebral hemisphere through which they
pass.

The situation of the internal capsule can be made clear to the reader
by a diagram (see Fig. 82). Let us suppose a section to be made from
the forehead to the occiput at such a level as to intersect the masses of
gray substance buried within the cerebral hemispheres, and known as the
268 LECTURES ON NERVOUS DISEASES.

“Dasal ganglia.” We encounter in such a section three prominent
masses of gray substance in each hemisphere,—the caudate nucleus, the
lenticular nucleus, and the optic thalamus. The caudate and lenticular
nuclei are but halves of the same hody—the corpus striatum—which are
separated in the plane of the sections by fibres of the internal capsule.
The optic thalami are united to each other by the gray commissure
which crosses the mesial line of the brain. This is not shown in the cut.

Now, to understand this diagram, let us suppose that a mass of fibres
like hairs are thrust vertically to the plane of the section between the

  
    
 

  

NUCLEUS

‘
'
1
'
\
'
'
1
'
'
\

Fic. $2.—A DIAGRAM DESIGNED BY THE AUTHOR TO ILLUSTRATE A HortzoNnTAL SECTION
THROUGH THE CEREBRAL HEMISPHERES AND THE Basar GANGLIA, SHOWING THE “ IN-
TERNAL CAPSULE”’ OF THE CEREBRUM.—The lettering of the figure will be explained in
the text. It may be remarked here that similar subdivisions of the internal capsule exist
in the left half as schematically depicted in the right half of the figure. Some of the state-
ments made with reference to the subdivisions of the internal capsule are not to be considered
as incapable of modification by the results of subsequent research. The bend observed in
the internal capsule is termed ‘‘the knee’ of the capsule a, the so-called “caudo-
lenticular’? portion of the capsule; /, , s, sf. and 9, constitute collectively the so-called
“thalamo-lenticular’’ portion of the same.

lenticular nucleus of each hemisphere and the adjacent caudate nu-
cleus and thalamus. Such fibres would constitute those of the internal
capswe of the cerebrum. The capsular fibres arise from the cerebral
conyolutions above the plane of the section and become gathered and
compressed into a bundle which presents the peculiar outline shown in
the figure. After they escape from the cerebrum they are continued
downward into the crus cerebri of the corresponding side (Fig. 11).
They cease to be capsular fibres (properly speaking) when they leave the
limits of the basal ganglia of the cerebrum,
CEREBRAL HEMORRHAGE. 269

It will be observed that the right internal capsule is divided in the
diagram into distinct regions. The region (w) contains fibres whose dis-
tribution and functions are not as yet thoroughly understood, although
they are probably indirectly connected with ‘the cerebellum; the region
(f) probably contains fibres going to the face exclusively; the region
(m) appears to contain fibres of motion to the opposite extremities and
lateral half of the body; the region (s) contains sensory fibres to the
same; the region (sé) contains the fibres of the motor speech-tract
(Wernicke),shown also in Fig, 24. Finally, the region (0) contains fibres
that are apparently designed to join the optic nerves with the convolu-
tions of the occipital lobes, and possibly some other fibres whose function
is not yet ascertained.

Now, it must be apparent to all that any hemorrhage into the sub-
stance of the caudate nucleus, the lenticular nucleus, or the optic thala-
mus of either hemisphere, or the development of any morbid condition
that would tend to enlarge them, would create pressure upon the adjacent
internal capsule and affect its component fibres. The seat of the lesion
will greatly modify the results of such pressure. If the anterior part of
the capsule posterior to its “knee” be pressed upon, motor effects will
follow ; if the part still farther back be involved, the general sensory tract
and the optic fibres may be affected. Both sensory and motor effects
may be simultaneously produced by lesions of the thalamus or lenticular
nucleus.

Lesions confined to the internal capsule do not differ materially in
their effects upon motion and sensation from lesions of the masses of gray
matter that lie adjacent to it. In either case, the compression of fibres
or their actual destruction will result in the separation of the limbs anc
trunk from connection with large areas of the cortex. A lesion of modc-
rate size in the region of the internal capsule would produce as profound
effects upon motion or sensation as would one.of extreme size if confined
‘to the cortex.

If an apoplectic clot within the substance of the brain does not pro-
duce death by direct injury or the filling of the ventricles, the patient gen-
erally recovers consciousness at the end of several hours. The mental
faculties, however, are more slowly regained, The memory is confused and
the movements of the tongue imperfect for some hours after the patient
seems to be conscious. We have reason to anticipate death, if profound
coma exists and is extremely prolonged; ifthe pupils remain immoble ;
if the sphincters are relaxed; if the pulse is slow; and if the respirations
are markedly diminished in frequency. The reflexes may be abolished.
The respiratory and circulatory centres are liable to be paralyzed if the,
hemorrhage involves the ventricles or the medulla oblongata.

In favorable cases, the paralysis of motion developed at the time of
270 LECTURES ON NERVOUS DISEASES.

the attack gradually improves; but it seldom disappears entirely. The
upper limb is more persistently affected than the lower. Nothnagel ex-
plains the fact that the lower lim} is the first to improve after a hemi:
plegie attack on the ground that the movements of the healthy side tend
to eall into play “associated movements” of the unhealthy member,
which are more easily excited in the leg than in the arm. He supports
this view by the clinical observation that those movements in which both
legs are employed (as in walking for example) are performed by the en-
feebled limb for some time before individual movements of it are pos-
sible. Healso brings forward many illustrations of associated movements
in cases where paralysis of the face and upper limb has existed. The
extensors of the fingers and wrist are usually the last to improve. In
exceptional cases, the lower limb is the last to show improvement. After
a lapse of time, post-paralytic contracture of the flexor muscles of the
arm and fingers is generally observed. The characteristic gait of the

 

Fic. 83.—ONE OF THE ATTITUDES OF A Hand Causep BY Post-HEMIPLEGIC CONTRACTURE.
(From a photograph.)

hemiplegic subject is hardly to be mistaken for any other condition. (See
page 162.)

The face may be turgid during the apoplectie attack, or pale. The
former condition is most common, As the coma deepens, asphyxia is
manifested hy a dusky and livid countenance. It is stated by some authors
that a pale face, if persistent during the attack, indicates a gradual hem-
orrhage.

Paralysis of the facial nerve alone las been observed by Duplay,
Gruveilhier, Chevostek, and Dupuytren (quoted by Nothnagel) as 4
result of cerebral hemorrhage within the thalamus and corpus striatum.

The marked relaxation of all the limbs which is commonly observed
in connection with apoplectic attacks of a severe type is to be attributed
chiefly to an anemia of the parts adjacent to the clot. This anemia has
been produced by the pressure consequent upon the extravasation, The
compensatory changes which take place in the capillary vessels soon
overcome the anemia; hence the muscular relaxation disappears rapidly
in those members whose nervous communication with the cerebral hemi-
CEREBRAL HEMORRHAGE, 271

spheres has not been severed by the actual destruction done to fibres by
the escaping blood. Should cerebral a@dema be an additional factor in
its causation (as it often is), the muscular tone will be more slowly
regained. :

The fact has been mentioned that some of the fibres of the internal
capsule terminate, anteriorly, in the motor convolutions of the cerebral
cortex. Although there are still some neurologists of note (chiefly Goltz
and his followers) who deny the value of the late attempts of Fritsch,
Hitzig, Broca, Ferrier, Charcot, Wughlings-Jackson, Pitres, Landouzy,
Exner, Chouppe, and a host of others, to locate special centres within
the convolutions of the cortex, clinical and pathological observations are
constantly being brought forward in support of the more generally ac-
cepted views. The region which embraces these motor centres appears,
however, to be somewhat limited. A critical review of the recorded
eases shows, I think, beyond cavil, that the white centre of each hemis-
phere of the cerebrum, as well as the cortex, may in some instances be
extensively diseased or injured without any. motor or sensory results
which can be determined. Pathological evidence seems to demonstrate,
however, that the rezion so impaired must not be situated where fibres
of the internal capsule, which lie posteriorly to its knee (Fig. 82), suffer
destruction or pressure if we expect to mect with negative results.
Abscesses of immense size have been found in the anterior part of the
frontal lobe, as well as in certain portions of the temporo-sphenoidal
Jobes of the cerebrum without any sensory or motor paralysis during
life to indicate the existence of such a lesion. Tumors, softenings, and
the most severe types of traumatism have likewise occurred without
creating serious effects. Certain tests have been referred to on page 183,
which may aid materially in the diagnosis of lesions of the white sub-
stance of the cerebral hemispheres.

In the case of the parietal, occipital and temporo-sphenoidal lobes,
to which some of the posterior fibres of the internal capsule are dis-
tributed, sensory and psychical symptoms in addition to disturbances
of nerves of special sense have heen observed to follow circumscribed
lesions. A careful consideration of such cases demonstrates the functions
of these convolutions more or less clearly. Some arguments have been
advanced of late to prove a relationship between the occipital lobes and
the mental faculties in opposition to the more commonly accepted and
probably correct. doctrine that the frontal lobes are alone connected with
the highest intelligence. The temporal lobes seein to exert an influence
upon the special senses of smell and hearing. An apparent connection
of the optic and anditory functions with the cerebellum and optic thala-
mus exists. The bearing of morbid phenomena of the special sense of
sight. upon diagnosis has been considered in previous pages.
272 LECTURES ON NERVOUS DISEASES.

Let me suggest, that it is by no means certain that lesions, which
primarily etfect the constricted portion of the internal capsule, may not,
in themselves, create sufticient pressure upon the corpus striatum and
the optic thalamus to cause interference with the free action of some of
the spectal centres which are said by Luys to exist within those bodies,
If this be the case, many of the interesting phenomena due to lesions of
the optic thalamus, would coexist with those symptoms of disease within
the internal capsule already mentioned. Ritti’s views respecting the re-
lations of the optic thalamus to hallucinations, and those of Luys per-
taining to its olfactory, optic, and acoustic functions have a special
interest in this connection.

Sensory Paratysis.—In most cases of intra-cerebral hemorrhage,
sensation is impaired to a greater or less extent upon the opposite lateral
half of the body. Both electro-cutaneous and electro-muscular sensibility
may be diminished. The anesthesia may even affect the smaller joints.
Fig. 81 will aid the reader in localizing lesions which involve the sensory
tracts.

The restoration of sensibility after an attack of apoplexy, while
often not complete, is usually more rapid than that of the power of
motion, Subjective sensations may remain, however, such as formication,
hyperzesthesia, the feeling of cloth upon the skin, etc. I have met with
exceptions to this rule, in which the anzsthesia remained complete after
the motor paralysis had nearly disappeared. I believe that in these
cases, the lesion affected the sensory fibres of the internal capsule more
severely than the motor.

The abolition of sensation is not always of the same kind. In rare
instances, sensations of touch are not impaired, while those of tempera-
ture and pain are. The appreciation of temperature and pain may also
be separately destroyed. -

DisoRDERS OF INTELLIGENCE AND ComA.—These may both precede and
follow a cerebral hemorrhage. The more common of these effects are
evidenced in the memory and emotional faculties. Some patients cry
more or less persistently after an apoplectic stroke. Occasionally uncon-
trollable fits of laughter are induced. Insanity is comparatively infre-
quent.

The memory is often seriously affected, and the patient relapses into
childish methods of thought or into a state of apathy. From personal
observation, I am inclined to think that the amount of destruction done
to the brain influences these sequelw, rather than the seat of the lesion.
They are more marked in cases where the symptoms of the attack have
been severe than when mild.

The abolition of consciousness that accompanies some attacks and
not others, is to be attributed, in my opinion, to the displacement of
CEREBRAL HEMORRHAGE. IS

cerebro-spinal fluid from the ventricles, as é€xplained by Duret. This
symptom is certainly less frequent in cortical lesions, that seldom attect
the ventricles, than in intra-cerebral lesions, which do so to a marked
degree.

IMPAIRMENT OF THE SpEctan Senses.—Respecting the possibility
of existence of special centres of smell, sight, hearing and sensation
within the substance of the thalamus there are differences of opinion
among authors of note. Svine clinical facts point strongly to a relation-
ship between nerve-fibres connected with certain special-sense percep-
tions and the internal capsule. It is impossible, with our present
knowledge, to definitely place the situation of all the cortical centres
which preside over the various special senses, or the course of sep-
arate fibres which seem to be associated with them; but we are forced
to admit that some of the fibres of the posterior part of the internal
capsule have a direct or an indirect association with smell, sight, hearing,
tactile sensation, and taste.

One peculiar fact cannot be omitted, however, viz.,that hemianopsia
sometimes occurs in connection with lesions of the internal capsule, with
a difliculty in discrimination of color.

When the radiating fibres of the internal capsule are involved in a
lesion which creates a gradually increasing ‘pressure (as in the case of
tumors which grow slowly) the fundus of the eye exhibits morbid changes
in the region of entrance of the optic nerve which are of value in
diagnosis. The condition so produced is commonly known as the
“choked disk.” (See Fig. 87.)

In exceptional cases of destruction of the internal capsule, the sense
of smell has been found to be abolished on the side opposite to the seat
of the lesion. This fact requires special consideration, as it has been
shown that the centre proper for olfactory perceptions seems to be in
the hemisphere of the same side. Meynert claims, however, to have
demonstrated the existence of an olfactory chiasm in the region of the
anterior commissure (in animals where the bulbs are largely developed) ;
and ‘fibres have been traced in the region of the “subiculum cornu
anmonis,” or the tip of the temporo- -sphenoidal lobe, which connect the
aldaatong: centres with each other. Some experiments of Ferrier tend to
disprove the decussation of the olfactory paths in the anterior commis-
sure; so that the question still remains unsettled. The sense of smell is
more commonly affected in the nostril of the side which corresponds
to the seat of the lesion.*

Among the fibres of the internal capsule which are distributed to
the temporo-sphenoidal lobe some appear to have some association with

* Ferrier reports a case where smell and taste were simultaneously abolished by a
blow upon the top of the head. Ogle records a similar instance.

18
274 LECTURES ON NERVOUS DISEASES.

the sense of hearing; but experimentation upon animals to determine
the exact seat of the centres of hearing and the effects of their destruc-
tion are exceedingly diflicult, because the evidences of impairment of
this sense are more or less vague. Ferrier thinks, however, that the
superior lemporal convolution is unquestionably connected with acoustic
perceptions. The area which he maps out as acoustic in function is quite
extensive, and the late researches of Starr respecting the effects of
cortieal lesions in man upon the sense of hearing tend to confirm this
deduction.

The cortex of the parietal lube scems to be chiefly connected with
tactile sensibility, because its destruction has been found to create a
total loss of that sense on the opposite side of the body. (Munk, Tripier,
Moeli, and others.)

As regards éaste, the results of experimentation upon the monkey
tribe seem to point to the lower portion of the middle temporal convolu-
tion as the probable seat of the centres which are related to that sense. *
When this region is subjected to irritation, certain reflex movements of
the lips, cheek, and tongue are observed, which seem to point to an
excitation of the gustatory sense. Its destruction causes abolition of
taste.

Tremor.—A symptom which points stronely to an existing lesion
of the internal capsule is churecform movements following hemiplegia or
hemiansthesia. These movements vary in type and degree. In some
cases, the movements exhibit the peculiarities of athetosis, the fingers or
toes being thrown into active motions which cannot be controlled by the
patient; in others, true ataxia may be developed; again, the spasmodic
movements partake of the character of genuine choren; finally, a tremor,
more or less marked may be detected.

It is not uncommon to find that both hemiplegia and hemianesthesia
may coexist with these post-paralytic forms of spasmodic disease; but
one usually overshadows the other, the hemiplegia being, as a rule, the
more marked. low we are to explain these late phenomena is not
definitely settled. They are probably to be classed with other morbid
manifestations which paralyzed muscles sometimes cxhibit, chiefly that
of “late rigidity ” so often seen, concerning the cause of which many
conjectures have been advanced, but nothing of a positive nature
demonstrated.

Errects upon TEMPERATURE.—It has been observed that lesions of
the internal capsule, if very extensive, are often followed by a very
marked rise in the temperature of the body. We have yet much to learn

*This may help to explain the fact that injuriés received upon the vertex and

occipital protuberance cause, in some instances, an abolition of taste. The temporal lobe
being injured by concussion against the adjacent bone.
CEREBRAL HEMORRHAGE. 25

concerning the vaso-motor centres which are variously disposed within
the substance of the brain and spinal cord.

ABNORMAL PostuRE oF HEAD AND Eyes.—We have now considered
some of the more prominent symptoms which are produced by lesions of
the internal capsule, and I pass to one which I believe to be of great
value in aiding the recognition during life of an extensive and rapidly
developing lesion of the white centre of the cerebral hemisphere, viz.,
conjugate deviation of the eyes and head.

When, in connection with rapid softening or an extravasation of
blood into the substance of the cerebrum above the level of the basal
ganglia, this peculiar symptoin is developed (either simultaneously with |
or following paralysis and coma), the patient's head and eyes will be
observed to be turned constantly away from the paralyzed side and
toward the side which is the seat of the lesion. Various attempts have
been made by late authors to throw discredit upon the clinical signifi-
cance of this symptom as particularly indicative of a lesion of the
cerebral hemisphere, but I am convinced that it is a valuable differential
sign. Ferrier has demonstrated that a cortical centre, which he locates
in the first and second frontal gyri near to their bases, presides over
conjugate movements of the head and eyes, and causes dilatation of the
pupils. He attributes this symptom, when occurring in connection with
hemiplegia of cortical or ganglionic origin, to the unantagonized action
of the corresponding centre of the uninjured hemisphere, thus explaining
the fact that the distortion is toward the side of the lesion. Clinical
evidence of the correctness of this view has been brought forward by
Hughlings-Jackson, Priestly Smith, Chouppe, Landouzy, Carroll, and
others; and, in some cases reported, the situation of the lesion has been
verified by pathological observation. The opportunity to record patho-
logical observations upon cases where this symptom was well marked
during life is, unfortunately for science, a comparatively rare one. It is
impossible, therefore, to speak positively concerning the diagnostic value
of this symptom, although the weight of clinical evidence seems to be
strongly in its favor.

Specran Symproms or CrreprsaL Lesions.—In connection with cere-
bral hemorrhage and other lesions that disturb the functions of the brain
mechanically, special types of paralysis and other evidences of impair-
ment of special functions are liable to he encountered. <A few general
statements are all that space will allow of in reference to them. Figs.
TT, 78, and 79 will aid the reader in appreciating the clinical significance
of many symptoms caused by focal brain-lesions.

Of the ocular muscles, the internal rectus of one side may alone be
paretic. Dilatation of the pupil, ptosis, and external squint coexist when
the motor oculi nerve is paralyzed. If these symptoms accompany a hemi-
276 LECTURES ON NERVOUS DISEASES.

plegia of the opposite side, the lesion is within the substance of the crus
cerebri, and on the side corresponding to the eve symptoms. In such
instances, it is not uncommon to observe a paretic condition of the lower
part of the face. (See Fig. 77.)

If the facial muscles are paralyzed upon one side and hemiplegia
coexists, the seat of the lesion is within the substance of the pons Varolii.
If in the upper part of the pons, the facial and body palsy will be upon
the same side. If in the lower part of the pons, the facial and body par-
alysis will be on opposite sides. In rare cases, a paresis of individual
facial muscles has been observed to follow a cerebral clot. (See Fig. 77.)

The sense of smell is liable to be lost in one nostri] when the caudate
nucleus, optic thalamus, or the internal capsule of the corresponding
cerebral hemisphere is the seat of the lesion.

A peculiar form of blindness, known as hemianopsia, has been
described in the first section of this volume. It may assume several
types. The clinical deductions to be drawn from this symptom have
been already given.

Ataric manifestations, occurring in connection with evidences of
impairment of the sense of sight, open a wide field for speculation. The
proximity and intimate structural relations of the cerebellum with the
optic lobes, basal ganglia, crus, and medulla, suggest the possibility of
cerebellar lesions when these two symptoms are present to a marked
degree.

The clinical value of aphasia, as a diagnostic symptom, has been
discussed in preceding pages. (See index.) .

In the closing pages of the first section a general summary of the
guides to the localization of cerebral lesions has been given. Many
additional points have been given there in detail.

The so-called “ contracture of muscles,” which occurs in connection
with hemorrhagic foci and local diseases of the brain, deserve a passiny
notice. Rigidity of muscles may be divided; clinically, into those which
accompany the onset of the exciting lesion, those which develop soon
after the onset, and those which appear late as post-paralytic manifesta-
tions (usually from two to five months after the attack).

The first form is most commonly observed in connection with cor-
tical lesions. It disappears within a few days. It is due to mechanical
irritation of the cortical centres.

The second form is to be attributed, according to the researches of
Todd, to the irritation produced by a reactive inflammation in the
neighborhood of the cerebral lesion.

The third form possesses greater clinical. interest than the others,
because of its persistency and the deformities which it is liable to
produce, It never affects all of the paralyzed niuscles with equal inten-
CEREBRAL HEMORRHAGE. Bei

sity. The upper limbs are more often attacked than the legs; the latter
being affected in conjunction with the arm, forearm or hand, if at all.
The trunk muscles escupe. Those of the face‘and neck are affected infre-
quently. The upper limb is usually flexed at the elbow. The hand is
pronated and flexed, with the fingers drawn toward the palm, in a large
proportion of subjects, although the opposite condition may be encoun-
tered in exceptional cases. The arm is generally drawn close to the side
or upon the anterior aspect of the chest. The knee is usnally flexed
when the lower limb is affected. The foot may be either flexed or
extended.

The intensity of post-paralytic contracture varies. The joints tend
to become immovably fixed, after it has existed for years without treat-
ment. After prolonged quictude, as in the morning on awakening from
slumber, the contractured muscles often become relaxed; but they soon
return to their state of rigidity when movements are attempted.

Vaso-motor and Truphie Disturbances.—Apoplectic clots, in common
with other forms of cerebral disease, may be productive of more or less
disturbance of the vaso-motor nerves, which result in modifications in
the temperature, color, and nutrition of the paralyzed limbs and the
trunk.

Not infrequently the paralyzed parts are redder than the healthy
side, and exhibit an elevation of temperature. The skin may become
edematous, and the limb may appear swollen from the infiltration of the
subcutancous tissues. Sweating of the paralyzed limbs is observed in
some instances; while in others the reverse condition may ensue, causing
the limb to be dry and scaly.

Bed-sores are developed in some subjects soon after the apoplectic
stroke. The nates, knee, and heel are the most common seat of these
sores. They are to be regarded as due to some impairment of the
so-called “ trophic nerve-fibres.”

The nails sometimes undergo post-paralytic changes. They tend to
become of a yellowish color, and are often disfigured with ridges. They
are more brittle than in health.

Occasionally the hair upon the paralyzed parts grows long, thick,
and dark.

The joints may become inflamed after paralysis. The larger joints
of the paralyzed side sometimes begin to exhibit the symptoms of acute
synovitis after the lapse of a few weeks in cases of cerebral hemorrhage.
The smaller joints are rarely attacked. Disorganization of the shoulder-
joint has been recorded by Nothnagel, Hitsig,and others. It may result
in dislocation of the humerus.

Finally, cerebral paralysis is less frequently followed by atrophy of
the paralyzed parts than if due to spinal or peripheral causes. This is
278 LECTURES ON NERVOUS DISEASES.

due partly to the fact that a hypertrophy of the skin is particularly
liable to be developed. It may exist to so great a degree as to give the
paralyzed limbs an appearance of increased size.

Differential Diagnosis.—In hospital cases, where often the clinical
history of the subject cannot be obtained, it ix not always easy to make
i positive diagnosis of cerebral hemorrhage. In the first place, the coex-
istence of coma and paralysis may be dependent upon many other causes,
such as cerebral embolism, cerebral tumors, cerebral softening, and com-
pression of the brain from depressed bone, pus, and exudations of various
kinds, as well as upon an apoplectic clot. Again, coma,if unaccompanied
with paralysis of motion, may possibly be an indication of the poisonous
effects of alcohol, opium, uremia, aud many other substances, as well as
some functional nervous derangements. In the third place, patients of
this kind frequently have wounds upon the head, as a result of falling.
This may sometimes mislead the physician in attributing the coma toa
cerebral cause.

From cerebral embolism the diagnosis of apoplexy is to be made by
the tendency of the coma to deepen in bad cases rather than to improve
within twenty-four hours; by the profoundness of the paralysis; by the
irregularity of the pupils; the slow pulse; the slow, stertorous, and
puffing respiration, and other evidences of cerebral compression; and
usually by the absence of aphasia. The history of the patient will
also assist in the diagnosis, because embolism has no prodromal symp-
toms. Furthermore, embolism oceurs at any age; it is frequently de-
pendent upon some valvular lesion of the heart; and it oecurs when no
evidences of arterial degeneration are present.

From cerebral tumors apoplexy is to he distinguished by the fact
that the headache which may have preceded an attack of cerebral hemor-
rhage is of a less severe type and not as well defined as in tumor; by the
absence of the “choked disk” on an ophthalmoscopic examination; by
the fact that some of the cranial nerves are liable to be separately
affected, in case of tumor, before the body is paralyzed; by the
absence of spasmodic conditions and neuralgias, so often encountered
curing the development of tumor; by the fact that syphilis is a common
cause of cerebral growths; finally,should bilateral or alternating paralysis
develop, the diagnosis of tumor is strongly suggested.

From vremic coma, apoplexy is distinguished by the existing paral-
ysis (either of motion or sensation), the absence of albumen and casts in
the urine, the irregularity of the pupils, the flushed face, and the absence
of edema or general nnasarea. It should be remembered that convul-
sions and profound coma may exist in both of these conditions, and the
prodromal symptoms may not be markedly dissimilar,

In alcoholic coma the pupils will be regular, the limbs will not be
CEREBRAL HEMORRHAGE. 279

paralyzed, the coma will not be as profound as in apoplexy, the breath
will smell of liquor, and aleohol may be detected in the urine.

The coma of opium and chloral is not attended with paralysis, and
the pupils are markedly contracted. The breathing and pulse resemble
those of cerebral compression in some respects,

Compression of the brain from inflammatory or serous erudation
eould hardly be mistaken for apoplexy. The history of the case
would not point to cerebral hemorrhage, nor would the attack be
instantaneous,

The ditterential diagnosis between apoplectie clots in the different
parts of the brain have already been considered at some leneth. Further
hints will be given in the closing pages of the section upon the diseases
of the brain, which deal with the localization of cerebral lesions.

Prognosis.— Whether it is possible for a patient to recover perfectly
from an attack of cerebral hemorrhage is a subject of great importance
to every patient aud his friends. The question, if asked, can be intelli-
gently answered as follows: (1) the changes which have occurred in the
brain are of necessity permanent to some extent; (2) the clot will do
more permanent injury in some parts of the brain than in others; (3) the
sear, which tends to form in the most favorable cases, is liable to cause,
by its presence alone, more or less disturbance of the cerebral functions;
(4) in most cases, a tendency to a recurrence of the hemorrhage exists,
(5) sometimes many years elapse before a recurrence takes place; (6)
finally, the term “recovery” must always he taken in its restricted sense
when applied to apoplectic subjects.

The prognosis is the most grave when the coma is prolonged beyond
the usual limits, when the temperature rises to an extreme point after the
attack ; when the vagus nerve shows the effect of impairment; when the
symptoms of pulmonary cedema are developed; when the sphincters are
paralyzed; when prolonged or frequent convulsions accompany or follow
the attack, and when the pupils are widely dilated.

In aged subjects, the prognosis is more grave than in those of middle
life,

Treatment.— At the onset, in cases of moderate severity, the head
should be kept elevated and cold compresses may be applied to arrest
the escape of blood. The stomach may be evacuated by running the
forefinger into the pharynx of the patient, or by a stomach-pump if the
attack should follow a hearty meal. The room should be kept at a com-
tortably cool temperature (about 60°). No food should be given to the
patient for twelve hours after the attack. Cool acidulated drinks will
do no harm and are often erateful. If the bowels he constipated, they
should be moved by a purgative enema or some mild saline cathartic.
Whenever the urine is not passed, catheterism should be resorted to. It
280 LECTURES ON NERVOUS DISEASES.

is best, as a rule, to do as little as possible outside of these simple
measures until all signs of cerebral irritation have disappeared.

In severe cases it is the custom of some practitioners to administer
croton oil at once and to bleed the patient. I would caution the reader
in reference to both practices, although they are sustained by some
authors. Bleeding is never performed hy me, and cathartics of an active
character should never be given, in my opinion, unless the bowels have
been obstinately constipated for several days in succession. Ice-hags to
the head and nape of the neck tend to arrest the hemorrhage, and are
advisable at the time of the attack. No attempts at medication, in order
to promote absorption, should be made until all signs of cerebral irrita-
tion have subsided. To dose these patients with enormous amounts of
the iodide of potassium early is to my mind nonsensical, and decidedly
opposed to all known pathological facts. The aim of the treatment
should be to preserve physical and mental quietude by every known
means, and to avoid everything that will tend to disturh it.

If any of the syinptoms of inflammation appear, after the symptoms
of onset have subsided to a greater or less extent, counter-irritation by
the use of blisters or the actual cautery to the back of the neck and the
renewal of the ice-bags will be of service. If the pulse becomes rapid,
small doses of aconite may be indicated. Opium in small doses will
often prove of aid in quieting restlessness and mental excitement.

In about a week, provided the case is to go on toward recovery, the
patient will show some desire to move his paralyzed limbs, and a slight
improvement in motion may be detected. By the end of the second
week the actual treatment of the paralysis should generally be com-
meneed. I question the propriety of ever beginning electrical treatment
before ten to fourteen days have elapsed, even in the most favorable cases.
I would also make the same remark in reference to massage, and the in-
ternal administration of phosphorus and strychnia. I believe that noth-
ing is lost, and much often gained, by delaying active treatment beyond
the time when anxious friends are apt to clamor for it.

Nutritious food should be administered to the patient as soon after
the attack as the stomach is well able to bear it. I have a decided
preference for milk over any preparation of beef. I think that an egg
broken into a goblet of milk and made palatable with sugar or nutmeg
contains more nutrition in a condensed and acceptable form, which can
be easily digested, than any other known combination. Still, Liebig’s
and Valentine’s extracts of beef are reliable ‘and valuable preparations,
and answer well as a means of administering nourishment.

Respecting the actual treatment of the paralytic symptoms, massage
and electricity are the mechanical agents upon which to rely, and phos-
phorus and strychnia the drugs that seem to he the most beneficial.
CEREBRAL HEMORRHAGE. 281

Charcot has lately advocated the use of powerful magnets applied against
the skin of the paralyzed parts, and has accomplished some apparently
startling results. They are too expensive and uncertain as yet in their
results, however, to be recommended for general use, even if their
curative properties are to be regarded as well established.

: Massage should form an important part of the treatment of motor
and sensory paralysis. It not only hastens the recovery of motion after
apoplectic attacks, but it helps also to prevent the extreme post-paralytic
contractures that frequently follow. It should be employed for ten or
fifteen minutes once or twice every day by a person experienced in the
art. Massage does not consist of rubbing, per se. I is an art in itself,
and should be scientifically performed when employed.

The faradaic current will answer well in the treatment of apoplectic
paralysis, provided that degenerative changes in the muscles do not
develop. The strength of the current should be sufficient to cause slight
muscular contractions, but not so intense as to create severe pain or
fatigue. If the muscles show secondary degenerative changes the static
or galvanic current is advisable. It should be employe: until the faradaic
current begins to show its normal reactions. A rapid improvement will
usually follow the use of electricity, even in very bad cases.

The wire brush, as the active pole, is the best method of applying
the faradaic current for the relief of sensory paralysis, in case it exists.
The anesthesia often disappears spontaneously, however; the proximal
parts of the limbs usually being the first to exhibit improvement.

The question of the advisability of venesection in apoplexy must,
to my mind, be decided in the negative. The abstraction of blood from
the general system, after a clot has formed in the brain-substance, or
upon its surface, cannot affect the existing lesion, and must necessarily
tend to weaken the power of reaction.

Strychnia often aids in effecting a cure. It may be given by the
mouth or hypodermically. The dose by the former method is about one-
twenty-fourth of a grain three times a day, and by the latter about
one-thirtieth of a grain once a day. This drug acts particularly well in
old cases of cerebral hemiplegia.

Phosphorus is another drug which may be indicated. It may be
administered separately or in combination. Phosphide of zine is a
favorite salt with some authorities. The combination of nux vomica,
mentioned in connection with the treatment of cerebral congestion, acts
well in many cases. :

Post-paralytic contractures are benefited greatly by massage, when
it is employed persistently from the date of their first appearance.

Regarding mental treatment, Tadvise my patients to avoid, for many
months after an apoplectic attack, all forms of occupation that demana
8) LECTURES ON NERVOUS DISEASES.

prolonged mental effort, or which occasion over-excitement or fatigue. I
instruct them particularly to dismiss anxiety, as an important step in the
cure, Travel, abstinence from tobacco or alcohol, and judicious exercise
in the open air are often important aids in re-establishing the health,
An excessive use of the eyes, as in reading, is to be prohibited. The
digestive apparatus should be carefully watched, and tonics may be given
with benefit in many cases. I prefer quinine to all other tonics after the
case has progressed well toward a cure.

HEMORRHAGE OF THE CEREBRAL MENINGES.

In this variety of hemorrhage, blood may be found (1) hetween the
dura and the skull; (2) beneath the dura; and (3) in the sul-arachnoidean
space. In the previous section we have discussed cerebral hemorrhage
in a general way (so far as its symptomatology is concerned); but some
facts of value may he given regarding this form in contradistinction to
apoplexy.

Morbid Anatomy.—Clots between the dura and the skull are almost
invariably due to injury. Hammond quotes five cases collected hy
Gintrac which were apparently of idiopathic origin, but they are to be
reourded as exceptional.

The subdural variety is closely allied to haematoma of the meninges
(pachymeningitis interna), It differs from the internal form of pachy-
meningitis, however, in that the hemorrhage:precedes the formation of
the investing membrane (which is usually detected in both); and also in
that the membrane does not present a well-defined laminated appearance
and a net-work of newly-formed vessels between the layers. Further-
more, the hemorrhave is less distinctly circumscribed than in the cases
of hematoma observed. Finally, this variety of hemorrhage may be
disseminated over a very extensive area of the brain’s surface.

In the sub-arachnotdal variety the clot is generally imperfectly
organized, because of the admixture of cerebro-spinal fluid. It is
frequently found at the base of the skull. The arteries are generally
atheromatous. An investing membrane to the clot is not present. This
form of hemorrhage is often associated with aneurismal dilatations of
the large arteries forming the “circle of Willis.”

Etiology.—Infancy and old age appear to be more frequently affected
than middle life. Tt is more common during the first and second years
of life, and after fifty than between those ages. The veins as well as the
arteries appear to be liable to rupture, especially in young children, after
injury received upon the head. Tater in life, aleoholism, insolation,
excesses in eating and venery, severe muscular exertion, constipation,
amenorrhea, and atheroma tend also to excite it.

Symptoms.—Much that has already been said when apoplexy was
HEMORRHAGE OF THE CEREBRAL MENINGUS. Joo

discussed, respecting cortical lesions, bears directly upon this field.
Some clinical deductions may be drawn, however, between lesions of the
extra-dural and sub-arachnoidal varieties. The dura is so closely
attached to the base of the skull that the former variety may be
anatomically excluded from that region. Hence the ettects of pressure
of extra-dural hemorrhages must, of necessity, be exerted chietly upon
the cerebral hemispheres. On the other hand, sub-arachnoidal clots
are frequent at the base of the skull, and may involve the crura cerebri,
the pons, the medulla, the cerebellar peduncles, and the cranial nerve-
trunks 2s well. We would therefore be more liable to encounter disturb-
ances-of the special senses, or the motility of the eyeball, the evidences
of facial palsy, vomiting, choked disk, rotary movements, and extensive
body-paralysis in the subarachnoidal variety than in extra-dural hemor-
rhage. Coma, vertigo, headache, and convulsions may occur in both of
these varieties. If the medulla is involved, reflex automatic movements,
such as the heart’s action, the respiratory rhythm, the act of swallowing,
etv., are liable to be more or less disturbed if death does not immediately
occur.

Small meningeal clots upon the convexity of the hemispheres are
indicated often by some special type of monoplegia, amnesic or ataxic
aphasia, or an impairment of some special sense. T[xtensive surface
hemorrhage of the convexity would result in a train of symptoms closely
allied to those of intra-cerebral clots. These have already been described,

Differential Diagnosis.—The reader is referred to previous pages and
to two tables which follow for information respecting the diagnosis of
apoplexy and surface hemorrhage.

Prognosis.— Extensive surface hemorrhage generally produces death
within a longer or shorter period, varying from a few hours to a few
weeks. Ihave known a child to live many days with a clot that covered
nearly an entire hemisphere. On the other hand, I lately saw in consul-
tation a gentleman of sixty years of age who died of surface hemorrhage
in a few hours after coma set in. In some instances, recovery takes
place by the clot becoming encysted and undergoing absorption.

Clots at the base of the brain are liable to cause instantaneous death
by the pressure exerted upon vital centres. The development of vomit-
ing, or of the so-called *‘Chevne-Stokes respiration” is a symptom of
evil import, whenever encountered in connection with a cerebral lesion.

Treatment.—Nothing can be said here in-addition to the suggestions
offered in the preceding section.

In closing the discussion of cerebral hemorrhage, I take the liberty
of quoting (with slight modifications) from the third edition of my work
on “Surgical Diagnosis” the following differential tables. which relate
more or less directly to this condition :—
Jet

PARALYSIS FROM CORTICAL
CEREBRAL LESIONS.

LECTURES ON NERVOUS DISEASES.

PARALYSIS FROM NON-CORTICAL
CEREBRAL LESIONS,

CONSCIOUSNESS.

Is seldom completely lost at the onset of
paralysis, unless the lesion be extensive or
due to’ traumatism.

If ushered in with an epileptic attack,
consciousness is of course lost.

A sudden loss of consciousness usually
accompanies the development of the lesion
or its manifestation in the form of paralysis.

Convulsiops are not usually present dur-
ing the ‘paralytic attack.”

PAIN.

Local pain within the head is often com-
plained of at the time of the attack.

The patient is usually unconscious at the
time of the attack and for some time after;
and (even after the attack) pain in the head
is a less constant symptom.

PERCUSSION.

Percussion over the seat of the lesion
often elicits pain.

Negative in its results.

Parabysis.

Afonoplegia (in any of its forms) is typi-
cal of this condition, whenever it exists.

Special groups of muscles are paralyzed,
and some more than others.

The paralysis is often transitory, if the
lesion be slight or superficial.

The group of muscles, which is the last
to show improvement, may be a valuable
guide in localizing the seat of injury.

Sensibility is usually unimpaired.

Hemiplegia or hemranesthesia, more or
less profound, follow the development of
the lesion, asa rule. Both may coexist in
some cases,

Jt is slow in recovery.

The improvement is comparatively uni-
form, so far as special groups of muscles are
concerned,

More or less anasthesia usually coexists
with the motor paralysis,

Muscutar Riarpity.

The paralyzed muscles often exhibit
rigidity at an early date.

Early rigidity of the paralyzed muscles
is rare in central cerebral disease.

CHOREIFORM \MoVEMENTS.

Infrequent as a sequel to the paralysis.

Frequently follow the development of the

hemiplegia or hemianeesthiesia.

ELEcTRO-CoNTRACTILITY.

The paralyzed muscles exhibit normal
electro-contractility.

May be impaired or modified, some time

after the onset of paralysis.

Symptoms in Common.

Both are associated with motor paralysis,

“

a “ ue

« « “ a

may be associated with post-paralytic ngidily of muscles,
e sudden advent:

traumatisin.

convulsions.
HEMORRHAGE OF THE CEREBRAL MENINGES,

IRRITATIVE LESIONS OF THE
CEREBRAL CORTEX.

(Jackson1an Eprepsy.)

285

DESTRUCTIVE LESIONS OF TILE
CEREBRAL CORTEX.

History.

Syphilis is by far the most frequent cause
of this condition.

Syphilis is only one of many causes of
this condition, and by no means the most
common.

ConvVULSIONS.

The patient is seized with convulsive
attacks of the epileptic type, which are
followed by transient paralysis.

The part which first shows rigidity during
the convulsion points toward the motor
centre for that part as the seat of greatest
umitation. It may thus assist in localizing
the seat of the lesion.

Convulsions are usually absent,

PaRALYSISs.

' The paralysis is somewhat of the ‘“ mono-
plegic” type, but is usually transitory. It
is not so well defined as in the case of de-
structive lesions. It exists, as a rule, on the
side opposite to the lesion.

A well-marked “monoplegia” is devel-
oped, which is more or less permanent ac-
cording to the character of the lesion. It gene-
rally affects the side opposite to the lesion.

The groups of muscles affected with pa-
ralysis will aid in deciding as to the seat
and extent of the lesion.

PRocNosis.

Good—on accountof its frequent syphilitic
origin.

CEREBRAL HEMIPLEGIA.

Depends entirely upon the character of

the lesion, its seat, and extent.

SPINAL HEMIPLEGIA.

Form oF ATTACK.

Onset usually sudden.
Consciousness is often lost when the lesion
is centrally situated in the hemispheres.

Onset may be gradual.
Consciousness is not lost.

History.

That of some cerebral disease, such as apo-
plexy, embolism, softening, tumor, etc.

That of some spinal lesion situated in the

cervical region, and involving only one
lateral half of the spinal cord.

PupPits.

Are liable to be irregular.

Are unaffected, unless the cilio-spinal

centre within the cervical region of the
cord be involved.
pupil” may exist.

If so, the ‘ Robertson

OPHTHALMOSCOPIC EXAMINATION.

» May reveal the “choked disk.”

Negative.
286

LECTURES ON NERVOUS DISEASES,

CraniaL NERVES.

The cranial nerves are frequently in-
volved, causing paralytic symptoms—com-
monly in the nostril, eye, or face. The
spinal senses are often modified.

Crossed paralysis (in any of its forms)
may be present.

The cranial nerves are not involved, un-
less a sclerosis of the cord extends upward
late in the disease.

Crossed paralysis is never present.

REFLEX PHENOMENA.

Are usually normal.

Some of the various reflexes are liable to
be impaired or lost.

Spasmopic PHENOMENA.

The paralyzed muscles are not rendered
particularly susceptible to spasm.

Spasms of the limbs are very frequent.

Execrro-MuscuLarR PHENOMENA.

Usually normal.

Modified according to the parts of the
cord which are affected by the lesion.

Sensory PHENOMENA.

Anzsthesia or Analgesia, whenever they
exist, are on the same side as the motor
paralysis.

Anesthesia or Analgesia, when present
are on the side opposite to the motor paral-
ysis.

Sensations of burning, pricking, formica-
tion, coldness, and heaviness often exist at
the onset. Hypermsthesia follows. Subse-
quently anesthesia may be developed.

RESPIRATION.

‘Respiration is seldom affected.

Difficulty in breathing is often experi-
enced when the spinal lesion is above the
origin of the phrenic nerve.

SPHINCTERS.

The sphincters are not involved, as a rule.

The vesical and anal sphincters are often
affected with inertia or paralysis.

SexuaL Functions.

The sexual power is commonly retained.

The sexual occasionally

abolished.

power is

Symptoms in Common.

Both are associated with hemiplegia.
Both may be associated with abnormal sensory phenomena.

PACHYMENINGITIS; OR, INFLAMMATION OF THE DURA MATER.

This condition is usually circumscribed, and rarely spreads over the
whole convexity of the brain. It is of two forms, the suppurative and

the non-suppurative.

Because it is frequently associated with extravasa-

tion of blood, it is described by some authors under the name of “ hema-
 

PACHYMENINGITIS ; OR, INFLAMMATION OF DURA MATER. 287

toma of the dura mater.” Other authors classify it, as regards the sur-
face of the dura involved, into the external and the internal,—the latter
being sanguincous, if of the chronic type.

The cause of this variety of inflammation often governs its seat, ex-
tent, and variety ; hence its symptoms will be modified somewhat, by its
method of origin.

Meningeal hemorrhage is classed by some authors under the head of
pachymeningitis. To my mind this is illogical and opposed to pathologi-
cal data. Hemorrhage may be one of its causes, as well as one of its
_ results, but not one of its varieties, because pachymeningitis is accom-
panied by changes in the dura.

Morbid Anatomy.—Suppuration more commonly accompanies the
hemorrhagic variety and that produced by caries of the bones. It may
occur also after traumatism, especially if thrombosis follows. A general
arachnitis is then liable to be induced as a complication of the circum-
scribed inflammation of the dura. The base of the brain is usually ex-
empt from this form of meningitis, except as a sequel of traumatism,
tumors, or diseases of the vertebrae. Hzematoma is very common at the
vertex, and sometimes affects both hemispheres of the brain simultane-
ously by crossing the mesial line.

In the non-suppurative variety the dura becomes composed of super-
imposed layers (as high as twenty in some instances). These are rich in
vessels (which tend to rupture where the arterial tension is excessive
from any cause). The dura subsequently becomes united to the arach-
noid. The layers of a hematoma occasionally ‘ossify. When the newly-
formed vessels sometimes rupture, they tend to create circumscribed
sanguineous cysts. When syphilitic caries is: the exciting cause, the
dura may become gangrenous.

The external variety is always a secondary inflam mation. The dura
is found to be injected, softened, and ecchymotie in its initial stage.
Later on, new connective-tissue formations induce a thickening and
opacity of the dura, and adhesions take place between it and the skull,
provided suppuration does not occur. Pigmentation of the dura and the
formation of osteophytes in that. membrane are sometimes encountered.

Secondary thromboses of the cerebral sinuses may follow a pachy-
Meningitis. These may suppurate and induce metastatic abscesses of
the viscera (as explained on page 230).

Etiology.—The causes which tend to produce pachymeningitis are
as follow: (1) injuries to the cranial vault ; (2) syphilitic disease of the
bones of the cranium, most commonly of site temporal; (3) hemorrhage
between the dura mater and the bone; (4) diseases of the vertebra and
their ligaments; (5) thrombosis of the cerebral sinuses, chiefly the trans-
verse and petrosal; (6) chronic inflammation of the middle ear; (‘)
288 LECTURES ON NERVOUS DISEASES.

suppurative inflammation of the orbit; (8) chronic alcoholismus ; (9)
pyemia; (10) Bright’s disease; (11) rheumatism; and (12) acute infec.
tious diseases.

Symptoms.—Lesions of this character may excite paralysis of parts
supplied by cranial nerves which lie adjacent to them; and when the
pressure becomes extreme, paralysis of the limbs and even coma may
follow.

Localized pain is usually present over the seat of the disease; and
percussion of the skull over the lesion tends, as a rule, to increase the
pain.

The defective blood-supply (in those convolutions of the brain
which lie adjacent to the lesion) that ensues from pressure upon them
may lead to softening. When suppuration occurs, the symptoms are
greatly aggravated.

In many cases, the symptoms of the EXTERNAL VARIETY are very
obscure, especially at the onset. When somnolence, vertigo, headache
of a localized type, delirium, photophobia, convulsions, or coma follow
any of the causes enumerated among the etiological factors, it may be
well to suspect the existence of one of the two varieties.

Chronic inflammation of the middle ear is often regarded by parents
as of trivial importance, and physicians not infrequently advise them to
that effect; yet it is one of the most prolific causes of this serious
condition, and is liable to produce death if not properly cared for.

If thrombosis of some of the cerebral sinuses has existed and created
this complication, the prodromal symptoms will be those enumerated in
connection with thrombosis.

Syphilis is a prolific cause of pachymeningitis, because it often
induces a carious state of the cranial bones and an extension of the
inflammation to the adjacent dura, which tends toward suppuration.
Cerebral symptoms, when occurring in connection with syphilis, should
always be the subject of careful inquiry.

The INTERNAL VARIETY of this discase may occur idiopathically, —
chiefly in connection with chronic alcoholism, the hemorrhagic diathesis,
blood-poisoning from urea, scurvy, pernicious anemia, leucocythemia,
general paresis, hydrocephalus, cerebral atrophy, cerebral tumors, and
pyemia. It may also develop secondarily to the external variety.

The symptoms of the internal variety are liable to be more distinetly
defined than are those of the external, because the development of
a hematoma of the dura creates localized pressure upon the brain or
some of the cranial nerves, the severity of which depends upon its size
and seat. Hence we are liable to encounter evidences of impairment of
intellect, temporary loss of consciousness, aphasic symptoms, early con-
traction and subsequent irregularity of the pupils, exacerbations and
PACHYMENINGITIS; OR, INFLAMMATION OF DURA MATER. 289

remissions of temperature, slowing of the pulse, choked disk, and a
gradual paralysis of motion or sensation, which may be preceded by
convulsive attacks. Headache is a marked symptom as a rule, especially
in the syphilitic variety. The hemorrhages that occur in this variety
are constantly recurring because the newly-formed vessels are in a loose
connective-tissue formation, and are often atheromatous. This fact
possibly helps us to explain why these patients have short periods of
loss of consciousness, transient paralyses, convulsive attacks at infre-
quent intervals, and periodical headache. Sudden death may follow an
extensive hemorrhagic extravasation. Bilateral paralysis may result
from hematoma of the dura, when it is situated at the vertex and crosses
the sagittal suture.

The SYPHILITIC VARIETY is classed as distinct from the others by
some authors, because the deposit upon or beneath the dura is usually
of a gummatous nature. In this variety, localized headache is very
persistent and usually grows worse as night approaches. Special cranial
nerves are not infrequently involved before the cerebral functions are
disturbed in any way. I have made the diagnosis of this condition in
several cases by the development of hemianopsia; also by the existence
of motor oculi paralysis,and facial paralysis alone. I once saw a patient
who lay in profound coma with dilated pupils, stertorous breathing, and
_ Yelaxed sphincters from this cause for ten days and eventually recovered.
Cases of this type of pachymeningitis may exhibit symptoms of insanity
early. On the other hand, they may become dull, stupid, and apathetic,
before other symptoms develop which may assist in definitely localizing
the seat of the lesion. In exceptional cases, I have seen hemiplegia
develop from this cause without any prodromal symptoms.

Differential Diagnosis.—'The obscurity of the symptoms in all forms
of pachymeningitis renders its differential diagnosis rather a matter of
conjecture than of scientific accuracy. The following hints may aid,
however, in the discrimination :—

1. In case necrosis of the cranial bones, otitis media, fracture of
the cranium or traumatism of the skull has existed and been followed by
evidences of gradual cerebral compression, we may strongly suspect the
existence of dural inflammation.

2. When a hematoma. is developing, the symptoms may resemble
those of either acute or chronic meningitis or cerebral softening, and a
positive diagnosis may be impossible. Bilateral paralysis is strongly
indicative of hematoma. The following symptoms are, in my experi-
ence, also strongly diagnostic: Contraction of the pupils; localized head-
ache; transient and recurring attacks of unconsciousness or paralysis;
aslow pulse; strabismus; ptosis; and facial palsy.

8. In connection with syphilis, the development of cerebral symptoms

19
290 LECTURES ON NERVOUS DISEASES.

of any kind should excite a suspicion of the existence of pachymenin.
gitis of the gummatous variety. The cranial nerves, especially the
olfactory, optic, motor oculi, and facial, are apt to be involved and to give
clinical evidence of more or less impairment.of function.

The following table is quoted from the third edition of the author’s
work on “ Surgical Diagnosis :”—

EXTERNAL PACHYMENINGITIS. INTERNAL PACHYMENINGITIS,
(Ha#matoma or THE Dura Maren.)
CausEs.

Traumatism of the calvaria. Chronic alcoholism and syphilis.

Diseases of the cranial bones. Acute febrile disorders (fevers, rheuma-

Caries and necrosis of the cervical vertebra.  tism and puerperal diseases).

Suppurative diseases of the vertebral liga- Chronic .diseases of the heart, tubercn-
ments, _ losis, and the paralysis of the insane may

It rarely follows syphilitic or rheumatic be associated with it.
conditions of the cranium or erysipelas of Old age.
the scalp. Males more frequently affected than fe-

males.
. HEADACHE.
_ Intense and circumscribed headache usu- Periodical headache is commonly pro-
ally exists. duced; gradually reaching extreme intensity
whenever the acute form exists.
ConVULSIONS.

Slight convulsions are common at the Convulsions are rare.
onset.

Brain SyMproms.

Vertigo, nausea, and vomiting are fre- Weakness of memory, apathy, somno-
quently met with at the onset of the disease. lence, and delirium are the more common
: symptoms.

Puplits.
The pupils are apt to become unequal, if The pupils are not necessarily affected,
the pressure upon the brain is severe. because the pressure of the sanguineous
cyst is more limited than that of a pus
exudation,
They may be contracted.
; PuLse.

The pulse is at first accelerated, but he- The pulse fails to exhibit the effects of
comes slow and irregular when cerebral general cerebral compression, except in
compression is produced. severe and. fatal cases.

Late Symptoms.

Coma and paralysis follow if cerebral Feebleness of tho limbs, unsteady gait,

compression or abscess is produced. and changes in the nutrition indicate the

latent progress of inflammation of the brain.

Symptoms in Common.

Both may be associated with headache.

a n ed “convulsions.
coma.
paralysis.
syphilitic history,
PACHYMENINGITIS; OR, INFLAMMATION OF DURA MATER. 291

Prognosis.— Patients may recover from pachymeningitis, in spite of
the fact that the prognosis is usually grave. In alcoholic patients, the
disease is generally fatal. If suppuration is developed, the dangers to
life are materially enhanced; hence the prognosis is grave if it be induced
by caries, necrosis, otitis media, cancer, traumatism, ete.

Hematoma of the dura is fatal in a very large percentage of those
attacked. These patients may die from hemorrhage, cerebral thrombosis,
cerebritis, dementia, pyzemia, and other complications, before the tumor
produces death by direct pressure upon the brain. Life may terminate
between the limits of two weeks and two years, according to the circum-
stances incident to the case.

In the syphilitic variety of pachymeningitis I have witnessed some
very remarkable recoveries. When the gummatous deposit is small, it
may be absorbed by active specific treatment. If it be large, the brain
may be softened and permanently impaired before the cause can be
removed. I have often observed a tendency toward a return of the symp-
toms in many of these subjects that have been greatly benefited at first
by treatment. If chronic alcoholism is a factor in the causation, as well
as syphilis, the prognosis is very grave; but recovery may occur even
under these circumstances. I lately saw a remarkable instance of that
character in connection with my late colleague Prof. A. L. Loomis.

Treatment.__When pachymeningitis is of the suppurative type,
surgical interference may overcome the difficulty to a large extent by
evacuating the pus. It is not always possible, however, to localize the
situation of the pus or even to determine its presence with certainty.
The cause may aid in this discrimination, in some cases. Traumatic
causes, otitis media, and caries or necrosis are especially prone to purulent
deposits between the dura and the bone. A careful study of the symp-
toms (from the standpoint of cerebral physiology) may, in exceptional
cases, indicate the seat of the abscess. I have given the surgical guides
for the employment of the trephine in such cases in my work upon
nervous anatomy,* and also in the first section of this volume.

During the development of a hematoma of the dura life may be
prolonged by a judicious use of ergot, stimulants, and a nutritious diet,
in conjunction with enforced physical and mental quietude and counter-
irritation. I do not believe that any line of treatment will effect a cure.

In the gummatous variety, I have found the best results to follow
mercurial fumigation and the internal administration of large doses of
the iodide of potash (grs. xxx. to lx. after each meal, and even larger
doses if necessary). I prefer the black oxide of mercury (one drachm
to a bath) to any other preparation when fumigation seems advisable,

*“The Applied Anatomy of the Nervous System.’’ D. Appleton and Co., N.Y.
24. edition 1886.
292 LECTURES ON NERVOUS DISEASES.

although calomel baths act well in some cases, if watched carefully to
avoid salivation. I have frequently employed inunctions of one drachm
of the 20 per cent. oleate of mercury night and morning with benefit,
when the baths were not to be obtained; but the effects are less certain
and the treatment more disagreeable to the patient than by the bath,
In one case I carried the iodide of potash up to a daily administration
of one and a half ounces for several consecutive days before I got
satisfactory results. The subcutaneous sublimate injection, recom-
mended by Lewin,* has yielded excellent results, in some instances,
under my observation. I frequently employ it in connection with mer-
. curial fumigation. In those cases where the iodide of potash is badly
tolerated, I have employed the iodide of calcium with excellent results.
This salt is unstable, and should be carefully bottled by the manufac-
turers so as to prevent its decomposition. It may be given in the same
doses as the other salt. All of the iodides should be administered in
combination with Vichy water, and very largely diluted.

The employment of cod-liver oil and tonics is advisable in these
cases, as they are anemic and badly nourished as a rule, All stimulants
should be withheld, unless serious damage to the patient is indicated by
so doing. In such a case they should be decreased in amount steadily as
fast as practicable. p

I have personally discarded for some years past the old routine
management of cerebral syphilis by the internal administration of the
so-called “mixed treatment.” It does not accomplish, in my experience,
what the fumigation, inunction, or subcutaneous injection methods will;
nor is it, tomy mind, free from other serious objections. My convictions
upon this point are strong, and are based upon quite a large experience
in the management of these cases. It is not necessary for me to defend
my views here; but it cannot be denied that‘one essential factor in suc-
cess in these cases is unimpaired digestion. Even if the improvement
was as rapid under the old plan as the new (which it certainly is not)
the digestive organs are more frequently deranged.

ARACHNITIS.

Thickening and opacity of the arachnoid has been observed in con-
nection with atheroma, cancer of the abdominal viscera, granular kidney,
senile dementia, delirium tremens, tuberculosis, heart-lesions, cerebro-
spinal meningitis, hemorrhage into the pia mater, and as a sequel to
disease of the bone and the dura mater.

It may be associated with an effusion of lymph or pus, and be either
local or general.

The exciting cause will be of the greatest aid in determining its char

*“ Syphilis,” by George Lewin. Blakiston, Son & Co., 1882.
INFLAMMATION OF THE PIA MATER, ETC. 293

acter during life. It is often impossible to discriminate during life be-
tween lesions involving the dura mater from those of the arachnoid ; and
it is still more difficult to separate its morbid conditions from those of
the adjacent pia mater which underlies it, and which usually participates
to a greater or less extent in its changes.

Atheromatous degeneration of the cerebral vessels seems to be com-
monly associated with those forms which have their apparent origin
either in cancer or the abuse of alcohol. As is the case with all inflam-
matory conditions of the coverings of the brain, the symptoms are pro-
duced either by the hyperzemia in thé early stages, or by the pressure of
the exudation upon the brain, or from cerebral thrombosis in the later
stages of the disease,

INFLAMMATION OF THE PIA MATER—DIFFUSED MENINGITIS OF
THE CONVEXITY OF THE HEMISPHERES.

We have already discussed diseased conditions of the dura under the
heads of meningeal hemorrhage and pachymeningitis, and it now be-
hooves us to consider the pia mater in its pathological aspects.

Meningitis may be subdivided into four forms: the acute, subacute,
chronic, and tubercular. The acute, subacute, and chronic varieties of
inflammation of the pia are generally diffused over the convexity of the
cerebral hemispheres. The tubercular variety (hydrocephalus) is com-
monly confined to the base of the brain to a greater or less extent.

The varieties of meningitis will be considered separately, because
their pathology and symptomatology differ widely.

ACUTE MENINGITIS.

Synonyms.—This condition is described by authors of note under
the following heads: 7. Simple meningitis of the convexity; 2. General
arachnitis; 8. Cerebral fever ; 4. Non-specific inflammation of the men-
inges; 5. Acute cerebral leptomeningitis.

Morbid Anatomy.—On-removal of the calvaria, the surface of the
hemispheres appears of a greenish hue. This is due to the presence
of an exudation into the meshes of the pia and the peri-vascular lymph
spaces,

The vascularity of the meninges is excessive. The vessels appear to
the eye as prominent red lines running over a green background. The
base of the brain is usually free from abnormal appearances.

The pia is thickened, reddened, and rendered opaque in spots. In
some cases the arachnoid and the dura may be adherent to each other.
Along the main fissures and the more important sulci, a creamy exuda-
tion (consisting of an admixture of serum, fibrin, and pus, in varying
proportions) is found. It constitutes in many cases an approach to a
294 LECTURES ON NERVOUS DISEASES.

false membrane, which can be readily detached from the convolutions
underneath it.

When this false membrane is raised, the surface of the brain is seen
to be.dotted over with small red spots. These indicate capillary extrava-
sations from the small branches of the vessels of the pia, which every-
where supply the cortex.

Occasionally the cerebellar meninges are implicated. Whenever
this is the case it is common to find the cranial nerves more or less
encapsulated in a sheath formed by the exudation.

If the exudation upon the cerebral hemispheres be large in amount,
the cerebral convolutions will appear more or less flattened, the sulci will
be deeper than normal, and the ventricles will contain little if any fluid.

Cross-sections made through the white substance of the cerebrum
will often reveal minute spots of extravasation,—the so-called “ puncta
vasculosa.”’

Etiology. Among the predisposing causes of this disease may be
mentioned: (1) age, since youth or young adult life is most commonly
attacked; (2) sex, because males are more often attacked than females;
(3) anxiety, prolonged mental labor, and grief; and (4) excessive indul-
gence in alcohol.

The exciting causes include (1) injuries to the bones of the head;
(2) caries or necrosis of the cranial bones; (3) otitis media; (4) insola-
tion; (5) extension of inflammation from the orbit and the vertebral
ligaments; (6) metastasis of skin eruptions; (7) blood-poisons, chiefly
those of the fevers, pyamia, rheumatism, uremia, diabetes, diphtheria,
and rheumatism.

Meningitis may be of idiopathic origin in rare instances, according
to some authorities. I have always doubted the accuracy of this state-
ment, if the term be used in its true sense.

Symptoms.—In tlie early stages of acute meningitis the symptoms
may be regarded as those of cerebral irritation combined with marked
febrile excitement. .

A persistent and intense headache exists from the onset, accom-
panied by contracted pupils, vertigo, photophobia, and profectile vomit-
ing in many cases. The attack may begin with a chill. The tempera-
ture may rise to 105° or 106° in asevere case; but it seldom exceeds 102°
or 103°. The highest temperature usually occurs from the fifth to the
seventh day.

Cutaneous hyperesthesia and muscular twitchings are developed
early.

The gait is tottering and indicates an impairment of codrdination in
the early part of the disease. A continuous high temperature is an ind
cation of a fatal termination.
ACUTE MENINGITIS: 295

=

The frequency of the pulse (which is small, firm, and tense) varies.
It ranges proportionately with the remissions and exacerbations of the
temperature.

Finally, constipation and retraction of the abdomen are usually
present during the stage of headache. With children, it is not uncom-
mon to have the first stage ushered in with convulsions and marked
strabismus,

The face is pale, as a rule, during the initial stage of meningitis, and
the conjunctiva is injected. Occasionally, the face may be flushed.

As headache is the prominent symptom of this stage, its character
should be fully described. It is intense from the onset, and is associated
with an excitation of the special senses. It steadily tends to grow worse,
instead of better. It may be confined to the frontal, temporal, or occi-
pital regions of the head. It may last for a variable space of time,—
{rom a few hours to as many days. ,

In most respects the initial stage of acute meningitis resembles that
of intense cerebral congestion. Hence what has been said respecting the
symptoms of that condition will apply here.

Second Stage.—Delirium usually sets in after the stage of headache
has lasted for a longer or shorter period (seldom more than a few days).
It is accompanied by an increase of the fever, jactitation, restlessness,
and mental excitability, or confusion of intellect. So prominent a
feature does delirium now become that this stage is denominated the
“stage of delirium” by some authors. It sometimes becomes so active
that it resembles acute mania. Hallucinations of sight and hearing often
accompany the delirinm, and the articulation of the patient frequently
becomes incoherent. In the aged, the delirium is of the typhoid char-
acter, and is manifested by incessant talking, accompanied by irration-
ality of ideas. The patient may laugh or weep over imaginary occur-
rences, and is apt to gesticulate wildly. Twitchings of the facial
muscles and a peculiar rolling of the eyeballs in the orbits are commonly
observed. Occasionally the flexors of the limbs contract powerfully and
produce episthotonos. Convulsions in adults are rare, but they sometimes
oceur. Hemiplegia and paraplegia are infrequent, although I have per-
sonally observed the former in one instance. Hammond reports two cases
where hemiplegia persisted throughout the entire course of the disease.

When the medulla is implicated or the nerve trunks which arise froin
it, the acts of respiration and of swallowing may be imperfectly per-
formed before coma develops. The pulse may then become irregular,
the abdomen will be retracted, and projectile vomiting may exist.

Occasionally the delirium merges into attacks of insanity, with
homicidal or suicidal tendencies. Hence it is well to guard against such
accidents by keeping a close watch over the patient.
296 LECTURES ON NERVOUS DISEASES,

Finally, an herpetic eruption occurs not infrequently during this
stage.

Third Stage.—A fter several days have elapsed from the onset of the
attack, the patient, as a rule, becomes more quiet and gradually sinks
into the state of profeund coma. The headache of the first stage, and
the cataneous hyperesthesia, as well as the delirium, the jactitation, and
the contractures of the second stage, give place to a stupor that deepens
from hour to hour. The pupils begin to exhibit oscillations and grad-
ually become dilated. The pulse becomes very slow, irregular, and inter-
mitting in character. The patient grinds the teeth, picks at the bed-
clothes, and often develops ptosis and more or less facial paralysis. The
urine is passed unconsciously, and the bowels are often moved in the bed.
Sometimes retention of urine occurs, and a catheter has to be passed at
regular intervals. Tie temperature remains elevated until death is immi-
nent, when it often falls rapidly. The pulse becomes very rapid as death
approaches, and can with extreme difficulty be counted at the wrist.
The Cheyne-Stokes respiration develops, the body becomes clammy and
bathed in a cold sweat, and life is extinguished as a result of heart-failure,
asphyxia, or pulmonary cedema.

In this stage of coma and collapse the face may become alternately
pale and suffused, or it may assume a purplish color from asphyxia.
The head may be drawn toward one side.

Differential Diagnosis.—This disease may be confounded with de-
lirium tremens, typhus fever, acute ureemia, small-pox, and encephalitis,

From delirium tremens, this disease may be told by the absence of
the clammy sweat during the stage of delirium, the presence of headache,
and the peculiar character of the delirium, The temperature, the pupils,
and the pulse are also widely different from those of alcoholism.

From typhus fever, meningitis may be diagnosed by the incompressi-
bility of the pulse, the comparatively low range of temperature, the ab-
sence of the mahogany or leaden face, the hyperesthesia of the surface,
the projectile vomiting, and the absence of the characteristic eruption of
typhus.

From acute uremia, it may be differentiated by a urinal analysis,
which will fail to reveal the presence of casts or blood, and by the absence
of frequent and severe convulsions. There will be no oedema of the
eyelids, and the face is pale rather than turgid. Evidences of cerebral
compression will also be present, and the temperature will aid greatly
in excluding uremia.

From smail-pox, meningitis can be told by the absence of pain in the
loins-and back, the absence of the characteristic eruption on the third
day of the disease, and the presence of projectile vomiting. Until the
eruption occurs the diagnosis is diflicult.
SENILE MENINGITIS. 297

a

From circumseribed encephalitis, the distinction is made by the
intensity of the headache, the activity and peculiar character of the
delirium, the severe muscular contractures, the active febrile symptoms,
and the rapid development of collapse.

Senile Meningitis.—When meningitis of the-acute form occurs in
the aged, the symptoms differ markedly from those described as typical
of that condition in the infant or young adult. The headache is either
absent or not severe. The rise in temperature is not so well marked.
The projectile vomiting is usually absent, and gastric derangement is not
developed, as a rule.

Senile meningitis so closely resembles cerebral softening that some-
times it is with difficulty differentiated from it. The speech is often
incoherent, the memory impaired, and many of the acts of the patient
appear irrational. Coma may occur in the initial stage. The delirium,
when it exists, is of a low and muttering type. It is common for these
patients to develop paresis of all the limbs.

The diagnosis of this type of meningitis from cerebral softening is
made chiefly by the rapidity of its progress and the absence of the pro-
dromal symptoms that usually precede softening of the brain.

Prognosis.—In any of the varicties described, the prognosis is
always unfavorable. Severe cases usually terminate fatally within ten
days; less acute cases may end in recovery. We are justified in
anticipating a fatal termination when paralysis of the limbs occurs,
when ptosis or strabismus is present, when hiccough exists, when the
temperature is high and shows no remissions in the morning, and
when the. Cheyne-Stokes respiration is developed. The prognosis of
any form of meningitis is always more favorable in childhood than
in adults.

Treatment.—The first and second stages of this disease are char-
acterized mainly by symptoms of cerebral congestion; hence, general
Dlood-letting by leeches to the neck or temples and by venesection at
the elbow are indicated. Leeches may be applied also inside of the
nostril (so as to directly deplete the superior longitudinal sinus) or
over the mastoid region, to deplete the lateral sinus. I doubt the
advisability of ever employing extensive blood-letting in children; but,
in adults of a vigorous constitution, as high as fifteen ounces of blood
may be abstracted from the vessels.

The second agent to be employed is cold to the head. The hair
should be shorn and ice applied to the sealp throughout the first and
second stages. The room should be darkened and all disturbing influ-
ences should be carefully guarded against. The rubber coil, through
which iced water is allowed to flow continuously, is an excellent and per-
haps the best way of keeping the head under the influence of cold. Ii is
998 LECTURES ON NERVOUS DISEASES.

best to maintain an elevated posture of the head, so as to assist the
venous return.

Active catharsis is a third agent which can be employed to advan-
tage. Oroton oil is always reliable and prompt in its action. Calomel
is also good, especially if its action is accelerated by the addition of jalap
or podophyllin.

The administration of small doses of calomel (one grain every two
hours) and also the employment of the iodide and bromide of potash
have been suggested. My experience with the iodide of potash has been
very satisfactory in some cases. Regarding the use of the bromide of
potash, Dr. Hammond reports that very great benefit has been afforded
in cases intrusted to his care by the daily administration of from ninety
to one hundred and twenty grains of that salt from the onset until the
stage of delirium had passed. Three of his cases recovered under this
treatment.

I have not had as good results with the continued administration of
calomel as those reported by Hammond and others.

In the stage of coma and collapse, blisters may be applied at the nape
of the neck or the actual cautery may be employed as a counter-irritant.
All medication should be abandoned in this stage, and the patient should
be stimulated and nourished. My guide to the employment of stimulants
is the effects which they have upon the pulse and temperature. If they
tend to bring both nearer to the standard of health, I continue their
administration. I believe that many patients die from the lack of stimu-
lants in a crisis of disease, especially in inflammatory conditions of the
meninges. Champagne, brandy,and whiskey, are preferable to port and
sherry. J am in the habit of giving stimulants often in small doses and
in combination with systematic feeding at short intervals. Beef-tea,
beef-juice, milk, pure cream, and a raw egg beaten in milk are my favorite
methods of giving nourishment in these cases. In the aged, the use of
stimulants is indicated early in the course of the disease.

Finally, the condition of the bladder and the bowels should be
carefully watched in this stage, especially in the case of extremely old
subjects. Retention of urine in comatose patients is liable to be over-
looked by the attendants and to cause great distress. A catheter should
be introduced into the bladder of patients so afflicted at regular intervals
during the day and night.

SUBACUTE CEREBRAL MENINGITIS.

This variety differs from the acute in that it is a secondary condition
(being the result of some exhausting disease), and also in that the
duration of the attack is longer, the brain-symptoms less marked, and
the prognosis proportionately less grave.
CHRONIC CEREBRAL MENINGITIS. 299

Morbid Anatomy.—The pathological changes differ little from that
of the acute form, except in that the exudation contains a smaller pro-
portion of pus and fibrin, and is less extensive in amount. The loss of
lustre and opacity of the pia is less extensive and adhesions of the pia
to the dura or to the cortical brain-substance are less common.

Etiology.— We are liable to encounter this form of meningitis as a
complication of chronic Bright’s disease, cancerous deposits, typhoid
fever, chronic diarrhea, rheumatism, and other exhausting diseases.

Symptoms.—The development of this complication is usually indi-
cated by delirium, The stage of headache and the initial chill are not
present asarule. If headache exists, it is moderately severe and lasts
but a few hours. Jactitation generally precedes the onset of delirium.

The delirium is not as active as in the acute form. The patient
develops a desire to constantly get out of bed, but is easily induced to
return. Muttering and an unsteadiness of gait develop.

The stage of coma is liable to come on rapidly. The pulse becomes
slow, the respirations sighing or puffing in character, and cyanosis
rapidly supervenes. Convalescence in patients who pass into the stage
of coma is very slow. Death is the more common termination.

Rheumatic meningitis may occur through metastasis, and as a com-
plication of that disease. It may be of the subacute or chronic variety.
It is often fatal.

Differential Diagnosis. Many hints given in connection with the
diagnosis of apoplexy from the various forms of coma encountered (p. 278)
will apply here, because coma is the prominent symptom of this variety
of meningitis. The cause is an important factor in the discrimination
in every case of suspected meningitis. Some of the differential diagnoses
mentioned when the acute form was considered might be repeated here.

Prognosis.-_When subacute meningitis occurs as a complication of
chronic Bright’s disease and rheumatism, it is generally fatal. The
chances of recovery are better when it develops from the blood-poisoning
of fevers, or accompanies exhausting diseases.

Treatment.—Blisters at the nape of the neck are often attended
with great benefit. If uremia exists, the elimination of the poison
should be hastened by catharsis, hot-air baths, and diuretics. If it be
due to exhaustion, stimulants are indicated.

CHRONIC CEREBRAL MENINGITIS.

This variety of meningitis may be confined to the convexity of the
cerebrum or to the base of the brain. It is essentially a disease of adult
life. Isis a common lesion in some forms of insanity. The symptoms
will be modified greatly hy the seat of the disease. If basilar in type,
the cranial nerves are especially liable to become involved.
300 LECTURES ON NERVOUS DISEASES.

Morbid Anatomy.—The connective-tissue elements of the pia are
chiefly affected in this form of meningitis. We encounter, therefore, an
opaque and thickened condition of that membrane, and an atimnlanon of
new connective-tissue cells. ‘Ihe coats of the vessels of the pia are often
thickened. The branches which nourish the cortex are sometimes
enclosed in meshes of new connective-tissue which bind the pia to the
brain’s surface. It is therefore frequently found to be difficult to
remove that membrane without tearing away portions of the brain. ‘The
connective-tissue of the brain (the neuroglia) sometimes participates in
the inflammatory process. Hence ditfuse interstitial encephalitis may be
one of the complications or sequel of chronic inflammation of the pia.

Chronic meningitis is usually more or less circumscribed in extent.
When pachymeningitis has been an exciting cause of this condition, the
pia will be adherent to the dura and appear thickened and very opaque,

The cortex may be found to have undergone atrophy, as a result of
long-continued pressure or impairment of its vascular supply.

Finally, an effusion which consists of serum, pus, or lymph may be
detected in the meshes of the pia. Tubercle has occasionally been
observed upon the convexity of the hemispheres in this form of menin-
gitis. Cysts may be developed by an encapsulation of the serous deposit
by false membranes. The Pacchionian bodies along the cerebral falx

may be increased. The ventricles are liable to contain an excess of fluid
over the normal amount. ;

Etiology.—This form of meningitts is commonly a secondary affecticn.
It is met with as a complication of syphilis, gout, rheumatism, chronic
kidney-disease, alcoholism, prolonged exposure of the head to extreme
heat, or the rays of the sun, and tuberculosis. It may be developed
idiopathically, especially in subjects who are badly nourished, or who
have suffered from privation, mental anxiety, grief, or great emotional
excitement. I recall one case that was apparently induced by a religious
revival. Hammond states that cooks are very prone to develop this
disease; on account of the exposure of the head to heat, This disease
is seldom met with until adult life. It is more common after the fiftieth
year than before it.

This form of meningitis may occasionally follow the acute variety.
It may also be induced by injuries received upon the head.

Symptoms. --I have several times encountered the pathological
evidences of well-marked chronic meningitis at an autopsy, when its
existence had not even been suspected during life. I mention this fact
as an illustration of the obscurity of the symptoms in some instances.

In many cases, the symptoms resemble those of general paresis.
The mind of the patient is usually affected, so that intimate friends
observe a change in the disposition or the intellectual attainments,
 

CHRONIC CEREBRAL MENINGITIS. 301

although the symptoms of mental impairment might escape a casual
observer. Moroseness, peevishness, apathy, somnolence, and delusions
are frequently developed.

The muscular power of the patient begins to show impairment later.
The act of walking is often rendered diflicult, ‘on account of a trembling
of the legs. The sphincters begin to act imperfectly, so that the patient
is often unable to prevent soiling of the clothing. The articulation of
words sometimes becomes affected. The speech is occasionally so blurred
and indistinct that only friends can understand what the patient says.
Paralysis of motion or sensation may be developed in the limbs, in some
cases.

Headache, which is increased by any mental or physical exertion, is
one of the most common symptoms. It is persistent, but not particularly
severe. In connection with chronic kidney-disease, this symptom forms
a peculiarly striking feature. Epileptic convulsions often follow the head-
ache, if the meningitis be due to this form of blood-poisoning.

Vomiting of a persistent type is a symptom that is very frequently
present in many cases. It is associated with great physical exhaustion.

The cranial nerves may give evidence of this disease when the base
of the brain is implicated. Facial palsy, strabismus, ptosis, irregu-
larity of the pupils, sloughing of the ball of the eye, ischemia of the
papilla of the retina, actual blindness or hemianopsia, choked disk, im-
pairment of the power of deglutition, irregularity in breathing, and slug-
gish movements of the tongue, may develop and be clinical guides to the
progress and seat of the lesion.

Finally, vertigo, buzzing in the ears, specks before the vision, attacks
of numbness and of hypersesthesia in the limbs, and general convulsions
may coexist with the symptoms already mentioned.

Profound coma usually occurs before a fatal termination. It is the
result cither of pressure upon the cerebral hemispheres or a mechanical
anemia of the brain.

Differential Diagnosis.— This is extremely diflicult, and often impos-
sible. We have in the majority of cases to deal with a combination of the
symptoms of meningeal inflammation and those of cerebral inflammation,
combined with the mechanical effects of pressure upon the nerve centres.
It is not always possible to decide positively between such a medley of
symptoms and those which accompany cerebral softening and cerebral
tumors,

The history of the patient may be of the greatest importance in the
discrimination.

From uncomplicated cerebral softening, chronic meningitis is to be
told by the persistency and severity of the headache; the absence of the
history of a previous apoplectic attack; the vagueness, so to speak, of
302 LECTURES ON NERVOUS DISEASES.

the mental symptoms; the infrequency of muscular contractions; and
the presence of undue mental excitement. As chronic meningitis and
cerebral softening are often associated, the diagnosis may be impossible,

From cerebral tumor, chronic meningitis is to be distinguished by
the character of the headache, which is more intense and circumscribed
where a tumor exists, by the frequent paralysis of the cranial nerves in
case of tumor, and by the slow development of mental symptoms when
a tumor is present. Moreover, the ophthalmoscope will usually reveal
the characteristic appearances of choked disk (fig. 87) when a tumor is
developing within the cavity of the skull.

It must be borne in mind, however, by the reader that tumors of the
brain or its meninges are frequently associated with a chronic meningitis
of a circumscribed character which is excited by the neoplasm. In such
a case the symptoms of both conditions would be so intermingled as to
render a differential diagnosis impossible.

Prognosis.— When syphilis is the cause of chronic cerebral menin-
gitis, active treatment in the early stages may effect a rapid cure. Hence
the prognosis is much more favorable in patients who give a history of
previous syphilitic infection than in those who do not.

The majority of cases of chronic non-specific meningitis do not
usually take so favorable a course under any form of treatment, although
recovery has been known to occur. Many of this type of patients de-
velop insanity or some complicating diseases of the viscera, chietly
pneumonia and pulmonary edema. Others may die from inanition or
the mechanical effects of direct pressure upon the brain by the exudation.

The tendency of this disease is toward progression, as a rule. The
prognosis is therefore unfavorable, provided syphilis can be excluded
from the factors of its causation.

Treatment.—If the disease be of syphilitic origin, I invariably em-
pley subcutaneous injections of the corrosive sublimate of mercury or
the mercurial bath. I use these in connection with the internal adminis
tration of large doses of the iodide of potash or calcium. I am convinced
that the effects of the iodides are more lasting (even in tertiary
syphilis) when combined with a mercurial treatment than when given
alone. The effects of the mercurial bath or of the sublimate injections
are more immediately beneficial to my mind than those gained by
the administration of mercurials in any other way. In fact, I have
arrested symptoms in this way which all other methods have failed to
relieve.

In non-specific cases, I have given the iodides in large doses, and
sometimes minute doses of the bichloride of mercury by the stomach.
1 also employ the bromides in combination with ergot.

When paralysis is developed, it is my custom to place the patient at
TUBERCULAR MENINGITIS—HYDROCEPHALUS. 303

once upon strychnia and electricity. Strychnia may be injected into the
paralyzed muscles if they fail to improve rapidly.

Counter-irritation at the back of the neck, either by the actual
cautery, severe static sparks, or blisters, often does good. In some
instances a seton may be introduced at this point to keep up active
counter-irritation,

The bowels and the bladder should be the objects of careful super-
vision. It may be necessary in some cases to use a catheter at regular
intervals, and possibly to irrigate the bladder when symptoms of cystitis
appear.

Finally, the mental symptoms must be treated by enforced quiet of
both the mind and body. The milk diet (from two to three quarts a
day) and the exclusion of all other foods has given happy results in my
hands in many forms of mental disorders. I frequently keep a patient
strictly upon this regimen for several weeks. Some of my patients have
lived largely upon milk for many months.

The hot-water treatment, to which I have referred elsewhere, is
indicated in some cases as a valuable adjunct to the remedies already
mentioned.

TUBERCULAR MENINGITIS—HYDROCEPHALUS.

Meningitis of the tubercular type (the so-called attacks of “ water
on the brain”) is most commonly observed during childhood.

The acute variety is described by German authors under the name
of “basilar meningitis,” because the morbid lesions are limited to the
base of the skull. English authors employ the term “ acute hydroceph-
alus,” when speaking of this variety.

The “chronic variety” of tubercular meningitis differs radically
from the acute form in its morbid anatomy, symptoms, and duration.

The two will be discussed separately because of their wide dissimi-
larity.

ACUTE HYDROCEPHALUS,

The pia mater, in this disease, becomes the seat of tubercular de-
posits and inflammatory exudation at the base of the brain.

It is essentially a disease of childhood, although it may occasionally
be observed in the adult.

Huguenin describes under the term “ leptomeningitts infantum” a
form of hydrocephalus of the acute variety, which, in his opinion, is
purely inflammatory, and is not associated with the formation of
tubercle. He excludes all “ predisposition” of an hereditary character
to this disease. Among the exciting causes of this variety of hydroceph-
alus he mentions the following: dentition, eruptive fevers, pulmonary
diseases which are accompanied with high fever, concussion of the
304 LECTURES ON NERVOUS DISEASES.

cranium, intestinal catarrh, and the ingestion of alcohol. He considers
an acute effusion into the ventricles of the brain as the chief pathological
manifestation of this variety of hydrocephalus.

Morbid Anatomy.—I shall confine my remarks upon this head to the
conditions found in typical cases of acute hydrocephalus of the tubercu-
lous type. These include (1) deposits of tubercle; (2) an exudation of
an inflammatory character in the meshes of the pia; and (3) a dropsical
effusion into the ventricles.

In the perivascular lymph spaces, chiefly but not exclusively at the
base of the brain, we find deposits of miliary tubercles. They are most
abundant at the bifurcations of the blood-vessels. They tend to mechan.
ically compress the blood-vessels, and when abundant they may occlude
vascular trunks or their branches. In the fissure of Sylvius and in the
region of the circle of Willis we are apt to find the most abundant de-
posit of tubercle, although they may also be scattered here and there
along the vessels upon the convexity of the brain. I have observed
them also in the longitudinal fissure, and upon the cerebellum and spinal
meninges,

The amount of tubercular deposit varies between extreme limits. If
very abundant, the vesscls may be completely imbedded in them; again,
they may be so scattered as to give to individual vessels an appearance
of localized swellings, which has been compared to a “string of beads ;”
finally, they may in some cases be overlooked by a casual observer on
account of their scarcity.

The effects of partial or complete occlusion of cerebral vessels by
tubercular deposits may be manifested (1) by multiple hemorrhages from
collateral fluxion ; (2) by spots of red softening; and (3) by effusions of
serum into the ventricles and at the base of the brain.

The tuberculous masses are found in this disease to exist in all
stages of development. Some may appear as large as a small pea,
from a confluence of smaller nodules; others may scarcely be visible
to the naked eye; finally, some may be seen to have undergone granu-
lar and caseous degeneration. Under the microscope, normal tubercle
appears as small grayish-white, semi-transparent, and partly gelatinous
bodies.

A well-marked inflammatory exudation is found in addition to the
deposit of tubercle at the base of the brain. This may consist of serum
alone, which is usually more or less turbid; or it may appear as a yellowish
sero-fibrinous layer which is most apparent about the Sylvian fissure, and
along the course of the larger blood-vessels. It may cover the entire base
of the brain, extending even to the under surface of the cerebellum. The
pia will be found to have lost its lustre and to be thickened, opaque, and
inelastic. It is more easily torn than in health, Finally, the ventricles
 

ACUTE HYDROCEPHALUS. 305

are found to be dilated, and to contain a serous effusion. The lining
membrane (ependyma) is thickened. The descending horn of the lateral
ventricle is particularly liable to become overdistended. The exudation
into the ventricles may be purulent, in rare instances. As a rule, it con-
sists of a serous fluid which is more or less turbid from an admixture of
white blood-corpuscles and epithelium. Tubercles may be often detected
in the ependyma, and along the vessels of the choroid plexus,

The effusion within the ventricles, if large in amount, may exert
pressure upon the convolutions of the cerebrum, and thus cause them to
appear more or less flattened and distorted. The brain-substance may
also appear dryer than normal, on account of an anemia that has been
similarly produced.

In closing my remarks upon the morbid anatomy of this disease let
me remind the reader that all the typical changes mentioned may not
exist in each case. The yellowish deposit at the base of the brain may
be absent; the distension of the ventricles forms an insignificant lesion
in some cases, and may even escape detection; finally, the deposit of
tubercle may be very slight and limited in extent, or, again, it may be
detected everywhere, even in the substance of the brain itself.

Tuberculous meningitis is associated in many cases with the patho-
logical manifestations of general tuberculosis. It is well, therefore, to
examine the viscera of the thorax and abdomen as well as the spinal cord
at every autopsy.

Etiology.—Between the first and seventh year, children of a tuber-
cular diathesis are particularly prone to develop this disease. It may
occur also from acquired tuberculosis, which follows infection from
caseous matter, etc. This probably accounts for its occasional presence
inadults. It may accompany general tuberculosis as one of its manifes-
tations.

Among the exciting causes may be mentioned any of the exhausting
diseases, such as the fevers, diarrhea, etc.; injuries to the head; den-
tition; otitis media; eruptions of the face or scalp; and improper
nourishment and hygiene.

These causes may occasionally produce the so-called “ lepto-menin-
gitis” described by Huguenin, in which all the morbid changes described
except the presence of tubercles are found.

Large and densely populated cities exhibit a greater mortality in
children from this cause than the rural districts of smaller towns.
Children who are not suckled, and who live in poorly-lighted and
imperfectly-warmed apartments, are very apt to develop an impairment
of the physical powers. This often leads to glandular swellings, the
development of hydrocephalus, and other manifestations of tuberculosis
or scrofula.

2)
306 LECTURES ON NERVOUS DISEASES.

Acute hydrocephalus, when it attacks adults, is most often encoun.
tered between the twentieth and fortieth years. Males are more often
attacked than women.

Symptoms.—These will vary with the pathological changes which
have occurred. Enough has been said already respecting the lesions
found in the brain after death to show the basis of this deduction. The
extent, and amount of the basilar exudation, and the amount of fluid
poured into the ventricles will determine the course of the disease and
its symptoms rather than the presence or absence of tubercle.

The advent of acute hydrocephalus may be very insidious or very
rapid. The former method of attack is observed, as arule. The latter
method of onset is frequently attended with convulsions.

It is a custom with some authors, although serious objections can
be advanced against it, to divide the symptoms of this form of menin-
gitis into those of distinct stages. Thus Huguenin speaks of a stage of
irritation, a second of pressure, and a third of paralysis. Examples of
a similar kind might be cited from other authorities. Now, while this
may be desirable from an author’s point of view for beginners, the excep-
tions to any type presented are so frequent as to almost disprove the
rule.

The premonitory symptoms (when the advent is gradual) are such as
may attract the notice of the nurse or parents. The child becomes
peevish and irritable, is observed frequently to stop in its play and rest
the head upon the hands or floor, or upon the knee of the mother; it
gradually becomes dull and apathetic, and desires to remain quiet; it
sleeps in a restless manner; the appetite becomes very capricious; the
tongue may be coated ; the breath is apt to be offensive, and constipation
often alternates with diarrhcea. Progressive emaciation of the body and
limbs takes place. This is a symptom of diagnostic importance, when
it is accompanied by those previously mentioned. The temperature of
the body may rise slightly in the evening. Sometimes a hacking cough
may be developed. The countenance of the child is apt to lose its expres-
sion of vivacity, and to become dull and immobile. Pallor is usually de-
veloped. Transient attacks of flushing of the face may be observed, but
they are of short duration. Headache is not common.

These prodromata may last only a few days in some subjects, while
in others they may persist for weeks.

First Stage.—This stage gives clinical evidence of cerebral irrita-
tion. The advent of the disease is marked by a variety of symptoms of
a more marked character than the prodromata. Vomiting is frequently
developed. It may be very persistent and projectile in character. Head-
ache is also complained of by the child, It is very severe as a rule, and
causes the sufferer to cry and put the hands to the head. It is not
ACUTE HYDROCEPHALUS. 307

constant, and is usually confined to the frontal region. It may prevent
protracted sleep and cause paroxysms of screaming.

In some instances, the onset of this disease is marked by convulsions
of an epileptic character. In these cases the prodromata may have
been absent.

During sleep the child flexes the thumbs upon the palms of the
hands, grinds the teeth together, and rolls the head from side to side or
bores it into the pillow. It often awakes during sleep with the so-called
‘hydrocephalic cry,” and spasmodic movements of the ocular and facial
muscles are sometimes observed.

Now, when we examine such a child with care, we shall see that the
abdomen is retracted, hard, and “ boat-shaped ;” that the pupils are small ;
that the skin of the abdomen or thorax will show a red line in about
thirty seconds after the finger-nail has been drawn across it (tache céré-
bral of Trousseau); that pressure upon the fontanelle, in a very young
child, will increase the symptoms of cranial pain; that the tongue is dry
and coated except at the edges and tip, which are generally red; that
there is photophobia, and often strabismus; and that the thermometer
shows a marked elevation of temperature which exhibits evening exacer-
bations and morning remissions of about two degrees.

The temperature rarely rises above 103° F. It may not exceed
101° F. When convulsions appear at the onset, it may go two or three
degrees higher. The exacerbations and remissions of the fever are not
as regular as in some other forms of disease.

The pulse is increased in frequency, but is regular, full in volume,
and compressible, except upon excitement or muscular exertion. It may
then be somewhat irregular.

In some cases, the breathing may be somewhat irregular; but as a
rule the rhythm is normal.

The restless and fitful sleep gradually gives place to an increasing
drowsiness. The child sleeps constantly unless aroused.

The duration of this stage is usually about a week. It may, however,
be prolonged to ten or even fourteen days.

Second Stage.—When the brain begins to exhibit the clinical evi-
dences of depression (as a result of effusion into the ventricles and at the
base of the skull) the symptoms of invasion disappear and new ones
take their place.

The pupils, which were contracted, now begin to dilate irregularly.
They respond slowly to light. The head becomes forcibly extended by
a tonic rigidity of the muscles of the neck so that it bores into the pillow.
Sometimes the muscles of the back contract so forcibly as to cause opis-
thotonos. Muscular spasms and paroxysms of delirium are developed.
In some instances, the patient lies motionless upon the back, with the eyes
308 LECTURES ON NERVOUS DISEASES.

staring fixedly and unconscious of surrounding objects. The projectile
vomiting of the first stage ceases. The urine and feces may be passed
involuntarily. 7

The muscles show the effects of cerebral disturbance in various
ways. We have already alluded to the tonic spasm of the back muscles.
The muscles of the upper extremity are usually thrown into a state of
excitability, as shown by a perpetual movement of the fingers, picking
of the bed-clothes, opening and shutting of the hands in an aimless way,
ete. General convulsions may occur from time to time. The ocular
muscles may be affected. When so, the third cranial nerve and also the
optic chiasm or the optic tracts are apt to be simultaneously involved.
We are liable to encounter nystagmus, strabismus, ptosis, and pupillary
spasm in such cases. Sometimes the facial nerve may be involved, and
facial spasm or paralysis may then ensue. I recall an instance where
the disease was associated with otitis media, in which the onset was
accompanied by facial palsy.

The temperature of the body falls during this stage. It may reach
the normal point.

The headache apparently persists in this stage, although the patient
does not complain of it. Weare justified in drawing this deduction
from the fact that these subjects utter at intervals a peculiar cry, known
as the “hydrocephalic cry.” It seems to be partly involuntary and to
express both alarm and pain. The facial muscles assume the attitude
expressive of pain when the cry takes place.

The respiration becomes more or less irregular during this stage.
In some instances I have observed typical “ Cheyne-Stokes breathing.”
These symptoms, as well as disturbances of the heart’s action and im-
pairment of the power of swallowing, which often exist, indicate that the
pneumogastric nerves are involved. ;

The ophthalmoscope may enable us to detect infiltration about the
papilla, varicosities of the veins of the retina, small punctate hemor-
rhages, and whitish granulations of the choroid and retina in some
instances. A choked disk has been observed also.

The urine may contain albumen. It is tsually high-colored, scanty,
an abundantly impregnated with chlorides and phosphates.

The feces are often slimy, and are greenish in color, and very offen-
sive in the large majority of cases.

The tonque becomes covered with incrustations, in which changes the
lips and gums may also participate.

Some years ago, my attention was called to the fact that the second
stave of this disease is often aecompanied hy a short interval of apparent
convalesrence. The patient may regain consciousness, be free from de-
lirium or pain, eat voraciously, and excite the belief that recovery has
ACUTE HYDROCEPHALUS. 309:

begun. But, in my experience, these intervals are of short duration, and
the patient passes after a lapse of a few hours into deep coma again.

Finally, hemiplegia may occasionally be developed. It indicates
pressure upon the motor tracts which join the cells of the cerebrum with
those of the anterior horns of the spinal cord. (See page 258.)

Third Stage—This is characterized by an increasing intensity of
the symptoms of the second stage, with an exacerbation of the febrile
symptoms of the first stage. Huguenin calls it the “stage of paralysis,”
because that symptom is a very prominent one. Hammond names it the
“stage of recurrence,” because the febrile symptoms return and the cere-
bral disturbance is more profound.

We observe, during this stage, the development of a paralysis of some
part of the body, which is permanent. Convulsions and contracture of
the muscles of the back, neck, and jaw may precede the paralysis.
Reflex movements can be excited in the paralyzed limbs, although the
power of voluntary motion is lost. The face, eyes, or limbs, may be the
seat of paralysis. It is probably due to excessive intra-cranial pressure.

The temperature rises higher than it did in the first stage. I have
observed it to reach 107° F., in one instance, a few hours before death
occurred. It often rises to 105° F.

The pulse becomes greatly accelerated, small in volume, and intermit-
tent. It resembles the pulse observed in animals after section of the vagus.

Coma becomes profound. It is accompanied by a clammy sweat,
involuntary evacuations, dysphagia, dilated pupils, stertorous breathing,
a tympanitic abdomen, and paralysis.

Death usually occurs from asphyxia, or convulsions. It may ensue
from impairment of the heart’s action.

Duration of the Disease.—This admits of the widest latitude of
statement. Cases have been reported where death has occurred in a few
hours, while others have lasted for many weeks.

Those which begin with paralyses or convulsions are rapidly fatal,
in my experience. ;

The age of the patient may modify the duration of the ainenee.
While I believe that no patlological differences exist between the infan-
tile and adult varieties of the disease, its duration is more apt to be
abnormally short in the child. When it develops as a complication of
general tuberculosis, death often occurs during the first week. A vigor-
ous constitution may cause the disease to be prolonged over a much
longer period. The vague character of the prodromal symptoms in
many cases renders it advisable to count the duration of the disease
from the first well-marked cerebral symptom.

Differential Diagnosis.—In common with many other observers, I
have seen cases of acute hydrocephalus which have resembled those of
310 LECTURES ON NERVOUS DISEASES.

acute Bright’s disease, infantile remittent fever, acute meningitis, gastro-
enteritis, and typhoid fever. A condition called “spurious hydrocepha-
lus,” which develops in children, may also closely resemble it in many
respects.

The acute form of Bright's disease is to be distinguished by the pres-
ence of albumen and casts in the urine, the existence of cedema of the
face and limbs, the peculiar waxy skin of uremic poisoning, and the
absence of the prodromal symptoms of hydrocephalus. The history of
the case may also afford a clue to the cause of the attack.

Infantile remittent fever is accompanied by a very high range of
temperature (105°-106° F.), which exhibits regular remissions and ex-
acerbations. It exceeds the customary limits of the fever of hydro-
cephalus (103° F.), and does not fluctuate irregularly. The pupils are
normal. The pulse does not intermit or become irregular. The hydro-
cephalic ery is not developed, nor are the thumbs flexed upon the palms
during sleep. The patient does not grind the teeth. The vomiting is
not projectile in character; it is accompanied by retching. The abdo-
men is distended with gas, and is tender. ‘“ Pea-soup discharges” from
the bowels occur.

Acute meningitis is less frequently accompanied by ocular symp-
toms, and a retracted and “ boat-shaped ” abdomen. It does not produce
the hydrocephalic cry, nor any of the prodromata of the tubercular
variety. It is a disease of sudden onset and rapid progress. The tem-
perature runs high, and exhibits very slight remissions. The pulse is
not irregular except when death is near. It attacks adults and children
in good health. Delirium and convulsions occur earlier than in the
tubercular form.

Gastro-enteritis fails to produce the prodromata of tubercular
meningitis, and also headache, projectile vomiting, hydrocephalie cry,
paralyses, irregular pulse, etc. It is associated with diarrhea, tenderness
of the abdomen, and pain in the bowels.

Typhoid fever is accompanied by diarrhea, tympanites, a character-
istic eruption upon the abdomen, and a typical range in temperature.
The prodromata of hydrocephalus, and the more prominent symptoms
of that disease mentioned above are wanting.

Spurious hydrocephalus usually follows an attack of cholera infan-
tum. It is sometimes accompanied by a few of the cerebral manifesta-
tions of the tubercular variety, but the abdomen is distended and tender,
the fontanelle is depressed, paralyses do not occur, and the temperature
and pulse do not indicate the more serious affection.

Prognosis. — Tuberculosis of the meninges and brain generally
terminates in death. So large is the percentage of mortality that
most authors deny that a case of recovery has ever occurred. On the
 

ACUTE HYDROCEPHALUS. 811

other hand, isolated cases of apparent recovery have been reported hy
Formey, Politzer, Rilliet, Hahn, Barthez,and others. Personally, I have
never seen a case where recovery has taken place, and I am inclined to
believe that lepto-meningitis has existed in all cases where a favorable
result has occurred. It is certain that idiocy, epilepsy, and the chronic
type of hydrocephalus is dependent upon a tubercular diathesis in some
instances; but it is not yet proven that they have ever been preceded by
a typical attack of acute bydrocephalus.

Treatment.—My remarks made concerning the prognosis of this
disease must preclude any suggestions relative toa cure of this aflection,
I have tried all the methods of treatment suggested by authors, including
the iodide of potash, the mercurial salts, the phosphate of soda, depletion,
ete., without any apparent benefits. Notwithstanding the incurability of
the disease, the individual symptoms should he ameliorated, however,
as long as life exists, by judicious medication. The preparations of
opium and the bromide salts are indicated when headache) photophobia,
restlessness, and jactitation are present. Ice-bags may often be applied
to the head with apparent benefit. The bowels should be moved by
laxatives when constipation exists. The patient should be kept in a
quiet and darkened room. When the convulsive attacks are frequent
and severe, I occasionally administer anesthetics. Venesection or local
depletion is of no benefit, and should not be performed.

The prophylactic treatment of this malady deserves more considera-
tion than is often paid to it by medical men. Iam convinced that I have
saved the lives of many children born of tubercular parents by the steps
which I shall here advise.

It is my custom, with children who are predisposed to this affection,
to insist that the child shall be nursed from birth by a woman who is free
from all hereditary or acquired diseases. ‘lhe child should be kept in
the country and allowed to romp in the open air until seven years old.
The hygienic surroundings and the diet of the child should also be care-
fully looked to until the period of danger has passed. It is my custom
to administer cod-liver oil to those who remain thin or poorly nourished
in spite of the precautions mentioned. Bathing the body in cool water,
and subsequent frictions of the skin are of benefit. It is also well to
change the climate and surroundings frequently, so as to avoid unneces-
sary exposure to cold or dampness during the winter months, or to
extreme heat in the summer. By these means many children are reared
to adult life when previous ofispring of the same parents have died
of hydrocephalus.

I would caution the reader also against allowing children with hered-
itary tendencies to tuberculosis to be subjected to extreme or prolonged
excitement of any kind. It is not well to send them to school until the
312 LECTURES ON NERVOUS DISEASES.

period of danger has passed. I am convinced that playing with children
before going to bed, especially if impressionable or emotional, conduces
to imperfect sleep and physical debility. The custom of forcing. the
young intellect by feats of memory or confinement in the school-room is
also very pernicious.

The proportion of shallow orbits and hyperopte eyes in persons who
haye a tuberculous ancestry is very large, as proven by the examination
of many hundreds of cases by my friend Dr. G. T. Stevens. My own
observations (lately published in a paper read by me before the Inter-
national Medical Congress, 1888) confirm this statement, and lead me to
believe that “latent hypermetropia” (p. 127) is remarkably frequent in
this class of subjects. This congenital defect (if it exists) should be
properly corrected by glasses before the child is allowed to study. I
have no doubt that this one factor has more to do with the so-called
“tuberculous predisposition ” than many of us imagine. The health of
any child must of necessity be seriously affected by this well-recognized
source of physical disturbance and excessive nervous expenditure.

CHRONIC HYDROCEPHALUS.

This disease is essentially surgical; the acute form comes more
particularly under the province of the physician. In either case, how-
ever, the “tubercular diathesis ” seems to influence its development.

Chronic hydrocephalus appears to be produced by a low grade of
inflammation which attacks the lining of the ventricles during foetal life
or early childhood. In some instances, it appears later in life. In a few
isolated cases, the serous effusion seems to be external to the brain. Some
authors state that this latter condition never occurs except as the result
of a hemorrhage into the cavity of the arachnoid. They consider the
condition which stimulates true external hydrocephalus as an evidence
either of a congenital defect in development (the cerebro-spinal fluid
taking the place which the brain should have occupied), or of atrophy
of the brain-substance that has resulted from the pressure of the fluid
within the ventricles.

Morbid Anatomy.—In chronic hydrocephalus, the sutures fail to unite
and the calvaria does not ossify as in health. The ventricles are enor-
mously distended, and the channels of communication between them are
widely dilated and open. Finally, the convolutions are flattened and the
cerebral substance rendered extremely thin and attenuated. The ossa
triquetra are often found to be excessive. A complicating meningitis
(which often exists) may involve some of the cranial nerves (especially
the optic) and induce atrophy of them. Fluctuation may be detected
often in the region of the fontanelles and the open sutures.

The deformity of the cranium is evidenced by an overhanging brow,
CHRONIC HYDROCEPHALUS. 313

an increase of the circumference of the cranium and its disproportion to
the size of the face, and by open fontanelles and unclosed sutures. The
latter are often widely separated. The mental condition of the subject
is below the normal standard whenever the pressure of the fluid has
induced changes in the brain-substance.

Instances have been reported where twenty or more pounds of fluid
have been found to exist within the skull. The circumferential measure-
ment of the head bas been known to exceed forty inches.

The fluid formed during the progress of this disease consists of water,
albumen, floceuli of lymph, salts of lime, soda, and potash, epithelial and
blood cells, and urea.

 

Fic. 84.—Curonic HyprocerHAtus. (After a photograph.)

The condition of the brain-substance found after death depends
upon the seat and extent of the dropsical effusion. It may be softened
and atrophied, when degeneration has been produced by a pressure which
has impaired its blood-supply. Occasionally it is rendered abnormally
resistant and of firm consistence.

Etiology.—The hereditary nature of this affection is proven by the
fact that several children of the same parentage have been successively
attacked in many recorded instances.

The acquired form may be independent of any hereditary taint. It
has been observed to accompany congenital defects of the walls of the
blood-vessels, chronic passive hyperemia, occlusion of the cerebral
sinuses, rickets, syphilis, alcoholism, some of the eruptive fevers, and
314 LECTURES ON NERVOUS DISEASES.

atrophy or imperfect development of the brain, Aged subjects may
sometime? be attacked. In the young, it is frequently developed during
or previous to dentition.

Symptoms.—The deformity of the head, which is characteristic of
this disease, may occasionally be present at birth. As a rule, however,
the increase in the size of the head does not manifest itself until the
child is a month or two old. If it exists at birth, the child is apt to die
soon after delivery.

Whenever the deformity becomes well developed, it seems to me
impossible for a medical man to err in diagnosis.

The countenance of chronic hydrocephalus (see fig. 84) is perhaps the
most typical of any of the conditions to which the attention of the phy-
sician or surgeon is directed. In it, the frontal bone is tilted forward so
that the forehead, instead of slanting a little backward, rises perpendicu-
larly, or even juts out at its upper part, and overhangs the brow. Watson
thus describes it: ‘‘ The parietal bones bulge, above, toward the sides; the
occiput is pushed backward, and the head becomes long, broad, and deep,
but flattened on the top. This, at least, is the most ordinary result. In
some instances, however, the skull rises up in a conical form like a sugar-
loaf, Not unfrequently the whole head is irregularly deformed, the two
sides. being unsymmetrical. Some of these rarer varieties of form are fixed
and connate; others are owing, probably, to the kind of external pressure
to which the head has been subjected. While the skull may be rapidly
enlarging, the bones of the face grow no faster than usual, perhaps not
even so fast, and the disproportion that results gives an odd and peculiar
physiognomy to the unhappy subjects of this calamity. They have not
the usual round or oval face of childhood. The forehead is broad, and
the outline of the features tapers toward the chin. The visage is triang-
ular. The great disproportion in size between the head and the face ig
diagnostic of the disease, and would serve to distinguish the skull of the
hydrocephalic child from that of a giant.”

As a result of the compression and atrophy of the brain, the limbs
do not develop as in health, the abdomen is usually distended and tym-
panitic, the child is unable to hold the head erect, and the pupils become
more or less dilated. Sometimes the eves bulge from their sockets. At
the fontanelles and open sutures fluctuation may be detected when the
dropsical effusion is external to the brain.

The digestive functions are carried on imperfectly during hydroceph-
alus. Hence these children exhibit inanition, and are prone to develop
some form of inter-current disease. I have seen instances where death
has occurred from starvation.

In a certain proportion of cases, life may be prolonged for years. It
will then he observed that the power of walking is acquired imperfectly
CHRONIC HYDROCEPHALUS. 315

and late. The gait is characterized by tottering, stumbling, and a
peculiar awkwardness of movement indicative of idiocy. ‘The mental
powers are more or less impaired. These subjects are generally very
irritable and peevish, and are liable to have recurring attacks of fever,
nausea, and vomiting. Convulsions are frequent, and paralysis of special
groups of muscles may be developed during the progress of the disease.

I have personally seen one hydrocephalic subject who lived to be
over thirty years of age. It is not common, however, for life to be pro-
longed to such extreme limits. The majority die within three or four
years. Whenever anemia or asthenia are induced, the patient dies within
a period of twelve months, as a rule.

Differential Diagnosis.—Little need be said regarding the diagnosis
of this disease. It can hardly be confounded with any other atlection.
Although the cranial deformity of rickets produces a lack of symmetry in
the contour of the head, the open sutures, the sense of fluctuation, and the
characteristic deformity of hydrocephalus do not exist, nor are mental
and physical derangements similar to those of hydrocephalus induced.

Prognosis.—The large majority of these subjects die within one year.
The exciting causes of death include the following complications: Men-
ingitis, apoplexy, ependymitis, anemia, asthenia, paralysis of the heart,
and escape of the fluid by rupture of the aponeurosis covering the skull
and open sutures. When recovery takes place, the fluid ceases to form
and the sutures gradually close.

Treatment.—Suggestions both of a medical and surgical character
have been brought forward from time to time as productive of good in
this disease; but I have laid most of them aside, as I have found them of
doubtful utility. Occasionally, it is well to strap the head. I doubt if
the exudation within the skull was ever arrested by mechanical compres-
sion; but it sometimes appears to give ease to the patient, and it inva-
riably gratifies the parents and interested friends.

Tapping of the head may be employed with advantage when fluctu-
ation can be detected at the fontanelles. It is contra-indicated when
inflammatory changes are present. The aspirating needle should be in-
troduced at the anterior fontanelle, and a few ounces of fluid only should
be withdrawn at one time. The head should be bandaged after the oper-
ation, and the child carefully watched for inflammatory sequele. Lan-
genbeck has employed aspiration of the lateral ventricle (by passing an
aspirating needle through the roof of the orbit behind the upper eyelid)
in the internal variety of chronic hydrocephalus. I have never resorted
to this method of treatment, because I regard it as a dangerous one and
of questionable benefit to the patient.

The medicinal treatment of this disease must be purely saeeivabiaintitas
It is well to administer tonics, such as cod-liver oil, the iodide of iron,
316 LECTURES ON NERVOUS DISEASES.

and quinine, at intervals throughout the course of the disease. Some
authorities recommend the iodide of potash. Calomel in minute doses
(gr. 1-4 daily) may be employed until severe purging occurs. Per-
sonally, I have little faith in the curative properties of any drug in this
disease. Plenty of fresh air, a good nutritious diet, warm clothing,
frequent bathing and rubbing of the skin, and a change of residence at
intervals will assist Nature more than constant medication. It is per-
haps advisable to administer some of the phosphates when the disease
coexists with rickets. I have never found the slightest benefit from the
use of mercurial inunctions.

ENCEPHALITIS.

The substance of the brain may take on inflammatory action with or
without the existence of a complicating meningitis. It is generally cir-
cumscribed, although many spots may be simultaneously atfected. The
latter is sometimes termed the “general” variety. Sometimes the gray
matter of the cortex is alone involved. Again, only the medullary sub-
stance of the brain may be implicated. Finally, the basal ganglia (the
“¢orpora striata” and “optic thalami”), the cerebellum, the medulla
oblongata, the pons Varolii, the crura cerebri, and the floor of the fourth
ventricle have been known to be the seat of this condition.

Morbid Anatomy.—The existence of encephalitis may be manifested
after death (1) as spots of injection associated with abnormal friability;
(2) by the presence of punctate extravasations seen on cross-sections of
its substance; (3) as localized indurations; (4) as red softening of the
brain-substance; (5) as circumscribed collections of pus; and (6) by
gangrene. ‘

Whenever cerebral abscess has occurred, the cavity is usually
encapsulated by a new connective-tissue formation.

Rindfleisch divides the stages of cerebral abscess as follow: 1. A
stage of hyperemia; 2. The development of infarction (page 230); 3.
Gidema or hemorrhagic extravasation; 4. Proliferation of the cell ele-
ments; 5. Hypertrophy and induration (in chronic cases); 6. Softening
of the brain-substance; 7. Suppuration; 8. A condition of foetid suppu-
ration, resembling gangrene, which is occasionally preceded by the devel-
opment of a false membrane; 9. Atrophy, as a late result of the inflam-
matory changes.

Etiology.—Among the causes of encephalitis which tend to induce
suppuration may be mentioned pyemic infarction, direct injury to the
head, disease of the internal ear or temporal bone, diseases of the nasal
cavity, syphilitic disease of the bones of the cranium, diseases of the
orbit, cancer, and certain idiopathic causes which are not well under-
stood,
CEREBRAL SOFTENING. 317

Symptoms.—Encephalitis is so closely allied to red cerebral soften
ing that it will be further discussed under that heading. The symptoms
of the disease must of necessity vary with the sext and extent of the
lesion. Hence it is difficult to interpret them correctly unless the func-
tions and anatomy of the various component parts of the brain are well
understood. Pages 68 to 102 will aid the reader in mastering cerebral
localization.

Differential Diagnosis.—The points of value in the discrimination
of this disease will be given in those pages which treat of the diagnosis
of cerebral softening.

CEREBRAL SOFTENING,

The three forms of this condition which are recognized by most
authorities are the white, yellow, and red.

Morbid Anatomy.—The pathology of softening of the brain may thus
be summarized ;—

The white variety is a chronic condition in the great majority of
cases, and is usually dependent upon some disease of the small arteries
and capillaries which gradually deprives the parts of their normal nutri-
tion. There isno hyperemia. The parts are usually of an opaque dirty
white.

White softening may sometimes be acute; in which case it is due to
a sudden obstruction of some artery of large size by an embolus ora
thrombus.

The yellow variety is simply an altered state of either the white or
the red. Its color is due either to the presence of altered blood-pigments
which have arisen from a previous slight extravasation ; or to a fine state
of division and a close aggregation of particles of fat formed within a
mass of the tormer varicty.

The red variety is commonly an acute affection. As has been stated,
it follows vascular ocelusion from an embolus or thrombus; or it may be
the result of an attack of encephalitis. A marked extravasation of blood
into a mass of white softening may cause a red appearance to the mass,
but the microscopical appearances will differ from that of the acute form
now under consideration. In the red variety, there is intense hyperamia
from the onset, followed by a rupture of.the capillaries and an extravasa-
tion of blood. Its pathology is similar to that of “infarction ” elsewhere
in the body (page 229).

All forms of cerebral softening are liable to be accompanied |v
disturbances of motion or sensation, aphasia, and mental impairment.
The seat and extent of the lesion will govern the type of its external
manifestations. The history of the patient will often be indispensable
in deciding as to the existence of softening, if in the anterior part of the
318 LECTURES ON NERVOUS DISEASES.

frontal, the occipital, or the temporal lobes, where the so-called “ motor
centres” of the brain are wanting. (See Fig. 5.)

There is more or less cedema into the brain-substance which sur-
rounds a spot of red softening. This often causes the area of softening
to appear as an clevation above the plane of the section when the brain-
tissue is divided with the knife. In cases where the focus of softening
is of the white or yellow variety this elevation is wanting.

The débris which constitutes a focus of cerebral softening will be
found to consist of fat granules, altered blood-corpuscles, pigment
masses, pus-cells, disintegrated nerve-tissue, caseous matter, and large
spherical cells, filled with fat granules (Gluge’s corpuscles). Each
variety of softening causes variations in the relative proportions of these
elements. The red variety will exhibit a large admixture of blood-

   

Fic. 85 —SorTenep Brain-Tissue. (After Fox )
corpuscles, pigment granules, and Gluge’s cells; the vellow and white
varieties will be accompanied by an excess of fatty matter or caseous
substance, and a small admixture of altered blood pigments, corpora
ainylacea, and crystals. /
Etiology.—It is a mistake to suppose that cerebral softening occurs
only in the aged. Old age is indeed a prominent factor in exciting cere-
bral thrombosis; and that condition is followed, as a rule, by softening of
the brain in the old. Still, the more common exciting causes of this dis-
ease include (in addition to cerebral embolism and thrombosis) pyemia,
syphilis, alcoholism, sun-stroke, and cerebral hemorrhage, all of which
may exist independently of old age. I have to-day under my care 4
young married lady (thirty years old) who has marked cerebral soften-
ing that was induced by an embolic attack during the puerperal state, in-
dependently of any lesion of the valves of the heart. Another of my
CEREBRAL SOFTENING. 319

patients developed cerebral softening as a result of cummatous pachy-
meningitis when but thirty-five years of age. All the exciting causes
of abscess of the brain may occasion cerebral softening under favorable
circumstances. Among these may be mentioned the exanthematous
fevers, glanders, the puerperal state, mercurial- and lead-poisoning, ne-
crosis,' osteo-myelitis, pyeemia and septicemia, abscess of the viscera,
and many others.

The white variety results from causes that tend to so impair the
blood-supply of the softened part as to deprive it of nutrition without
creating at the same time a hemorrhage from the surrounding capillaries.
It is often designated as the * non-inflammatory form,” in contrast to the
red, which is commonly of inflammatory origin.

The nature and mode of suppression of the blood-supply to portions
of the brain, more or less limited, governs to a great extent the variety of
softening which results. As has been stated in a previous page, the ar-
teries, capillaries, or sinuses of the brain may be independently occluded.
Thrombosis or embolism may be the immediate cause.of such occlusion,
or the blood-supply may be arrested by pressure upon the vessels by new
growths within the skull, or from without, as in the case of hemorrhage,
tumors, ligation, edematous infiltration, etc.

The rapidity of arrest of the circulation, and the extent of collateral
fluxion which immediately follows (within twenty-four or forty-eight
hours), are the factors which govern the results which follow. The col-
lateral circulation may be sufficient in some cases to arrest the immediate
death of the parts suddenly deprived of blood by an embolus or thrombus,
or some quickly-developed and extreme pressure upon the blood-vessels.
Again, it may be so great as to cause a capillary hemorrhage, giving the
softened area a red appearance (infarction) immediately after the arrest
of its normal blood-supply. Finally, inflammatory action, as in true
encephalitis, may create the red variety of softening.

Symptoms.—It is not always possible to make a positive diagnosis
of cerebral softening. The symptoms may be influenced to a greater
or less extent (1) by the exciting cause; (2) by the seat of the focus of
softening; (3) by the variety of softening which exists; (4) by the de.
velopment of suppuration; and (5) by the occurrence ‘of hemorrhagic
extravasation into the softened brain-tissue.

Notwithstanding these elements of uncertainty in diagnosis, it is
generally possible to arrive at some definite conclusions by a careful
study of each case and the exclusion of the other conditions of the brain
whose symptoms closely resemble those of softening.

Encephalitis or inflammatory red softening is accompanied, as arule,
by febrile symptoms of a marked kind. The temperature often rises to
108° F., and the pulse becomes more or less accelerated at first. Later
320 LECTURES ON NERVOUS DISEASES.

in the disease, the pulse may be slower than normal. Headache is a
marked symptom. It is often accompanied by vertigo, somnolence,
hy peresthesia, formication, pruritus, neuralgic pains, vomiting, and con-
fusion of intellect. Later, it may be attended with delirium, muscular
twitchings, general conyulsions,a tottering gait, imperfections of speech,
motor or sensory paralysis, and coma, Amnesic or ataxic aphasia may
he developed. The face freq uently becomes flushed, and an irregularity
of the pupils may be occasionally observed.

When an apoplectic extravasation occurs into the softened mass, pro-
found coma and paralysis suddenly appear. Other evidences of cerebral
disturbance may also exist. Hemianmsthesia will generally coexist with
hemiplegia, the functions of sensation and motion being affected upon the
same side, if the disease is confined to one cerebral hemisphere. When
the hemorrhage is extensive, death occurs within forty-eight hours. In
instances of a less severe type life is not destroyed, but the recovery of
motility and sensibility is seldom complete.

The ophthalmpscope may often prove of service in the diagnosis of
cerebral softening. It enables the physician to detect changes in the size
and course of the retinal vessels.

Cerebral softening of the non-inflummatory variety may be due to an
attack of embolism or thrombosis, or to nvchanical compression of some
of the cerebral arteries or sinuses. The method of onset will be modified,
therefore, by the exciting cause. The symptoms of each of the causes
cnumerated have been given in preceding pages.

When aged subjects are attacked by cerebral softening, the history
of the case is often extremely vague and unsatisfactory. Many instances
have been recorded in which extensive foci of softening, abscesses of large
size, and direct injuries to the brain have not been suspected during life,
although they were encountered at the autopsy. We are justified in
attributing diagnostic value, therefore, to certain symptoms when taken
collectively, which would he of little importance alone. Thus, for ex-
ample, when an aged person begins to exhibit an impairment of memory,
unnatural peevishness and irritability, an imperfect control over the
cmnotions, despondency, an incapacity for prolonged mental eftort,
physical weakness, 1. diminution of motor power in the legs or arms, a
monotonous habit of speech or gesture, ete., we are forced to the
conclusion that they indicate collectively some scrious form of disease.
We are strengthened in this conclusion if these symptoms are followed
after a lapse of time by an awkwardness of movement, a tottering gait,
dementin, or the sudden development of paralysis of sensibility or
motility.

Cases of cerebral softening frequently develop a peculiar tendency to
clip off words during attempts at conversation or reading. These cases
CEREBRAL SOFTENING. 321

exhibit also an inability to maintain continuous muscular contraction,
a excitability when questioned concerning their ailments, a lack of
regard for personal cleanliness and the decencies of life, groundless
prejudices, and many other evidences of mental decay.

Paralysis of motion may develop gradually (as well as suddenly) in
counection with cerebral softening, In such a case the impairment of
motility will generally be perceived in the fingers or toes first, and
steadily advance toward the trunk. ‘This method of attack is called
“erceping palsy,” in contradistinction from paralysis of sudden advent.

When cerebral softening is far advanced, it is not uncommon to en-
counter bed-sores upon the nates. They resist all methods of treatment,
and indicate “trophic disturbances” of the skin.

Respecting the seat of softening, some deductions can occasionally
be drawn during life from the symptoms presented.

When deglutition hecomes difficult, or when the respiratory or cir- .
culatory functions are markedly affected, we are justified in suspecting
that the basilar artery has probably been ovcluded, and that softening
of the pons or medulla exists.

The ocular muscles may be rendered paretic by a focus of softening
in the cerebri crus.

If the tenporal lobes of the cerebrum are attacked, we may meet with
disturbances of hearing, smell, and taste. Word-deafuess may also be
encountered, especially if the left hemisphere is involved.

Softening of the oreiital lobes may give rise to visual disturbances,
such as colored spectra, hemianopsia, a loss of the memory of past sight-
perceptions, word-blindness, ete.

Evidences of impairment of motility are liable to be developed early
when the motor area of the corte, or that part of the centrum ovale
through which the motor fibres pass to the internal capsule (fig. 6) are
attacked.

Lesions of the centrum ovale may be diagnosed in some cases hy
tests mentioned on page 184.

The cerebral cortex, the basal ganglia (corpus striatum and optic
thalamus of each cerebral hemisphere), and the white substance of the
cerebrum are most frequently attacked. The area of softening seldom
crosses the mesial line.

The causes of death in this disease are various. Some patients die
of slow exhaustion. Others develop asphyxia, on account of a disturb-
ance of respiration. Not infrequently convulsions produce death by
interfering with respiration. Instances have been recorded where a
patient has been choked to death during an attempt to swallow, or from
regurgitation of food when in a convulsion. Finally, deep coma may
develop before death.
322, LECTURES ON NERVOUS DISEASES.

Differential Diagnosis. —The inflammatory variety may be mistaken
for acute meningitis. The non-inflammatory varieties sometimes re-
semble, in their symptomatology, the conditions of cerebral tumor,
cerebral abscess, chronic meningitis, and haematoma of the dura,

Acute meningitis is accompanied by a higher range of temperature
than red softening. Its stages are distinctly marked. It has a com-
paratively short duration. Headache is intense at the onset. Vomiting
is a prominent symptom. The pulse is also characteristic,

Cerebral tumors do not, as a rule, cause a8 much embarrassment of
speech or impairment of intellect as softening, because they affect the
frontal lobes less frequently than some other regions. They are accom-
panied, in a large proportion of cases, by a pain in the head that is more

 

Fic. 86.—THE Funpus oF THE Norma Eye.—The Fic. 87.—THE APPEARANCE OF THE Funpus OF

reader should compare this cut with the next one THE Eve wHEN AN Excess oF InTRA-CRANIAL
in order to appreciate the appearance of the so- PRESSURE HAS CAUSED A NeEuRO-RETINITIS,
called ‘‘ choked disk.’” RESULTING IN THE CONDITION KNOWN AS

““CuHoKep DIsK.”

localized than when due to softening of the brain. The cranial nerves
are liable to be implicated early. Monoplegia or monospasm is not an
infrequent symptom of tumor near the motor centres. Convulsions are
more frequently observed in connection with tumors than with soft-
ening, and are of the epileptiform type. A history of syphilitic infection
is often present, since many cerebral tumors are of the gummatous
variety. Choked disk is generally detected when cerebral tumor is
present. The thermo-electric differential calorimeter (Fig. 71) will often
show a marked variation in the temperature of the scalp over the tumor
frem that of surrounding parts. This instrument is of great value,
therefore, in such cases.

Cerebral abscess usually follows traumatism, or an attack of cerebral
embolism or thrombosis. It may be accompanied by a swelling of the
CEREBRAL SOFTENING.

scalp, the so-called “ Pott’s puffy tumor.”

connection with pyzmia.
hemorrhage or cerebritis.

323

It sometimes occurs in

Occasionally it follows an attack of cerebral
Rigors may be present when the abscess is

forming, and more or less febrile disturbance will generally exist.
Chronic meningitis so closely resembles cerebral softening in some

cases that the differential diagnosis is impossible.

As a rule, however,

the headache of chronic meningitis is more diffused than in softening.
The intellectual faculties and speech are not as progressively embarrassed.

Spasms of the limbs are frequently developed.

The impairment of

motility in the limbs is not as diffused as in softening.
Pachymeningitis interna (hematoma of the dura) may be confounded

with cerebral softening.
to clear up existing doubts.
condition.)

The history of the patient will generally suffice
(See previous pages, which treat of this

The following table * will possibly aid the reader still further in
making the discrimination between cerebral softening and cerebral

tumor :—

CEREBRAL TUMORS.

CEREBRAL SOFTENING.

HEADACHE.

Headache usually exists in the frontal or
temporal region; occasionally in the occi-
‘pital region. It is either intermittent or
paroxysmal at first; but it.tends to become
continuous and rebellious to treatment. It
is not necessarily over the seat of the tumor.
This symptom is most marked in those
cases where the meninges are subjected to
tension by the growth of the tumor.

Headache is less severe, and usually con-
fined to the frontal region.

Paroxysms of pain in the head are less
frequent. It is more commonly continuous.

VERTIGO.

Vertigo is quite a frequent symptom in
connection with the headache. If the tu-
mor is near the temporal region, the vertigo
is apt t beespecially severe. The same de-
duction applies to tumors of the cerebellum.

Vertigo is not specially characteristic of
cerebral softening.

Earty Errects oF Lesion.

Disturbances in both sensation and mo-

tion are apt to be developed when the cor-

tex is subjected to irritation or is pressed
upon by the tumor.

Monoplegia, monospasm, monoanesthe-
sia, monoparesthesie, aphasia, etc., may be
encountered,

The mental faculties exhibit impairment
early.

Later in the-disease the body may be sud-
denly rendered hemiplegic or the patient

-may become aphasic.

* This-table is modified from one originally published in the Author’s work on

“Surgical Diagnosis,” 3d edition.
324

LECTURES ON NERVOUS DISEASES.

Seysory PHENOMENA.

Late sensory disturbances which may de-
velop include neuralgic attacks; numbness;
formication ; reflex cramps, etc. These may
be followed by more or less general anws-
thesia, abolition of the muscular sense, etc.

Sensory symptoms,. when present, are not
as marked as intumors. In some situations,
cerebral softening does not induce them.

Motor PHENOMENA.

The motor phenomena which may be
induced comprise a stiffness of the muscles;
a relaxed condition of one member or limb;
spasms of the tonic or clonic type; tremor;
permanent contraction of muscles; paresis ;
monoplegia; hemiplegia; paraplegia; uni-
lateral ataxia, etc.

Crossed paralysis in any of its more com-
mon forms may occur.

Double or alternate paralysis, when pres-
ent, is especially characteristic of tumors.

Hemiplegia (which is usually of sudden:
origin and complex) is more common than in
tumors.

Aphasia is often developed with the hem-
iplegia.

Double or alternate paralysis is rare.

SPECIAL SENSES.

Choked disk, anosmia, amblyopia, amau-
rosis, auditory disturbances, and loss of taste
have all been observed to follow the devel-
opment of cerebral tumors.

Disorders of the special senses are less fre-
quent than in tumors; when present, they
do not tend to progressively involve one
special sense after another.

SPEECH ; :

Ts infrequently affected by motor or sen-
sory aphasia.
rassed, however, by sputtering, imperfect
ulterance, etc,

The speech is often embar-

Is frequently affected. When so, the con-
dition of aphasia is commonly present.

MENTAL FACULTIES

Impaired late, if at all.

Impaired early.

Erttozoey,

Tuberculosis, cancerous cachexia, syph-

ilis, and diseases which induce changes in
the cranial bones, are frequent causes of
tumors within the skull.

Frequently follows disease of the tem-
poral bone; if so, it is preceded by aural
disturbances,

Embolism, cerebral thrombosis, and apo-
plexy, are frequent causes of cerebral soft-
ening.

Symptoms in Common.

Both may be associated with headache.

“ “a “ “

impairment of mental faculties.

as “ motion, —

* “ sensation,

= ‘“ speech,

m “ special senses,
CEREBRAL SOFTENING. 325

Prognosis.—The duration of life depends upon the cause, extent,
and variety of softening. While it may be said that death usually results
from cerebral softening sooner or later, I believe that recovery may occur.
Many of the reported cases of cure are undoubtedly those of error in
diagnosis; but small foci of softening may, to my mind, become encap-
sulated in young and healthy subjects, and do no more harm than
extravasations of a limited extent.

Red softening is liable to lead to cerebral abscess, It frequently
destroys life within two weeks. The non-inflammatory varieties may
cause progressive symptoms for years. When death occurs in these
cases, it is usually the result of some complication, such as those of the
lung, meningitis, apoplexy, diarrhea, interference with the centres of the
medulla, bed-sores, anaemia, etc.

Treatment.—The fact that instances of apparent cure of this affec-
tion are occasionally reported (two of which I have personally observed)
should justify us in not discarding all remedial measures,

The treatment of each individual case will be modified somewhat
by the history of the patient. If the symptoms of cerebral softening
follow an attack of cerebral embolism or thrombosis, the suggestions
previously offered regarding the treatment of those conditions will
be indicated. If it be due to some form of tumor, or the pressure of
inflammatory exudation, efforts should be made to create absorption and
to arrest its development. (See treatment of meningitis and tumors.)
When cerebral softening follows any of the varieties of blood-poisoning
enumerated in previous pages, the indications for treatment are to aid
nutrition by all possible means, and to systematically promote physical
vigor. In young and previously vigorous subjects, this can be done
more satisfactorily than in aged or enfeebled constitutions.

The treatment of the acute variety should differ from that of the
chronic form, since enforced confinement to bed, mental quietude, cold to
the head, the internal administration of stimulants in some cases, and the
employment of heat to the extremities are frequently indicated in the
former,

When the disease is inclined toward chronicity the management of
each case must be moditied by the symptoms presented. It is always
well to guard against any mental anxiety or fatigue of mind or body ;
hence pleasant surroundings, cheerful companionship, regular exercise,
abstinence from business, cessation from reading or writing, driving or
riding in the open air, etc., are important factors in the treatment. I
prefer the milk diet to any other form of administering nutrition in these
cases. One of my patients consumed three quarts of milk daily for over
three months without solid food, and experienced the greatest benefit.
The bowels should be carefully watched. Jt is my custom to give from
326 LECTURES ON NERVOUS DISEASES.

a teaspoonful to a tablespoonful of unground white mustard-seed before
breakfast and at bed-time to patients who suffer from habitual constipa-
tion. It acts charmingly in many cases.

As a tonic I often give to these patients a pill recommended by
Hammond, consisting of a half-grain of the extract of nux vomica and
one-tenth grain of the phosphide of zinc. One of these pills should be
taken after each meal. Combinations of phosphorus, iron, strychnia,
and quinine, are usually of benefit to these subjects. Cod-liver oil is of
the greatest service in some cases.

The insomnia and delirium which often accompanies the disease can
be oyercome by the bromides of soda or potash (thirty grain dose),
chloral (ten to twenty grain duse), cannabis indica (one-quarter grain
dose), and by the judicious use of alcoholic stimulants.

Electricity forms a valuable adjunct to the other methods of treat-
ment already mentioned. It is my custom to use the faradaic current
daily upon the extremities when paralyzed, and the galvanic current
(about fifteen or eighteen cells) transmitted from the forehead to the
back of the head for about five minutes every other day, irrespective of
paralysis. When the paralyzed muscles begin to exhibit evidences of
defective nutrition, I employ the galvanic current in place of the faradaic.

The employment of the actual cautery to the nape of the neck, and
of croton oil to the shaven scalp has been recommended. I have never
tried the latter because I can see no indication for its use. The former I
have tried with the most unsatisfactory results. The experience of most
of the prominent neurologists seems to be in accord with my own. Ham-
mond states that the speech was rendered more embarrassed and the mind
weaker than before its application in his experiments with it.

Finally, the development of bed-sores should be regarded as a
serious complication. They should be treated by a fenestrated air-
cushion, or some form of dressing that will relieve the seat of ulceration
from pressure.

The use of alcoholic stimulants is indicated when the vital forces are
below par. To aged subjects I frequently give a liberal supply of wine
with the meals. The effect of stimulation upon the patient is the guide
to the quantity which should be prescribed in each case.

CEREBRAL ABSCESS,

Suppuration of the brain-substance may be due to a variety of causes.
Cerebral abscesses may be sinzle or multiple, and acute or chronic.

Morbid Anatomy.—Collections of pus within the brain are most
frequently found in the centrum ovale of the cerebral hemispheres and
next in the cerebellum. Occasionally they are developed in the substanee
of the basal ganglia, the crus, and the pons. Their size varies from that
CEREBRAL ABSCESS. 32F

of a small walnut to a goose-egg. A limiting membrane may or may not
exist.

The contents of the abscess consist of: a creamy fluid, which is
usually of a greenish hue, and inodorous except when pyemic. It is
composed of pus corpuscles, the débris of broken down brain-tissue,
fatty matter, crystals, and salts. The periphery of the abscess is often
surrounded by a zone of yellow softening (Rokitansky). Sometimes a
well-marked encapsulation is detected, due toa fibrinous wall which may
teach a quarter of an inch in thickness.

Embolic abscesses are multiple,asa rule. They are usually of small
size.

Abscesses of the brain sometimes rupture into the ventricles—more
rarely into the tympanum, the nostril, or the cavity of the orbit. They
often create a complicating meningitis by pointing toward the cony exity
of the cerebral hemispheres. After an extensive meningitis, the pus hus
been known to perforate the calvaria.

The reaction of the fluid contents may be alkaline or acid. If
mucine be present, the pus may appear gelatinous and ropy. If the
process of absorption takes place the contents of the cavity may disap-
pear, and be followed by a retraction of the wall of the cyst and the
formation of calcareous deposits or of cheesy masses.

The pressure created by the accumulation of pus tends to distort
and flatten neighboring convolutions, and to interfere more or less with
their nutrition.

Etiology. Among the most frequent causes of cerebral abscess the
following may be mentioned: Suppuration of the middle ear; blows re-
ceived upon the convexity of the skull; erysipelas of the face or scalp;
suppuration of the orbit or nasal fossa; caries or necrosis of the skull;
cerebritis; embolism; pysemia; glanders; some of the eruptive fevers;
and other blood-poisons.

Symptoms.—These will be modified (1) by the seat and extent of the
abscess ; (2) by the causes which induced it; and (3) by the complications
which are developed. The presence of rigors, with paroxysms of fever
at irregular intervals, should lead us to suspect suppuration when in
doubt. The fact that abscess has been known to exist for many months
in some parts of the cerebrum without inducing any symptoms, should
be remembered by those who are inclined to be hasty in their clinical
deductions. I would again impress upon the mind of the reader in this
connection the necessity of a familiarity with the deductions embodied
in the first two sections of this work, as a basis for all clinical deductions
respecting the localization of cerebral lesions during life.

Differential Diagnosis.—The symptoms of cerebral abscess are apt
to be confounded with those of cerebral tumor and softening.
328 LECTURES ON NERVOUS DISEASES.

From cerebral tumor, the rapid emaciation and short duration of
life, the presence of rigors and paroxysms of fever, the history of the
case, the infrequency of paralysis of special cranial nerves, and the pos-
sible escape of pus from the ear, nose, or orbit, would make the diag-
nosis of abscess possible in many cases.

From cerebral softening the presence of intra-cranial pain, rigors,
and paroxysms of fever, a healthy state of the superficial blood-vessels,
and other symptoms mentioned above would point toward the diagnosis
of abscess.

The table on the opposite page may prove of assistance to the reader
in making a diagnosis.

Prognosis.—If suppuration occur in connection with acute enceph-
alitis, death may follow rapidly (from three days to three weeks).

Chronic abscess of the brain may exist for years. If it excites com-
plications of a serious kind, such as diffuse meningitis, thrombosis of the
sinuses, cedema, extensive softening, effusion into the ventricles, pressure
upon vital centres, pulmonary congestion, etc., death may be indirectly
produced by it. .

Treatment.—Trephining for well-defined collections of pus within or
upon the brain has lately assumed a prominent place among the modern
surgical procedures. The recent discoveries made respecting the cortical
centres of the cerebrum enable us to interpret the clinical evidences of
circumscribed pressure upon distinct areas of the brain, and to take
steps for their relief which were not dreamed of until within the last
decade. It is hoped that the first two sections of this work will aid the
reader to take such a step when necessary with confidence and judg-
ment.

SCLEROSIS OF THE BRAIN.

The term “ sclerosis ” is used to designate a condition characterized
by an increase in the connective tissue of an organ.

This newly-formed connective tissue subsequently contracts, and
induces atrophy of those parts which are thus subjected to pressure,
because the blood-supply is gradually diminished.

Morbid Anatomy.-—In the nerve-centres, this condition may assume
different forms: 1. It may constitute the so-called “ general ” or “ diffuse
sclerosis ;” seldom involving the brain, but not infrequently affecting
large tracts of the spinal cord. 2. It may be disseminated throughout
the brain and spinal cord, constituting the “ selérose en plaques” of the
French authors, or “ multiple sclerosis” of English and American
writers 3. A variety of the second form, termed “miliary sclerosis,”
has also been described.

Sclerosis of the brain probably starts as a chronic congestion, which
CEREBRAL ABSCESS.

329

 

DIAGNOSTIC SYMPTOMS.

IN CEREBRAL
SOFTENING,

IN CEREBRAL TUMOR,

IN CEREBRAL
ABSCESS.

 

HEADACHE

VERTIGO

Menta IMPAIRMENT. ,

Sensory PHENOMENA .

Motor PHENOMENA. .

SPECIAL SENSES. . . .

Course oF THE DISEASE.

TEMPERATURE

CurnicaL Irstory

 

Usually _ frontal.
Generally — con-
tinuous, May be
absent through-
out the disease.

May be absent.

Apt to be a
marked sy mp-
tom.

Develops gradu-
ally (as a rule).

May be normal.

Paralysis of mo-
tion may occur
suddenly or pro-

gressively. Itis
sometimes not
developed.

May be normal.

Seldom observed.

Progressive or
wanting.

Chronic,

Normal.

Cause may be ob-
; scure,

 

Is apt to be im-
j paired.

Seat variable, but
pain is seldom
absent. Is most
severe when the
cerebellum is dis-
eased, Is apt to
exhibit, distinct
paroxysms. Is
caused by ten-
sion of the me-
ninges.

Is particularly apt
tooccur when the
cerebellum or
temporal lobe is
affected.

Often absent.

The sensory con-
ducting tracts are
sometimes very
markedly dig-
turbed.

Motility is not in-
frequently affect-
( ed by the growth

| of the lesion.

Generally absent.

Liable to be pro-
uae affect-
“Choked

Sisk "is pathog-
nomonic.

Progressive or ab-
sent.

Usually chronic.

Usually normal.

Tf non-syphilitic,
the history will
be of a negative
kind.

 

i Usually normal,

 

May be absent, but
is usually very
well marked and
localized.

May be absent.

:

|
!
|

Develops rapidly
if at ait

Tf sensation is dis-
turbed, anasthe-
sia of a ‘unilateral
type may be de-
tected.

Sensation may be
unaffected.

Paralysis of mo-
tion may or ma
not be developed.

May escape im-
pairment if the
abscess be of
moderate size
and circum-
scribed.

A strong diagnos-
tic symptom.

Rapid, as a rule.

Rapidly fatal, as a
rule.

Meet ly ele-
vated.

The history will

usually point to

an exciting cause

of the symptoms.

May be impaired.

 
330 LECTURES ON NERVOUS DISEASES.

leads to an exudation of an albuminous fluid, and subsequently to cell-
proliferation in the neuroglia.

It is closely allied to inflammatory processes, if not strictly de-
pendent upon them.

Injuries to the convolutions of the so-called “motor area,” or a
severance of the “motor tracts” of the brain (complete or partial)
seem to act as an exciting cause of a so-called “descending scle-
rosis”” which confines itself to the tract of fibres that are. functionally
associated with the parts injured. In this way it eventually reaches the
spinal cord. Similar changes may involve the cranial nerves, chiefly the
optic.

In chronic insanity, sclerosis of the brain is not infrequently de-
tected; and the same may be said of general paralysis, some cases of
epilepsy, Duchenne’s malady, paresis, paralytic tremor, and idiocy.

The diffused or general variety is described by some authors under
the term “induration of the brain.” This is because an abnormal hard-
ness of the cerebral tissue can be detected, and the brain cuts with
greater resistance than when healthy.

In all forms of cerebral sclerosis, the medullary substance is most
often involved.

Sections of a sclerotic patch reveal to the eye a moistened surface,
more or less transparency, anil small bluish or reddish spots. The
microscope enables us to detect newly-formed cells in abundance, an
excess of connective tissue, atrophy of the nerve-fibres, fatty granules,
scattered amyloid corpuscles, and a thickening of the coats of the cerebral
capillaries.

Etiology.— Little is definitely known regarding the causes of cerebral
sclerosis. It is supposed to accompany chronic cerebral congestion
and morbid changes in the walls of the capillary vessels. It may be
developed in connection with epilepsy, insanity, idiocy, bulbar paralysis,
tremor, destructive lesions of the brain, and old age. Diffused cerebral
sclerosis is most commonly observed during infancy.

Symptoms.—The variety of sclerosis which exists will tend to
modify the symptomatology of this disease.

The diffused form occurs, as a rule, during infancy. It is usually
accompanied by imperfections in development of both mind and body,
and by paralysis, epileptic convulsions, and post-paralytic contractures.
The imperfections in development are generally most marked upon one
side. One leg or arm will oceasionally fail to grow, or it may. grow
slower than its fellow.

The mental faculties exhibit an abnormal dullness (approaching to
idiocy). Articulate speech is acquired imperfectly and late; again, it
may never be developed. In some recorded instances, where the disease
SCLEROSIS OF THE BRAIN. 331

became manifest after the child had Icarmmed to talk, serious imperfections
of utterance were occasioned by it.

Later in the disease, the limbs begin to show symptoms of paralysis.
Still later, contractures of the paralyzed muscles occur, and produce de-
formities of the limbs. All intuitive or acquired sense of cleanliness of
habit, or attention even to the requirements of Nature, seems to be lost
or wanting in many of these subjects. The urine and faces are passed
not infrequently in the clothing or bed.

The sensibility of the limbs is apt to be impaired at the time when
paralysis of motion is developed. It is most marked upon one side, as
a rule.

The so-called ‘‘ multiple sclerosis” seldom occurs except in the adult
or the aged. The period of onset is frequently marked by the develop-
ment of numbness, hyperesthesia, dysesthesia, and other sensory dis-
turbances, in one or more of the extremities, for many months before the
characteristic trembling appears. Sometimes these patients complain
only of shooting pains, which are paroxysmal and of short duration,
resembling an electric shock. Again, an epileptic attack may occur. In
one of my patients the disease began with a slight attack of facial
paralysis, which followed a heated discussion over business affairs with
his partners. In another, attacks of “petit mal” were first observed.
These were followed, after the lapse of a few years, by tremor of an
aggravated type.

The most characteristic symptom of this disease is tremor. It de-
velops gradually, as arule. At first, the patient may notice only a slight
tendency of some limited part of the body to rhythmical twitching. It
may be so slight in the beginning as to attract the attention of the
patient only when quiet and unoccupied; as, for example, during the
moments preceding sleep. I have known it to be limited to a single
muscle of the leg or arm for many months: One of the most typical
cases which I have ever encountered observed it for over a year in the
exterior part of the thigh.

Gradually these convulsive and involuntary twitchings become more
ageravated, and are diffused over a larger area.

If the hand be affected, its movements become uncertain. Such
patients often become afraid to dine with strangers, on account of their
liability to accident during the meal. They cannot write as well as
before the trembling commenced, and are forced after a while to discon-
tinue all attempts to carry on correspondence or book-keeping. The
constant movements of the extremity render them the objects of painful
scrutiny when out-of-doors or among strangers. Dressing and undress-
ing become extremely difficult. One of my patients requires the aid of
a body servant for that reason alone. Finally, dynamographic tracings
332 LECTURES ON NERVOUS DISEASES.

will show an inability to maintain continuous contraction of the
muscles. a

When the legs become attacked the gait closely resembles that
of paralysis agitans (page 163). The knee and foot are apt to move
involuntarily when the patient is sitting or reclining. These subjects
frequently acquire the habit of constantly changing the position of the
affected limb when not walking, because it seems to produce a tem-
porary respite from trembling. During sleep, the shaking ceases for a
greater or less period of time; but, finally, the movements continue day
and night. Excitement of any kindland muscular effort invariably causes
the spasmodic movements to become markedly intensified.

Occasionally, the eves and face become affected with this disordered
condition of motility. The tongue may also participate in the tremor.

 

Fic, 88.—Crresrar Sciexosis. (After Fox )

When symptoms of ataxia are induced, we have reason to believe
that the fillettract of the brain, or the posterior columns of the spinal
cord are involved. I once saw a case where the patient could not
respond to any of the tests for codrdinated movements of one arm (page
180), but could use the opposite arm and the lower limhs perfectly.

Paralysis of motion or sensation is apt to follow the development
of tremor. The limbs are not usually completely paralyzed. They are
more. or less parctic,

The sense of touch and the conscious appreciation of pain, tempera-
ture, pressure and the muscular sense may be disturbed to a greater or
less degree.

The special senses may be impaired late in the disease. Smell, sight,
taste, and hearing have been known to be individually destroyed.
SCLEROSIS OF THE BRAIN. 833

The condition known as the “choked disk” (page 322) may be
detected by the ophthalmoscope in some cases,

Finally, these paticnts gradually become unable to perform any
mental or pliysical effort. They give evidences of mental decay by their
inability to retain urine or freces, 1 loss of memory and of mental con-
trol, dementia, 2 disregard of surroundings, etc. Death may occur from
general convulsions, exhaustion, coma, or some complicating disease.
The duration of this disease nay vary between the limits of a few months
to ten years. It seldom exceeds five or six yeurs.

Differential Diagnosis.—This condition may be confounded with
chorea, paralysis agitans, the tremor which follows cerebral hemorrhage,
and spinal sclerosis.

Chorea is occasionally developed in adults. It is never associated,
however, with the head-symptoms of sclerosis due to cerebral congestion,
such as vertigo, pain in the head, ete. The peculiar gait of cerebral scle-
rosis is never encvountered in chorea, The spasmodic movements of
chorea are irregular, and differ markedly from the rhythmical movements
of tremor. Tmpairmeut of sensation or motility is not developed in con-
nection with chorea. Feebleness of intellect, when present, appears
during the early stages of chorea.

On the other hand, the dittused variety of cerebral sclerosis, although
confined almost exclusively to children, is characterized by symptoms
of idiocy, convulsions, hemiplegia, ete. It could, therefore, hardly be
confounded with chorea.

Paralysis agitans is not accompanied hy evidences of impairment
of sensibility or motility in the limbs; nor are the “ head-symptoms ” of
cerebral sclerosis developed whenever the tremor is due to a purely
functional disturbance. Patients with fimctional paralysis agitans can
usually cause the dynamograph to exhibit a tracing of continuous mus-
cular contraction. This is impossible in subjects affected with multiple
cerebral sclerosis,

To my mind, however, many cases of sclerosis are diagnosed as
paralysis agitans. It is easy to understand why this should be so. Both
are liable to exist after middle life ; both cause marked tremor; and the
gait of the two diseases are nearly identical.

Post-paralytic tremor is to be diagnosed by the history of the case.
Unlike that of cerebral sclerosis, the tremor follows the development
of paralysis. Post-paralytic tremor is more liable to follow lesions
of the internal capsule of the cerebrum than of the cortex; hence the
history will point probably to a simultaneous impairment of sensation
as well as of motion in one lateral half of the body at the time of the
attack, and possibly, also, to a disturbance of the function of smell,
sight, hearing, or taste. The ophthalmoscope may reveal the condition
334 LECTURES ON NERVOUS DISEASES.

known as a “choked disk.” This has been described on a previous
page.

Spinal sclerosis can be excluded by the history of the case. Of
course, all “ head-symptoms ” would be absent. The evidences of mental
decay would not be developed. The cranial nerves would escape. The
evidences of impairment of sensibility or motility would be irregularly
manifested in the limbs, in accord with the seat and extent of the sclerotic
patches.

Prognosis.—The diffused variety, when occurring in infants, is almost
invariably fatal. When it is developed in the adult the symptoms may
sometimes be ameliorated by judicious treatment, and I doubt if a cure
was ever complete.

The multiple variety perhaps offers a little more hope of cure. Still,
it must be confessed, I think, by all who have experimented in these
cases, that a very large proportion grow steadily worse and die in spite
of all remedial measures. One thing is certain to my mind, viz., that all
benefit which can be expected must be derived from active treatment in
its early stages. Hence a prompt diagnosis is essential if a hope of relief
is to be extended to the patient with any prospect of its realization.

Treatment.—Among the remedial agents which have been suggested
for this disease, may be mentioned the chloride of barium combined with
hyoscyamus (Hammond), the bichloride of mercury (Mitchell), the
phosphate of zine, the chloride of iron, the nitrate of silver, strychnia,
cod-liver oil, and electricity. I would add to these the internal adminis-
tration of hot water and the removal of all recognized sources of reflex
irritation.

Hammond claims that great benefit may be derived from the admin-
‘istration of a grain of the barium salt three times a day, when employed
in conjunction with the tincture of hyoscyamus in doses of one or two
drachms three times a day. His suggestion that the chloride of barium
be fresh and properly prepared seems to me particularly well taken. It is
an unstable salt, and is difficult to obtain. If not a reliable preparation,
it is inert.

I have found that it acts favorably (as does also the nitrate of silver
and strychnia) upon tremor. It also tends to diminish disorders of sen-
sation and motility in some cases. On account of these effects, it is
indicated in cerebral sclerosis.

The mercurial treatment, in the form of baths, hypodermic injection
(page 290), the bichloride, ete., is indicated when a syphilitic history can
be obtained. I do not believe that small doses of mercurial salts arrest
the new connective-tissuc formation of nerve-centres.

Strychnia, nitrate of silver, iron, and cod-liver oil may be employed
either as substitutes for the chloride of barium or as tonics. The first
CEREBRAL ATROPHY. 335

two have a decided anti-spasmodic action. A moderate quantity of
alcoholic stimulants with meals, and exercise in the open air (if tempered
with judgment) are often beneficial, and should be employed as adjuncts
to the other methods of treatment mentioned.

Electricity is employed by me in all cases where tremor exists. It
is my custom to apply the galvanic current (derived from five or ten
milliamperes of current to the head, passing it from the forehead to the
occiput. Hammond recommends the stimulation of the main sympathetic
cords. This can be best accomplished by placing the poles at the neck.
J am in the habit also of using from ten to twenty milliamperes upon the
‘tremulous muscles, one pole being placed at the nape of the neck. Further
directions relating to the electrical treatment of tremor will be given later.

When paralysis has been developed the faradaic current should be
substituted for the galvanic, as a remedial agent to the paralyzed muscles,
or the static spark should be administered.

For reasons previously given, I believe that the internal adminis-
tration of hot water (page 248) exerts a marked effect upon all diseases
where the sympathetic system is at fault. I should advise that it be
tried upon these subjects. ;

Finally, all mental efforts of a laborious kind should be forbidden.
Emotional excitement of any kind should also be carefully guarded
against.

CEREBRAL ATROPHY.

This condition may be of two varicties,—the infantile and senile.

Morbid Anatomy.—In the infantile form, the characteristic lesions
include (1) obliquity of the skull, one lateral half being shrunken and
deformed; (2) a premature closure of the sutures; and (3) atrophy of
the corresponding cerebral hemisphere, involving its convolutions and
basal ganglia. ;

The atrophic changes may extend to the pedicles of the brain, the
pyramids of the medulla, and the columns of the spinal cord.

This form is due chiefly to fetal apoplexy, encephalitis, hydroceph-
alus, and physical shocks or violent emotions on the part of the mother
during pregnancy.

In the senile variety, the atrophic changes may be due to any cause
which tends to slowly impair the nutrition of the brain. Among such
may be mentioned embolism, thrombosis, hemorrhage, tumors, encepha-
litis, inflammations of the pia mater, alcoholic, opium- or lead-poisoning,
syphilis, and excessive venery (?).

Etiology.—Something has already been said respecting the probable
causes of the two varieties. The fact that pathological chunges in the
meninges are generally found to coexist with cerebral atrophy—
336 LECTURES ON NERVOUS DISEASES.

especially in that form which occurs in connection with the so-called
“yeneral paralysis of the insane”—is worthy of remark as shedding
some light upon the causation of the disease in individual cases. Senile
marasmus is one of the chief causes of this condition when occurring in
the aged. Males are more frequently attacked than females.

Symptoms.—The symptoms of the infantile vartely vary with the
extent of the atrophy. Weakness of intellect, deafnutism, abolition of
some of the special senses, incomplete paralysis, muscular contractures,
and impairment of the sensibility of the paralyzed parts may be present,
in addition to the cranial deformity. The bones, muscles, nerves, etc., of
the side opposite to the cerebral atrophy may be impertectly developed.
Ptosis and strabismus often occur.

The peculiarities in the appearance of the cranial bones (enumerated
in the preceding lines) would naturally suggest the presence of this
morbid condition. Not only is the skull misshapen, but the bones are
upt. to become altered in their relative size and thickness.

The symptoms of the senile form include many manifestations of
enfeebled mental powers. The memory and intelligence are affected
early; apathy and somnolence develop; the power of motion is slowly
but gradually lost; tremor makes its appearance; finally, the patients
take to their beds and pass into the condition of childishness, accom-
panied by the symptoms of bulbar paralysis, from which they die.
Bed-sores, bronchitis, and acute pulmonary edema are frequent com-
plications.

Differential Diagnosis.—The senile form might possibly be con-
founded with cerebral softening and apoplexy. The history of the case
and a careful study of the symptoms would rapidly dispel all coubts.

The infantile variety can hardly be confounded with any other con-
dition. The spasmodic attacks and the paralysis which occur, not to
speak of the cranial distortion, are sufficient for a diagnosis.

Prognosis.—The infantile variety usually results in death before the
fifth year. The senile form is apt to be associated with intercurrent dis-
eases which hastens death, among which may be mentioned various pul-
monary complications, bed-sores, and renal or vesical diseases. When
the condition exists in connection with the “ general paralysis of the in-
sane,” the duration of life seldom exceeds one year.

Treatment.—General hygienic measures are indicated in order to
increase the physical vigor. Massage may be substituted for active
physical exercise, when the patient is unable to walk with ease. Gal-
yanism is sometimes of benefit. The bowels and bladder should be
looked after if the patient be old. I do not believe in the curative effects
of the iodides, calabar bean, cold douches, tepid baths, etc., although they
have been recommended.
CEREBRAL HYPERTROPHY. 337

CEREBRAL HYPERTROPHY.

This disease is comparatively rare. We owe most of our knowledge
concerning it to Virchow, who published the results of autopsies and
deductions concerning its pathological changes. It is not a true hyper-
trophy, because the connective-tissue elements ure alone increased.

Morbid Anatomy.—The cranial bones are abnormally thin, and the
brain protrudes when the calvaria is removed. An enormous increase
in the circumference of the head is present when the disease attacks a
child, and the sutures fail to close. In these respects it resembles chronic
hydrocephalus. ‘The brain is abnormally heavy, and is rendered abnor-
mally tough and elastic. It is very anemic; the ventricles are found to
be empty ; the membranes are dry and attenuated; the convolutions are
compressed and flattened; and the dura may. be firmly adherent to the
skull. The cerebral hemispheres are more often attacked than the basal
ganglia, the pons, the cerebellum, or the medulla.

Etiology.— When not congenital, it usually attacks a child before
the third year. It seems to he hereditary in some instances. It
accompanies idiocy, and may follow plumbism, traumatism, rickets,
alcoholism, and epilepsy. It sometimes occurs in adults. Dwarfs seem
to be particularly predisposed to its development. It may accompany
insanity.

Symptoms.—When present in the child, the head is apt to lean
toward one side, and a tottering gait or tremor may he developed.
Sometimes there are convulsions, strabismus, fecbleness of mind or
idiocy, somnolence, protrusion of the tongue, and severe headache. The
thymus gland may become enlarged and cause spasm of the larynx. In
the final stage coma develops. It is generally preceded by dilatation of
the pupils, vomiting, convulsions, and a slow pulse.

When adults are attacked, vomiting, dyspnwa, and difficulty in
swallowing are developed in connection with delirium, vertigo, epilepti-
form attacks, headache, and abnormalities of the heart’s action.

Differential Diagnosis.—It is impossible, in some cases, to distin-
cuish between this disease in a child and chronic hydrocephalus. The
presence of a cerebral souffle, pulsation of the fontanelles, and a previous
precocity of the child point to cerebral hypertrophy.

Prognosis.—It is always fatal. In the child progressive stupor de-
velops. In adults, complications are more liable to shorten the course
of the disease.

TUMORS OF THE BRAIN AND ITS ENVELOPES.

The various forms of new growths which may be encountered in the
brain have been enumerated in a tabulated form on page 218. All of the

22
338 LECTURES ON NERVOUS DISEASES.

attempts which have been made to classify tumors of the nervous
system, from that of Jaccoud to the present time, are more or less
illogical. Every classification must be open to some objection, but
attempts of that kind unquestionably serve to assist memory and to
systematize description.

We have already touched upon aneurisms as one of the lesions of
the vascular apparatus. Parasites of the brain (which are enumerated
by Jaccoud) are discarded by Fox, because they can hardly be said to
constitute a tumor. Exostoses should be discussed among the tumors
of bone, rather than in this connection, although they may develop in
the brain and its coverings.

Morbid Anatomy.—Among the entire list of cerebral neoplasms,
gummata (syphilitic tumors) possess more clinical interest than any of
the others. This is because they are more frequent than the rest, and
also because the prognosis is favorable,—often after the most severe
effects to the brain are manifested.

1. We owe much of our knowledge of syphilitic tumors to Broad-
bent, who has studied their effects upon the nerve-centres. They start
from the membranes or attack the surface of the brain directly. They are
strictly localized and grow slowly. They usually affect only small por-
tions of the organ. Gradually they tend to induce adhesions of the
membranes, both to each other and to the brain itself; and, by pressure,
they cause local softening of the brain-substance. The effects of pressure
upon the cranial nerves which lie adjacent to these tumors are apt to
be also exhibited early, and thus the diagnostician is enabled to locate
the tumor. This statement applies, however, with equal force to all
tumors of the brain.

Gummata appear as reddish-gray, jelly-like masses, which are infil-
trated, as it were, into the brain-tissue.

2. Perhaps the most common form of cerebral tumor is tubercle.
The pathology of this form of deposit has been discussed already at
some length in the pages devoted to tuberculous meningitis. It tends,
as a rule, to invade several regions at the same time,—when deposited
within the substance of the brain. Tubercular masses in the aggregated
form may be of different sizes. They vary from that of a small pea to the
dimensions of a cherry, or even of a small hen’s egg. They are sometimes
encapsulated, being separated entirely from the cerebral substance.
Again, the line of demarkation of the deposit may be indistinctly defined
from that of the gray or white matter. Caseous degeneration is not infre-
quently encountered in the central portions of these tubercular masses.
Similar deposits are apt to be found simultaneously in other viscera and
tissues. Tubercle of the brain, when softened, might easily be mistaken

for a gummatous deposit. The examination of the viscera, the history
TUMORS OF THE BRAIN AND ITS ENVELOPES. 339

of the case, and a microscopical cxamination, would dispel any such
elements of doubt.

3. The brain or its envelopes may become the seat of carcinoma or
cancerous growths. Scirrhus and encephaloid are the more: common
types. Occasionally the melanotic variety is detected. Old age seems
to be a factor in the development of cancer of the brain in most cases.
It may start either in the brain-substance, the meninges (chiefly in the
pia), or in the bony skull-cap.

The size and rapidity of progress of carcinomata of this region
depends upon the type. The encephaloid variety grows rapidly, is very
vascular, and may attain an immense size. The scirrhous type is of
slower growth, and is less vascular.

4. Regarding other varieties of cerebral tumors which have been
enumerated in the preceding table (page 218), it does not seem to me

 

Fig, 89.—CrruskaL Giioma.

necessary to describe the microscopical appearances of each, because most
of the works on pathology afford all necessary information respecting
them. It may he well, however, to mention a few facts pertaining to
each which possess a clinical value.

Cysts of the brain are generally the result of an old apoplectic clot
which has undergone certain morbid changes already described.

Glioma are formed of connective-tissue elements of the brain; hence
they are usually developed in the substance of the organ.

Epithelial growths may spring from the cerebral vessels or the walls
of the ventricles, as well as from the cells of the pia and arachnoid. This
statement does not comprise those epithelial tumors which are properly
classed as cancerous.
340 LECTURES ON NERVOUS DISEASES.

Psammoma or sand-tumors consist of granules of carbonate of lime
held in a matrix of connective-tissue, in whose meshes concentric layers
of epithelial cells are also found. (Virchow.) They are encountered
chiefly in the dura (particularly in that part which covers the parietal
lobe) and in the choroid plexus of the fourth ventricle.

Cholesteatomata, or pearl-tumors, are composed of cholesterine and
stearine. They are destitute of vessels. Their size is, as a rule, small.
They are known to arise from the bones, meninges, and in the brain itself.

Tumors of the osseous type spring, as a rule, from the calvaria. In
rare instances, however, they do not do so. The falx is sometimes more
or less osseous. ‘True ossific deposits have been encountered within the
brain-substance. I lately discovered one in the brain of an epileptic
patient.

 

Fic, 90,—SvPHILIS OF THE Bran. (After Fox.)

Fibrous, fibro-plastic, and fatty growths within the skull are to be
classed as accidental neoplasms. The fibro-plastic variety has been
known to attain the size of an orange. (Hammond.) The consistence
of these tumors is subject to extreme variations. Fibrous tumors
are rare, but they may arise from the ependyma of the ventricles.
Lebert reports seventeen to have developed simultaneously within the
lateral ventricle.

Hydatids (when present) are generally detected within the cerebral
hemispheres. The parasite (echinococcus) is enveloped in a eyst, which
may be as large as an oranve. The number of such cysts 1s usually
small. They are often solitary.

Another form of parasitic tumor (due to the cysticercus) may be
encountered within the brain-substance. The surrounding cyst is usually
wanting in this variety. They lie near to the surface of the brain. as %
TUMORS OF THE BRAIN AND ITS ENVELOPES. 341

rule. Sometimes they are found in the ventricles and pia. They are
seldom solitary. Cruveilhier reports a case where over one hundred were
found.

Vascular tumors of the miliary type have been discussed in connec-
tion with the morbid anatomy of cerebral hemorrhage. It may be well,
however, to mention the statistics of Gouguenheim (as quoted by Ham-
mond) respecting the relative frequency of aneurismal dilatations of the
more important vessels. This anthor found that out of 69 cases, seven-
teen affected the basilar; fourteen attacked the middle carotid; twelve
involved the internal carotid; eight, the anterior cerebral; five, the
posterior, or communicating ; four, the cerebellar; three, the posterior
cerebral; and two, the anterior communicating and the middle meningeal.

M. P. Jacobi has lately contributed a classical article on the subject
of cerebral tumors,* a study of which will well repay the reader.

Etiology.— Much that has been said already respecting the morbid
anatomy of cerebral tumors relates to their causation as well.

Large aneurismal tumors usually occur after the age of fifty, and
are preceded by textural changes in the arterial walls (atheroma, fatty
degeneration, etc.). In such cases, the exciting causes of the aneurism
may include all forms of traumatism to the head or body, cardiac hyper-
trophy, prolonged anxiety or emotional excitement, excessive mental
labor, embolism, etc.

Cancerous growths may occur at any age, but they are most com-
monly encountered in male adults. It may be excited by traumatism
(according to Hammond). :

Tubercular deposits within the skull are most frequently encountered
in the young. They may occasionally be developed during adult life, as
a sequel of similar deposits within the lungs or other viscera, and after
infection from caseous masses in the viscera, joints, glands, etc.

Gummata are invariably due to syphilitic infection. They are
developed late in the disease, as a rule.

Parasitic tumors are due to the transportation of the embryos from
some distant part.

_Symptoms.—It must be evident to the reader that the symptoms
of a cerebral tumor necessarily depend upon three factors, viz., its seat,
its rapidity of growth, and the amount of pressure or injury created by it
upon the cortical cells or nerve-tracts which lie in close proximity to it.
I would refer the reader, therefore, to a preceding section which treats
of the localization of lesions of special areas of the cortex and the more
important component parts of the cerebral architecture; as well as to
those pages also which deal with cerebral thermometry, the use of the
ophthalmoscope, and the symptomatology of cerebral hemorrhage.

* Reference Handbook of Medical Sciences, vol. i. p. 668.
342 LECTURES ON NERVOUS DISEASES.

It should be remembered, however, that the slow growth of a cere-
bral tumor does not allow of pressure-effects upon neighboring parts as
rapidly as would an apoplectic extravasation, although in time it might
create even more serious damage.

Again, the presence of a tumor of the meninges or bone might at
first cause symptoms of irritation of the cortex (Jacksonian epilepsy,
frequent convulsions, etc.). Later on, other symptoms, which would be
apt to appear, would indicate a destruction of the functions of parts
which at first were only irritated by the slight pressure upon them
exerted from the growth of the neoplasm.

Third, the vascularity of the tumor and the activity of the circula-
tion required to insure its development would be apt to create modifica.
tions in the temperature of the scalp over the seat of the tumor, provided
it was superficially situated.

Fourth, we would be apt to notice that the steady increase in size
of the growth would progressively impair one or more of the cranial
nerves, and possibly some of the tracts of nerve-fibres which help to
form the cerebral hemispheres.

Fifth, tumors of the brain, and in fact any lesion which tends slowly
to increase intra-cranial pressure, tend to manifest their existence by
development of a double optic neuritis,—the so-called “choked disk”
(Fig. 87).

This condition is only apparent when the ophthalmoscope is em-
ployed, but it possesses a decided clinical value. I have described the
condition in detail in a brochure, from which I quote as follows :—

‘When the radiating fibres of the internal capsule are involved in
a lesion which creates a gradually-increasing pressure (as in the case of
tumors which grow slowly), the fundus of the eye exhibits morbid changes
in the region of entrance of the optic nerve which are of value in diag-
nosis. The condition so produced is commonly known as the ‘choked
disk.’ It is nearly always bilateral, but often most marked in one eye.
It may be considered as one of the most positive signs of an extensive
intra-cerebral lesion, and especially of tumors of the brain. When the
eye is examined with an ophthalmoscope, this condition is characterized
by a swollen appearance of the optic nerve, which projects appreciably
above the level of the surrounding retina; the margin of the disk is
either obscured or entirely lost; the arteries appear small, and the veins
large and tortuous; finally, small hemorrhagic spots may often be de-
tected in the retina near the margins of the disk. In spite of this con-
‘dition, the power of vision may be little impaired; so that the existence
of ‘choked disk’ may be unsuspected unless the ophthalmoscope be used
before the diagnosis is considered final. After a number of weeks, and
very much longer if a tumor is the exciting cause of the condition, the
TUMORS OF THE BRAIN AND ITS ENVELOPES. 343

appearance of the disk changes. An unnatural bluish-white color, which
denotes atrophic changes, develops; the outline of the disk becomes
sharply defined; the retinal vessels become small, and vision becomes
markedly interfered with.”

Differential Diagnosis.—The chief points by which the existence of
a cerebral tumor is indicated are as follow: (1) Severe and persistent
pain of a more or less localized type; (2) the occurrence of convulsive
attacks, which may or may not be followed by transient paralysis and
unconsciousness ; (3) the retinal changes of optic neuritis; (4) the pres-
ence of monoplegia or the paralysis of some (one or more) of the cranial
nerves; (5) the history of the case when syphilis, tuberculosis, or the
development of parasitic cysts are suspected.

Since cerebral softening often accompanies the development of a
cerebral tumor, it is possible that all the symptoms of that condition
(except the choked disk) may exist and render the diagnosis more or
less obscure.

From epilepsy the diagnosis is to be made by the presence of intra-
cranial pain; by the age and history of the patient; by the fact that the
convulsion is apt to be more or less unilateral, and to start in that par-
ticular part of the body whose motor centres are subjected to the greatest
amount of irritation; by the presence of consciousness during the con-
vulsive attack, or of incomplete coma; by occasional development of
transient paralysis after the fit; and by the fact that the mental powers
of the patient are seldom weakened.

From the multitude of causes that may induce hemiplegia, mono-
plegia, or paralysis of some cranial nerve, the diagnosis must be made
by exclusion, after the facts revealed by a clinical examination of the
patient hacwuing to Section II) have been thoroughly and accurately
determined.

One of the most remarkable cases of supposed hysteria that ever
came under my observation was found after death to be due to a widely
diffused form of enchondroma of the falx cerebri.

Prognosis.— Unless of the syphilitic type, cerebral tumors are liable
to cause death in spite of treatment. Lately, cases of successful re-
moval of a cerebral neoplasm have been reported. In the light of modern
cerebral localization it is possible that surgical measures may occa-
sionally be employed with benefit to the patient when the tumor is
non-malignant and superficially situated.

Gummata are unquestionably absorbed in many cases when the
iodides are pushed to extreme limits.

Treatment.—The remarkable successes in treatment of syphilitic
tumors of the brain or its envelopes, which are frequently reported,
should lead us to carefully investigate the question of syphilitic infec-
344 LECTURES ON NERVOUS DISEASES.

tion in every case. I have personally witnessed in four of my own
patients a perfect cure, when the prognosis appeared to be extremely
grave. In one, hemiplegia and homonymous hemianopsia existed ; in
another, aphasia, strabismus, and extensive paresis had been produced ;
in a third, almost total blindness existed when the patient was first seen
by me; in the fourth, complete coma suddenly occurred after an attack
of ocular paralysis, which was accompanied by very marked mental dis-
turbance. Another of my patients had several convulsions within a
week, and is to-day in perfect health.

As early as 1872, I began experiments with enormous doses of the
iodide of potash and the iodide of calcium in these cases. To one
patient, seen by Prof. A. L. Loomis with me in consultation, I gave an
ounce of the former salt daily for three days. I have frequently given
half of that amount daily for a week at a time, or until the effects of
iodism became very marked. With some patients, who bear the potash
salt badly, I employ the calcium preparation in about the same doses, as
I have found that it creates less gastric disturbance. The objection to
it is that the salt decomposes easily and free iodine is liberated, causing
the solution to become of a brown color. Care should therefore be
exercised in using the pure drug and in exposing a solution of it to light.

My experience is strongly in favor of combining mercurialization
with the internal administration of the iodides in the tertiary as well as
the secondary stages of syphilis. I prefer the mercurial bath and the
hypodermic injection method to the administration by the stomach,
when it is practicable to employ them.

When the tumor is of the aneurismal type the use of the iodide of
potash in moderate doses seems to exert a curative influence in some cases.
It is well to keep such patients in a recumbent position, and to avoid all
excitement and other possible causes of an excessive action of the heart.

Regarding the treatment of the other varieties of tumors mentioned
as liable to exist within the skull, I can offer but little encouragement.
If it be possible, in any given case, to decide positively respecting the
character and size of a tumor as well as its exact seat, and if none of
the contra-indications to trephining existed, I might be tempted to
employ the trephine. So far, however, I have never encountered a case
that justified such a measure in my opinion.

A SUMMARY OF THE SYMPTOMS OF CEREBRAL DISEASES.

As an aid to the reader, I have deemed it wise to add to this chapter
a differential table of the more common symptoms of cerebral diseases.
Tables of this kind are particularly of service to the busy practitioner
in reviewing the prominent features of the separate diseases which have
been previously described.
345

SUMMARY OF THE SYMPTOMS OF CEREBRAL DISEASES.

A TABLE DESIGNED TO SHOW THE DIAGNOSTIC VALUE OF CERTAIN SYMPTOMS IN BRAIN-CONDITIONS.

 

 

 

 

 

DISTURB- IMPALR-
MOTOR | SENSORY | MUSCU- | ELECTRO- DEFECTS
ADVENT.| cCoMs. | PARALY- | PARALY- | CONVUT" [Lar CON-) CONTRAC- eR Species IN EL | TREMOR.
SIS. SIs. TRACTURE, TILITY, SENSES, | SPEECH. LECT.
|
oe Sudden. Cee pis Rare. Infrequent, Absent. Normal. |Infrequent conte Marked. CEG Absent.
. Depends ; e ace
CEREBRAL ei Not | Not in- Very 1 : Ear often Rather in-| Delirium, | Usually
Turomposis.| Variable. | infrequent.) frequent. | P S°% Of | eommon, | Absent. | Normal. | Common. suppurates frequent. ete absent.
g paren clot. q
CEREBRAL Seldom Not in- Not ine May/follow, Normal Not in- Some May be |May follow} May be
Apopiexy, | Sudden: | Usual. absent. |.frequent. | frequent. the attack. .at first. | frequent. tapeled induced. | attack. -| developed:
CEREBRAL May be May be_ Very often Very | May be Not May be
TUMORS. Gradual. Infrequent geveloped. dewevened: occur. end Normal. | gommon, | Common. developed. ee 48 developed.
: i Very in- ;
PAcHY- Nip ce Not in- in) Often ‘i ' : May be May be | Usually
MENrNarttis, | Gradual. oe occur.’ frequent. eee | occur, frequent Normal. | Common. | Frequent. developed.| developed.| absent.
SIMPLE Moderate- Not in- Un- May be Lad Usually
MENINGITIS. Ty sudden.) frequent. | common. Infrequent May ocene a eroe ed. Normal. Severe. Common. penne Delirium. absent.
HYDROCEPH-, Late in Late in |Rather in- | . ' Delirium,
ALUS (ACUTE); Gradual.  Gisease, | disease. | frequent. ; Marked. | Marked. | Normal. | Severe. | Marked. [Infrequent tah Absent.
HyYDROCEPH-| ' . Frequent A ate
| Usually | : Not in- Un- ‘ Mia i . Moderate ; Not in- Imbecility,| May be
OAR Oey, ‘congenital. Rare. | frequent. | common. Common. nde Modified. | oy absent. | frequent, | Common, ete. °’| developed.
CEREBRAL May be May be i May be Often Not un- May be May be Very

 

 

May occur.

| !
SCLEROSIS. | Gradual, Infrequent) qeveloped. developed. May event.’ developed. modified. | common. developed.) developed.| common.

|

CEREBRAL | Modified | | |

ANZMIA —byitsexcit- May occur.| Absent. Infrequent May occur.
(Gen’lvariety) ing cause. |

May be_: Transient Absent.

Absent. Normal. | Common. | Frequent. developed.’ or absent.

 

 

 

 

 

 

 

 

CEREBRAL |, Modified | Very in- | : 4 os 2 May be May be Usually
Tig baR Mra. iby a ase. | oceur.| frequent. Infrequent May ee Absent. Normal. | Common. | Frequent. developed.) developed.| absent.
CEREBRAL qa | Not in- | M ‘Ma: -| ON 1 Dull M C ae ’
SOFTENING. | Gradual. in occur.’ Common. frequent. ay oceur:, yy occur. ormal. ull, ay occur.) Common. oa May occur.
| 1 ry
' ’ pe | o in- 0
GEREARAS Gradual. | ae | Common. en ok May occur. ‘oes occur.) Normal, | Severe. | on an May occur. Erecedes Infrequent
+ ’ + | we

 

The preceding pages of this section will aid the reader in obtaining further information respecting any symptom of disease mentioned in this table.
SECTION IV.

DISEASES OF THE SPINAL CORD AND ITS
ENVELOPES.
SECTION IV.

DISEASES OF THE SPINAL CORD.

In the first section of this volume, certain anatomical, physiological,
ind clinical deductions have been given respecting various component
parts of the spinal cord. It is very important that the reader familiarize
himself thoroughly with these before he attempts to master the symp-
tomatology of spinal lesions.

One of the first distinctions that must be drawn respecting spinal
lesions (in order to make accurate diagnosis) is that which exists
between what is known as “systematic” and “ non-systematic” or
“focal” lesions of the cord.

By “ systematic” lesions, we mean any pathological condition which
tends to progress along definitely recognized subdivisions of the spinal
cord, without spreading laterally to adjacent parts.

By “‘non-systematic” or “ focal” lesions, we mean any pathological
condition which tends to spread laterally, and thus to involve adjacent
columns of the cord as the lesion progresses.

For example, a systematic lesion of the anterior horn would remain
confined to the anterior horn, irrespective of its extent up or down the
cord. On the other hand, a focal lesion starting in the anterior horn
might spread to any of the various subdivisions which lie adjacent to
the horn, viz., the column of Ttrck, the crossed pyramidal column, the
anterior root-zone, the spinal commissure, etc. (See Fig. 91.)

Clinically, this distinction is very important. A systematic lesion
of a motor column would, for example, yield exclusively motor symp-
toms during the life of the patient, while a focal lesion starting in a motor
column might subsequently spread to a sensory column, and thus occa-
sion both motor and sensory symptoms during life.

The table on the next page will give the reader a knowledge of the
more important spinal diseases which are to-day clinically recognized.

It must be remembered that the spinal cord, like the brain, consists
of two anatomical elements, viz., nerve-cells and nerve-fibres.

The sPINAL FIBRES are connected with the spinal cells in such a way
as to allow of a communication (1) between the spinal cells and the
periphery of the body (the spinal nerves); (2) between the cells of the
cord and those of the various gray masses of the brain (the conducting
tracts); and (3) between the cells of the different spinal segments them-

selves (the associating fibres of the cord). a
390 LECTURES ON NERVOUS DISEASES.

A TABLE OF THE ABNORMAL STATES OF THE SPINAL CORD.

A.

SYSTEMATIC LESIONS OF TILE
Moror PORTIONS OF THE
Corb—or of the so-called
“ Hinesodic System.”

B.

SYSTEMATIC LESIONS OF THE
SENSORY PARTS OF TILE CORD
—or of the so-called “ dfsthe-
sodi¢ system.”

ey
Non-SYSTEMATIC OR “FOCAL”
LESIONS OF THE CORD.

D.
FUNCTIONAL DISEASES OF
THE CorD.

E.
VASCULAR CHANGES (of a dif-
fused or circumscribed char-
acter).

F.
CONGENITAL ABNORMALITIES
OF THE CORD.

A

rc

~

<

=y;

 

|

SCLEROSIS OF THE DIRECT PYRAMIDAL COLUMN (usually
secondary to a lesion of the braim or cord).

SCLEROSIS OF THE Primary—Usually bilateral—
CROSSED PYRAMIDAT. 4 ,(letanoid paraplegia).
COLUMNS. Secondary — Usually unilat-

eral—(descending variety).

INFLAMMATION OF THE CELLS OF THE AN- { Acute,
yERIOR HORNS OF THE SPINAL GRAY Kvn-| Statute,
STANCE (poliomyelitis anterior), 3 varieties. Chronie.

DEGENERATION OF THE CELLS OF THE ANTERIOR
HORNS (progressive muscular atrophy).

PROGRESSIVE FACIAL ATROPHY.

PsEUDO-HYPERTROPHIC PARALYSIS.

AMYOTROPHIC LATERAL SCLEROSIS,

CENTRAL MYELITIS.

PRIMARY BILATERAL SCLEROSIS OF THE POSTERO-
BXTERNAL AND POSTERO-INTERNAL COLUMNS (loco-
motor atari).

SECONDARY NILATERAL OR BILATERAL DEGENER-
ATION OF THE SENSORY COLUMNS (ascending variety),

“( Acute leptomeningitis spinalis.

s Meningitis 4 Chronic = *

SPINAL 4 ° External pachymeningitis spinalis,
-Internal x i

 
 

{ Of the bones.

SPINAL TUMORS..++-e-esseeeeeereeeee Of the meninges.
Of the spinal cord.
é ‘ Hematomyelia.
SPINAL HEMORRHAGE. .....--++see005 ( Harmatorrhachis.
: Acute.
MY EDITIS cc cccccccceccccsccecssececssessresceenee Chronic.
SYRINGOMYELIA and HYDROMYELIA.
SPINAL IRRITATION.
. Lead.
FuNcTIONAL PARA- ( From Hysteria. | Arsenic.
PLEGIA, ‘* Poisons. Phosphorus.
THOMSON’S DISEASE, L “Anemia. | Ergot.
Alcohol.

SPINAL NEURASTHENIA.
ACUTE ASCENDING PARALYSIS.
WRITER'S CRAMP.

TETANY.

SPINAL CONGESTION oR HYPERAMIA.

SPINAL ANEMIA.

SPINAL EMBOLISM.

ATHEROMA OF THE VESSELS.

Patty of AMYLOTD DEGENERATION OF ARTERIAL
ANEURISMAL DILATATIONS.

SPINA BIFIDA (with alterations in the cord).

ABSENCE OF SPINAL CORD.

INCOMPLETE DEVELOPMENT OF SPINAL CORD.
CONGENITAT, CAVITIES OF THE CORD (Syringomyelia).

Thus we have within the spinal cord the following groups of fibres :—
1. Those which constitute the antertor* and posterior nerve-roots.F

* The fibres of the antcrior nerve-roots may be said to have the following connections
(indirectly, of course, through the multipolar cells of the anterior horn of the corre-
sponding side): 1, with the lateral motor column of the corresponding side of the cord ;
2, with the anterior motor column of the corresponding side of the cord; 3, with the
anterior motor coiumn of the opposite side of the cord, by means of fibres which decus-

sate in the white commissure.

tA direct continuity of some of the fibres of the posterior nerve-roots in the column
of Goll has been asserted to exist by Singer. This observer detected a tract of degenera-
tion in these column» extending to the medulla after section of the posterior roots in

dogs.
DISEASES OF THE SPINAL CORD. sol

They pass, of necessity, through the white substance of the cord to reach
the spinal gray matter.

2. The paths of motor and sensory conduction. These are prolonged
to the brain, and probably do not enter directly into the formation of
the spinal nerve-roots.

3. The associating fibres. These do not extend to the cerebrum ;
nor do they leave the substance of the cord. They simply join the
various spinal segments with each other.

<———--==-- >

io

a ace

r

(

=
a a

{

He

 

Fig. 91.—DraGram ILLUSTRATING THE RELATIONS OF THE NERVE-FIBRE TRACTS IN THE
Spina Corp.—The section is supposed to be taken transversely through the lower part of
the cervical enlargement (slightly modified from Flechsig): A, Anterior median fissure ;
B, posterior median fissure; C, intermediate fissure; D, anterior gray cornu; E, posterior
gray cornu; F, gray commissure, with central canal; G, “uncrossed pyramidal tract (Flech-

* sig), or column of Tiirck; H, fundamental part of the anterior column (anterior root-zones
Charcot and his pupils) ; 1, anterior part of lateral column; Kk, crossed pyramidal tract
of lateral column; L, direct tract from lateral column to cerebellum ; M, column of Burdach,
posterior root-zones “of Charcot and his pupils; N, column of Goll: S, sensory tract of
Gowers. The posterior columns of descriptive anatomy include the fields M and N extending
on the surface from Bto R. The antero-lateral columns extend on the surface from R to A.
Their anterior division includes the fields G and H; their lateral division, the fields K, L,
and!. Similar colors are supposed to indicate in this plate a similarity of function.

4. Trophic and vaso-motor filaments. These connect the cells of
the cord (by means of the spinal nerve-roots) with the blood-vessels and
the organs related to motion and sensation.

We can therefore draw the following conclusions, which bear upon
diagnosis :—

Interference with the function of the first and second of these
352 LECTURES ON NERVOUS DISEASES.

groups of spinal fibres will result in a disturbance (more or less pro-
found) of the patient’s capabilities either of motion or of perceiving and
recording sensory impressions of various kinds (those of touch, pain,
temperature, muscular sense, and electrical stimulation).

Destruction of the third group of fibres will cause symptoms of
incodrdination of movement.

Impairment of the functions of the fourth group may create abnor-
malities in the calibre of blood-vessels, and an unhealthy state of the
skin, hair, nails, muscles, ete. The etiects of spinal lesions upon the
pupil (p. 411) are probably attributable to the vaso-motor fibres,

The arrangement of the cells and fibres of the spinal cord are very
clearly shown, from a physiological standpoint, in a table which I have
prepared (p. 355). It is somewhat similar to one lately published by
M. A. Starr.

It is well to know that there are certain symptoms which are pecu-
liarly apt to be encountered in connection with spinal diseases. These
may be separately discussed with advantage to the reader prior to the
description of the separate Cliseases.

It is also important that a beginner in this field of diagnosis
should grasp certain general axioms that will materially aid him in
discriminating between focal or systematic spinal lesions which may be
creating an impairment of the functions of one or more of the groups of
fibres just described or the horns of the spinal gray matter.

The following paragraphs and table may possibly shed some light
upon the diagnosis of spinal diseases :—

1. CONTRACTURE OF MUSCLES, when present in a case afflicted with
paresis or paralysis, points strongly to a lesion of the motor fibres in the
lateral column of the same side (the “crossed pyramidal fibres”).

2. EXAGGERATION OF TIIE TENDON-REFLEXES is a symptom which
points to the same conclusion.

3. RAPID ATROPHY OF MUSCLES (either as an independent affection or
as a sequel to paralysis) points to a diseased condition of the cells of the
anterior horn of the spinal gray substance. A piece of muscle (when
bitten out by means of Duchenne’s trocha and subjected to a micro-
scopical examination) will quickly show whether atrophy is occurring
as a result simply of disuse or of organic disease of the nervous
mechanism.

4. ABNORMAL SENSORY PHENOMENA (such for example as pain, hyper-
xsthesia, smeusthesia, analgesia, formication, numbness, tingling, etc.)
point to the existence of a lesion which affects either the posterior
nerve-roots or the esthesodic portions of the cord (p. 98).

5. DIMINUTION OR ABOLITION OF THE REFLEXES (p. 96) points to lesion
which affects a reflex-are (Fig. 95).
DISEASES OF THE SPINAL

CORD.

303

A Tasie or Some or tHE More Important Diacnostic SyMProMs OF SPINAL Lestons.

PART OF,SPINAL CORD
AFFECTED.

 

CoNTRACTURE (tonic

shortening of muscle,

of a persistent type).

Arropuy oF MuscLes
(due to fatty degen-
eration of the sarcous
elements).

EXAGGERATED RE-
FLEXES.

Diuinution orn ABO-
LITION oF SPINAL
REFLEXES.

Tropuic DisruRBANCES.

ABNORMAL SENSORY
PHENOMENA.

 

( (1) Generally due to an im-

| pheation of the ‘crossed-
pyramidal fascicult” (Fig.
32

(2) day possibly follow (?)
implication of the fibres of
Turck’s column (Fig. 32).

(1) Is generally due to a
esion confined to the cells
of the anterior horn.

(2) It may follow a severance
of the motor fibres which
compose the anterior nerve-

L roots.

Occurs from implication of
the motor bundles of the
lateral column, as a rule.

(1) Usually occurs with
esions of the posterior
columns of the cord (loco-
motor ataxia).
(2) Lesion of the posterior
nerve-roots may also cause
| this symptom.

( Lesions of the gray substance
of the cord are particularly
liable to cause symptoms
of this variety.

(1) May indicate either an
arritative or a destructive
lesion of the cord.

(2) The posterior columns or
posterior nerve-roots are
enerally involved.

(3) The posterior horns of
spinal gray substance may
be implicated. .

L

 

 

|
|

 

 

ONSET.

(1) May occur simultaneous
with paresis or paralysis
(primary contracture),

(2) May follow paralysis of
motion (post-paralytic con-
tracture), if the lateral scle-
rosisis asecondary affection.

(1) Rapid, and preceded by
motor paralysis, if the lesion
be an inflammatory or trau-
matic one.

(2) Slow, and not associated
with motor paralysis, if the
lesion be ae degenerative
kind (progressive muscular
atrophy).

When complete paralysis of
motion exists in a limb, this
test cannot be employed.

(1) Usually occurs indepen-
dently of motor impairment.

(2) Abnormal sensory phe-
nomena generally coexist
with it.

Are apt to accompany symp-
toms of vesical or rectal
impairment (myelitis).

(1) May develop slowly or
ramdly. ;
" Are often accompanied

ry inco-urdination of move-
ment, or trophic disturb-
ances, or impairment of the
bladder or rectum.
(2) Spinal reflexes are apt to
e diminished or abolished.

 

Let us now examine some of the symptoms, which have been already
referred to, more in detail.
Moror Paratysis (of spinal origin) may assume one of four varieties:
(1) Hemiplegia—where one lateral half of the body is affected with

motor paralysis.

(2) Paraplegia—where the lower half of the body is affected with

motor paralysis.

(3) Hemi-paraplegia—where the lower half of one lateral half of
the body is affected with paralysis of motion.

23
LECTURES ON NERVOUS DISEASES.

(4) Paralysis of special nerve-roots (spinal-nerve paralysis).

1

 

Fic. 92.—A DIAGRAMMATIC
REPRESENTATION OF THE
SgeconpDary EFFECTS OF A
LESION OF THE ENTIRE
SPINAL CorD_ ar (5),
(After Erb.) Note the as-
cending degencration of
the sexsory tracts in sec-
tions 4, 3,2 and 1; and the
descending degeneration
in the motor tracts in sec-
tions 6, 7 and 8,

The SENSORY PHENOMENA, which may be pro-
duced by lesions of the spinal cord, or of the posterior
nerve-roots, include the following :—

(1) Pain—usually of a. peculiar kind (see loco-
motor ataxia, and the various focal lesions of the cord),

(2) Hyperesthesia, or increased sensibility of parts.

(3) Numbness, or a sense of tingling (as if “the
part. were asleep”’).

(4) Sense of culdness or of heat in some part of
the body.

(5) Anesthesia, or loss of sensibility. It may be
complete or partial and be limited to the apprecia-
tion of pain, touch, or temperature by the patient.

(6) Delayed sensation (see locomotor ataxia).

(1) Formication, or a feeling likened to the
crawling of ants over the body.

Among the remaining symptoms which are of value
in the diagnosis of spinal lesions may be mentioned :—

(1) Incoérdination of muscular movements.

(2) Diminution, abolition, or increase of the spinal
reflexes (see Section II of this volume).

(3) Abnormal — electro-muscular
Section IT).

(4) Contracture of muscles—often preceded by
stiffness (see lateral spinal sclerosis).

(5) Atrophy of muscles (see poliomyelitis and
progressive muscular atrophy).

(6) Vaso-motor phenomena (see myelitis, ataxia,
etc.).

(7) Symptoms which are indicative of destruction
or wrritation of some of the special physiological cen-
tres of the spinal cord (see focal lesions of the cord).

(8) Lremor or some other form of spasmodic
movement.

Fig. 67 exhibits in a diagrammatic way several
of the above-mentioned abnormal conditions which
may coexist as a result of an unilateral lesion of
the dorsal segments of the spinal cord. It will
serve to aid the reader in mastering the statements
made in subsequent pages,—chiefly those which
refer to the symptomatology of focal spinal lesions.

The methods which should be followed in dnves-

reactions (see
DISEASES OF THE SPINAL CORD.

300

tigating each of the above-mentioned symptoms (prior to a diagnosis) have
been fully described in Section II., to which the reader is referred.
Before we pass to the consideration of the separate spinal diseases,
I would call attention to a carefully prepared summary of the functions
of special spinal segments, which differs but slightly from one compiled

and tabulated by Starr.*

table of Gowers (p. 90), as each will explain the other.

It should be compared with the diagram and

A TABLE SHOWING THE ARCHITECTURE AND FUNCTIONS OF THE VARIOUS
COMPONENT PARTS OF A SPINAL SEGMENT.

r

1, ‘ANTERIOR MEDIAN COLUMN.” (‘' Tiirek’s
column’ — direct pyramidal column,” )

2.

“ANTERIOR ROOT-ZONE.”
umn.«)

(Anterior col-

(a) Un-named
portion.

3. LATERAL COLUMN (con-
sisting of three subdivi-
sions).

(b) “Crossed
pyramidal col-

UA wamnn.”*

THE WHITE
MATTER OF
THE CORD.

(c) “Direet cere-
L bellar column.”

4d. “ PosTERO-LATERAL COLUMN.” (“Column
of Burdach’—“ posterior root-zone” — SLUS-
ciculus cuneatus’? — postero-external  col-
uinn.)

Ny, “Column
5. “\POSTERO-MEDIAN COLUMN, (‘Co
of Goll’— fasciculus gracitis” — “ postero-
internal column.”’)

 

!
|

|

Fibres of conduction of

Motor fibres from the
“motor area” of the
cerebral hemisphere
of the same side (figs.
5 and 29).

(1) Fibres of associa-
tion between differ-
ent segments of the
spinal cord (vertical
in direction).

(2) Motor fibres passing
from the cells of the
anterior horn of the
spinal gray matter in-
to the anterior nerve-
roots (horizontal in
direction),

(1) Associating fibres

etween spinal seg-

ments.

(2) Fibres of the sensory
tract of Gowers (°).
(3) Vaso-motor sibres(?).
(1) Motor fibres from
the ‘‘motor area” of
the opposite cerebrul
hemisphere (vertical

in direction).

(2) Fibres passing from
the cells of the col-
umn of Clarke to form
the direct cerebellar
column (horizontal in
direction).

Fibres passing from the
cells of Clarke’s col-
umn to the cerebel-
lum. The “vegeta-
tine-tract” of Starr.

(1) Sensory fibres from

posterior nerve-roots

to spinal cells (except
those associated with
the ‘superficial’ or

“skin reflexes’) (hori-

zontal in direction).

(2) Associating fibres
between spinal seg-
ments (vertical in di-
rection).

3) Fibres of conduc-
tion of sensations of
touch and the museu-
lar sense, from the
arms and neck, up-
ward (vertical in di-

rection).

sensations of touch
and the muscular
sense, from the legs
and lower half of the
trunk, upward.

* Am. Jour. Neurol. and Psychiatry, November, 1884.
306 LECTURES ON NERVOUS DISEASES.

A TABLE SHOWING THE ARCHITECTURE AND FUNCTIONS OF THE VARIOUS
COMPONENT PARTS OF A SPINAL SEGMENT (continued).

fi

(

(2) Lateral groups in the extension of the limbs
(possessed by all verte-
brates).

a.

1) Mesial group of cells. Presiding over flexion and
cervical and lumbar en-

largements.

Presiding over move-
ments of the hand and
fingers(peculiar to man)
and the act of walking
erect.

Motor cells, whose peculiar functions are not deter-
mined.
d. Trophic centres for the motor nerves and the muscles
supplied by them. ;
e. Motor mechanism necessary to spinal automatism and
zB. L reflex spinal action.
THE GRAY (a. Anterior part. Trophic centres for the skeleton.

. 1) Trophic centres for the skin

pa aro i CELLSOF THE | y Posterior purt. f ae pindder, joints. ?
THE CORD. CENTRAL 4 (2) Vaso-motor centres.

GRAY ec. Automatic centres of a complex nature, and the asso-

MATTER. ciating fibres necessary to their peculiar functions
L (sexual, vesical, rectal, cilio-spinal, etc).

Trophic centres for sensory conducting-tracts.

Paths of conduction of sensations of pain, and tem-
perature from all parts below. :

ce. Clarke's column of cells (vesicular column) which are

CELLS ORTH apparently associated with the fibres of the “direct
POSTERIOR  « cerebellar column.”

lL FIORE: d. Posterior group of cells; related to sensations of all
kinds.

The sensory mechanism necessary to spinal automatism
and spinal reflex action.

(2) Central group of cells
in the cervical and lum-

{
(1) Middle group of cells.
{ bar enlargements.

ANTERIOR 7

CELLS OF THE b.
Horn.

a

rP

 

 

The size of the multipolar cells of the anterior horns seems to depend upon two factors:
(1) the size of the muscle supplied by the cell, and (2) the length of the nerve-fibre which
connects the cell with the muscle (Spitzka).

We are now prepared to discuss the separate lesions enumerated in
the table of diseases of the spinal cord. The scattered hints which have
been already given in a previous section will possibly help us to grasp
the salient features of each, and their physiological interpretation.

In examining a case of paralysis of spinal origin, the following points
should be ascertained with great care :—

(1) The area of distribution of the paralysis (be it sensory or motor
in character). ,

(2) The degree of the paralysis; by separately testing the motor
power of different sets of muscles, and also the skin for sensory paralysis
by means of the esthesiometer.

(3) The state of nutrition of the paralyzed muscles (see pages which
treat. of poliomyelitis and progressive muscular atrophy).

(4) The electrical reactions of the paralyzed muscles; noting all
abnormal formule and the intensity of the current required to produce
muscular contraction (see section on electricity).

(5) The presence or absence of rigidity in the paralyzed muscles
(see pages which discuss sclerosis of lateral columns).

(6) The condition of the superficial and deep spinal reflexes of the
two sides. These have been discussed in Section IT.
SCLEROSIS OF THE ANTERIOR COLUMNS. 357

(7) The presence or absence of symptoms of incodrdination of
muscular movements (see locomotor ataxia),

SCLEROSIS OF THE ANTERIOR COLUMNS.

The anterior columns of the cord are frequently called “the columns
of Tiirek” and “the direct pyramidal fasciculi.”

The first of these names was given in honor of a distinguished
pioneer in pathological research relating to spinal lesions. The latter is
employed because the bundles which compose these columns pass directly
from the hemisphere of the cerebrum to the ultimate spinal seements
without decussating in the medulla,—the anterior pyramids of which they
help to form.

Several diagrams have been introduced in Section I of this volume
to illustrate the formation of these columns; as well as their physiologi-
cal association with the motor bundles of the opposite lateral column of
the cord (see Figs. 29 and 82).

Morbid Anatomy.—Sclerosis of these bundles of nerve fibres usually
coexists with similar changes in those which compose a part of the lateral
column of the cord,—the so-called “ crossed pyramidal fasciculi.” It may
occasionally exist as an independent lesion; but it usually follows the
development of some brain or cord lesion and travels downward. It is
then unilateral. The symptoms which are peculiarly characteristic of
its development are unknown. Its existence is to be inferred when
secondary sclerosis of the postero-lateral columns is manifested by
symptoms which are clinically well determined. The pathological changes
of sclerosis of the cord do not differ from those of that condition else-
where. They have been described in the preceding chapter, in connection
with the brain.

The discovery, made by Flechsig, that the relative proportion of the
direct and decussating pyramidal fibres differs in individuals, helps us
to properly interpret those rare cases where a lesion of the cerebral
hemisphere has been known to produce a hemiplegia of the same side
_ (instead of the opposed side); as well as those cases of greater frequency
where a paresis of the corresponding side coexists with a hemiplegia
of the side opposed to the cerebral lesion. In one case in sixty, no
decussation of the pyramidal tracts occurs.

SCLEROSIS OF THE MOTOR FIBRES OF THE LATERAL COLUMN.
(Lateral Spinal Sclerosis—Tetanoid Paraplegia—Spastic
Paralysis—Spasmodic Tabes.)

Within the lateral columns of the cord, we encounter a bundle of
motor fibres which decussate anteriorly in the medulla at its lowest
part. They are, therefore, associated with the opposite cerebral hemis-
358 LECTURES ON NERVOUS DISEASES.

phere. These fibres occupy only a portion of each lateral column, and
lie adjacent to the posterior horn of the spinal gray matter. They are
known as the “ crossed pyramidal ” fibres. They are separated from the
periphery of the spinal cord (in some of the spinal segments, although

MOTOR FIBRES
OF LATERAL COLUMN

mu

MUSCLES | | |
CONTROLLED BY |
EACH SPINAL | 1
Tee bh
1]
|

 

CELLS OF THE

ANTERIOR HORNS
OF SUCCESSIVE

SPINAL SEGMENTS

 

 

  
 

 

Fic. 93.—A DIAGRAM DESIGNED BY THE AUTHOR TO SHOW THE DISTRIBUTION OF THE
** CROSSED PYRAMIDAL FIBRES’’ (OF ONE SIDE) TO THE CELLS OF THE ANTERIOR HORN
or Successive SpinAL SzeGments.—Note that the motor fibres of the lateral column can
act upon the muscles only indirectly (through the cells of the anterior horn); also that each
segment of the cord receives from the lateral column certain fibres which put the muscles
associated with that particular segment in the circuit of cerebral influence (volition). In
this diagram, the circles represent groups of cells,and not a single cell. Eachred fibre
represents a dundle of fibmes having similar termination. The blue lines represent bundles
of motor fibres, which form the anterior nerve-root of successive spinal segments. The
terminal muscles (in red) represent the ex¢/re group controlled by each spinal segment,—
not individual muscles. Figs. 19 and 32 will help to further interpret this diagram. ‘Ihis
diagram illustrates the reason why the motor columns of the spinal cord grow smaller in size
as they reach the terminal segment.

not so in all) by the so-called “direct cerebellar column.” (Fig. 19.)
The size of this motor bundle decreases gradually (by the giving off of
fibres to the various spinal segments) from the cervical enlargement of
the cord till it ends in the lumbar enlargement.

Morbid Anatomy.—Sclerosis of this tract may exist as a-primary
disease; and also as a secondary result, occasioned by the development
of a lesion higher up in a cerebro-spinal axis.

 
SCLEROSIS OF MOTOR FIBRES OF LATERAL COLUMN. 309

When the disease is of the primary variety, sclerosis is usually
found on both sides of the cord in the lateral column. When it is of the
secondary variety, the sclerotic process in the cord (if due to a cerebral
lesion) is usually detected in the lateral column of one side and the
anterior column of the opposite side. Fig. 32 will make the reason of this
fact apparent to the reader.

In some cases, sclerosis of the posterior columns and the morbid
changes of poliomyelitis anterior may coexist with lateral spinal sclerosis.
Whether this is due to an extension of the morbid process or not is
as yet not thoroughly determined.

Etiology.—Sclerosis of this tract of fibres, when it occurs as a
primary aftection, is rarely encountered before the twentieth or after
the fiftieth year of age. It may follow exposure to cold or dampness
and injuries of various kinds. In many cases, its causation is very
obscure. Some authors believe that it starts as a transverse myelitis.

The secondary variety occurs as the result of any morbid process
which tends to cut off the fibres of the so-called “ motor tracts ” from
their trophic centres in the motor area of the brain. It is commonly
known, therefore, as “ secondary degeneration ” of the spinal cord. We
are apt to encounter this condition as a sequel to any form of cerebral
disease which affects the motor fibres or “ will-tract.” It may also be
due to any spinal lesion which has involved the motor fibres of the
cord above the seat of the sclerosis.

Secondary degeneration of nerve fibres travels, as a rule, in the
direction of the impulses conveyed by the fibres affected (downward in
the motor, and upward in the sensory bundles).

PRIMARY LATERAL SCLEROSIS.
(Primary Spastic Paraplegia— Tetanoid Paraplegia.)

This condition is usually present upon both sides of the spinal cord.
It is most frequently encountered in adults between the ages of thirty
and fifty, although it may exist in children. It seems to be more fre-
quent among males than females, and to attack individuals in apparently
robust health. It has been suggested that any excessive muscular exer-
cise or strain may predispose to its development. Among children, this
form of paralysis may be traced, apparently, in some instances, to an
Injury received upon the spinal column, to the head during birth, or to
some congenital defect in the development of the motor apparatus.

In the opinion of Bramwell, lateral sclerosis of the primary variety
is very rarely observed. He attributes the frequency of those cases
(which are usually considered as of the primary type) to a transverse
myelitis unassociated with disturbances of sensation, and usually present
360 LECTURES ON NERVOUS DISEASES.

in the dorsal segments of the spinal cord. In this view he is supported
by Leyden,

Irrespective of the relative frequency of this condition as a primary
disease or its etiology, the bilateral character of its symptoms is in
marked contrast to the unilateral character of the form which is com-
monly regarded as secondary.

Symptoms.—In this form of spinal sclerosis, the patient is attacked
by a paresis of a progressive character. This develops slowly and
attacks, as a rule, the lower limb of both sides simultaneously. Subse-
quently the upper limbs may exhibit similar symptoms. There is in
almost every case a marked increase of the spinal reflexes. The paralyzed
muscles tend to become rigid to a greater or less extent when sitting, rising
or walking. This accounts for peculiarities in the gait of these patients.

No evidences of atrophy in the paralyzed muscles, more than would
be accounted for by disuse, are observed. Sensation is preserved in the
affected limbs, and there are few if any well-pronounced clinical evidences
of disturbed sensory functions. Pain is infrequent, there is little numb-
ness, tingling, or other subjective phenomena, and the viscera of the
pelvis are not usually affected, as they are liable to be in myelitis.

The stiffness in the legs which accompanies the development of
paresis compels the patient to use two canes early in the disease when
attempts at walking are made. Subsequently crutches, and possibly an
attendant, are rendered necessary. The patient moves with the most
extreme difficulty. When an advance step is made the feet appear to he
glued to the ground, and are scraped or dragged alone rather than lifted.
The pelvis and the limb asa whole is lifted in order to allow of the scraping
of the foot forward, because little if any flexion is made at the knee.

The knees frequently tend to become locked together during the act
of walking, because the foot is apt to cross its fellow as it is brought
forward. This is an evidence of spasm of the adductor muscles.

As a rule, these patients are inclined to stand upon the toes, rather
than on the entire sole of the foot, when walking.

Occasionally the muscles of the calf are affected with spasm during
attempts at walking, and the foot is then suddenly raised from the
ground irrespective of the will of the patient (hopping gait). This pecu-
liarity in gait closely resembles that of a horse when affected with what
is known as the “string-halt.” Again, the patient may be lifted suddenly
upon the toes when endeavoring to walk, by contraction of the extensor
muscles acting upon the foot.

A peculiar attitude of the back and chest is observed as the patient
leans heavily first on one cane and then on the other in order to raise
the weight of his body hy the arms. The dack is strongly arched and
the chest is thrown very much forward.
SECONDARY LATERAL SCLEROSIS. 361

Whenever the muscles are manipulated they become more or less
tense and rigid. This is due to the fact that the spinal reflexes are very
much. exaggerated in this disease.

The knee-jerk is markedly intensified and an “ankle-clonus” can
gencrally be elicited. Sometimes a blow upon the patella-tendon causes
a response in the opposite limb. This is known as “vadialion of the

reflex.”

The superficial reflexes are sometimes decreased or abolished; but
in exceptional instances they may be exaggerated.

The tests employed to determine the condition of the spinal reflexes
have been already described in the second section of this work.

After a lapse of several months or years, these patients are obliged
to remain in bed from an inability to walk. The legs then tend to
remain stiffly extended; and the thighs are closely approximated, as the
result of spasm of the adductor muscles. The feet are usually inverted.
Ultimately, the upper extremities may become affected with contracture,
in which case flexion predominates over extension.

The electrical reactions of the affected muscle are normal or slightly
decreased. Those of the nerves may be diminished, both to the fnradaic
and galvanic currents.

Cerebral complications are rarely if ever developed; the viscera are
apparently healthy ; and the pelvic organs are not, as a rule, affected.

In somewhat rare instances, one leg alone, or one leg and one arm
may be attacked. Such cases are to be diagnosed from. hemiplegia or
monoplegia of cerebral origin.

Diagnosis.—This condition is to be distinguished from the secondary
form of lateral sclerosis; from poliomyelitis; from amyotrophic lateral
sclerosis; and from focal lesions of the spinal cord. A subsequent
table (p. 364) will make the points of discrimination more apparent than a
verbal description.

SECONDARY LATERAL SCLEROSIS.
(Descending Spinal Sclerosis.)

This morbid condition is due to a degeneration of the motor fibres
of the cord from any cause which tends to separate them from their
trophic centres (which are situated within the cortical motor centres of
the cerebrum). Whenever a nerve fibre is separated from its trophic cell,
it tends, with few exceptions, to degenerate in the direction of the
impulses which it is designed to transmit. Hence motor fibres usually
exhibit under such circumstances a progressive degeneration downward,
and the sensory fibres a similar alteration in an wpward direction.

The CEREBRAL LESIONS which are liable to produce this form of spinal
disease may affect one of the following parts: (1) those convolutions of
the brain which are chiefly associated with motion; (2) the motor
LECTURES ON NERVOUS DISEASES.

bundles of the ‘corona radiata” or of the “internal capsule,” (3) the

 

Fic. 94.—A DIAGRAM DESIGNED Yo
ILLustRATE THE SECONDARY SCLE-
ROSIS WHICH WOULD FOLLOW A
Lesion or THE Lerr CEREBRAL
HemispHEre, (After ot Note
the involvement of the column of
‘Tiirck is seen on the left side in
sections 1, 2, 3, 4, 5 and 6 (where its
fibres end). That of the crossed
pyramidal tracts extends throughout
the entire length of the spinal cord.

caudate nucleus or lenticular nucleus; (4) the
crusta cruris; (5) the motor fibres of the
pons; or (6) the anterior pyramids of the
medulla, above the point of decussation of
the pyramidal fibres. Figs. 36 and 79 will
make this apparent to the reader.

Secondary degeneration of the spinal
fibres, which occurs after cerebral disease,
tends, 1s a rule, to progress downward both
in the column of Turck on the same side,
and in the lateral column of the opposite
side of the cord.

Although, in the majority of cases, this
results in a bilateral spinal lesion, the pre-
ponderance of the symptoms are due to the
sclerosis of the lateral columns. They are,
therefore, most marked upon the side of the
body which is opposed to the cerebral hemi-
sphere primarily attacked.

If, on the other hand, the primary lesion
is confined fo one side of the cord, secondary
sclerosis of the lateral column will occur only
below the level of the primary lesion on the
corresponding side of the cord.

Finally, when a transverse spinal lesion
which affects both sides of the cord exists,
or when a lesion of both cerebral hemi-
spheres or one which crosses the median line
cuts off both motor tracts, it may induce
secondary sclerosis of a descending charac-
ter in both of the lateral columns. In the
latter case, the symptoms exhibited hy the
patient during life would be of a markedly
hilateral type.

Secondary sclerosis produces, as a rule,
about the same train of symptoms as the
primary form, with the exception that the
symptoms are most marked upon one side;
provided they are not exclusively confined
to it.

Symptoms.—In this disease, paresis or
paralysis, contracture of muscle, and ez
SECONDARY LATERAL SCLEROSIS. 363

aggeration of the tendon reflewes are the chief symptoms which are to

be expected.

The paralysis or paresis precedes the de-
velopment of contracture. The paralytic symp-
toms are usually of a very marked character;
and they may have developed suddenly. The
pelvic organs sre liable, moreover, to be affected.
The skin, hair and nails may also exhibit
trophic disturbances.

All of these symptoms are usually observed

either upon one side only; or, if on both sides,

one will be more markedly affected than the
other. Whenever the exciting lesion is of a
bilateral type, the symptoms will be identical
with those described under the primary variety’.
Diagnosis.—This form of sclerosis is to be
distinguished chiefly from a chronic myelitis
which involves one lateral half of the spinal cord
in its anterior and lateral portions; and also
from those diseases which tend to produce a
gradual compression of the spinal cord, such as
meningitis, tumors, etc. It is far more frequent
than the primary variety; and cannot, as a rule,
he confounded with it. Moreover, the history of
the case will usually point toward some cerebral
or spinal lesion as its exciting cause. A sub-
sequent table will aid the reader in making the
necessary discriminations between it and other
spinal lesions which might be mistaken for it.
Something has already been said regarding
the discrimination of the primary and second-
ary forms of this disease from other spinal
affections. The chief diagnostic points by which
lateral spinal sclerosis can be distinguished from
all other spinal diseases (provided it be itself
uncomplicated) are: (1) the development of
paralysis with contractures and rigidity of the
muscles; (2) the absence of atrophy; and (8)
the marked increase in the tendon reflexes.
When no cerebral symptoms or those of a

 

 

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Fic. 95.—A DiaGrammatic RE-
PRESENTATION OF THE CORD IN
MULTIPLE SPINAL SCLEROSIS.
(After Erb.) This condition,
as will be seen, affords a marked
contrast with systematic scle-
rosis shown in Figs.92 and 94.

lesion of the upper part of the cord (bulbar symptoms) have preceded
the development of the contractures and paresis, it is safe to infer that

the primary variety exists.
364

LECTURES ON NERVOUS DISEASES.

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INFLAMMATION OF CELLS OF ANTERIOR HORNS. 364

 

Prognosis —Cases of apparent recovery from this affection have
been recorded ; and in many instances a period of indefinite duration, in
which no advance of the symptoms takes place, seems to be developed.
I believe that a few cases may be cured by proper treatinent, and that

-ahnost all can be materially helped if seen sufliciently early.

When it results fatally, the nuclei of the medulla are usually first
atfected, thus producing the symptoms of the so-called “ glosso-labio-
laryngeal paralysis,” or Duchenne’s disease.

Treatment.—It is my custom to administer large doses of ergot to
these patients very early in the disease,—before the paresis or contract-
ures become very apparent. This drug alone will occasionally arrest
the disease, in my opinion.

To syphilitic patients in the active stage, or those who have been
infected with that discase at any time, I administer the treatment sug-
gested on page 291.

I usually employ the galvanic and static currents to the paralyzed
muscles from the onset ; and, as a tonic, I am in the habit of giving cod-
liver oil and quinine. he nitrate of silver in combination with the
extract of belladonna may prove of service. Hot water (as recom-
mended on page 248) has helped some of my caxes.

I am satisfied that I have obtained marked and permanent improve-
nent by the use of the cauwery and severe static sparks when applied on
each side of the spinous process of the vertebra and the contractured
muscles every other day, or less often, for several weeks consecutively.

The spasms may be relieved by daily hypodermic injections of
er. yi, of atropine to begin with, and gradually increasing the dose.

The eflicacy of static electricity (administered chiefly by the
“spark ”) in relieving contracture and spasm of muscles is now quite
well established to my mind. I have had quite an extended experience
with this agent; and I know of nothing that will give such immediate
relief. to patients so afflicted.

The great disadvantage which most static machines labor under (in
the hands of those who own them) is their lack of power. A machine
which gives but a feeble and thin spark is practically useless for medical
purposes. Personally, I cannot recommend revolving plates of less than
24 inches in diameter ; and several such plates are needed to generate the
quantity which is requisite to a satisfactory use of the induction machine.

INFLAMMATION OF THE CELLS OF THE ANTERIOR HORNS.

(Poliomyelitis Anterior, of Infants and Adults—Atrophic Spinal
Paralysis—Infantile Paralysis.)
This condition sometimes coexists with lateral sclerosis. It fre-
quently occurs, however, as an independent affection, especially during
childhood.
366 LECTURES ON NERVOUS DISEASES.

The cells of the anterior horns are affected by an inflammatory
process in this disease; which, if sufficiently severe, leads to their atrophy
or destruction.

Morbid Anatomy.—W hen these cells become inflamed, their function
is at once arrested; hence sudden paralysis is developed, provided the
inflammatory action be of the acute type. If the gray matter be so
affected beyond the possibility of recovery, acute pigmentary degenera-
tion of the cells so attacked apparently follows. The name poliomyelitis

 

Fie. 96.—PoLiomyvevitis ANTERIOR (ACUTE) FOLLOWED BY EXTENSIVE ATROPHY, CHIEFLY OF
tHE Ricut Sipe, (From a photograph in the possession of the author. )

(MtoALds, gray, and (LvEAdS, marrow) expresses the seat of the lesion, 2s
well as its inflammatory character.

Asa result of inflammatory and degenerative changes within the cells
of the anterior horns, the spinal nerve-fibres (which serve to connect the
inflamed cells with the muscles) degenerate as a result of defective nutri-
tion; and the muscles connected with those fibres also undergo rapid
fatty deeeneration and atrophy. The symptoms of this disease tend to
confirm the view that the eanelion-cells of the anterior horns preside not
only over muscular movement, but that they also serve to regulate the
nutrition of the muscles connected with them by means of the fibres which
INFLAMMATION OF CELLS OF ANTERIOR HORNS. 367

compose the anterior nerve-roots. It is believed hy some observers,
however, that some of the cells found in this locality have a peculiar
trophic function.

The inflammatory changes observed in the spinal cells during an
attack of poliomyelitis must not be confounded with a non-inflammatory
degeneration of the cells in the anterior horns. This is probably the spinal
cuuse of “ progressive muscular atrophy ” (in which there is no paralysis).

The changes observed in poliomyclitis anterior are commonly con-
fined to a few spinal segments. It is not uncommon for the horn of one

 

il WS QQ NY SVE S

Fic. 97—Back View or SamE CASE, SHOWING THE SO-CALLED “WinG-scaPpuLa” (xS-
PECIALLY ON RIGHT SIDE) FROM ATROPHY OF THE MUSCLES.

side to escape while the other is seriously involved. Whenever the
attack has been a severe: one, the anterior horn of the affected segments
will appear after death to be more or less distorted from atrophy of its
cells and the development of newly formed connective-tissue.

The form of paralysis which develops in any given case will be
modified by the spinal segments attacked; and also by the character of
the attack, whether unilateral or bilateral. One of my cases exhibited
an attack confined to the right horn of the cervical segments and the left
horn of the lumbar segments. He had paralysis and extensive atrophy
368 LECTURES ON NERVOUS DISEASES.

of the right arm and paralysis of the left leg, which passed away after a
lapse of a few weeks.

If the inflammatory process is not sufticiently severe to prevent the
recovery of the cells attacked, the spinal cord may exhibit no evidences
after death of destructive processes.

Etiology.—This disease is commonly deseribed as of three varieties,
—the acute, subacute, and chronic. It is more common in children than
in adults, although the chronic variety is less frequently observed during
childhood than the acute.

 

Fic. 98.—PRroFiLE VIEW OF SAME CASE, SHOWING ATROPHY OF DeLtoin REGION, THE
ALTERED POSITION OF THE RIGHT SCAPULA, AND THE WASTING OF THE Richt ARM.

The infantile variety has been known to follow exposure to cold or
dampness, overfatigue of the muscles, some forms of blood-poisoning
(such as eruptive fevers, diphtheria, lead-poisoning, etc.), dentition, and
traumatism. Some cases develop from imperfectly understood causes.
It generally occurs before the second year,—seldom later than the seventh
year. It is most common among boys.

The adult variety seems to be excited chiefly by exposure to cold or
dampness and overexertion. Lead-poisoning is said to sometimes excite
it. Debility, convaleseenee from fevers, malaria, pneumonia, etc., are
INFLAMMATION OF CELLS OF ANTERIOR HORNS. 369

mentioned by authors as among its factors of causation. It inay develop
between the ages of twenty and fifty years. One of my patients (Figs.
99 and 100) was so affected (after severe exertion and excessive in-
dulgence in alcohol) from sleeping on the ground during a summer
shower. The paralysis in this case attacked the muscles which were
chiefly employed by him in his occupation.

Symptoms.—The three forms of this disease will he described
separately, as they should be distinguished at the bedside.

Acute Form. (lnfantile Spinal Paralysis—Acute Spinal Paralysis of
Adults.) —The onset of this form is usually marked by a sudden elevation of

 

Fic. 99,—Pouromveitis ANTERIOR ACUTA, OCCURRING IN THE ADULT FROM SLEEPING ON
Wer Grounp. (From a photograph in the possession of the Author.) Note the extensive
atrophy of deltoid region, forearm, and hand.

temperature. The febrile symptoms may be either continued or remittent
intype. The fever may last from twenty-four hours to several days. It
is not uncommon to observe pains in the limbs, muscular twitchings,
tremors, convulsions, delirium, and occasionally a sense of numbness in
connection with the stage of fever.

Sudden paralysis of a marked character soon follows, and with ts
appearance the febrile symptoms disappear. The paralysis usually attains
its height at the onset.

The seat and type of the paralysis vary with the spinal segments
affected and with the character of the attack,—whether unilateral or

24
370 LECTURES ON NERVOUS DISEASES.

bilateral. All the Lmbs may he aifected in some cases. (Complete
paralysis.) Again, it may be confined to one lateral half of the
body. (demuplegia.) When the lesion is bilateral and confined to the
dorsal or lumbar segments, paraplegia may develop. Finally, if the
lesion be unilateral and confined to the cervical or lumbar seg-
ments, monoplegia may occur. I have personally reported an unique
case, where the right upper and left lower limb were simultaneously
paralyzed.

The paralysis of motion is usually quite complete at the onset. It is
not accompanied by any disturbances of the sensory function as a rule,

\i

 

Fic. 100.—Furt View oF sami CASE, SHOWING THE DEFORMITY AND ATROPHY OF Hanp.
(From a photograph in the possession of the Author. )

although a slight numbness may be complained of by the patient. The
pelvic organs are not affected.

In infants, the existence of paralysis may be overlooked. Sooner or
later, the nurse or mother may notice that the child does not move its
arm or leg. When this disease is suspected during infancy, the move-
ments of the limbs should he very carefully observed. Nurses are often
unjustly blamed by physicians as well as parents for the development of
paralysis in infants intrusted to their charge. The misfortune is in
many cases erroneously attributed to some blow or fall which the child
may have received. The fever which precedes the development of the
INFLAMMATION OF CELLS OF ANTERIOR HORNS. dtl

paralysis is, therefore, a very important and valuable point in the
diagnosis of this affection,

Soon after the onset of the paralysis, the affected muscles of the
limb (some usually escape) cease to respond to the faradaic current.
They also contract slowly and with abnormal formule when the galyanic
current is used (thus exhibiting evidences of nerve degeneration and
muscular degeneration. (Fig. 58.) Later on, they exhibit a marked
increase of galvanic excitability, with abnormal formule.

Whenever the cells are not sufliciently impaired to produce a
permanent arrest of their function, the paralyzed muscles begin in a
short time to show a return of power. In such.a case, the normal formule
of muscular reaction to galvanism returns, and faradaic currents begin
to cause muscular contraction.

After several weeks have elapsed, signs of atrophy will begin to be
apparent in those muscles whose cells have been most seriously injured.
In all such cases, the muscular atrophy is markedly progressive and
more or less permanent. If a piece of such a muscle be removed by
Duchenne’s trocha, evidences of extensive fatty degeneration could be
discerned under a microscope. This step is sometimes a valuable one in
making a diagnosis or a prognosis.

This variety is commonly described as “infantile spinal paralysis,”
because children are more often affected than adults. Nevertheless, it
is still encountered in adult life, but rarely in old age. Prévost and
Charcot were the first observers to discover the exact morbid changes
which occur in the anterior horn in this type of disease.

Subacute Form.—This is a rare type of disease, and never affects
children. It differs from the acute variety in the gradual onset of the
paralysis, the total absence of all cerebral symptoms, the presence of
only slight febrile symptoms, and the fact that it attacks adults
exclusively. It may closely resemble lead-paralysis and progressive
muscular atrophy.

Chronic Form.—A chronic type of inflammation confined to the
anterior horns causes symptoms which may closely resemble those of
multiple neuritis and “progressive muscular atrophy.” It is a com-
paratively rare form of disease. It may attack children or adults.

This condition may be recognized from the other forms of polio-
myelitis chietly by its chronicity. The presence of severe neuralgic pains
and other abnormal sensory phenomena, which exist for weeks or months
prior to the development of atrophic changes in the muscles, points
rather to multiple neuritis. The type of muscular atrophy which occurs
in this affection differs from that observed in progressive muscular
atrophy, in that it affects entire groups of muscles simultaneously. In
the latter disease, separate bundles in the affected muscles may be
372 LECTURES ON NERVOUS DISEASES.

destroyed, while others may remain unchanged. The reactions of the
affected muscles to the faradaic and galvanic currents are similar to
those of the acute variety.

Diagnosis.—Acute poliomyelitis in the infant may be mistaken for
lowie neuritis, progressive muscular atrophy, rickets, the wasting diseases
of childhood, pseudo-hypertrophic paralysis, hemiplegia from cerebral or
spinal lesions, and (during its initial stage) with the exanthemata or some
of the inflammatory disorders.

In the adult, the acute form might be confounded with multiple
neuritis, progressive muscular atrophy, amyotrophic lateral sclerosis,
hemipleyia, monoplegia, myelitis, and the subacute variety of polio-
myelitts.

It. does not seem to me possible for the reader to err in the recog-
nition of this affection, provided the essential facts pertaining to this
disease are firmly fixed in his memory.

It should be remembered that the acute form of the disease begins

with a stage of febrile excitement, which ceases in a short time; that —_.

paralysis develops suddenly, and reaches its height at once; that the
paralysis begins to improve ulmost immediately after its appearance;
that atrophy of some of the muscles previously paralyzed also begins
soon after the attack; that noe cerebral symptoms will have existed
previous to, during, after the attack; and that the child or adult has
usually been in perfect health up to the commencement of the disease.

The paralysis is at first generally extensive; but it soon becomes
limited to a greater or less extent. Rare exceptions to this rule have
been recorded, however, where the reverse has occurred. Atrophy of
the muscles follows the paralysis. There is usually a diminution of
reflex spinal irritability. Bed-sores do not ‘occur, nor are the bladder
and rectum affected. Disturbances of sensibility are absent, as a rule.

The distinctions between the acute, subacute, and chronic types of
poliomyelitis are those of degree rather than of kind. The respiratory
muscles are never involved in true spinal paralysis, according to Seguin.
In this respect he draws a line of distinction between the so-called
“acute ascending paralysis” and poliomyelitis. To my mind_ this
clinical distinction is questionable.

From progressive muscular atrophy acute poliomyelitis is to be
distinguished hy the rapid development of the paralysis, the febrile
stage which precedes its development, its appearance before the seventh
year of age, and the fact that the faradaic current fails to create a
response in the paralyzed muscles; whereas in progressive muscular
atrophy the uninvolved fibres of the affected muscles respond to
faradaism. The insidious advent of progressive muscular atrophy and
the effects of electric tests (p. 189) would decide between it and
INFLAMMATION OF CELLS OF ANTERIOR HORNS. B73

poliomyelitis in the adult. Furthermore, by means of Duchenne’s
trochar (p. 212), the fibres of the muscles attacked may be examined
microscopically.

Pseudo-hypertrophic paralysis can be easily distinguished from
poliomyelitis by the absence of a febrile stage, the increase in size of

 

Fics. 101 and 102.—A_Casr of INFANTILE PARALYSIS, WITH INVOLVEMENT OF THE MEDUL-
Lary Nucrer (From two photographs in the possession of the Author), The deformity of
the left side of the patient and the facial atrophy of the left side is wellshown. Several years
had elapsed between the date of the attack and the taking of the photographs.

the muscles, the locality affected, the normal electro-muscular phenomena,
the characteristic gait (p. 164), the late development of symptoms in the
extremities, the peculiar curve of the vertebral column, and the micro-
scopical examination of the muscles.

Rickets never produce paralysis, alterations in the normal electro-
muscular reactions, nor a stage of well-marked fever.
old LECTURES ON NERVOUS DISEASES.

Hemiplegia vf cerebral origin can be diagnosed from poliomyelitis
by the history of the case, the presence of symptoms of impairment
of the intellect or speech, by paralysis of some of the cranial nerves,
the development of hemiplegia and hemianesthesia upon the same
side [if the lesion be non-cortical (p. 72)], the presence of normal electro-
muscular formule, the absence of a febrile stage, and abnormalities in
the pupil.

Myelitis commonly causes more or less trophic disturbances; but it
is very liable to create symptoms referable to the genito-urinary tract
as complications, and to present all forms of combinations of motor and
sensory symptoms, which do not exist in poliomyelitis.

Some other points in the differential diagnosis of this affection have
been given in a table when discussing sclerosis of the lateral column of
the cord. (P. 364).

The condition of multiple neuritis has been very frequently mistaken
for poliomyelitis. There seems to be little, if any, doubt that many
cases reported in the past by authors of note as those of poliomyelitis,
were improperly classed.

The development of abnormal sensory phenomena, such as pain,
anesthesia, parasthesiw, etc., in connection with motor disturbances and
muscular atrophy, should always lead to the suspicion of the existence
of multiple neuritis.

Prognosis.—In cases afflicted with poliomyelitis, partial or complete
recovery usually takes place. Some of the muscles may undergo per-
manent atrophy. Deformities muy ensue from -post-paralytic contracture,
in some cases. As arule, the electro-muscular phenomena return to the
normal standard in the muscles which are the least affected. The power
of motion is regained with greater or less rapidity and completeness ;
and the reflexes tend to return to the condition of health. If the muscles
continue to respond at all to the faradaie current during the height of
the attack, it is safe to predict a total recovery. I have never seen a
muscle undergo permanent atrophy when it constantly preserved even a
trace of faradaic excitability. Ifthe disease creates interference with the
action of the respiratory nerves, it is possible for a fatal termination to
take place. Happily, such instances are uncommon,

Treatment.—There exists experimental as well as clinical evidence
to show that a regeneration of the cord may sometimes take place after
a scrious injury. Hence we are justified in devoting particular care and
attention to the medicinal and mechanical treatment of the peripheral
manifestations of spinal disease with the hope that the cord itself may
he stimulated and eventually regain its functions.

The administration of large doses of evyot early in the acute variety
of poliomyelitis (as first suggested by Hammond) often tends to check
INFLAMMATION OF CELLS OF ANTERIOR HORNS. 30)

the inflammatory process. Ten drops of the fluid extract ma y be given
with safety three times a day to a six-months-old infant. It should not
be given after evidences of muscular atrophy appear.

Strychnia by the mouth, or by injection into the paralyzed muscles,
is sometimes of benefit to these subjects later in the disease. The dose
must be graded to the age of the patient. I never give over one-
hundredth of a grain at a dose to a child under one year of age. Der-
sonally, I prefer the hypodermic method of administration.

Daily immersion of the limbs in hot salt water (110°-120°) for thirty
minutes, friction (made by the hand ora rough towel several times a
day), massage, and passive movements all tend to excite a determination
of blood to the paralyzed muscles, and are of great utility in these cases.
I do not believe in the use of Jounod’s boot, as I have known of serious
harm being done by it. It isa dangerous instrument in the hands of
inexperienced persons.

To adults J often recommend the internal administration of hot-
water drinking. If administered to children, a competent nurse must
supervise its use. JI have given the rules for its administration in a
preceding section (p. 248).

Hlectricity is an extremely valuable adjunct to treatment in these
eases. It must be kept up for a long period of time, and the parents or
the patient must be prepared for slow results, When the faradaic
current fails to create responsive contractions of the muscles, the
galvanic or static current must be substituted for it. The strength of
the current must be sufficient to create muscular contractions. It
should not be used oftener than on alternate days, as a rule. Months,
and even years, may elapse before the muscles are brought back to the
standard of health.* Pieces of the affected muscles may be removed
from time to time (through the aid of Duchenne’s trochar) and examined
microscopically. In this way we can decide regarding the progress of
the muscular atrophy. If the disease is progressing favorably, the
percentage of oil-globules scattered throughout the muscular fibres will
show a decrease.

During the acute stage, the patient should be kept in bed. After all
febrile symptoms have disappeared this is not, necessary.

The tonic plan of treatment—iron, quinine, cod-liver oil, arsenic,
phosphorus, etc.—may be combined with hypodermics of strychnia when
deemed necessary. The diet should be nutritious and adapted to easy
digestion and assimilation.

* One of my cases made a perfect recovery under electrical treatment and massage, in
spite of the fact that the lower limbs had been almost completely paralyzed for over three
months previous to my examination of the child. She moved about the room by the aid
of her hands only when I made my first examination of the patient.
376 LECTURES ON NERVOUS DISEASES.

AMYOTROPHIC LATERAL SCLEROSIS.

In connection with two systematic spinal conditions which have been
already described, viz., lateral sclerosis and changes in the anterior
horns, it may be well to consider another systematic affection of the
spinal cord where the two are combined. This has been named by
Charcot, who first recognized the pathological changes which tended to
produce it, “amyotrophic sclerosis.” The term “amyotrophic” (signi-
fying an absence of muscular nutrition) expresses well the chief morbid
change which characterizes this form of spinal sclerosis.

Morbid Anatomy.—The lesion is not confined necessarily to the
spinal cord, for it tends to extend throughout the medulla oblongata
and even into the peduncle of the cerebrum. Hence the nuclei of the
hypoglossal, spinal accessory, and facial nerves are involved, as a rule,
late in the disease. The changes in the anterior horns in this disease are
apparently identical with those which exist in connection with progres-
sive muscular atrophy. The morbid process seems to start first in the
cervical enlargement of the spinal cord; for that reason the muscles of
the upper extremity are first attacked.

From these segments the sclerotic and degenerative processes gen-
erally extend both upward and downward. Bands of dense, newly-formed,
connective tissue are often detected between the sclerosed lateral
columns and those portions of the anterior horns which are involved.

In the atrophied muscles, the perimysium undergoes a marked
hyperplasia. Inflammatory changes are more apparent than in pro-
gressive muscular atrophy.

When the medulla becomes involved, the cells which constitute the:
motor nuclei within the gray matter of the floor of the fourth ventricle
undergo a rapid degeneration.

The deformities of the limbs which result from muscular contracture
are extreme in this type of spinal sclerosis.

Etiology.—The causes which conduce to the development of this
condition are apparently similar to those mentioned in connection with
poliomyelitis and primary sclerosis of the lateral columns. Exposure to
cold or dampness seems to be a prominent cause. In one of my cases,
it developed after prolonged and intense mental anguish following the
death of a child. :

Charcot, who has investigated this disease, divides its manifestations
into three distinct phases. These are as follow :—

1. The first stave is manifested only in the muscles of the upper
extremities. 2. During the second stage, the muscles of the lower
extremities are attacked. 3. In the third stage, the morbid process
extends to the medulla oblongata.
AMYOTROPHIC LATERAL SCLEROSIS. 377

Although this clinical distinetion is generally truc, there may be
exceptional instances in which the disease attacks the medulla first, and
gradually extends downward. Again, cases in which the disease first
attacks the lower limbs and gradually extends upward, have been reported.

First Staye—The duration of this stage varies from four months to
ayear, During this time tremors of the upper limbs appear early, and
paresis or paralysis subsequently develops. There is no alteration in
the electric tests of the muscles. Fibrillary twitchings are commonly
observed in the muscles of these patients.

An extensive sorm of atrophy follows the paralysis, and the muscles
tend to develop a state of rigidity and contracture which creates
permanent deformities. The characteristic deformity of this discase is
chiefly observed in the hand, the wrist and fingers being permanently

 

Fic. 103.—Hanp in Amyorropuic LATERAL ScLerosis. (Charcot.)

flexed to a greater or less extent, and more or less rigid. Fig. 103
illustrates this attitude.

Sometimes the muscles of the neck and jaw are thrown into a state
of spasm, which is more or less persistent. After atrophy has progressed
to a marked extent in the forearm, this rigidity of the neck and jaw
usually tends to disappear. Several months usually elapse between the
first and second stages, during which time the disease appears to remain
stationary.

Second Stage.—As this disease advances, after it has apparently
remained stationary for a time, the muscles of the lower limbs begin
to exhibit evidences of paralysis, and, at the same time, tonte or clonic
spasms (or both forms) may simultaneously develop. Gradually the
state of permanent rigidity or contracture appears in some of the affected
muscles,
378 LECTURES ON NERVOUS DISEASES.

The spinal refleres, chiefly the knee-jerk, are very much increased,
and in some cases an ankle-clonus may be detected.

Aiter a considerable lapse of time has occurred, the muscles of the
lower limbs tend to become less rigid and give place to atrophy and
jibrillary twitchings.

The pelvic organs are not usually disturbed, nor is there any
tendency toward the development of bed-sores which are so commonly
observed in connection with myelitis.

The muscular atrophy in the upper limbs increases to a very marked
extent during this stage.

Third Stage-—In many patients aftlicted with this disease, the
development of ‘“ bulbar” symptoms are superadded to the symptoms of
the second stage.

When these occur the disease has extended to the mnedulla, and has
involved the nuclei of origin of the cranial nerves which arise from the
medulla. These nuclei are situated in the gray matter of the fourth
ventricle. (Fig.16.) In this stage, we are Hable to encounter evidences
of paralysis in the muscles of the tongue, lips, larynx, and pharynx.
The patient experiences difficulty in articulation, in swallowing, and in
controlling the escape of saliva from the mouth. During the act of
swallowing the food is liable to be expelled in part through the nose, and
it is with great difficulty that some patients are able to get the bolus of
food into the pharynx. This distressing condition is commonly known
as Duchenne’s disease. Its physiognomy is shown in Figs. 108 and
109.

Serious disturbances of the circulation and respiration are apt to
occur during this stage from paralysis of the pneumogastric nuclei.
These symptoms may prove the cause of death.

Amyotrophic lateral sclerosis usually proves fatal within two years
after its initial symptoms make their appearance.

Diagnosis.—This disease can hardly be confounded with any other
spinal affection, in spite of the fact that some of its manifestations
closely resemble those of progressive muscular atrophy and poliomyelitis.
When we review the symptoms of the three we may easily make the
necessary discrimination. (Sce table on p, 364.)

From progressive muscular atrophy this disease can be distinguished
by the following facts: The atrophy follows the paralysis and attacks
groups of muscles, rather than individual fibres. Contractures develop,
resulting in characteristic deformities of the limbs. The progress of
the disease is rapid. The lees are attacked soon after the arms. The
medulla becomes implicated in almost every case. The disease is rapidly
fatal.

From poliomyelitis (adult variety) the diagnosis is made by the fact
PROGRESSIVE MUSCULAR ATROPHY. 379

that the reflexes are impaired, but the farado-muscular excitability not
decreased. Moreover, the atrophy is more rapid and permanent in this
form of spinal sclerosis. The contractures of muscles are conducive to
greater deformity ; the medulla is implicated; fibrillations are present ;
improvement in the symptoins is rare; and the ciscase is always fatal.

Prognosis.—I am not aware that a case of cure has ever been
reported. Death usually results from an embarrassment of the circu-
latory and respiratory functions, in consequence of an extension of the
morbid changes to the nuclei of the medulla. It is uncommon for these
patients to live over two or three years.

Treatment.—Nothing can be said under this head which will aid the
reader in curing this disease. Its advent deprives the patient of all
hope of cure, and places the fatal termination at no very distant date.
I have, however, apparently succeeded, by employing static sparks daily
to the spine and limbs, in greatly relieving the contracture of the
muscles and holding the progress of the disease in check for many
months.

PROGRESSIVE MUSCULAR ATROPHY.

The close analogy which this disease bears in some instances to
“poliomyelitis anterior” in the adult as regards its symptoms will help
to explain the fact that such cases are sometimes erroneously regarded
asa variety of progressive muscular atrophy.

This disease is essentially one of adult life, although the so-called
“pseudo-hypertrophic paralysis” of children bears some resemblance to
it. It affects males more frequently than females, and usually appears
between thirty and fifty years of age.

Morbid Anatomy.——A slow degeneration of the ganglion cells of the
anterior horns of the spinal gray matter, probably independent of
inflammatory changes, exists in this disease. It is one of the most
chronic and incurable of all spinal affections, and is comparatively
common. By some authors, this disease is believed to start in the
muscular tissue, in some instances,—and possibly in all.

The vessels of the cord are often abnormally dilated. The arterioles
may be sclerosed, and an inflammatory exudation sometimes surrounds
the larger arterial trunks.

The neuroglia is excessively developed. Sometimes the anterior
roots of the spinal nerves exhibit atrophic changes and discoloration.

The anterior horns of gray matter are altered both in their size and
appearance. The ganglionic cells within them are atrophied or com-
pletely obliterated.

The affected muscles are shrunken and pale in color to the naked
eye. The microscope reveals 4 disappearance of the transverse strie in
380 LECTURES ON NERVOUS DISEASES.

the fibrille; and in those bundles most diseased all traces of muscular
tissue may have disappeared. The muscular tissue has been replaced
hy oil-globules. This process of muscular disintegration does not
appear to affect whole muscles at once; it seems to attack only individual
bundles, or even fibrilla. Eventually, an entire muscle may thus be
destroyed, bundle by bundle, or fibre by fibre.

I am personally inclined to believe that this disease is primarily
one of the spinal cord, and that the muscular changes are a result of
trophic disturbances dependent upon the morbid process within the
spinal gray matter.

Etiology. —.\ mong the exciting causes of this affection, which have
been reported by authors of note, may be mentioned: (1) a hereditary

 

 

 

Fic. 104,—Fiares From THE DIAPHRAGM IN Fic. 105.—SAME TAKEN FROM A CASE OF PRo-
Heattu. (Charcot.) GRRSSIVE MuscuLtaR ATROPHY AFFECTING
tHE DiarpHracm. (Charcot.) The muscular
fibres (a) are greatly atrophied but preserve
their transverse striz. The connective tissue
intervals (4) are enlarged.

tendency; (2) excessive muscular efforts: (3) traumatic injuries of
peripheral parts of the body ; (4) lead poisoning; (5) certain blood
conditions, such as rheumatism, measles, typhoid, ete. ; (6) exposure to
cold and dampness ; (7) excessive venery and masturbation.

There seems to he no doubt regarding an etiological relationship
between certain occupations (demanding an excessive and continual use
of the fingers and hand) and progressive muscular atrophy in some of
the cases reported.

Symptoms.—The chief clinical feature of this disease is the develop-
ment of erfensive and progressive atrophy of certain muscles.
PROGRESSIVE MUSCULAR ATROPHY. 381

The wasting of the muscle may not be detected hy the patient for
some time after its onset. It is unattended with any symptoms of
paralysis, and there are no febrile manifestations to mark its advent.

The patient usually first perceives that certain muscles are appar-
ently wasting, and that some loss of power has occurred in the diseased
part in consequence of the diminution in size of the affected muscles.
This loss of power is always proportionate to the extent of the
atrophy. In this respect, this disease differs from those spinal affections
in which paresis occurs independently of alteration in the muscular
structure.

As a rule, progressive muscular atrophy commonly affects the upper
extremities first; and, in many cases, homologous regions on both sides
are successively attacked.

Patients commonly first observe a wasting of the muscles of the
hand and of the shoulder. A considerable lapse of time usually occurs
before any evidence of atrophic changes in the lower limbs can be
detected.

In the hand, certain muscular groups are generally attacked ,—chietly
those of the thenar and hypothenar eminences, and the interossei muscles.
These patients complain early of more or less stiffness in the fingers
and an inability to perform delicate manipulation with the hand. Cold
tends to increase this difficulty, and warmth to diminish it. The ball of
the little finger and thumb becomes very much wasted as the disease
progresses, and the bones of the metacarpus tend to become unduly
prominent.

Sooner or later the hand assumes a characteristic deformity on
account of a predominance of power in the extensors and abductors of
the thumb (the so-called ‘“ape-hand”). Marked atrophy of the interossei,
combined with the unopposed action of the lumbricales, may give rise
to a condition commonly known as the “claw-hand.” Fig. 106 well
illustrates this deformity.

Flattening of the palm is occasionally observed as the result of
atrophy of the lumbricales.

‘When the muscles of the shoulder become involved, the movements
of the arm are more or less interfered with, and the deltoid region is
markedly flattened. Atrophy of the scapular muscles may also occur; in
which cage movements of the arm are still more seriously embarrassed,

In the forearm, the extensor muscles undergo atrophy more
frequently than the flexors. The supinators usually escape atrophy.

Asarule, the right hand is attacked before the left. The muscles
of the scapula and trunk are not generally attucked until the arms
exhibit very marked atrophic changes.

When the muscles of the back or abdomen undergo atrophy, a
382 LECTURES ON NERVOUS DISEASES,

characteristic posture during the erect attitude is developed. (See Figs.
54 and 55.)

In very rare instances the diaphragm may undergo atrophy, and
create difficulties in respiration.

The lower limbs are usually attacked late in the disease. I have
observed one very striking case, in which the muscles of the thigh were
very extensively wasted, in spite of the fact that the arms and trunk
remained unaffected. Generally, the flexors-of the legs are the first to
exhibit atrophy when the disease has extended to the lower extremities.

The electrical reactions of the muscles undergoing atrophy are
normal in their formula. They are, however, impaired (as is the power
of the muscle) in a direct proportion to the number of fibres which are

 

Fic. 106.—Two Views of THE Hanp oF a PATIENT SUPFERING FROM PROGRESSIVE
MuscuLar Arropny.

involved in the muscle tested. The faradaic current, as well as the
galvanic, will produce contractions of the affected muscle so long as any
of its individual fibres escape atrophy. The “ reaction of degeneration ”
is not observed in this disease.

In the carly stages of this disease the spinal reflexes may be more
or less increased, this heing the rule for many of the so-called “ wasting
diseases.” They are of course abolished whenever all the fibres are
destroyed, and they tend to diminish proportionately to the extent of
the atrophy whenever it becomes established.

Some diagnostic symptoms are frequently observed in connection
with the clinical evidence of muscular atrophy. Among these the
following may be mentioned as prominent :—
PROGRESSIVE MUSCULAR ATROPHY. B83

1. Fibrillary Twitchings.—These are more apparent perhaps in this

disease than in any other. They are confined to the atrophied
muscles. They consist in repeated and brief contractions of
individual parts of the museles. They are apt to be most marked
when the muscles are tapped with the finecr, subjected to a current
of cold air, or faradized. They are often observed by the patient
while disrobing. Occasionally, involuntary movement of the
fingers, arm, or leg, may be caused by them. It is difficult to
detect them whenever the integument is fatty.

peaertniasis

 

Fic-107.—Procressve Muscurar ATRopHY OF ALL THE Limps. (After Friedreich.) The

3.

=

age of the patient was 45 years.

Diminished Temperature in the Affected Parts.—A peculiar sensi-
tiveness to cold on the part of the patient is perhaps attributable

to this fact.

Pains in the muscles and in the neighboring joints are occasionally

observed.

Deformities.—These are due to shrinking of the muscles and the

unantagonized action of unaffected muscles. The joints of the
fingers may become enlarged.

The skin may appear mottled or of a bluish-red color over the
wasted muscles. The epidermis may become sealy, the nails may
384 LECTURES ON NERVOUS DISEASES.

thicken, the growth of hair diminish, the secretion of perspiration
become unnaturally excessive, and eruptions may occasionally be
detected.

6. Changes in the Pupils—The pupils may be unnaturally small on
one or both sides, dilate imperfectly, and react slowly to light.

7, Bulbar Symptoms.—These indicate an extension of the spinal
lesion to the medulla. Whenever the pneumogastric nerve
becomes involyed, death may occur from a disturbance of the
heart and the function of respiration.

Diagnosis.—This disease cannot well be confounded with any other
spinal affection, except perhaps one of three forms of poliomyelitis which
have been described. <A lesion of the ulnar nerve might create a
deformity which could be easily mistaken for a progressive muscular

 

Fic. 108.—ExpRESSION DUE-TO IMPLICATION OF THE NUCLEI OF THE MEDULLA GOVERNING
tue Mourn, Toncur, anp THroat. (After Hammond.)

atrophy of one extremity. Amyotrophie lateral sclerosis and lead-
poisoning present points of difference which should be readily recognized.

The deformity of the hand which ensues'from progressive muscular —
atrophy can be distinguished from that due to paralysis of the ulnar,
musculo-spiral or median nerves by the following points: (1) the groups
of muscles attacked are not supplied by one nerve, as a rule, but often
by several; (2) the thenar eminence is usually attacked first, then the
hypothenar eminence, and finally the interossei muscles ; (3) the muscles
of the arm and shoulder are liable to be attacked simultaneously with
those of the hand; (4) a microscopical examination of the muscles
ulected reveals extensive fatty chanees; (5) the so-called “ bird-claw
hand” is produced, which differs from that of any post-paralytic
deformity.
PROGRESSIVE MUSCULAR ATROPHY. 385

The reader is referred to page 156 for information as to other forms
of hand-distortion or the varieties of paralysis exhibited in the hand.

From poliomyelvzs (adult variety), this disease is distinguished by
the fact that no paralysis precedes the atrophy. The wasting muscles
respond to faradaism as long as a fibre remains unaffected. We do not
have the febrile stage nor the galvani¢e “reaction of degeneration,” both
of which are characteristic of poliomyelitis. The deformity of the
hand may be identical in both diseases. For that reason the history of

 

Fic, 109 —Prorire or PATIENT SIMILARLY AFFECTED. (After Hammond.)

the case is very important, provided the patient had not been seen until
the hand-deformity: became well marked.

From amyotrophic lateral sclerosis, the diagnosis may pe made by
points already given on page 3878.

From lead-poisoning, this disease is to he told by the fact that the
extensor muscles of the wrist and fingers are invariably paralyzed by
lead, causing the so-called “drop-wrist.” Furthermore, the blue-line
about the gums, the existence of attacks of lead-colic, the marked
decrease in the electro-muscular contractility, and the history of
exposure to lead, would be wanting in a patient affected with progressive

muscular atrophy.
"OK
386 LECTURES ON NERVOUS DISEASES.

Progressive Facial Atrophy.—I am inclined to agree with Ham.
mond in considering this rare condition as one of the manifestations of
a condition closely allied to progressive muscular atrophy. Hence it
may be well to mention it in the same connection, before the indications
for treatment of the more common malady is considered.

It is more common in females than in males. Its causes are
unknown. It affects adults. The pathological lesion which is associated
with atrophic changes in the facial, palatine, and lingual muscles seem to
be a degeneration of some of the cells which constitute the various
nuclei of the medulla.

The cuts introduced here show the effects produced in a remark-
able case of facial hemiatrophy. The
face, tongue, and palate show atrophic
changes upon the same side.

 

Fic. 111.—HeMta TROPHY OF TONGUE AND PALATE,
(Exhibited by the preceding case.)

The left side of the face is gene-

Fic, jet inaraaeey OF THE Facer. rally attacked: Wig iis ts ee 1 am

(From a photograph.) unable to explain satisfactorily to my

own mind. It is not an unvarying

rule, however, since over a dozen cases have been reported where the
right side was involved.

It is to be diagnosed from facial paralysis by its gradual onset, its
progressive character, unimpaired electro-muscular reactions, and the
incurability of the affection.

Prognosis. —Progressive muscular atrophy is, as a rule, incurable.
It may run its course very slowly in some cases, and apparently remain
stationary for long periods of time, but there is little, if any, hope of
permanently arresting its development. Complete recovery is extremely
rare. The disease usually runs its course in about five years, although

 
PROGRESSIVE MUSCULAR ATROPHY. 387

it may last indefinitely. When a well-marked hereditary predisposition
to the disease is present, the prognosis is particularly grave. This
disease may cause death by attacking the museles of deglutition or
respiration, and also by exciting fatal complications, such, for example,
as bronchitis, pneumonia, pulmonary congestion, ete.

Treatment.—Among the various remedial agents employed in the
treatment of this disease may be mentioned the following: galvanism,
faradaism, franklinism, the actual cautery, phosphorus, arsenic, massage,
inunctions, warm baths at the natural springs, and tonics.

In Sinai ie electricity, it is advisable to use a strong galvanic
current or static sparks to the spine, and to treat the atrophied muscles
with the faradaic or static current, or with alternating applications of
the three. The polar method (p. 186) is commonly employed in case the
spine is to be stimulated by galvanism, the neutral point being placed
at the nape of the neck or over the sternum. Each application should
not exceed ten minutes. They should not be given oftener than on
alternate days. The secondary or induced current is preferable to the
primary when the muscles are being stimulated by faradaism. The
interruptions should be slow, and the current strong enough to throw
each muscle into firm contractions. If the induced current fails to
produce contractions, then employ the galvanic or static eurrent. I
have seen very marked benefit follow a judicious use of electricity in
these cases, but I cannot say that I have ever seen a case where I
believed a perfect recovery took place. Many cases of reported cures
- have, in my opinion, been wrongly diagnosed, or watched for too short
a period. Error in diagnosis, in the case of this serious malady, is not
uncommon with general practitioners, and even with some neurologists.

When a history of syphilitic infection can be discovered, it is well
to put the patient upon specific treatment (according to the rules
suggested on page 291).

I usuaily advise moderate exercise, friction of the skin, massage of
the atrophied parts, and a highly nutritious diet to these patients. They
should clothe their bodies warmly in silk or flannels, and avoid over-
fatigue. Arsenic, phosphorus, cod-liver oil, and the bitter tonics, are
often indicated. My experience with hydropathy is limited. It is claimed
that great benefit has been afforded by it in some eases of this malady.
The employment of baths in warm natural-spring waters affords relief
to the pains and cramps in many cases, and cases of reported cures
have been recorded by enthusiastic advocates of their therapeutical
efficacy.

The employment of static electricity by the “direct” or “ indirect
spark” methods to the affected spinal segments and to the atrophied
muscles has, in my experience, so far surpassed galvanism and faradaism
388 LECTURES ON NERVOUS DISEASES.

in its beneficial effects, that I always use it in the treatment of these
cases, The machine employed for this purpose must, however, be of
considerable power. (See subseqent pages which treat of this thera.
peutical agent.)

PSEUDO-HYPERTROPHIC PARALYSIS.

This term is applied to a rare disease of childhood which differs
from progressive muscular atrophy in the following respects :—

(1) In the fact that the muscles of the lower limbs are primarily
affected with atrophic changes; (2) in that the small muscles of the hand
are not affected; and (3) in the circumstance that some muscles become
increased in size when involved. It has been named “ pseudo-hypertro.
phic paralysis,” because the increase in the size of the affected muscles
is not a genuine hypertrophy, but rather an increase in the interstitial
fibrous tissue and fat of the muscles.

Morbid Anatomy.—The question of the exact pathological changes
which exist in this form of disease is not yet decided, observers of
equal note having differed in their examinations of the nerve-centres of
patients so afflicted. Some authors hold that the disease is primarily
one of the muscles, while others claim to have established the fact that
the muscular changes are secondary to spinal lesions. When spinal
changes exist, the motor and trophic cells of the anterior horns are
usually involved.

Etiology.—An hereditary tendency to the disease on the maternal
side seems to be more clearly proven than the exact pathological pro-
cesses which cause it. Boys are more frequently attacked than girls,
and the changes in the muscles usually commence before the tenth year.

Symptoms.—The symptoms of onset are very gradual, and are
characterized by a weakness of the legs and a clumsiness in walking
which is exhibited by frequent stumbling and falls. Gradually the
patient assumes a characteristic attitude and gait. These will require a
separate description.

The attitude is very peculiar. In the standing posture the back is
thrown beyond the proper position, so that a vertical line dropped from
the shoulders frequently falls behind the sacrum, (Fig. 112.) This
antero-posterior curvature entirely disappears, however, when the patient
is in the sitting posture. The feet are placed wide apart so as to increase
the base of support. The heels are usually drawn upward by a con-
traction of the tendo-Achilles, In the effort to preserve the balance, the
arms are held at the side with the hands extended, and the slightest
touch may cause the patient to fall.

Another remarkable feature of the disease is the difficulty which is
experienced in rising from the recumbent, or even the sitting posture.
PSEUDO-HYPERTROPHIC PARALYSIS. 389

The sufferer uses surrounding objects as means of rising, drawing the
body upward by the hands. When unable to reach such assistance the
steps which are taken to rise are thus described by Gowers: “If laid,
for example, on his back upon the floor and told to rise, he would first
with great difliculty turn on his face; he would next get on his knees,
his head being almost between his thighs; from this position he would
gradually extend himself, so that he stands upon his feet and hands with
al his limbs extended; finally he would extend the hip-joint by grasping
the thigh with the hand, and pushing up the body, as it were, by the

 

Fic, 112.—Sipe View or Arrirupe or Psrupo- Fie. 113.—Rear View or ATTITUDE oF Psrupo-
HYPERTROPHIC PARALYSIS. (Duchenne.) HYPERTROPHIC PARa.ysis. (Duchenne.)

arm.” This movement of “climbing up the thighs,” as it has been
termed, is an indication of weakness in the muscles which straighten
the knee, and also those which extend the trunk upon the thigh,—the
extensors of the hip-joint. (See Figs. 52 and 53.)

The gait of these patients is associated with an oscillation of the
body from side to side, or a waddling movement. The advance made at
cach step is very small, and a difficulty seems to be experienced in
flexing the thigh upon the abdomen. —

The muscles of the calf exhibit early a firmness and increase in size
which is not proportionate to their motor force,—as that is far below

 
390 LECIURES ON NERVOUS DISEASES.

normal. Soon they become excessively developed, as do also those of
the buttock, while the other muscles of the leg commonly grow smaller
from atrophic changes.

The latissimus dorsi and the lower part of the pectoralis major
muscles exhibit marked wasting in a very large percentage of cases. In
some instances all the striated muscular fibres of the body, i
even the heart, may become affected.

The electric. reactions of the muscles to faradaism are markedly
diminished.

The spinal reflexes are diminished in the carly stages, and, later on,
are abolished. The bladder, rectum, and the sensory functions of the
skin are not interfered with as a rule.

Diagnosis.—The diagnosis of this affection cannot easily be con-
founded with that of any other disease. A simple hypertrophy of
muscles, as a result. of increased vascular supply, could easily be dlis-
tinguished from it by the aid of Duchenne’s trochar and a microscope
The symptoms of muscular weakness and the characteristic gait and
attitude would be wanting, moreover, in case the muscles had undergone
a genuine hypertrophy.

Prognosis.— Although cases of recovery have been reported, the
prognosis of this disease is unfavorable. Life may, however, be pro-
longed for many years, and death usually occurs as the result of some
intereurrent affection.

Treatment.—Authorities agree in the statement that electricity
forms the chief therapeutical agent in the treatment of this malady.
Duchenne employed the faradaic current in the two cases of cure
reported by him. They were subjected to its influence from the incip-
iency of the disease. Hammond recommends the use of galvanism to
the spinal segments which are related to the muscles affected, and
faradaism of the muscles themselves with as strong a current as the
patient can bear. Massage and the external use of heat have proved
beneficial. Strychnia, phosphorus, and iron may assist, on account of
their tonic properties, in promoting the general vigor. Static electricity
may be substituted for faradization of the muscles. It is best applied
in the form of the “spark” and the “static-induced” current. (See
subsequent chapter.)

SCLEROSIS OF THE POSTERIOR COLUMNS.
(Progressive Locomotor Ataxia —Tabes Dorsalis—Gray Degeneration
of the Posterior Columns.
This is an extremely common spinal affection of a chronic type. It
is characterized, when fully developed, by a difficulty in walking, and, in
some cases, by an imperfect use of the upper extremities, defects in the
SCLEROSIS OF THE POSTERIOR COLUMNS. 391

visual apparatus, and marked disturbances of the sensory functions and
visceral reflexes. There is no actual loss of muscular power ; but, because
the muscles of the limbs are imperfectly coordinated, the existence of
paralysis is often erroneously suspected.

Morbid Anatomy.—The spinal lesion which is cluracteristic of this
disease is confined chietly, but not exclusively, to the sensory columns
of the cord. (See Fig. 115.) For this reason we should expect to
encounter during life well-marked disturbances of sensation, and also

U- 5 50"

      

 

 

||| MV
Le Ss I
wee | S 4
ee ] SN : ies
28 SS 2
nee SS 1
er
AON,

 

 

 

Fic. 114.—A Dracrammatic RePRESENTATION OF THE LusIoN oF THE SENSITIVE TRACTS
IN AN UNILATERAL LESION OF THE RIGHT SIDE, TO THE EXTENT OF THE COLORED
Space. (After Erb.) All sensitive tracts of corresponding’height, as well as those coming
from farther back, on the left side, are interrupted. Qn the-right side only those are inter-
rupted which enter by the roots from 1 to 3. Numbers 0 to 6 represent the sensitive tracts of
the right side, entering with the posterior roots; 0/ to 6’ thesame on the left side.

incodrdination of movement. The clinical history of this disease fully
sustains such conclusion.

To the naked eye the spinal cord may, in exceptional cases, appear
normal, although the microscope may reveal marked pathological
changes. As a rule, the posterior part of the cord is more or less
flattened and somewhat narrower than normal. The consistency of this
part of the cord is usually increased. The pia is generally more or less
thickened and opaque over the posterior columns of the cord. It may
also be pigmented and adherent both to the cord itself and to the
392 LECTURES ON NERVOUS DISEASES.

arachnoid and dura. Calcareous plates may be found in the arachnoid
and the dura,

The most marked changes are usually observed in the lower dorsal
and upper lumbar segments of the cord. In these localities, the columns
of Burdach are usually most affected, but in the cervical segments the
columns of Goll are generally very markedly sclerosed.

The posterior nerve-roots are usually more or less atrophied as far
as their ganglia.

In exceptional instances, sclerotic changes have been observed in

‘ (Cut Colored.)

Ze

c=

 

Fic. 115.—A TRANSVERSE SECTION OF THE SpinaL CorD OF AN ATAXxIC PATIENT IN THE
Upper Lumpar SEGMENT. (Weigert's staining—25 diameters.) Attention is called to the
thickening of the coats and the expanded lumen of the posterior spinal artery; the thickened
coats and contracted lumen of the anterior spinal vessels; the thickened coats and altered
lumen of the vessels in the spinal substance; the diffused sclerosis in the anterior and
lateral columns of the cord; the extensive sclerosis and disappearance of the nerve-fibres
in the postero-internal column; and the very marked hypertrophy of the meninges. This
beautiful eves was made by Dr. Van Schaick, of New York, from a section of a typical
ataxic cord.

the medulla, the pons, the corpora quadrigemina, and some of the
cerebral ucrves. Among the latter, the nerves connected with the eve
are more commonly affected.

A microscopical examination of the diseased area in the cord shows
a disappearance of the nerve-fibres and an excess of connective tissue
SCLEROSIS OF THE POSTERIOR COLUMNS. 393

which is poor in cells. The walls of the blood-vessels are usually
markedly thickened. Their walls may also contain an excess of nuclei.
The medullary sheath of the nerve-fibres may have undergone absorption,
leaving naked axis-cylinders.

Occasionally, and perhaps more frequently than most authors seem
to believe, an increase of connective-tissue may be detected in the
vesicular columns of Clarke and in other parts of the cord; but the cells
of this column are usually unaffected,

Respecting the exact nature of these changes and the causes which
induce them, authorities of note differ. Some regard them as inflamma-
tory, others as the result of a primary non-inflammatory degeneration
of the nerve-tibres; while a few consider this disease as the result of
primary changes in the blood-vessels. An inflammation of the pia and
arachnoid may possibly act as an exciting cause, according to some
published observations.

Respecting the pathology and etiology of locomotor ataxia, my
friend, Prof. William H. Porter, has lately called my attention to some
pathological facts which his extended investigations lead him to regard
as of greater importance than is usually attached to them. The beautiful
drawing of Dr. Van Schaick (Fig. 115) is taken from one of Dr. Porter’s
sections, and serves to illustrate the pathological changes encountered
in locomotor ataxia.

Dr, Porter’s views may be summarized as follow :—

(1) That in ataxia, there is found after death in every case a thickening
of the caats of the larger vessels with an alteration in their calibre.
‘This he believes is generally due to syphilis.

(2) That the lumen of the posterior spinal artery is always greatly in
excess of the normal, while that of the anterior spinal vessels is
generally below the normal size.

(3) That a chronic hyperemia of the posterior columns of the cord is
thus primarily induced.

(4) That excessive nutrition induces an abnormal development of
connective tissue in the spinal cord.

(5) That the complete organization of this newly-formed tissue is
followed by its contraction, which, in turn, causes atrophy and
destruction of the nervous elements of the spinal cord.

That this observer’s views may be accurately presented I quote
from a communication received lately from him, in which he says :—

When we study carefully the anatomical arrangement of the arterial system dis-
tributed to the spinal cord, we find that the anterior spinal artery is formed (by a branch
from each vertebral artery) near the junction of the pons and medulla, From this pont
it passes downward upon the anterior surface of the spinal cord, until it reaches the third
or fourth cervical vertebra, where it is lost as a distinct and separate vessel. Here it forms
304 LECTURES ON NERVOUS DISEASES.
f

a plexiform net-work with the lateral spinal vessels, which constitute the source of nutritive

supply upon the anterior surface of the cord from this point to its termination. On the

posterior surface of the cord the posterior spinal artery, arising at nearly the same point,

descends as a distinct vessel, as far as the second lumbar vertebra, and then divides into

numerous hranches to the cauda equina.

From this arrangement it is quite apparent that the nutritive supply of the postero-
internal and postero-lateral columns is directly from this posterior spinal artery, while the
anterior and lateral columns have a more general nutritive supply.

Physiology teaches that with a high tension and increased rapidity of the blood-
current, nutrition is diminished; but with a moderate or low arterial tension a larger
spe lane: of blood comes in contact with the tissues, and a longer period occurs in which it
is in contact with the tissues. By this alternation in the nutritive supply the various
changes are compensated for, and a normal standard 18 maintained. Whenever, for
any reason, we have this dilatation unduly prolonged, and the increased nutritive
supply constantly above normal, we are apt to have a development of new connective-
tissue cells and basement substances (too often called an inflammation), without the
production of serum, fibrin, or pus, but with the development of new histological elements.

With these anatomical and physiological facts clearly in mind, we are in a position te
study the vascular changes in locomotor ataxia, and possibly to explain the reason for the
major part of the lesion being located in the posterior or postero-lateral columns; also the
more or less general sclerosis in the superior portion, and throughout the cord as the
disease advances.

None seem to deny the common if not universal vascular changes in this affection. In
Cornil and Ranvier’s “Pathological History,” the following statement is made: “A
peculiarity of these scleroses consist in a thickening of the walls of the capillaries and
small vessels.” But thus far no one of note appears to have attached any special
importance to these vascular changes as a causative agent in producing this disease, or as
an explanation for the localization of the lesion in the postero-external and _postero-
internal columns of the spinal cord.

The following anatomical conditions have been found in all the cases examined by
me. In some of the cases examined the history was of short duration, while in others the
disease had existed from eight to ten years. There was a marked thickening of the
pia-mater of the cord, which is well illustrated in the drawing which was kindly made for
me by Dr. George G. Van Schaick. This thickened membrane was often firmly adherent
to the spinal cord, especially at the sclerotic zone, and occasionally also to the dura-mater.,

The vascular changes in all the cases examined by me constituted the first and most
apparent lesion. -It was in the form of a peculiar or hyaline thickening of the walls of
the smaller arteries and arterioles. In some instances this caused a marked thickening of
the wall with an increased lumen, while in others a marked decrease in the lumen was
found.

A noticeable feature in all the cases examined was the marked changes in the
posterior spinal artery. It was found in every instance to have its coats thickened and
its lumen expanded. On the other hand, the vessels of the anterior portion of the
meninges were thickened and their lumen contracted. [These vascular changes are well
illustrated in the accompanying drawing, (Fig. 115).—Aurnor’s Nore]

When the arterioles are thickened in this way they undoubtedly lose their power to
contract and expand to meet the varying changes of nature, and thus to regulate the
nutritive supply to be distributed to the various parts and organs of the body. In this
particular lesion the posterior spinal artery being thickened and its lumen expanded,
the posterior columns of the cord receive an increased quantity of the nutritive material.
SCLEROSIS OF THE POSTERIOR COLUMNS. 395

Ultimately this condition results in a hypernutrition, the development of new connective
tissue corpuscles, and new basement substance. According to the law of all newly-formed
connective tissue, contraction follows and thus causes a coimpression-atrophy, and
ultimately a disappearance of the nerve-tibres in the sclerotic zone.

Owing to the irregular thickening and dilatation of the posterior spinal artery and
its small branches (especially the latter), we find in some the sclerotic condition most
marked in the posterior external columns; in others, in the posterior internal or the
columns of Goll. In fact, in the same cord, the lesion may be also observed most
marked in one column at one part, and in another column at another part; but in all cases
the vessels immediately supplying the sclerotic patch are invariably found thickened and
dilated, while in the unaffected portions they are thickened and contracted, or nearly
normal in appearance.

In the cord from which this drawing was made the sclerosis in the inferior lumbar
region-was in the posterior external columns; but higher up in the cord it was distinctly
in the columns of Goll, as represented in the drawing.

As there is an increased rather than a decreased nutritive supply, there is no primary
change in the ganglion cells in ataxia. They only suffer whenever the new-formed con-
nective tissue becomes sufficiently abundant to cause a compression of the cells. When
this stage is reached, some of the cells may be found in a‘state of atrophic degeneration.

At the anterior and lateral portions of the cord (the vascular supply being in these
regions more general) the increase in new-formed or sclerotic tissue is more surely
developed, forming either a general or patchy sclerosis, which is never confined to a
distinct column.

In the medulla oblongata this general sclerosis is apt to be found throughont the
section. Taking this view of its development, we may say that the disease is caused by
these vascular changes. In my opinion, these are primarily due to syphilis in a majority
of the cases, if not in all. I believe that the disease is non-inflammatory, but one due to
a prolonged and increased nutritive supply. Finally, it is generally conceded that the
change in the nerve-fibres and ganglion cells are secondary, and the result of simple
compression. tae ;

The insidious development and slow progress of this disease argues strongly against
the lesion being inflammatory in the generally-accepted, sense of acute vascular changes,
with an exudation of the liquor sanguinis, and a migration of the blood-corpuscles.

. Etiology.—-This disease may be congenital or acquired. If acquired,
it may follow traumatisms of the spine, exposure to cold or dampness,
sexual excesses, syphilis, and some acute blood-diseases. wee con-
genital, it is commonly associated with a syphilitic diathesis, although
not necessarily dependent upon it.

The question whether syphilis can or can not be included among the
etiological factors of this disease is still an open one. There can be no
question regarding the statement that this disease is often encountered
in patients who give a positive history of syphilitic infection; but slue
fact does not in itself prove that the ataxia is a result of the noquired
syphilis. The coexistence of the two conditions may be a mere coincr
dence. Those who combat the idea that a syphilitic origin of ataxia is
ever present, advance the following grounds for their belief: (1) that the
records from which statistics that support the opposing view are drawn
596 LECTURES ON NERVOUS DISEASES.

are very unreliable and often worthless ; (2) that the statistics of ataxia
published by different compilers show a percentage of previous syphilis
that fluctuates between 4 per cent. and 90 per cent. of the collected cases
(extremes which cannot be reconciled) ; (3) that syphilitic lesions of
nerve-centres do not tend to follow definite nerve-tracts (systematic
lesions), and that the opposing view is in opposition to all established
pathological data relating to syphilis.

On the other hand, it is urged: (1) that late statistics (from which
all elements of error have been carefully expunged) show a percentage
of syphilis too large to be classed as a mere coincidence; (2) that
specific treatment often relieves the ataxic symptoms to a marked
degree; and (3) that our knowledze of syphilitic processes in the nerve-.
centres is as yet imperlect.

Personally, J am rather inclined to exclade the recognition of ataxia
as a syphilitic disease, per se,in any case. I have never seen a cure
follow the most active anti-syphilitic treatment. I am, however, open to
conviction when the disputed points regarding it are involved in less
obscurity than I think they are at the present time.

This disease is more common among males than females. It is
usually encountered during middle life. It is very rare during childhood,
and after the fiftieth year.

Acute infectious diseases are sometimes followed by the typical
spinal.changes observed in this condition. It is claimed that ataxia may
also occur as a result of chronic ergot-poisoning.

Heredity can unquestionably be shown to exist in certain cases. In
one family eighteen cases of well-marked ataxia were observed, accord-
ing to Carré.

Progressive paralysis of the insane is not infrequently accompanied
or preceded by the symptoms of this disease.

Symptoms.—The symptoms of this chronic disease* extend over so
long a period of time (five to thirty years) that they have been com-
monly divided into three stages, viz., those of invasion, incodrdination,
and the stage of complications.

The STAGE OF INVASION is characterized by the following sensory
phenomena: (1) pains of a peculiar character, which will be described
later; (2) hypereesthesia of the skin; (3) anesthesia of the skin; (4)
retarded conduction of sensation; and (5) peculiar subjective sensations
in the parts associated with the affected spinal segments. These are
commonly observed in the lower extremities, because the sclerosis is
confined, as a rule, to the dorsal and lumbar regions of the cord. If the
disease has progressed to the cervical region, the upper extremities will

*T quote from my work on ‘Surgical Diagnosis’’ the paragraphs relative to the
symptoms of this disease, subject to some slight changes,

’
SCLEROSIS OF THE POSTERIOR COLUMNS. 397

be similarly atlected, and in addition the pupils will be contracted and
fail to respond to light. (P. 120.)

In addition to the sensory phenomena de-
scribed, the spinal reflexes (especially the
patella reflex or knee-jerk) will as a rule be
diminished or abolished.

Lhe pains of this disease are to be dif-
ferentiated chiefly from those of rheumatism
and neuralgia. They are pathognomonic of the

' first and second stages of ataxia, and may
persist even in the third. They are best
described as “lightning pains,” which are of a
stabbing or boring character and extremely
severe. They are paroxysmal and of momentary
duration. Some patients compare them to an
electric shock, which gives a sensation as if a
knife were run into the muscles or a joint.
Unlike the pains of rheumatism, with which
they are often confounded, they attack cireum-
scribed areas which are usually between joints,
and successive paroxysms seldom occur in the
same spot. After the attack of pain has sub-
sided, the skin over the seat of pain is extremely
sensitive to the touch. They ditter from the
pains of neuralgia in that they do not follow
the course of individual nerve-trunks; they
are not associated with the so-called ‘ puncta
dolorosa ” or points of sensitiveness to pressure
along the course of the affected nerve, as is
the case with neuralgia; they do not radiate in 7
the superficial area of distribution of any special
nerve-trunk ; they are not commonly referred to
the skin, but to the deeper structures. Finally,

 

 

 

 

they are most frequently confined to the lower 8
extremities or to the pelvic organs,—chiefly the
bladder and rectum. Fic. 116.—A DiaGrammatic Rep-
. . : RESENTATION OF THE PATHo-
These lightning pains are so severe and LOGICAL LESION OF THE CORD
. : . fs ate OBSERVED IN LOCOMOTOR
constant in some instances as to induce suicide ; Ataxia (After Erb.) Note
; é that the diseased portions are
while in less severe cases the paroxysms are represented as confined to the
inf < posterior columns (those of Goll
Inlrequent and easily controlled by anodynes. and Burdach) exclusively.

They may affect the stomach and be mistaken
for those of dyspepsia; or the rectum, and be confounded with hsmor-
thoidal disease; or the bladder, and suggest the possible existence of a

 
398 LECTURES ON NERVOUS DISEASES.

calculus or cancer of the bladder. As the paroxysius of pain in some
cases not infrequently occur at long intervals for months or years before
the evidences of incodrdination of movement appear, it is common for
the specialist to meet with these patients after an incorrect diagnosis
(usually of rheumatism or neuralgia) has resulted in a long-continued
and ineffectual course of medication on the part of many medical
wulvisers.

Hyperesthesia of the skin (especially at the seat of pain after the
paroxysm has passed away) is commonly met with in these cases. Like
the pain, this increased sensitiveness is fugitive.

Anesthesia of the skin to the sense of touch, pain, or temperature,
is more or less completely developed as the disease progresses. These
patients often experienced, as a result of this anzesthesia, subjective
feelings which are peculiar; for example, as if the feet were cold or
numb; or again, as if the patient was standing upon feathers or wool, or
a pebble was in the shoe.

Delayed Conduction of Sensution.—W hen the sclerosis of Burdach's
column has progressed to an extent suflicient to interfere with, but uot
arrest, the conduction of sensation to the brain through the spinal cord,
asymptom is produced which is of great clinical value, viz., the occur-
rence of a perceptible interval of time between the infliction of a wound
(a pin-thrust, for example) or a simple tactile impulse and its perception
by the patient. In making this test, it is well to have the patient close
the eyes so as to obviate all danger of seeing the test applied. I have
met with one case where the interval was ten seconds, and a much
lonzer interval than that has been recorded.

The STAGE OF INCOORDINATION OF MUSCULAR MOVEMENTS follows after
a lapse of time, which varies between the extreme limits of a few months
and many years. Incodrdination is usually first exhibited in the gait,
because the lesion is confined primarily to the dorsal and lumbar regions
of the cord in the great majority of cases. When the cervical region
becomes involved, the upper extremities also exhibit a marked impair-
ment of cobrdinated movements,—as manifested, for example, in the
efforts to button and unbutton the clothing, to carry the hand with
accuracy and rapidity to designated parts of the face or body when
the cyes are closed, and in writing letters with continuous curves.

The gait of ataxic patients (although walking is extremely difficult
in some cases) is not that of paralysis. The two should not he con-
founded with each other. In this disease, the motor power of any indi-
vidual musele is not impaired, nor do the limbs usually show any lack
of development. It is only when some act is demanded which involves
nu coirdination of muscular movement, or, in other words, where several
muscles must be employed in some special order, that the difficulty
SCLEROSIS OF THE POSTERIOR COLUMNS. 399

becomes manifest. Too much emphasis can not be laid upon this
distinction between incodrdination and a loss of muscular power.
Among the early symptoms of incotrdination which the patient ex-
periences may be mentioned a difficulty in performing feats of locomotion
when suddenly called for, as in hastily crossing a strect, chinbing a flight
of steps, or washing the fuce with the eyes closed. Under sueh eireun-
stances a sense of insecurity first dawns upon the patient and causes
him to avoid such acts. Gradually he finds it necessary to stand with

aes AO ae,

 

   

Fic. 117.—ExvTensive Jornt-CHANGES IN ConnecTION wiTH .LocomoToR ATAXIA. (Charcot.)

the feet apart to increase his base of support; to keep his eyes upon the
ground when walking, so as to use the visual sense in directing his
movements, and to employ canes to aid him in preserving his balance.
Such patients have great difficulty from the first in placing the fect upon
small objects, as in mounting into a saddle by means of the stirrup,
climbing ladders, or in getting upon a chair to reach some object.

When incodrdination becomes still more impaired, the patient walks
slowly and with great deliberation. The feet may be suddenly jerked
outward, the heel generally strikes the ground before the sole of the foot,
400 LECTURES ON NERVOUS DISEASES.

causing the peculiar ‘‘stamping gait;” and sometimes the movements

of the legs are so unexpected that the patient falls to the ground.

When the upper extremities become similarly involved, the hand
cannot be rapidly carried to designated portions of the body, such,
for example, as the nose, mouth, ear, shoulder, etce., when the patient
is instructed to do so, with the usual accuracy, provided that the eyes
are closed. The clothing ig buttoned and unbuttoned with great diffi-
culty. When the patient is asked to convey a glass of water to the lips,
it is raised to the proper level, held there for an instant with the eyes
fixed upon it, and then darted suddenly toward the mouth. The
handwriting becomes markedly altered (especially when the eyes are
closed), because all continuous curves are made with less ease than
straight lines, if not too long.

The pupils frequently show the preternatural contraction which
indicates that the cildo-spinal centre is implicated; and they also fail to
properly respond to light, although they do move when vision is adjusted
for a proper focus upon objects in proportion to the distance of the
object from the eye, when within a space of less than twenty feet.
This condition constitutes the so-called “ Argyll Robertson's pupil.”
The tests for it have been already described. (P. 120.)

The various tests employed to determine the ability of any given
subject to codrdinate the muscles have been quite fully described in a
preceding chapter. (P. 179.)

In rare cases, the loss of cotrdination affects the muscles which
move the spine.

The spinal rejleres are greatly altered in this disease, and form an
important factor in the diagnosis. The knee-jerk is usually abolished at
an early stage. Tickling the soles of the feet generally fails to elicit the
so-called “ plantar reflex.” /

In the Lasr svace, that of complications, the bladder, rectum, sexual
organs, eyes, bones and joints, skin and stomach, are liable to give more
or less constant evidence of effects of the spinal disease upon them.

The bladder, which in the earliest stage was affected by the lightning
pains, accompanied often by hasty urination and pain during the act.
gradually exhibits the symptoms of paresis in slow micturition, drib-
bling, or incontinence. The latter symptom occurs as the result of
retention of residual urine, which overflows at last when the distended
bladder cannot longer control its escape. This condition should not be
allowed to go unrelieved from a neglect to insert a catheter. Finally,
cystitis is often produced; and, in rare instances, anesthesia of the
urethra is observed,

The rection, which in the carly staves is frequently affected with
stabbing pains and a painful sense of excessive distension, suffers 2
SCLEROSIS OF THE POSTERIOR COLUMNS. 401

diminution in its reflex action later in the disease, which induces consti-
pation. In the final stage, paralysis of the organ may be developed, and
anesthesia of its mucous lining is observed in exceptional instances.

The sexual organs, which in the early stages are often abnormally
stimulated (the sexual desire being increased, but the act itself being
more or less imperfect), are very much impaired in the advanced stages
of the disease; the sexual appetite as well as the power of erection being
often completely abolished.

The organ of vision sutiers late changes in locomotor ataxia. The
peculiar alterations of the pupil, first described by Dr, Areyll Robertson,
have been already mentioned. In addition, ptosis, strabismus, diplopia,
and loss of color perception are not infrequently recorded as compli-
cations of this disease. Atrophy of the optic nerve may also be one of
the results of the first stage. Some authorities lay great stress upon
the diagnostic value of the ophthalmoscope as a means of detecting this
early symptom of locomotor atawia.

Charcot’s Disease.—The bones and joints may become disinteiated,
as a late result of this form of spinal disease, and deformities are ftnus
produced. Charcot was the first to describe these conditions, and we
owe fo him much of our knowledge of the subject. The larger joints,
such as the knee, shoulder, and elbow, are the most liable to be attected.
Females are most frequently attacked.

The changes which occur are to be differentiated from those of
chronic rheumatic arthritis by the following peculiarities : (1) that they
are acute; (2) that they involve large joints and infrequently the hip,
whereas the reverse is true of rheumatic arthritis ; (3) that effusion into
the affected joint is extensive, whereas the effusion is rare in rheumatic
arthritis; (4) that dislocations are spontaneously produced, while they
are extremely rare in rheumatic arthritis; (5) the changes are usually
painless, probably because analgesia is associated with them; (6) some-
times spontaneous fractures occur. The most plausible exuiumatlen of
these bone changes, to my mind, is that advanced by Buzzard, viz., that
they are due to changes within the medulla oblongata.

, Considerable discussion has taken place (chiefly of late in the
London Clinical Society) relative to the pathological position and rela-
. tions of “ Charcot’s disease.” It was claimed by some eminent authori-
ties at that time that the disease was but a type of chronic rheumatic
arthritis. With this view I cannot agree. The points already mentioned
seem tome to confute this deduction. I have personally seen three
cases of a typical character, and I present a photograph of one. Each
of these patients was afflicted with ataxia before the joint complications,
Large joints (the knee in two cases and the elbow and both knees in one)
were attacked. The sraall joints were normal. The disorganization of
26
402 LECTURES ON NERVOUS DISEASES.

the affected joints was rapid and so extensive as to result in a “ flail-like”
mobility. The morbid changes were absolutely painless. The kneejerk
was absent in every case.

Buzzard states that in Charcot’s disease the Haversian canals are
dilated; that the bones are thinned and eroded; that the inorganic

 

Fics 118 anp 119.—Case or ‘‘Cuarcot's Disease” or Lert KNEg-JOINT FOLLOWING
Locomotor Ataxia. (From photographs in the possession of the Author.)

constituents of the bones are diminished and replaced by fat; and that
probably the specific gravity of the affected bones would show a decrease
from that of those unaffected. In these respects, the morbid changes are
totally at variance with those of rheumatic arthritis.

In connection with the changes in the bone and joints, gastric com-
plications sometimes occur. They are characterized by attacks of
SCLEROSIS OF THE POSTERIOR COLUMNS. 403

vomiting and severe gastralgia. They are more commonly observed in
females than in males.

Finally, the skin may exhibit trophic disturbances in the form of
herpetic eruptions and bed-sores.

Kichhorst has contrasted the percentages of the more important
symptoms of locomotor ataxia, according to the deductions given by
Bernhardt and Erb, in the following table :—

 

 

 

 

AUTHORITY QUOTED.
SYMPTOM. :
BERNHARDT. ERB.
(58 Cases.) (56 Cases.)

1. ApsENcE of PaTeLtar Tenpon Reriex . . .| 100.0 percent. | 98.0 per cent.
2. LANcINATING Parns.............{ 7050 “ 92.5
3. PARESIS OF BLADDER... ...-- 2.04. 74.1“ slo
4, Paratysis oF OcuLAR MuscLrs ....... 39.6 38.7“
BMV OSIS: i sy cesar, eo na de aS a Zi 54.0 “
6. Riewwity oF Pups .......--04~2% 484 “ 50.0 *
i, Oprig} ATROPHY. 2 x a a Ge a eA oe aS .| TOs « 1240
8. Sensory DISTURBANCES . . - 2... 859 = *
9, ANALGESIA. © 0 0 0 ke ee ee es 316% 69.0 *
10. DeLAvrn Conpuction or Pain... .... 34.4 © 895 «
ll. Brach-Rompere Symptom (swaying and totter-

ing when eyes are closed.) . . . . . 2... 90.2 * 83,5 “
12. Feruinc or ExwausTION  ........ 92.0 “ 979
VORA, oc is ok sg. gs sae de wepae se" ky Sey “con aR oe ae Sw 94.1 fe 100.0 “
14. SexuaL WEAKNESS... 1) ee ee 43.7 © 78.5  «
15. Joust AFFECTION. . 2... 2 ee ee 96 *
16. Gaspric CRISES. © 2 - 1. ee we ee es og

 

 

 

It will be observed that a wide difference exists respecting the
relative frequency of symptoms 2, 5, 9,10 and 14 of the table. Future
investigation will probably tend to determine these percentages with
greater accuracy.

The patellar reflex is being quite extensively investigated at the
present time. It may be absent in apparently healthy subjects. It has
been estimated that about two per cent. of all adults fail to exhibit the
kneejerk. Such subjects very frequently belong, however, to families.
which exhibit a strong neuropathic predisposition. The Tees jerk is
liable to disappear in advanced age, and in subjects suffering from
chronic alcoholism it may occasionally be totally absent. It has been
suggested that an abnormal length of the ligamentum patelle may exist
in healthy subjects where the knee-jerk cannot be elicited. Such a
condition would prevent the ligament being put upon the requisite
tension.

The effects of locomotor ataxia upon the sexual functions are
404 LECTURES ON NERVOUS DISEASES.

usually manifested at first by an increase of desire, with hasty ejacula-
tion of semen. Later on, frequent seminal emissions are apt to occur
spontaneously, and impotency generally follows. I have observed
exceptions to this rule, however, in several cases.

Respecting the diagnostic importance of alaxia as a symptom, the
fact should not be lost sight of that lesions of the cerebellum and of
the ‘‘lemniscus tract’ within the pons or medulla may create incodrdina-
tion of movement, and also that acute infectious diseases may occasion-
ally tend t> induce it.

Diagnosis.— Locomotor ataxia may be, and too frequently is, mis-
taken in its initial stage for rheumatism and neuralgia. Occasionally
the abdominal crises of ataxia may cause the physician to suspect the
existence of visceral derangements. The points by which the pains of
ataxia may be distinguished from those of other affections of a painful
character have been given already (p. 397).

In its second stage, locomotor ataxia must be distinguished from
motor paralysis, spinal meningitis, cerebellar ataxia, hysterical mani-
festations, chronic myelitis, and multiple sclerosis of the cord.

The symptoms known as those of “Charcot’s disease” must. be
diagnosed from those of chronic rheumatic arthritis.

Motor paralysis can readily be distinguished from ataxia by the
gait (p. 164) and by testing the power of individual muscles. Ia ataxia
there is no diminution of motor power, as may be demonstrated when
the muscles are subjected to proper tests. There is no incodrdination of
movement when motor paralysis exists. The nutrition of paralyzed
muscles is generally impaired. This is not the case in ataxic subjects.

Spinal meningitis can be recognized ly the existence of pain on
motion of the spine and when pressure is made over the spinous pro-
cesses, both of which tests are negative in ataxia. Moreover, febrile
disturbances and more or less motor paralysis are liable to accompany
meningitis. The reflexes will be normal or exaggerated in meningitis;
ocular symptoms will not be discovered; no incodrdination of move-
ment will be developed; nor will the clini¢al history. of the two diseases
be alike,

Hysterical ataxia may be recognized by the history of the case and
the condition of the reflexes. If the patient be a male, hysteria can
gencrally be excluded.

Cerebellar lesions produce a peculiar gait and attitude which closely
resembles that of ataxia in some respects. It has been described on 4a
previous page (p.165). Vertigo is a symptom of cerebellar lesions, and
gastric crises which are attended with vomiting are frequent. Rotary
movements may be developed. The reader is referred to page 46 for
further information respecting cerebellar lesions.
SCLEROSIS OF THE POSTERIOR COLUMNS, 405

Chronic myelitis is to be distinguished from ataxia by peculiar
combinations of sensory and motor phenomena, which are developed
during the progress of the inflammatory affection; by the usual absence
of incodrdination of movement; and by the presence of spasms, con-
tractures, bed-sores, cystitis, vesical paralysis, febrile disturbances, ete.
The pupils are seldom aflected, nor are typical ataxic pains’ ever
encountered in myelitis.

Prognosis.—It is my belief that some cases of ataxia may be cured.
The majority are usually capable of being greatly relieved by proper
treatment, although some are not. If it proves fatal, it gencrally
does so by the aid of an intercurrent affection, The duration of the
disease can hardly be estimated. I have one patient now under my care
who gives a clear history of ataxie pains for the past thirty years.
Sometimes the second stage of the disease is never reached. In rare
instances, the progress of the disease may be rapid. In one of my
cases, general paresis set in after fifteen years of suffering. He is now
in an insane asylum.

Treatment.—In: the early stayes of locomotor ataxia, it is my custom
to place the patient upon the internal administration of hot water (p.
248), and to give ergot in large doses (one drachm of the fluid extract
three times a day). I sometimes administer the bromides of potash,
sodium, or calcium, in place of the ergot. Three times a week or more
T usually employ heavy static sparks to the spine and muscles, and I
employ also the actual cautery to the spine very actively at intervals.
In this way, I have repeatedly caused a total arrest of the pains, which
had been very frequent and severe up to the date when this treatment
was begun. In a few instances a cure seems to have been accomplished.
The kneejerk has returned, and all symptoms of the disease have
disappeared.

During the parorysms of intense pain, hypodermic injections of
morphine, or the internal administration of codeine are of service.

When a distinct syphilitic history can be obtained from the patient,
I give the iodides and mercurial baths as an adjunct to some of the other
agents mentioned. :

When the stage of incotrdination has been reached, the treatment
must be somewhat modified. The bromides are of no service. The
ergot may be continued, but the nitrate of silver in one-third grain
doses should be administered in conjunction with it three times a day.
Care should be exercised against continuing the administration of this
agent long enough to cause staining of the skin. The electrical* and
cautery applications should be regularly employed. Belladonna is of
benefit when the bladder becomes affected. Hammond recommends the

* My experience with galvanism has not been as satisfactory as with the static spark,
406 LECTURES ON NERVOUS DISEASES.

hypodermic use of atropia in doses of one hundred and twentieth of a
grain at first, the dose being gradually increased until one-thirtieth of a
grain is administered.

The employment of crutches when walking, in order to prevent
excessive use of the muscles, has produced beneficial results in the
experience of some authors. I am inclined to think that the suggestion
is a good one. They certainly aid the patient in walking.

The question of the utility of stretching the sciatic nerves, as first
suggested by Langenbeck in 1879, for the relief of incoUrdination and
the pains of ataxia is still undecided. Some remarkable results have
been accomplished by this procedure, and also some remarkable failures.
The nerve is exposed by an incision made above the popliteal space,
The finger should then be introduced beneath it, and the limb raised
by means of the nerve, thus subjecting it to a tension sufficient to
stretch it.

By means of the different methods of treatment suggested, inco-
drdination of movement and the paroxysms of pain may be very
markedly decreased in the majority of cases. One patient, for example,
was lately placed under my care. He came to my office at first in a
carriage, and was able to ascend the steps of my residence only by the
aid of two canes and a body servant. In less than three months he
walked alone to my house with only one cane, the servant having been
dispensed with. Another had his pains (which were typical and of daily
occurrence) arrested for nearly six weeks by six applications of the
static spark.

Incontinence of urine is sometimes a serious complication of ataxia.
As a rule, it is properly an overflow from a highly-distended bladder,
rather than a true incontinence. It is always well to remember this
fact, and to introduce a catheter into the bladder at once when this
symptom is presented by an ataxic patient If the bladder be found to
be distended with retained urine, catheterization should be employed
several times each day at regular intervals, and the bladder washed out
with care each day. This can be easily done by the patient himself by
attaching a soft-rubber catheter to a fomntain syringe. Raising the
fountain fills the bladder, and lowering it siphons the fluid back into the
rubber bag.

T recall a case, which was sent to me some three years ago, in which
the patient (an ataxic) had worn a urinal in his trowsers-leg for many
months, at the advice of a physician. When IJ introduced a catheter,
over a quart of urine was taken from the over-distended bladder. The
treatment mentioned above cured this symptom in less than a month,
and the patient was relieved of a source.of great annoyance and mortif-
cation.
7 CENTRAL MYELITIS. 407

CENTRAL MYELITIS.

Ina previous table, I have seen fit to classify inflammation of the
central gray matter of the spinal cord as a systematic lesion. I am at
variance with some authors in so doing. The other varieties of myelitis,
with the exception of poliomyelitis, should unquestionably be included
under the head of focal spinal lesions, because they tend to spread
transversely and to involve, as they progress, one column of the cord
after the other. In this respect central myelitis seems to be an excep-
tion. It tends to spread chiefly both up and down the cord, and
transversely to a limited extent only.

Morbid Anatomy.—This form of myelitis 1s a rare one. It has been
known to extend throughout the entire length of the spinal cord. It
may extend also to the anterior or posterior horns of the spinal gray
matter. Its pathology does not differ from that of ordinary myelitis.

Etiology.—Little is positively known respecting the exciting causes
of this peculiar form of myclitis, or the physical condition which par-
ticularly predispose to it. The remarks which I shall make later relative
to the causes of myelitis are probably applicable to this condition.

Symptoms. —These will be moditied (as might be inferred from the
statements made in the early pages of this section) by the extent of the
lesion. The combination of symptoms which the patient is liable to
present may be an exceedingly complex one. All the disorders of
sensibility mentioned on a preceding page (p. 854), as well as paralyses
of motility of various types and degrees, with or without contracture,
may be observed. Whenever the anterior horns are attacked, more or
less atrophy of muscle may accompany or follow the clinical evidences
of impaired motility.

The disease is essentially 2 chronic one; hence, sufficient time is
afforded to carefully observe and study the development of the various
symptoms. The inflammatory process may gradually extend to portions
of the spinal cord which are diametrically opposed in their functions.

As in all inflammatory processes, a stage of irritation first exists.
We observe, therefore, this train of symptoms early, but usually for
only a short duration. The effects of irritation upon the motor and
sensory apparatus have already been discussed.

Whenever destructive changes occur, a totally different set of
abnormal nervous phenomena from those of the irritative stage are
produced.

Finally, these destructive changes may become an exciting cause of
a secondary degeneration of those bundles of nerve-fibres which are cut
off by the destructive changes from association with certain cells in the
cord which act as regulators of their nutrition (trophic centres).
408 LECTURES ON NERVOUS DISEASES.

The symptoms of irritation may be manifested by disturbances of
sensibility, such as pain, numbness, paresthesie, hyperesthesia, ete. ;
and also by disturbances of motility, such as motor spasm, exaggerated
spinal reflexes, contracture, and changes in the pupils.

Destruction of the spinal gray matter may result in a total loss of
sensation, marked paresis or paralysis, marked atrophy of muscles,
paralysis of the pelvic organs, the development of bed-sores or other
atrophic disturbances of the skin, and Robertson’s pupil (p. 120),

Diagnosis.—This disease cannot be confounded with any of the
systematic spinal diseases previously described, because a combination
of motor and sensory phenomena of an abnormal character is clinically
observed.

Focal lesions of the cord closely resemble it in many respects.
They can usually be recognized, however, by certain evidences which the
patient presents during the progress of central myelitis of a progressive
destruction of superimposed spinal segments. When the symptoms of
focal lesion shall have been discussed, this distinction will be better
understood.

Prognosis.—In the majority of instances, this disease is a fatal one.
Active treatment, if commenced sufficiently early, may possibly arrest
the morbid process in some cases.

Treatment.—This will be discussed under that of myelitis.

*NON-SYSTEMATIC” OR “FOCAL LESIONS” OF THE SPINAL CORD.*

By reference to a table on page 350, it will be seen that these lesions
differ in their character from the systematic diseases which have been
described. .

The clinical features which they present differ in each individual case;
because they are modified hy the situation of the lesion, in respect to the
different columns of the cord involved, as well as its height in the cord.

The height of the lesion is determined partly by the region to which
- the so-called “ cincture ” or “ girdle sensation” is referred ; partly by the
extent of the motor paralysis or sensory phenomena; again, by the
superficial spinal reflexes which are found to be unimpaired ; and, finally,
by the history of the case, when the seat of the exciting cause can be
well defined. -

Focal lesions differ from the systematic or non-focal lesions in that
they. tend to spread laterally from column to column. They often
extend to the gray matter of the cord, and sometimes involve the entire
structures of both lateral halves of the organ. At first such a lesion may
be small and affect only a limited area; in such a case the symptoms may

* Several pages which relate to focal lesions of the cord are quoted from the Author’s
work, entitled ‘‘ The Applied Anatomy of the Nervous System.”’ D. Appleton & Co., N.Y.
“FOCAL LESIONS” OF THE SPINAL CORD. 409

be confined exclusively to either motor or sensory phenomena, depending
upon the column which is attacked. As it spreads to adjacent columns,
the symptoms are modified, new ones being added ‘which indieate the
direction of its growth. Phy siological and anatomical knowledye can
alone aid in deciding as to the height of the lesion in the cord, or
the portions which are destroyed by it, provided that the cause of the
symptoms is not of a traumatic character.

Before we pass to the consideration of lesions confined to special
seoments of the cord, it may be well to refer again to a few general state-
ments which have heen made on page 352.

Focal lesions commonly give rise: (1) to paresis or paralysis of the
extremities ;, (2) to anesthesia or paresthesize—such, for example, as
numbness, formication, etc.; (8) to modifications of the superficial and
deep spinal reflexes; (4) to paresis or paralysis of the bladder and
rectum; and (5) to a tendency to bed-sores.

The spinal cord may be regarded from a physiological stand-point
as composed of numerous segments which are superimposed; each of
which is capable of an automatic action. In some of these are placed
special centres which govern the action of the viscera, the sexual organ,
and the calibre of blood-vessels.

The segments of the cord may be controlled, when necessary, by the
ganglia of the brain which are of a higher order; but when this con-
trolling power is interrupted from any cause, as in spinal lesions, for
example, the spinal segments may still continue to act automatically.
This is one of the many explanations that have been advanced to explain
the etaggeration of the spinal reflexes (which often exists when focal
lesions of the spinal cord are present), as well as the fact that the bladder,
rectum, sexual apparatus, and the skin are sometimes affected by such
lesions, and again are not.

It is often possible and of great practical importance to the diag-
nostician to tell in what region of the cord a lesion is situated, and to
estimate the height to which it has progressed. Of course, this is much
easier in focal lesions than in the systematic, because the different
columns of the cord then simultancously furnish symptoms which can
be compared, and thus aid in the diagnosis. In the table, to which
I some time ago directed attention, you will perceive that the focal
lesions include traumatisms (of all forms); compression of the cord
(chiefly by inflammatory exudation, bone, and tumors) ; transverse
sclerosis of the cord ; transverse softening of the cord; hemorrhage into
the substance of the cord; and, finally, certain tumors which involve the
cord itself. There are many other causes which might excite some local
lesion, but these are the ones which will most frequently come under the
notice of the practitioner.
410 LECTURES ON NERVOUS DISEASES.

A few anatomical points are suggested in this connection as of value
in spinal diagnosis; (1) the hypoglossal and pneumogastric nerves arise
from the medulla, which lies above the level of the axis; (2) the phrenic
arises on a level with the spine of the axis; (3) the brachial pleaus and
the ulnar nerve are connected with the cord in the region of the neck
(third and sixth cervical spines); (4) the cilio-spinal centre is situated
between the fifth cervical and the second dorsal vertebrie ; (5) the lumbar
enlargement of the cord gives off the crural and sctalic nerves at different
points, and the space between the eleventh dorsal and the second lumbar
spines includes the point of origin of both; (6) the spinal cord ends at
the second lumbar spine, although the nerves continue to escape from the
spinal canal much below that point.

Before we discuss the various conditions siuaneoated in a previous
table.as “focal lesions” of the cord (page 350) as separate diseases, it
may be advisable to consider in a general way the effects of focal lesions
of the cord at different levels. These may be made use of in diagnosis,

We have already studied the effects of systematic lesions, both of
the kinesodic and esthesodic systems, and have noticed how perfectly
the physiology of the spinal cord is confirmed by lesions affecting
the anterior or posterior portions of the cord separately. We are now
called upon to investigate those lesions which, by extending in a trans-
verse direction, are liable to be accompanied by symptoms referable to
both the sensory and motor portions of the cord.

Of course, the symptoms will be modified by the extent of the lesion
in a transverse direction, so that they may be mostly sensory or motor;
but the presence of both sensory and motor symptoms is strongly
diagnostic of focal lesions, irrespective of :a predominance of either,
and is never produced by any systematic lesion of the cord, with the one
exception of central myelitis.

We may start with a general statement in our study of focal lesions,
as follows: Focal lesions usually give rise to paralysis of motion; to an
alteration in the reflex excitability of the cord (usually an increase) ; and
to more or less anesthesia, numbness, and pain. The bladder and rectum
are often paralyzed, and a tendency to bed-sores is frequently produced.
The first two of these effects, and also the last, are due to alteration
in the kinesodie system; the remaining ones are the result of some
disturbance to the esthesodic system.

‘In studying focal lesions situated in different regions of the spinal
cord, we must adopt some system if we expect to grasp the fine distine-
tions which can be drawn between the results of lesions of the upper
cervical region, the cervical enlargement, the mid-dorsal region, the
region just above the lumbar enlargement, and, finally, the lumbar
enlargement itself.
“FOCAL LESIONS” OF THE SPINAL CORD. 411

FOCAL LESION IN THE UPPER CERVICAL REGION.

Hemiplegia will be produced if one lateral half of the cord be alone affected ;
while paraplegia will be present if the lesion extends transversely to both lateral halves
of the cord. The hemiplegia or paraplegia will be complete below the head, and the
entire body may be rendered anesthetic. Since the phrenic nerve arises at this point,
the act of respiration will be interfered with, creating dyspnea and hiccough; but
respiration will not be arrested, since the pneumogastric nerves continue to excite it, and
the auxiliary muscles of respiration can expand the chest without the action of the
diaphragm, Should the lesion be a surgical one (as it usually is), the respiratory centre
of the medulla may be affected, and death take place fromm asphyxia; but I do not think
such a result can be explained as a simple effect of paralysis of the phrenic nerves alone.
The involvement of the cilio-spinal centre in the lower cervical region may cause the
pupils to show an irregularity, and the face and neck may manifest a marked increase of
temperature. The pulse may be rendered variable, from irritation of or pressure upon
the acceleratory centre of the heart.

Now, as I have before said, this type of lesion is almost always a surgical one, com-
prising pressure from fracture, dislocation, caries, tumors of the vertebra, etc. These
cases seldom live long enough for us to study the effects of such a lesion with much detail.
In those rare instances where the lesion is non-traumatic and slowly developed, the
effects of irritation have been shown in a hiccough (probably due to irritation of the
phrenic nerve), acceleration of the pulse (from irritation of the acceleratory centre of
the heart), and dyspncea (from some interference with the phrenic nerve or the nucleus
of the pneumogastric nerve in the medulla); while the paralysis has first appeared as a
paretic condition of the arms, then of the chest, and, finally, of the lower limbs.

FOCAL LESIONS OF THE CERVICAL ENLARGEMENT,

This type of lesion differs in its effects if developed suddenly or gradually, and also
when situated in the upper or the lower part of the enlargement. If the lesion be so
situated as to create only irritation of the cilio-spinal centre, or the acceleratory centre for
the heart (both of which are in that vicinity), the effects will differ from those due to
actual pressure upon or destruction of those centres, In the first instance, the pupils will
usually be dilated and the face pale, while the heart will be accelerated; in the latter, the
pupils will generally be contracted, the face and neck flushed, and the pulse retarded.
The effects will also differ if the lesion affects both lateral halves of the cord or only one.

Wherever the lesion be situated within the cervical enlargement, the arms and legs
will gradually become paralyzed; the-arms and hands usually becoming first numb and
paretic, and the lower limbs exhibiting, for some time, only a sense of weakness and
evidences of an increased reflex excitability. A sense of constriction around the chest
(the so-called “cincture feeling”) is generally present, the seat of which varies with that
of the exciting lesion. ;

When the lesion is situated at the upper part of the enlargement, the motor and
sensory symptoms will be manifested in the lower extremities, the trunk, and in nearly all
the regions of the upper extremities. The constricting band around the thorax is
referred to the devel of the clavicles, and dyspnea is often excessive,

The brachial plexus is associated with the upper part of the cervical enlargement,
and the ulnar nerve with the lower part; hence, the paralysis of the arms in this case
would naturally be manifested in almost all of the regions of the upper extremity, and
also in those parts supplied by the brachial plexus above the clavicle.
412 LECTURES ON NERVOUS DISEASES.

If the lesion be situated in the lower part of the cervical enlargement, the symptoms
exhibited will include a loss of faradaic reaction of those muscles which are supplied by
the ulnar nerve (rather than' those of the arm and the extensors of the forearm), and
atrophy of these muscles will often be developed, chiefly in the flexors of the wrist and
the small muscles of the hand. The sense of constriction (cincture feeling) experienced
in most spinal lesions of a local character will exist, but it will be referred to the upper
part of the chest. A paralytic condition of the muscles of the trunk (the intercostals,
triangularis sterni, and the accessory muscles of respiration), as well as of the abdominal
muscles, will be detected in severe cases, rendering both inspiration and expiration
embarrassed, and thus adding to the danger to life. The lower limbs may exhibit evi-
dences of numbness, anesthesia, paresis, or complete paralysis, depending upon the extent
of the lesion and the destruction done to the tissues of the cord. A condition of paralysis
may also exist in the upper extremity.

In surgical injuries to the upper portion of the cord, a peculiarity is often noticed in
the temperature of the body, which is sometimes greatly elevated. This clinical feature
may be associated with a marked retardation of the action of the heart (apparently
confirming the situation of an acceleratory centre for that organ in the spinal cord).

FOCAL LESIONS OF THE MID-DORSAL REGION OF THE SPINAL CORD.

In the early stages of these conditions the lower limbs become paretic, and a
condition of increased reflex excitability is manifested by a rigidity and stiffness of the
impaired muscles whenever the patient attempts to stand or walk. As the disease
progresses, the muscles become paralyzed and contractured* (probably on account of
changes of a secondary character in the lateral columns of the cord). In some cases the

_ reflex ‘movements assume the type of spasms, so as to exhibit both tonic and clonic con-
tractions. It was this symptom which suggested to Brown-Séquard the name of “spinal
epilepsy,” since it occurs when the patient is exposed to the slightest peripheral irritation,
and often when in the recumbent posture.t The sense of constriction around the body is
referred to the region of the navel, or that of the lower ribs, or possibly as high as the
axilla, since it may be taken as a relative guide to the highest limit of the lesion. A
peculiarity exists in this condition as regards the bladder and the rectum; although they
may be paralyzed, they are often enabled by the aid of reflex action to expel their
contents, thus apparently having regained their function. In the early stages the urine
and faeces may be too hastily expelled for the comfort of the patient, often compelling the
performance of either act before a proper place can be reached; but, in the advanced
stages the urine is retained to such an extent as to cause an “overflow,” which is often
mistaken for an actual incontinence, since a constant dribbling is present. This symptom
is always an indication for the regular use of a catheter. The sexual function seems to be
often unimpaired, as coition is frequently possible. It is seldom that the paralyzed
muscles exhibit a tendency to atrophy, and the electrical reaction of the affected parts is
either normal or exaggerated. The chief seat of weakness is usually first detected in the
feet; subsequently the paralysis gradually involves the entire lower limbs.

FOCAL LESIONS ABOVE THE LUMBAR ENLARGEMENT OF THE SPINAL CORD.

In this situation, a focal lesion of the cord produces about the same sensory and
motor’symptoms as those described in connection with a lesion of the mid-dorsal region,

* A term used in contradistinction to the word ‘ contracted,” to designate a permanent
shortening rather than a temporary response to a motor impulse.

} The presence of urine in the bladder or of faces in the rectum may often create
these spasms.
‘FOCAL LESIONS” OF THE SPINAL CORD. 413

with the exception that the reflex spasms, present in the paralyzed muscles, are perhaps
somewhat less violent than when the lesion is higher up-the cord. These tonic and clonic
spasms are, however, sufliciently well marked to constitute a. prominent symptom,* and
they indicate an increased reflex excitability of the gray matter of the’cord below the seat
of the lesion. An ingenious explanation of this increased reflex has been advanced by
Professor Seguin, of this city, which seems to merit respectlul consideration. I quote
from a paper of his upon affections of the spinal cord, as follows :—

“The classic theory of the physiology of contracture in hemiplegia is thal it is due to
the secondary degeneration; ie., actively caused by the lesion of the postero-lateral
column, Seven years ago (sce Archives of Scientific and Practical Medicine, vol. i,
p. 106, 1873,) I rejected this hypothesis, and suggested a different one, which I have since
elaborated and taught in my clinical lectures. This hypothesis, which I intend shortly to
publish in detail, is briefly that the spasm is due, not to direct irritation from the
sclerosed (?) tissue in the postero-lateral column, but to the cutting off of the cerebral
influence by the primary lesion, and the consequent preponderance of the proper or
automatic spinal action—an action which is mainly reflex. This theory explains the
phenomena observed in cases of primary spinal diseases with descending degeneration,
and can be reconciled with results of experiments on animals (increased reflex power of
spinal cord after a section high up, Brown-Séquard; inhibitory power of the encephalon
on the spinal cord, Setchenow).” j

The urinary and rectal organs are affected in about the same way as in lesions of the
dorsal region. Coition is often possible, and erections are normally frequent. The rectum
is paralyzed, as a rule, and constipation is usually present on that account. Micturition
becomes slow and interrupted, as the bladder grows paretic, and retention and overflow are
produced later on in the disease.

The paralysis of the extremities is first noticed in the feet, which have long before
exhibited a sense of weakness and easy fatigue. Numbness and anesthesia usually
accompany the motor paralysis, and extend as high as the groin or the waist. The sense
of a constricting band around the body is present here, as in lesion of other localities, and
is referred to the waist, below the level of the umbilicus, or at the level of the hips.

FOCAL LESIONS OF THE LUMBAR ENLARGEMENT.

The lower portion of the lumbar enlargement gives origin to the sciatic nerve; hence,
it is reasonable to expect that a lesion situated in the lower part of this enlargement
would be manifested by symptoms of an incomplete paraplegia, in which the muscles
supplied by the sciatic nerves would be the most affected. Now, this fact seems to be
confirmed by clinical experience, since the feet, legs, posterior aspect of the thighs, and the
region of the nates are chiefly paralyzed when the lesion is so situated. The bladder is
unaffected, but the sphincter ani muscle is often rendered paretic, or it may be entirely
paralyzed. The portions of the limbs which are to become the seat of paralysis usually
exhibit a sense of numbness before the effects of the lesion are fully developed, and, in case
the posterior columns of the cord be involved, complete anesthesia may also exist in the
parts supplied with motor power by the sciatic nerve. The condition of the paralyzed
muscles, as to their electrical reactions, and the presence or absence of the evidences of
increased reflex excitability will depend greatly upon how much damage has been done
to the gray matter of the lumbar enlargement. If the gray matter be so destroyed as to
impair its function, the reflex movements will be absent; and, if the trophie function of
the cord be affected by changes in the ganglion cells of the gray matter, the paralyzed

* These reflex spasms have been called by Brown-Séquard ‘‘ spinal epilepsy.”
414 LECTURES ON NERVOUS DISEASES.

muscles will undergo atrophy. The sense of constriction, or ‘‘band feeling,” will usually
be referred, in this lesion, either to the ankle, leg, or thigh.

FOCAL LESIONS CONFINED TO THE LATERAL HALF OF THE SPINAL CORD.

In discussing the focal lesions of the cord, we have described the clinical points which
are afforded by destruction, to a greater or less extent, of the substance of the cord in both
of its lateral halves; hence the motor and sensory symptoms have been usually referred
to both sides of the body. It was necessary to thus describe them, since focal lesions,
unless traumatic, are seldom confined to one lateral half of the cord; but, in some cases
which may be presented to your notice, where a tumor, a fractured vertebra, a hemorrhage,
a severe contusion, or some other localized lesion exists, the injury done to the spinal cord
may be confined exclusively to one lateral half, resulting in one of two named conditions,
viz., ‘spinal hemiplegia” and “hemi-paraplegia.” :

Any lesion of a lateral half of the spinal cord must produce anesthesia on the
opposite side of the body, since all the sensory nerves decussate and enter the gray matter
of the-cord, which serves as a conducting medium for sensory impressions, while the motor
symptoms produced by the same lesion must be confined to the same side of the body as the
lesion, since no decussation probably occurs in the spinal cord (these fibres decussating
only in the medulla oblongata).

Lateral lesions, as well as those which affect the entire cord, are modified, as regards
their symptomatology, by the height of the lesion in the cord; since the motor nerves, and
the special centres which are situated in the cord itself, will only be affected when they lie
below the seat of the lesion, or are directly involved in the destructive process,

When the focal lesion is placed high up in the substance of the spinal cord, the motor
paralysis affects one side only of the body (provided the lesion is confined to a lateral
half), and the term “spinal hemiplegia” is applied to this form of paralysis in contra-
distinction to a hemiplegia of cerebral origin. If the spinal lesion be situated in the
dorsal region and be confined to the lateral half of the cord, a motor paralysis of one
half of the same side of the body below the seat of the lesion is developed,—a condition to
which the term “hemi-paraplegia” is commonly applied. In closing the clinical aspects
of lesions of the spinal cord, it will be necessary, therefore, for us to consider the essential
features of these two remaining conditions.

SPINAL HEMIPLEGIA.

In order to produce a typical case of this condition, it is necessary to have a lateral
focal lesion of the cord in its uppermost part (in or above the cervical enlargement of the
cord). If we suppose, then, that such a lesion be present, let us see what we might
reasonably expect, on purely physiological grounds, would be the result. We can then
examine the clinical records of such cases, and either confirm our deductions or gain some
additional information. Snch a lesion would, in the first place, shut off all motor impulses
sent out from the brain to parts below the lesion, on the same side as the lesion, since the
decussation of the motor fibres has already taken place in the medulla; hence, motor
paralysis should, theoretically, occur in the arm and leg of the side of the body corre-
sponding to the seat of the exciting lesion, and the trunk should also be paralyzed upon
that side. This we find clinically to be true,* with the exception that the intercostal
nerves often retain their motor power when the nerves of the arm and leg are no longer

* The researches of Brown-Séquard, as early as 1849, and his published memoirs (1863-
65, and 1868, 1869) have probably done more to clear up this field and to place it upona
positive foundation than those of any other observer.
SPINAL MENINGITIS. 415

capable of carrying motor impulses. In the second place, we should expect to find that
the sensation of the side of the body opposite to the seat of the lesion would be destroyed
or greatly impaired, since the sensory nerves decussate throughout the entire length of the
cord, This we also find confirmed by clinical facts; and so perfect is this anesthesia that
the line can often be traced to the mesial line of the body exactly, and upward to the limit
of the exciting lesion. In the third place, the situation of the cilio-spinal centre in the
cervical region of the cord would naturally suggest some effects upon the pupil, and the
circulation and temperature of the face, neck, and ear of the same side, This is also
confirmed, as the pupil does not respond to light, but it still acts in the accommodation
of vision for near objects, and the skin of the regions named becomes red and raised in
temperature, Finally, the presence of vaso-motor centres in the cord might occasion a
rise in temperature in the paralyzed muscles; and, strangely confirmatory of this fact, we
often find the temperature of the paralyzed side of the body hotter than that of the
anesthetic side.

In some exceptional cases, the face, arm, and trunk are alone paralyzed, the legs seem-
ing to escape, and often giving evidence of reflex spasm (perhaps most commonly on the

anesthetic side). ‘his must be explained as the result of incomplete destruction of the
lateral half of the cord.

HEMI-PARAPLEGIA.

This condition is the result of some focal lesion of the spinal cord in the dorsal region,
which involves only its lateral half. The results of such a lesion differ but little from those
of one causing spinal hemiplegia, as regards the motor and sensory symptoms, excepting
that the situation of the exciting cause is below the cervical enlargement, where the nerves
to the upper extremity are given off, and where the cilio-spinal centre is situated. For
that reason the muscles of the upper extremity are not paralyzed, nor are the effects upon
the pupil and the skin of the face, ear, and neck (mentioned as present in spinal hemiplegia)
produced. The muscles below the seat of the lesion are paralyzed on the side of the body
corresponding to the exciting cause, and the skin is sometimes rendered hyperesthesic upon
that side ;* while the integument of the side opposite to the lesion is deprived of sensibility.
The bladder and rectum may be paralyzed in some instances. The sense of constriction,
or “band feeling,” will vary with the seat of disease in the spinal cord. The amount of
reflex irritability and the presence or absence of muscular atrophy in the parts paralyzed
will depend upon the depth of the lesion in the spinal cord and the changes which have
been produced in the gray matter. The same increase of temperature in the paralyzed
limb, which was mentioned as occurring in spinal hemiplegia, may also be present in this
variety of paralysis.

Should the side affected with anesthesia give any evidence of motor paralysis or
muscular weakness, or symptoms of anesthesia appear upon the side where the motor
paralysis is present, you may regard either one as conclusive evidence that the exciting
lesion is progressing, and that the opposite lateral half of the cord is being involved to a
greater or less extent.

SPINAL MENINGITIS.
(Pachymeningitis Spinalis—Leptomeningitis Spinalis.)
The membranes of the spinal cord may become inflamed inde-

pendently of, or in conjunction with, similar changes in the cerebral
envelopes. I shall discuss the former variety here.

* This is probably due to some irritation of the gray matter of the cord.
416 LECTURES ON NERVOUS DISEASES.

Spinal meningitis may be of two forms: (1) pachymeningitis
(internal and external varieties), and (2) leptomeningitis (acute and
chronic varieties). I have chosen to include both of these conditions
among the focal lesions of the cord, because their effects upon the
functions of that organ are due chiefly to pressure. The pressure so
produced is liable to spread in a lateral direction from column to column
of the cord.

Although the acute variety of leptomeningitis (inflammation of the
pia and arachnoid) is generally diffused over a much larger area than
the chronic, the distinction drawn on a previous page between systematic
and focal lesions of the cord (see table on p. 350) clearly justifies the
classification adopted.

When the symptomatology of this disease is reached, many of the
hints given in connection with the diagnosis of focal lesions (p. 411 to
415) will prove of great assistance to the reader.

                                                        

branes (chiefly the pia) are rendered thicker than normal, more or less
opayue and oedematous, sometimes ecchymotic, and often adherent to
each other, The meshes of the pia are filled with a turbid exudation,
which may be tinged with blood. It is sometimes clear, but generally
more or less filled with floceuli of lymph. The consistency of this
exudation varies. It may be fluid, or of the density of jelly. It is
usually most abundant at the posterior part of the cord and around the
posterior nerve-roots ; but it may envelop the entire circumference of
the cord.

Tn the arachnoid, hard cartilaginous plates are occasionally detected.
The size of the plates may reach a quarter of an inch in diameter, but
they are usually much smaller,

The dura may become involved in conjunction with the arachnoid
and pia; or it may be separately affected, as is’ also the case with the
dura lining the cavity of the cranium. We may thus have an énternal
and external variety of spinal pachymeningitis, as well as leptomeningitis
(inflammation of the pia).

The external form of spinal pachymeningitis is primarily an
affection of the dura. The other membranes may, however, occasionally
become involved by an extension of the inflammatory process. Its most
common seat is in the cervical region, and it seldom extends beyond the
limits of two vertebrie, Several such foci of inflammation may coexist.
The membranes hecome hypertrophied and encroach upon the spinal
canal. This may result in a compression of the spinal cord. Myelitis
may be thus induced. Again, the roots of the spinal nerves may be
compressed by the changes in the membranes through which ihey pass,
thus causing disturbances of sensibility and motility.
SPINAL MENINGITIS. 417

The external variety of pachymeningitis spinalis is confined to the
loose connective tissue between the dura and the vertebral canal. This
is more abundant in the posterior part of the spinal eanal than elsewhere ;
a fact which helps to explain the circumscribed character of its morbid
changes, as well as the tendency of these changes to become most
marked posteriorly. /

Swelling and redness are generally to be detected at the seat of the
extra-dural cellulitis. Abscesses may develop in exceptional instances.
In other cases the dura is simply thickened and adherent; or dry, cheesy
masses of considerable size may be detected.

The pains, which are a prominent symptom of the first stage of this
affection, are probably due to a slight compression of the posterior nerve-
roots. Rigidity of muscles may also occur from a similar condition of
the anterior nerve-roots. Later on, the compression of the cord may
induce paralysis, contracture, and atrophy of muscles (chiefly those
supplied by the median and ulnar nerves), anaesthesia of limited areas
of the body, and possibly symptoms of incodrdination of movement.
We owe most of our knowledge of this affection to the publications of
Charcot.

The internal form of spinal pachymeningitis (the hemorrhagic
variety) was first fully described by Meyer, although it was partially
recognized by Albers. A laminated sac enclosing » hemorrhagic con-
dition of the spinal membranes exists in this disease, which is identical
with that described in connection with the dura of the cranium. It
seems to occur in connection with alcoholism, some cases of insanity,
general paralysis, caries of the bones, and syphilis.

This form of spinal pachymeningitis usually runs a chronic course.
It is not always of the hemorrhagic variety. The dura presents in rare
cases upon its inner surface a series of concentric lamelle of a fibrous
character, while the arachnoid and pia have become similarly affected,
constituting the so-called “ hypertrophic internal spinal pachymeningitis.”

In this disease, the spinal cord is constricted by a ring of fibrous
tissue (with numerous interstitial spaces) whose concentric lamelle: may
exceed one-twentieth of an inch in thickness. This ring is generally
situated in the lower half of the cervical enlargement of the cord. It
tends to compress the spinal nerve-roots, and later the substance of the
cord itself. When the latter occurs the spinal gray matter is apt to
suffer. Frequently newly-formed canals are detected near to the gray
commissure, which are lined with a membrane and contain fluid.

When spinal meningitis is developed in connection with syphilis,
the lesion is usually of the type of gummata, and is more or less circum-
scribed. The antero-lateral portions of the cord are more often involved

than the posterior; hence, we are more apt to encounter disorders of
27
418 LECTURES ON NERVOUS DISEASES.

motility than of sensation or codrdination. When these gummata are
not multiple, they are commonly found in the region of the lower dorsal
and upper lumbar segments of the cord. If multiple, they may occa-
sionally be detected higher up.

In the chronic variety of spinal leptomeningitis, the membranes
are excessively thickened and puckered. The adhesions are also
abundant and very firm. Finally, the opacity of the membranes is
greater than in the acute form. In some cases pigmentation exists.
Caleareous plates within the membranes are not uncommon. The
amount of fluid within the subarachnoidean space is increased, and may
contain flocculi of lymph, with pus, or blood. The cord is generally
anemic and frequently sclerosed. The nerve-roots are usually more or
less degenerated and atrophied.

Etiology. Among the predisposing causes, bad hygienic surround-
ings, an excessive use of alcohol and tobacco, indulgence in narcotics,
exposure to cold or dampness, rheumatism, venereal excesses, scrofula,
wasting diseases, tuberculosis, and general debility may be mentioned as
prominent.

The exciting causes comprise injuries to the spine of all kinds,
operations for spina bifida, syphilis, aleoholismus, some of the diseases
of the cord, tumors of the cord or its meninges, caries of the vertebra,
tetanus, hydrophobia, cancer, spinal concussion, infectious febrile
diseases, and rheumatism.

External pachymeningitis is almost always a secondary disease.
Among the primary conditions which may induce it by extension
through the intervertebral foramina, may be mentioned caries of the
vertebre, suppurations in the neck or pharynx, tuberculosis, pleurisy,
empyema, peritonitis, pelvic suppuration, syphilitic ulceration, ete.

Youth and early adult life are more prone to this disease than old
age. It is most frequent in males. The acute form is liable to be
followed by the chronic. Spinal pachymeningitis is a very common
complication of Pott’s disease.

Leptomeningitis is most frequently met with during the winter
months. Sun-stroke is said by some authors to induce it, but I think
such instances must be very rare, The chronic variety generally coexists
with locomotor ataxia, multiple spinal sclerosis, myelitis, and other
organic spinal diseases.

Symptoms.—The most important and marked symptom of the onset
of leptomeningitis is pa‘. This may be localized in the back, or it may
shoot into those parts which are associated with the seements of the cord
nearest to the seat of inflammation. The pain is generally constant,
but it may often be intensified by movements of the spine, pressure
over the spinous. processes, or the application of an electric current to
SPINAL MENINGITIS. 419

the spine. Like some other symptoms which occur early, it may be
regarded as a clinical evidence of irritation of the posterior nerve-roots.

A chill or severe rigor may usher in this disease in some cases. It,
is often followed by nausea, vomiting, a moderate rise in temperature, and
a sense of weakness. The pulse is seldom greatly accelerated : it inay
even be below the normal standard.

Soon a rigidity of the muscles of the spine appears. Opisthotonos
is developed in some cases, especially when the cervical region is in-
volved. The patient generally maintains a fixed position, since move-
ment intensifies the pain.

Convulsive twitchings of the muscles may be developed. They are
exceedingly painful.

The spinal reflexes will be found, as a rule, to be exaggerated; this
symptom indicates an irritation of the lateral columns of the cord.

Sensory and motor symptoms gradually develop. The skin may
become intensely hyperzesthesic, and, as a rule, the motility of the
hyperesthesic parts is more or less impaired. It is common to encounter
an incomplete form of paraplegia, or anzesthesia when the cord or nerve-
roots are seriously affected.

Some of the other symptoms of this disease depend upon the seat
and extent of the lesion. There may be frequent micturition or retention,
whenever the vesical centre of the cord is involved. Dyspncea may be
produced when the lesion is high up. Sweating of a profuse type indi-
cates an impairment of the vaso-motor nerves or centres. The pupils
may be irregular from defective innervation of the cilio-spinal centre.
Bed-sores may be produced on account of trophie disturbances. It is
unnecessary to repeat here all that has been ‘discussed when the effects
of focal lesions of the cord were described. (Pages 411 to 415.)

Chronic spinal leptomeningitis generally follows an acute attack.
There are exceptions to this rule, but they are infrequent. The extreme
pain of the acute stage usually gives place to a sense of dull aching,
Soreness, or an itching and burning of the limbs. The “cincture
feeling” is well marked, and is a guide to the height of the lesion. The
intestinal, vesical, and sexual centres of the cord may be affected and
cause marked disturbances of their functions, We are apt to have
constipation or incontinence of fieces, incontinence of urine, impotence
or priapism, bed-sores, etc. The lower limbs are particularly liable to
become partially paralyzed. Hyperesthesia is also a common symptom.

In the external variety of pachymeningitis spinalis, the symptoms
closely resemble those of leptomeningitis. A stiffness in the back when
the patient rotates the spine (or when sitting or standing for any length
of time) is noticed early. The application of heat, cold, pressure, or the
negative pole of a galvanic battery increases the pain at the seat of the
420 | LECTURES ON NERVOUS DISEASES.

morbid changes. The “cincture feeling” is generally experienced
around the body at a level approximating closely to the height of the
lesion. The pain is apt to be more paroxysmal than in leptomeningitis,
Sometimes the spine may present evidences of the primary disease which
has induced the morbid changes in the extra-dural connective tissue,
The neck is not usually rigid, because this condition is infrequent in the
cervical region.

In the internal variety of pachymeningitis spinalis, the symptoms
run amore chronic course, and more closely resemble those of spinal
and meningeal tumors.

In the “hypertrophic” form, the stage of irritation is followed
(after a lapse of a few months) by paralysis and atrophy of the muscles,
These later symptoms are due to compression of the spinal cord or
the spinal nerve-roots. The stage of irritaticn is characterized by
paroxysms of severe neuralgic pain in the shoulders, the occiput, the
cervical region of the spine, and the large joints of the upper extremity.
It is not usually affected by pressure upon the spinous processes.
Hyperzsthesia and pareesthesie are frequently observed early in these
subjects. The skin of the upper limbs may show trophic disturbances,
chiefly by desquamation, vesicular eruptions, or a roughness of the
epidermis. The hand may assume the typical attitudes depicted by
Charcot and Ross.

Diagnosis.—The different forms of spinal meningitis previously
described are not always easy of diagnosis. The best clinicians have
been misled in cases where the autopsy has revealed very marked lesions
of the spinal meninges. As a rule, however, it is well to suspect the
existence of spinal meningitis whenever we encounter a persistent and
severe pain in the back which is aggravated by movement, and which
oceasionally shoots along the spinal nerves (those associated with the
diseased area). Our suspicions are strengthened if we observe also a
tendency toward muscular rigidity, distortions of the spine, or an
exaggeration of the spinal reflexes, together with marked clinical
evidences either of irritation or impairment of the motor or sensory —
functions.

The presence of marked febrile symptoms at the onset of any attack
associated with spinal symptoms should lead us to suspect the develop-
ment either of a meningitis or a myelitis. It may be justly said, how-
ever, that these two conditions usually go hand in hand, and that one or
the other simply predominates. The existence of a “girdle pain” ora
“eincture feeling” is rather diagnostic of myelitis; as is also the
presence of exavyerated reflexes, with bladder and rectal complications,
changes in the pupils, contractures, or trophic disturbances.

The difficulties in diagnosis are to be attributed chiefly to the fact
SPINAL MENINGITIS. 491

that it makes very little difference clinically whether the spinal cord is
actually diseased or subjected to pressure, and that we cannot always
discriminate between lesions of the cord and those which involve the
spinal nerve-roots.

The table on the following page will possibly prove of value to the
reader in making the diagnosis of the different types of spinal meningitis
from each other, and in discriminating between them and other conditions
which resemble them in many respects.

Prognosis.—In the external form of pachymeningitis spinalis, the
prognosis is always grave. Recovery is very rare and seldom complete.
In the internal variety recovery is possible.

In leptomeningitis spinalis, the acute variety is apt to coexist with a
myelitis, and the proguosis is grave. It is especially so if paralysis and
atrophy are developed, or if the sphincters are involved. A bad con-
stitution, a high range of temperature, dysphagia, an extension to the
medulla, and extreme youth or old age are all unfavorable to the patient.
Relapses are very common, even if the case progresses favorably.

In the chronic variety, death is apt to occur from cystitis, bed-sores,
an acute exacerbation of the disease, or an extension to the medulla. It
is apt to last for years, and to lead to permanent paralysis and atrophy
of muscles.

Treatment.—The cause of the morbid condition, as well as the
symptoms which it creates, must necessarily modify the treatment of
each case.

Irrespective of syphilitic origin, some authcrs advise calomel by the
mouth, Personally, it seems to me a dangerous and unscientific way of

‘controlling (?) inflammatory processes.

If syphilis exists, mercurial inunctions or fumigation may be
employed with benefit, and the iodides may be given in conjunction
with mercury. This subject is quite fully discussed on page 291.

Applications of ice-bags, wet-cups, leeches, or the actual cautery
may be made to the spine over the painful regions.

Bed-sores may be prevented by extreme care respecting the patient
and the bed, and by a change in posture (preferably upon the side or
abdomen). Bathing the skin daily in alcohol, and applying diachylon
plaster over any inflamed spots, may prove of service as preventative
measures. Air-cushions are often employed to remove pressure from
tender surfaces. If sores actually occur, they may be treated by the
permanent water bath or by ordinary surgical dressings.

If the bladder becomes involved, and exhibits incontinence, over-
flow or retention, it is advisable to introduce a catheter at regular and
short intervals, and to thoroughly cleanse the bladder daily by attaching
the catheter to the pipe of a fountain syringe filled with water and
LECTURES ON NERVOUS DISEASES.

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TUMORS OF SPINAL CORD AND ITS COVERINGS. 423.

raising and lowering the bag. This alternately distends and empties
the organ and affords great relief to many patients. The patient can
regulate the pressure by having a string which is attached to the
fountain run through a pulley in the ceiling directly over the side of
the bed, so that he can raise or lower the bag without changing his
posture in bed.

The pain is best controlled by opiates in full doses. I usually
administer it by the hypodermic method. The stomach is less affected
by so doing, and you can control the dose better than by trusting it to
the patient or the attendants. If nausea is created, add one grain of
atropia to one ounce of Magendie’s solution of morphia in preparing
the hypodermic solution. Acid should not be used in dissolving the
morphia, as it increases the danger of abscesses.

Ergot and iodide of potash are commonly employed in full doses
by most authors who have written upon this disease and myelitis. I
have not much faith in the beneficial effects of the latter, and I scldom
push ergot to extremes.

As the patient becomes able to walk it is best to insist on very
gradual exercise, care being taken to avoid over-exertion. In this con-
nection, sexual intercourse should be interdicted.

Paralyzed and atrophied muscles may be subjected to massage,
faradization, galvanization, or static sparks of a mild character. I
think that strong currents are generally detrimental in these patients.

Finally, strychnia, arsenic, iron, and a well-regulated diet are of
service in building up the strength during convalescence, or in prolong-
ing the life of the patient.

TUMORS OF THE SPINAL CORD AND ITS COVERINGS.

Within the substance of the cord, glioma is most often found among
the tumors; and sarcoma comes next in frequency. Tubercle and gum-
mata, as well as fibro-sarcoma and myxo-sarcoma, may likewise be
detected at an autopsy. Tumors may also spring from the meninges
and the vertebra and affect the spinal cord indirectly.

Morbid Anatomy.—Glioma most often affects the cervical and
lumbar enlargements. If extremely vascular (as it sometimes is) the
tumor may be infiltrated with blood and contain blood-cysts. It
probably starts from the neuroglia. Mixed varieties of glioma are
sometimes found in the substance of the cord (chiefly glio-sarcomata).

In the meninges of the cord, we may encounter all the varieties of
tumors mentioned excepting glioma; and, in addition, carcinoma,
psammoma, parasitic growths, fibromata, and myxomata.

The bones of the vertebral column and their periosteum may be the
starting point of intra-spinal growths. These may compress the cord.
424 LECTURES ON NERVOUS DISEASES.

Finally, aneurisms of the spinal arteries or of the thoracic or
abdominal aorta may interfere with the functions of the cord. The latter
can only do so by first causing absorption of the vertebra.

Etiology.— Wounds, injuries, and the results of tubercular, cancerous,
and syphilitic cachexiz are the only definitely known causes of these
morbid growths.

Symptoms—Tumors of the spinal canal cause symptoms either by
irritation or compression of the cord or the spinal nerve-roots or by
inducing changes in the bones. Even when of large size they may
produce no symptoms. In some cases we may encounter all the clinical
evidences of a myelitis, or of spinal meningitis. The general remarks
made in reference to focal lesions of the cord (pages 411 to 415) are
applicable to spinal tumors.

Diagnosis.—Although it is often impossible to recognize a spinal
tumor and its seat during life with certainty, there are some symptoms
which should lead to a suspicion of this condition, These comprise:
(1) an excess of motor paralysis on one side of the body over that
observed on the other, with an excess of anwsthesia on the side where
motility is least affected; (2) a clinical history which would lead to the
suspicion of tubercle, cancer, or syphilis in the patient; and (8) the long
duration of the disease (usually from six months to several years) and
the gradual development of the spinal symptoms. Moreover, the ability
on the part of the patient to recognize with closed eyes the position of
the limb during passive movements (muscular sense) is apt to be more
affected on one side (that corresponding to the tumor) than on the
other.

When more than one tumor exists, the diagnosis ig even more
uncertain than if the growth were single. It might then simulate
multiple spinal sclerosis. I lately treated a case of this description.
By a careful study of the symptoms I was enabled to recognize during
life a multiple lesion of the cord and the seat of the morbid processes
with some exactness, and I suspected either multiple sclerosis or multiple
tumor. The autopsy confirmed the latter view, as sarcomata of the
mcainges were discovered.

Prognosis.—This depends upon the nature of the growth. If it is
syphilitic, recovery under the treatment indicated on page 291 may be
expected, provided the spinal cord has sustained no permanent injury
from compression. Tubercle may, in exceptional cases, be recovered
from, Asa rule, however, spinal tumors are fatal.

Treatment.—lodide of potash, arsenic, cod-liver oil, phosphatic
salts, etc., may be employed as symptoms arise which seem to demand
them, unless the case be clearly of syphilitic origin. In the latter
form the most active specific treatment is indicated.
= SPINAL HEMORRHAGE. 425

SPINAL HEMORRHAGE.

Blood is rarely extravasated into the substance of the spinal cord.
It is generally poured out into the spinal meninges. We can therefore
divide spinal hemorrhage into the intra-medullary variety or “spinal
apoplexy,” and the extra-medullary variety, or ‘ meningeal hemorrhage.”

SPINAL APOPLEXY.
( Hematomyelia.)

Etiology.—This condition is somewhat rare. It may occur from
changes inthe coats of the blood-vessels or from excessive blood-
pressure. Probably the latter cause is not alone sufficient to induce it
in health.

Morbid Anatomy.—We encounter intra-medullary hemorrhage in
connection with gliomatous tumors, acute myelitis, and traumatisms.
The clot is usually small in size, seldom exceeding that of an almond.

In exceptional cases, the blood may escape through the pia into the
subarachnoidean cavity.

The age of the clot will modify its appearances at an autopsy. If
recent it will be red or blackish-red. Older clots become brown or
yellow in color. If sufficient time has elapsed to allow of still further
changes, the clot may be found to be encapsulated by a fibrous deposit,
or possibly an apoplectie cyst or a pigmented cicatrix may be all that
remains of the original lesion.

Symptoms.—These depend upon the seat and extent of the lesion.
Asarule, the patient is attacked with sudden paraplegia, accompanied
by severe pain in the back. The pain usually subsides within twenty-
four hours. Occasionally, the symptoms will indicate a unilateral lesion
of the cord. (Fig. 67.) Again, the effects of disease confined to the
posterior or anterior horns will be evidenced at the onset.

Prodromata are very infrequently observed. Consciousness is not
lost except when the lesion is situated near the medulla, A slight fever
is apt to follow the attack after a lapse of some hours. A high range of
temperature only occurs as the result of complications, such as cystitis,
bed-sores, ete.

The ‘pavalyeis may be of the type of monoplegia, hemiplegia, or
paraplegia,

The sensory functions may be disturbed, causing anesthesia, anal-
gesia, hypereesthesia, parsesthesie, ete.

The bladder and rectum may be affected.

The reflexes may be abolished or exaggerated.

Vaso-motor and trophic disturbances have been observed, and also
hematuria and albuminuria.
426

LECTURES ON NERVOUS DISEASES.

The effects of focal lesions of the cord at different levels may he

studied in this connection with benefit.

(Pages 411 to 415.)

Diagnosis.—Some of the more important symptoms of this affection
can be contrasted with those of other spinal diseases (which closely
simulate it) as follow :—

 

RAPIDITY OF
ONSET .scecssoee

FEVER. scssecevers

PAIN, ccvcccceecees

HYPERASTHESIA

ANJZESTILESIA «206

CoNTRACTURE
AND SPASM.....
SPHUINCTERS OF
BLADDER AND
RECTUM ....48.-

BED-SORES .....06

ATROPHY oF
MUuUS¢LES

ELECTRICAL
TESTS

PROGNOSIS......:

. SPINAL
sna oee: MENINGEAL
Eee HEMORRHAGE.

(Heematomyetia.) (rematorrhachis)

!
{

 

Rapid or instan-

Rapid. May be
taneous.

instantaneous. |

Absent at onset,
Occurs on second

Absent at onset. | {
or third day.

Occurs on second.
or third day.

Severe in back at
onset and gradu-
ally subsides.

Marked in back
and limbs, and
are of consider-

 

 

aoe ™ | able duration.
May be wanting. | Generally present.
May exist in | (Usually imper-
arts below j fectly devel-,
esion. Appears 1 oped and ap-}
at onset. pears late.

Occur at onset
(if at all) as a
rule,

Are strongly di-
agnostic.

Z
{

Frequently de-!
veloped.

{

potten paralyzed.

Unaffected until
late in the dis-;
ease. |

Oceurs rapidly,
only in those
muscles con-
nected with af
fected spinal
segments.

|

} May not occur.

l

Reaction of de-
generation in
steeped jane
cles associated) > Ma: .
with tot | pee OTEE

cord.

Often fatal. Re-

covery always| | Complete recov-

 

segments of

{

incomplete. ery is possible.

' { Not developed.

POLIOMYELITIS
ANTERIOR
ACUTA.

Never instanta-
neous.

| Preeedes pa-
f ‘ralysis,

+ Vo pain.

J

Absent.
1

i Absent.

i Absent.

 

format

Not developed.

{

Rarely fatal.

Occurs rapidly in
all the para-
lyzed muscles.

Reaction of de-
generation in
all paralyzed
muscles.

MYELITIS.

Never instanta-
neous. Compar-
atively slow, as
a rule.

Not prominent
as asymptom,

May be absent,
Is generally
marked,

May be totally
absent.

Not marked.

{
!

An early sign,
and is generally
well marked.

Not usually very
prominent,

Peculiarly liable
to be affected.

Extremely com-
mon.

pry not exist.

exaggerated, or

May be normal,
abolished.

Generally un-

favorable.

 

Prognosis.—The situation of the clot modifies the prognosis, as well
as the amount of blood which is extravasated into the substance of the
cord. Hemorrhages into the dorsal segments cause less serious symp-
toms than if present in the cervical segments (where the respiration may
be disturbed by interference with the phrenic nerve), or in the lumbar
segments (where the centres for the vesical and rectal sphincters are

probably situated).

The rapid development of bed-sores is an unfavor-
SPINAL MENINGEAL HEMORRHAGE. 427

able sign. In any case, a complete recovery is impossible, and a long
duration of life improbable.
Treatment.—To arrest danger to the patient from a further escape
of blood, ice-bags should be applied to the spine as soon after an attack
as possible, and large doses of ergotine should be given by the mouth or
hypodermically. The patient should be placed in a horizontal posture,
and absolute rest and quiet should be insisted upon. All undue excite-
ment should be carefully guarded against. The subsequent treatment
does not differ materially from that already recommended for myelitis.

~ SPINAL MENINGEAL HEMORRHAGE.
(Hematorrhachis.)

This morbid condition is not commonly encountered. It is more
frequent among males than females. It may be secondary to a spinal
apoplexy which has perforated the pia, or to an aneurism.

Etiology.—No cause can be discovered in some cases. In others, a
history of traumatism, tuberculosis or cancer of the spine, violent
excitement, suppressed menstruation, cardiac hypertrophy, attacks of
spasmodic diseases, purpura, a hemorrhagic diathesis, some infectious
disease, or the presence of an aneurism (which has at last burst into the
spinal canal), may be detected. It may occur in the infant from the
use of forceps. A cerebral hemorrhage has been known to be  suf-
ficiently severe to flow into the spinal canal.

Symptoms.—These are dependent upon the extent and seat of the
hemorrhage. They are largely due to irritation or compression of the
spinal nerve-roots at first, and possibly, later’on, to spinal compression
or myelitis.

The character of the onsct depends to a great extent upon the
rapidity of the effusion. A large clot will cause at once very severe
shooting pains in the back and the limbs, with more or less muscular
twitchings, cramps, spasms and rigidity.

The onset is unaccompanied by fever; and the paralysis and anas-
thesia are not very pronounced at first. On the second or third day
reactive fever sets in to a moderate extent.

There is apt to be a“ cincture feeling ” around the chest or abdomen.

If the bladder or rectum show any impairment, or when bed-sores

occur, it indicates that the spinal cord is compressed.
Whenever the nerve-roots become seriously impaired by pressure
of the clot, the functions of motion or sensation, as well as the spinal
reflexes and the electrical tests of nerves and muscles begin to show a
progressive deterioration. ;

Prognosis.—This disease lasts from two weeks to an indefinite
period. It is possible for death to occur from shock, soon after the
428 LECTURES ON NERVOUS DISEASES.

onset, provided the clot be near the medulla. Spinal hemorrhage may
induce a complicating meningitis ; and the extension of this inflammation
to the medulla may cause death. Permanent paralysis and atrophy of
muscles may be induced by pressure upon the anterior nerve-roots,
although the spinal cord may have entirely escaped injury.

The published records of these cases go to show that quite a large
percentage tend to ake a recovery without any very serious impairment
of motion or sensation.

Treatment.—This is similar to that given for spinal apoplexy.

MYELITIS.

Inflammation of the substance of the spinal cord has been partially
studied already under the heads of two systematic spinal diseases, viz.:
poliomyelitis anterior, and central myelitis.

We now approach the consideration of structural changes in the
cord of an inflammatory type which assumes the character of a focal or
“non-systematic ” spinal disease.

We shall discuss this morbid condition as of two varieties, the acute
and chronic.

ACUTE MYELITIS.

This disease may be primary or secondary. It is comparatively a
rare affection; more frequent in males than in females, and is generally
observed during middle life.

Etiology.—The causes of this disease vary with its type; although
a predisposition to it may be engendered by excesses in alcohol, bad
hygiene, overwork, venereal excesses, and exposure to dampness.

The primary variety may be developed as the result of rheumatism,
traumatism to the spine, severe emotional excitement and certain poisons.
Among the latter causes, lead, arsenic, mercury, phosphorus, alcohol,
and carbonic oxide have been known to induce it. Some of these
poisons may be taken into the system while following certain manu-
facturing pursuits.

The secondary variety may be induced by diseases of the vertebre
and the spinal meninges; either by extension of inflammatory processes
or as the result of compression of the cord. Again. it has been known
to follow pneumonia, phthisis, syphilis, diphtheria, pyzmia, the eruptive
fevers, and malarial poisoning.

Morbid Anatomy. — Myelitis of the acute form most commonly
attacks the dorsal segments; occasionally the cervical and lumbar
enlargements of the cord. The extent and seat of the inflammation
varies. It may attack the central gray matter (central myelitis); again,
it may traverse the entire spinal segment (transverse myelitis); finally,
ACUTE MYELITIS. 429

it may be distinctly circumscribed and contined to one lateral half of the
cord (circumseribed myelutis).

A very rare condition, known as “ pertmyelitis” or “myelo-
meningitis (in which only the periphery of the cord is inflamed) has been
observed.

The appearance of spots of myelitis must not be confounded with
post-mortem changes which are commonly detected during the warm
months in subjects which have been kept some time,

When myelitis is present, we may encounter the sewnatedee
appearances of red, white, or yellow softening. These have been
described in connection with the brain (page 317).

The formation of a distinct abscess of the cord is sometimes
observed in myelitis of the acute form. It is most often found in
pyemic and traumatic cases. i

The meninges, especially the pia, are generally more or less reddened,
softened, and infiltrated with pus. The nerve-roots may be markedly
swollen and appear redder than normal. Finally,evidences of ascending
or descending spinal degeneration (see Fig. 92) are generally to be
detected.

Symptoms.—The onset of an acute myelitis may or may not be
preceded by prodromata. If so, they are poorly defined and are those
of slight febrile disturbance.

The onset may be accompanied by convulsions in children; and, in
adults, by a chill and marked fever.

Within a short space of time the patient: begins to notice abnormal
sensory symptoms, such as pain in the back, a cincture feeling around
the chest or abdomen, formication and shooting pains in the limbs,
pains in the joints or cardialgia. The pain in the back is not increased
by movement, unless a spinal meningitis coexists.

The muscles may exhibit twitchings or temporary contractures
early. The bladder may be affected almost: from the onset; causing
either retention, overflow, or incontinence of urine.

Later in the disease, paralysis of the muscles of a complete or
partial character develops. Complete anesthesia may be observed in
other parts.

The muscles begin to waste rapidly whenever the anterior horns of
the spinal gray matter are attacked ; and the “reaction of degencration ”
is then developed in the nerves and muscles associated with the spinal
segments thus affected.

Tf the muscles of the abdomen or chest are paralyzed, respiration
becomes markedly interfered with, and slight pulmonary complications
become a source of danger to the patient. Asphyxia develops suddenly
when the phrenic nerve-roots are attacked.
430 LECTURES ON NERVOUS DISEASES.

In some cases delayed sensation (page 398) is observed. In rare
instances, circumscribed stimulation of the skin, as in the case of a pin-
thrust, is followed by a vibration of the limb. This is known as
“ dysasthesia.”

The vaso-motor nerves generally give clinical evidence of their
impairment quite early in the disease. The paralyzed limb may cease
to perspire. The joints may swell from cedema, and become cold and
peculiarly pale. Eruptions may develop, usually of the vesicular type.
Over the bony points which sustain the weight of the patient, the skin
is peculiarly liable to become reddened, and to undergo a rapid form of
gangrenous destruction. We encounter bed-sores of this type chiefly in
the region of the sacrum, and over the trochanters, malleoli, and the os
calcis.

Cerebral symptoms are generally absent. In rare cases, atrophy of
the optic nerve has been observed.

The urine may become ammoniacal, bloody, albuminous, and sac-
charine. Indications for regular catheterism are often clearly pro-
nounced. Involuntary evacuations of the bowels may follow a paralysis
of the sphincters.

The condition of the reflexes varies with the seat and extent of the
lesion. Ifthe lateral column is alone affected, they will be exaggerated.
If the “reflex arc” (Fig. 34) is injured anywhere in its course, they
will be decreased or abolished.

Diagnosis.—Acute myelitis is apt to be confounded with spinal
meningitis, spinal apoplexy, spinal meningeal hemorrhage, hysterical
paralysis, and multiple neuritis.

From the first three of these diseases, the distinguishing points are
clearly shown in a diagnostic table on page 426.

From true hysterical paralysis, without organic spinal changes,
acute myelitis is to be told by its rapid course, its febrile symptoms, its
bladder and rectal complications, its trophic disturbances, and the sex
affected.

From multiple neuritis, myelitis is to be differentiated in many cases
by the absence of severe pains in the limbs, an imperfect history of
excess in alcohol, the pain in the back, and the retention of normal
electrical formule, both of nerves and muscles. In a few cases, the
diagnosis is difficult. While it is not always easy to make the distine-
tion, it must be remembered that bed-sores and a disturbance of the
bladder and rectum are peculiarly characteristic of myelitis.

Prognosis.—If the myelitis is not of the hemorrhagic variety,
the duration of the acute form is usually from one to several weeks.
The patient may die of ammonizmia, septiceemia, pyemia, exhaustion,
paralysis of the respiratory or cardiac centres, or some pulmonary
CHRONIC MYELITIS. 431

complication (chiefly pneumonia). Some patients pass into a subacute
or chronic variety of myelitis. A few are said to have recovered
completely.

Treatment.—The steps indicated in connection with the treatment
of spinal meningitis are applicable to that of myelitis.

CHRONIC MYELITIS.

_ Under this head some authors place all inflammatory conditions of
the substance of the spinal cord which are focal in type, run a pro-
tracted course, and are unattended with febrile symptoms. Some of’ the
“systematic ” diseases already described are but special forms of chronic
myelitis; as, for example, primary lateral sclerosis, locomotor ataxia,
amyotrophic lateral sclerosis, poliomyelitis anterior acuta, ete. .

Etiology.— A congenital or acquired hereditary predisposition to
this form of myelitis is more pronounced than in the acute variety.
The exciting causes are similar to those of the acute form of the disease.

Morbid Anatomy.—The eye will usually detect a flattening or
depression of the spinal cord, with an unnatural firmness of its substance,
at the seat of the disease. The pia may be adherent over the diseased
area; and it, as was the dura, may be markedly thickened. In
exceptional cases softening of the cord is observed; possibly, also, the
formation of cavities in its substance (syringomyelia) may be detected.

The microscope will usually show an increase of Deiter’s cells,
which are often enlarged and present numerous nuclei; a marked
increase of the neuroglia; a thickening of the coats of the blood-
vessels; a dilatation of the lymphatic sheaths of the blood-vessels ; an
enlargement of the axis-cylinders (chiefly at the periphery of the lesion);
a disappearance of the medullary sheaths; and the presence of granulo-
fatty cells.

Chronic myelitis may in exceptional cases be confined to one lateral
half of the cord. It more often tends to spread transversely to both
jateral halves. It may also assume a multiple form.

The abdominal and thoracic viscera may exhibit evidence of existing
somplications of myelitis.

Symptoms.—These are modified somewhat by the seat and extent
of the lesion,—a statement which is true of all focal spinal lesions. In
a general way, they resemble those of the acute variety of myelitis, save
in the fact that their approach is more gradual and unattended with
‘fever.

Hyperesthesia, numbness, formication, and occasional severe pains
in the limbs are commonly observed. These are followed or accom-
panied by a steadily increasing weakness of the lower limbs, usually
associated with imperfect micturition and defecation.
432 LECTURES ON NERVOUS DISEASES.

Paraplegia is more frequent than unilateral paralysis in this disease.
Whenever the lateral column of the cord is attacked, the gait of spastic
paralysis may be induced (p. 163), We are particularly apt under these
circumstances to encounter, in addition to the progressive paresis of the
legs, contracture, muscular spasms, and exaggeration of the tendon
reflexes.

The later symptoms of this affection are similar to those of the
acute form already described. In some instances, “ bulbar symptoms”
(p. 384) may be added to those already mentioned.

Diagnosis.— All forms of paraplegia must be differentiated from
each other. Whenever this symptom is clinically encountered, the
differential tables given on pp. 422 and 426 will assist the reader in doing
so; and the light thrown upon the symptomatology of diseases of the
spinal cord in the first section, together with the general remarks on
“focal” spinal lesions will aid in localizing the exact seat of the lesion
which has induced paralysis.

It is very important in all focal spinal lesions (1) that the exact
limits of both the motor and sensory paralyses be accurately mapped out
in each individual case; and (2) that the vertical extent of the lesion be
determined by testing each of the spinal reflexes. This can be done by
the methods already described in Section II of this work. Those only
are abolished which depend upon a reflex arc in the diseased segments.
If a bed-sore develops it is clinical evidence, as a rule, that the nerves
which supply that particular area of skin are involved directly in the
spinal lesion.

Prognosis.—Syphilitic cases may make a complete recovery; pro-
vided treatment be begun before spastic symptoms become developed.
The course of the other varieties of chronic myelitis is very protracted
(often ten to twenty years), but is usually fatal.

Treatment.—The treatment suggested for spinal meningitis is
applicable to this disease. Erb extols the effects of the “cold-water
cure” in Ziemssen’s Encyclopedia, and gives some directions for its use.
I have never tried it personally.

If spastic symptoms are prominent, ergot and the nitrate of silver
act better than strychnia, in my experience. When the paralyzed
muscles are relaxed and flaccid, strychnia, iron, arsenic, phosphorus and
quinine are of benefit.

I have obtained very beneficial results in several cases by the
withdrawal of heavy static sparks from the spine and the paralyzed
muscles. This treatment certainly surpasses any other form of electrical
application. The machine must have large plates to generate suflicient
quantity to yield good results.
SYRINGOMYELIA AND HYDROMYELIA. 433

SYRINGOMYELIA AND HYDROMYELIA.

Cavities in the substance of the spinal cord muy exist either as a
congenital or acquired condition. Their extent, situation, and contour
vary in different cases. They usually contain a serous or hemorrhagic
fluid, and occasionally a hyaline material.

These cavities may be single or multiple. They are most common in
the posterior white columns of the cervical and dorsal segments of the
cord. They may be totally independent of the central canal of the cord,
but they usually communicate with it. The anterior horns are occasion-
ally found to be the seat of such cavities.

Morbid Anatomy.—The wall of these cavities
is generally composed of a firm fibrous tissue
(which is apt to be friable and highly vascular),
or of myxomatous tissue. Its inner surface may
or may not be lined with epithelial cells of the
cylindrical variety.

Acquired cavities may result from the soften-
ing and degeneration of clots or of spinal tumors
(chiefly glioma), and from spinal compression.
Chronic myelitis may possibly induce cavities
within the cord. Meningeal adhesions have been
considered by some authors as a possible factor
in their development.

Symptoms.—Large cavities in the cord may
exist without causing any symptoms during life.
If they are created by the morbid conditions
mentioned above, the symptoms will be those of
the exciting cause.

The situation of these spinal cavities being,
as a rule, confined to the anterior horns, the

Fic. 120.—CAVITIES WITHIN THE
central gray matter and the posterior columns — Sunstance or THE Sprvat

Corb, CONSTITUTING rHE Con-
of the cord would naturally suggest the Co-  bimon Known as “Svrinco-

existence during life of interference with the ae
sensory, vaso-motor, and trophic functions of the

spinal segments involved, as well as more or less atrophy of the muscles,
and possibly motor paralysis. The reported cases, where post-mortem
observation hag confirmed the diagnosis, seem to sustain such a
conclusion.

 

Among the abnormal sensory phenomena noted by various observers,
we find the following mentioned: Analgesia, an imperfect perception
of varying degrees of temperature, and occasionally anzesthesia and im-
perfect localization of touch-impressions. The seat of these abnormal

28
434 LECTURES ON NERVOUS DISEASES.

sensory phenomena depends upon the spinal segments attacked. (See
tables on pages 411 and 415.)

The abnormal trophic or vaso-motor phenomena may comprise any or
all of the following conditions: Eruptions (chiefly of the bullous type),
defective secretion of perspiration in some localized form, abscesses or
intractable ulceration, fragility or atrophy of bones, lowering of the
temperature of some parts, cyanosis, etc.

The abnormal muscular phenomena may comprise all the symptoms
enumerated when describing the clinical history of poliomyelitis.

Diagnosis.—This disease may be confounded during life with mul-
tiple neuritis, amyotrophic lateral sclerosis, poliomyelitis, multiple
sclerosis, and spinal tumors outside of the cord,

From multiple neuritis, it is told by the fact that impressions of
touch, temperature, and pain are not equally and simultaneously im-
paired, as they are when a nerve-trunk is undergoing extensive degenera-
tion. The history of the patient might also exclude the exciting causes
of neuritis.

From amyotrophic lateral sclerosis, this affection is told by its being,
as a rule, a unilateral spinal affection, and by the absence of the peculiar
rigidity of the muscles and the characteristic deformity of amyotrophic
spinal sclerosis. Moreover, the duration of life is much longer in
syringomyelia.

From poliomyelitis anterior, it differs in that sensory symptoms
generally coexist with paralysis and atrophy, and also in that the vaso-
motor and trophic disturbances are quite marked.

From multiple spinal sclerosis, it may be told by the absence of
tremor, and the limited number of spinal segments involved in syringo-
myelia.

From spinal tumors, pressing upon one lateral half of the cord, this
disease is to be distinguished chiefly by the absence of all symptoms
pointing to an implication of the vertebra.

Prognosis.—Syringomyelia seems to follow a somewhat uncertain
course. It may progress slowly, or become stationary for long periods
of time. Occasionally it causes a sudden fatal termination.

FUNCTIONAL DISEASES OF THE SPINAL CORD.

In a preceding table (p. 850) we have included under this head the
conditions of spinal irritation, functional paraplegia, spinal neurasthenia,
writers’ cramp or paralysis, and tetany.

Some of these will be discussed under the general head of functional
nervous disease, to whose special consideration the sixth section of this
work will be devoted. Others demand some passing notice in this.
section.
SPINAL IRRITATION: 435

SPINAL IRRITATION.
(Anzemia of the Posterior Columns.)

Notwithstanding the opinions of many writers to the contrary, it is
questionable to my mind whether it is proper to regard this condition as
a special form of disease. The symptoms which are generally enumer-
ated under this head are very often nothing more than manifestations of
the hysterical or neurasthenic states. It is probably a purely functional
derangement, and affects young adults (from fifteen to thirty-five years
of age), chiefly of the female sex.

Etiology.—F or information on this subject, I would refer the reader
to my remarks relating to the causes of neurasthenia and hysteria.

Symptoms.—Pain in the region of the spine and marked tenderness
over the spinous processes of the vertebra and adjacent skin are the
prominent symptoms of this affection.

The pain is of a most distressing kind, usually described by patients
as a severe “ache.” It is very commonly experienced between the
shoulder-blades and in the lumbar region; but it may extend into the
thighs and down the area of distribution of the sciatic nerves.

Nausea and vomiting may coexist with tenderness confined to the
cervical spines.

The hyperesthesta is often of an extreme kind. It exists over the
vertebral spines. The slightest pressure along the spine may call forth
evidences of acute suffering on the part of the patient.

The general health is usually below par. The urine may be loaded
with phosphates, the digestive functions poor, the eyes asthenopic, and
the mental condition sluggish and apathetic.

No evidences of impairment of motility are observed, nor is there
any anesthesia. The bladder or rectum is never paralyzed.

Treatment.—The reader is referred to my remarks on the treatment
of spinal neurasthenia and hysteria.

FUNCTIONAL PARAPLEGIA.

The lower limbs may sometimes be paralyzed without an organic
cause, We encounter this condition chiefly in women and children,

Etiology. Among the causes of this condition may be mentioned
hysteria, anemia, blood poisons (malaria, lead, arsenic, phosphorus,
ergot, alcohol, etc.), ovarian irritation, phimosis, and many other forms
of reflex irritation. I believe that “ eye-strain ” is a factor in these cases
too commonly overlooked.

Symptoms.—When hysteria exists, Drummond thinks that an in-
sensibility to pain, but not to touch or temperature, is peculiarly char-
acteristic. Duchenne, on the other hand, regards the loss of muscular
436 LECTURES ON NERVOUS DISEASES.

sensibility as of great diagnostic importance. Todd has describe
certain facial changes (p. 170) as of value in recognizing this condition

Reynolds has described a type of functional paraplegia “ dependen
purely upon idea,” in which the patient is strongly impressed with th
fact that voluntary movement is impossible. He claims that this stat
is not necessarily hysterical.

In malarial paraplegia, the paralysis is said to be intermittent ir
type. I have never observed a case of this kind.

In reflex paraplegia, the bladder, external genitals, urethra, ovaries
and the eye may act as the exciting cause.

In alcoholic paraplegia, the symptoms of “ multiple neuritis” are
apt to be encountered ; hence this condition is not purely functional in
many cases. Pains in the limbs and the coexistence of the “ reaction of
degeneration ” (p. 189) are diagnostic of the latter condition.

Treatment.—The removal of the cause and steps judiciously directed
toward the improvement of the general health are indicated. Electricity,
massage, tonics, etc., are beneficial. In my opinion, a correction of
“ eye-strain ” will generally prove of immediate service to a large pro-
portion of adult cases.

WRITERS’ CRAMP.
(Professional Cramp ; Mogigraphia; Graphospasm ; Chetrospasm.)

Writers, pianists, violinists, telegraphers, the counters of paper
bills, ete., often become unable to pursue their vocations from a peculiar
form of weakness and pain, ora tendency toward sudden spasm of the
muscles of the hand and forearm.

Etiology.—Any occupation which requires incessant use of a certain
set of muscles of the forearm or hand may lead to this distressing con-
dition. It is doubtful to my mind if injuries, sprains, or exposure to
cold ever induced this morbid state. - I regard causes of that character
as mere coincidences. ,

Symptoms.—This condition develops gradually. The patient feels
at first a peculiar sense of distress or ‘fatigue in performing for any
length of time the vocation which has induced it. This sense of distress
may be in the fingers or forearm. It is accompanied sooner or later by
a peculiar awkwardness in the finger-movements, a sense of stiffness in
the fingers, or a tendency to uncontrollable spasm of the fingers when
these acts are persisted in.

Gradually these symptoms increase in severity. The fingers become
more and more uncontrollable when used by the patient in lis vocation.
For example, when writing, the pen may be flung from the hand or
pressed violently upon the page. A pain becomes marked along the
arm, often as highas the shoulder. After ceasing all attempts at writing,
TETANY. 437

the limb affected may feel relieved by rubbing it and kneading the
muscles for some time. In many cases, the vocation which has occa-
sioned the cramp has to be abandoned.

Strange as it may seem, these patients can use their affected hand
for any other purpose with their accustomed facility. I have seen cases
where the patient could draw for hours but could not write for one
minute without distress. Some sufferers learn to use the left hand, so
as to.avoid using the afflicted member. If the left hand is then over-
taxed, the condition tends to become bilateral.

This disease is very persistent, after it is well-developed. I per-
sonally suffered from it for many years; and am still unable to write
continuously with a pen for any length of time without severe distress,
T can use a type-writer, however, for hours without the slightest symptom
of cramp.

Respecting the morbid anatomy of this disease, many theories have
been advanced. Althaus regards it as an exhaustion and abnormal
irritability of the codrdinating centres in the upper part of the cord.
Some authors consider it an affection of the muscular system only or of
the terminal plates of the nerves. Ross claims that he can locate the
disease by the electrical reactions of the affected muscles. He places it
in the ganglionic spinal cells, when the reactions are diminished; and in
the cortex, when the reactions are intensified.

Treatment.-—Entire rest from the occupation that causes distress is
the first step in the treatment. This must be ensured for many months,
if possible,

Some patients who cannot do this are benefited by wearing a rubber
band around the forearm; others by holding the pen in an unusual way ;
afew, by employing a‘cork pen-holder of an extreme size (often over an
inch in diameter); while many have recourse to a type-writer for corre-
spondence.

Showering the arm in hot and cold water alternately, and using
friction, percussion of the affected muscles, and massage (Wolft’s
method) after the water application is often very beneficial.

Blisters and the actual cautery over the median nerve is of service
in many cases. It must be kept up for some weeks

Static sparks to the cervical spinal segments and to the affected
forearm and hand often give immediate relief.

TETANY.

This condition is characterized by paroxysms of tonic muscular
spasm confined to groups of muscles. It is also known as “ intermittent
tetanus” and ‘intermittent cramp.”

The upper extremities are most often attacked. Generally the
438 LECTURES ON NERVOUS DISEASES.

spasms are bilateral in character. In exceptional cases they may be
unilateral. Sometimes the spasins are confined to the legs, and occa-
sionally the muscles of the back, thorax, and-abdomen may be involved.
Cases where the attacks have been general in character, affecting the
limbs, trunk, and even the face, have been reported.

Etiology.—This disease is most frequently encountered in children
at the time of dentition, and at the age of puberty. It is rare in
advanced life.

Heredity seems to be apparent in some cases. Several of one
family have been so afflicted, according to Murdoch, and the researches
of Bouchut seem to show a history of neurotic affections in the ancestral
line of many so afflicted.

A state of low vitality is generally present in these subjects. Rickets,
acute infectious diseases, impaired digestive functions, etc., are among
the predisposing causes.

Among the exciting causes may be mentioned a marked exposure to
cold or dampness, rheumatism, peripheral irritation of all kinds, and
violent mental excitement.

Morbid Anatomy.—Little is positively known respecting the morbid
changes which probably exist in the nerves or the nerve-centres. Weiss
believes that diseases of the sympathetic system exists and induces
circulatory changes in the spinal cord.

Symptoms.—These may be grouped into two classes, the prodromal
and the actual.

The prodromal symptoms may include pains in the limbs, formica-
tion, coldness of the extremities, vertigo, a sense of confusion in the
head, and tinnitus aurium. They may exist for days or weeks prior to
the attack. .

The symptoms of an attack may occur after mental excitement or
excessive muscular effort. They may occur at night or during the day.

When the upper limbs are attacked, the flexors of the fingers
(usually of each hand) and also the flexors of the wrist cause the
attitude of the hand to assume a position which Trousseau very aptly
compares to that of an obstetrician when about to pass the hand into
the vagina. Occasionally the forearms are flexed, and the arms are
drawn to the chest to an extent suflicient to cause a crossing of the
distorted hands over the epigastrinm. In very exceptional instances
the spasm is unilateral and the extensors may be attacked. During the
paroxysm the muscles are very prominent and firm, and are sensitive to
pressure,

When the lower limbs are attacked the foot is distorted at the ankle by
spasm of the calf-muscles, the leg is extended upon the thigh, the big toe
is drawn beneath the adjacent toe, and the thighs are strongly adducted.
TETANY. 439

When the trunk is attacked the back muscles may cause opis-
thotonos or pleurosthotonos. Again, the spine may be bent anteriorly.
The chest-muscles may cause disturbances of respiration of an alarming
kind. The muscles of the neck may create cyanosis, prominence of the
jugulars, and protrusion of the eyeballs.

During the paroxysm the contractures may be partially overcome
by a voluntary effort, but the deformity returns at once when the effort
issuspended. The contractures may even persist during sleep. Fibrillary
contractions are often observed during the paroxysm.

The duration of the attacks varies from a minute to several days.
They may return with great frequency or at long intervals.

The attacks are not excessively painful, as a rule. They are
generally accompanied by a sense of tingling, formication, coldness, or
slight neuralgic pains of a shooting character. Fever and sweating may
be observed in some cases.

Trousseau lays much stress upon the diagnostic importance of a
test to be employed during the intervals between the paroxysms, which
consists in the ability to enduce these attacks at will by pressing upon the
arteries or nerve-trunks of the arm. After such pressure of two or more
minutes the spasm occurs. It rapidly disappears when the pressure is
removed. The same test can be applied to the crural artery and the
sciatic nerve, but with more uncertainty.

The electrical irritability of the affected motor nerves is markedly
increased. The nerve responds to abnormally weak faradaic currents.
Applications of galvanic currents to the nerve-trunk by the polar
method show the following conditions: C.C.C. and A.O.C. occur very
early; cathodal-closure-tetanus and anodal-closure-tetanus are rapidly
developed ; finally, anodal-opening-tetanus is produced in almost. every
case with ease, and cathodal-opening-tetanus in some cases,

Diagnosis.—This disease may be confounded with tetanus, hys-
terical contractures, and ergotism.

In tetanus, there is an inability to use the muscles of mastication,
more pain, a traumatic history, and a general rigidity and abnormal
posture of the limbs and trunk.

In hysterical contractures, the test of Trousseau is inoperative, there
is no increase of the mechanical and electrical irritability of motor
nerves, children and males are seldom attacked, and the history of the
case is suggestive of hysteria. :

In ergot poisoning, the history of the case would point clearly to the
exciting cause of the attacks.

Prognosis.—These sufferers usually recover perfectly after a lapse of
time. The disappearance of Trousseau’s phenomena, and the abnormal
irritability of the motor nerves, is indicative of a favorable change in
440 LECTURES ON NERVOUS DISEASES.

the patient. Recurring paroxysms are to be anticipated for some
months after the first attack.

Treatment.—If a history of rheumatism or a rheumatic tendency
_can be elicited, it is well to give iodide of potassium, salicylic acid, or
the oil of wintergreen. Ice-hags, wet-cupping, and blisters to the spine ;
the application of the actual cautery, and galvanism to the spine have
been recommended by different authors,

The general health of the patient should be restored by all judicious
means. Tonies, massage, good hygiene, nutritious food, stimulants in
moderation, and moderate exercise will conduce toward that end.

Among the electrical applications, static sparks to the limbs and
spine, general faradization, the polar action of the anode to tender
points applied by the stabile method, and labile applications of the
anode to the peripheral nerves (stroked slowly from the distal extremity
of the nerve toward the proximal end) have proven of service in many
cases.

TIIOMSEN’S DISEASE.
(Myotonia Congenita—Congenital Dluscular Spasm.,

In this disease, a tendency of the muscles to tonic spasm during
attempts at voluntary movement is the characteristic feature.

By such spasms, the execution of intended movements of the limbs
is always more or less delayed, and sometimes entirely prevented.

This disease is also known as “ Myotonia Congenita,” because it is
seldom, if ever, observed except in patients who are not predisposed to
it by heredity. Dr. Thomsen, who first described this affection, noted
its occurrence in five generations of his own family. He suffered from
it himself, as did also one of his sons. A very complete monograph on
this subject has been published by Erb, who has collected and analyzed
all cases reported to that date. Jacoby and Dana have lately added to
the literature of this affection. .

Etiology.—As has already been stated; heredity plays a very im-
portant part in this disease. In one reported case, fright seems to have
acted as an exciting cause. It is questionnble, however, if this disease
ever occurs without some congenital defect either in the spinal cord or
in the muscles themselves. A late monograph upon this subject by
Dr. G. W. Jacoby seems to show conclusively that muscular anomalies
were present in the case reported by him.

Morbid Anatomy.—Although this disease has been classed by me as
a functional disease of the spinal cord (because no spinal changes have
ever been shown to exist in connection with it), it must be said that the
muscles appear to show characteristic conditions which are probably
congenital. The individual muscular fibres are greatly augmented in
THOMSEN’S DISEASE. 441

point of size, and the number of their nuclei is in excess of that observed

‘in healthy muscle.

The muscles are generally unnaturally large in this disease. This
gives to the patient an appearance of strength, which is in marked
contrast to the actual power of contraction which the patient possesses.
The anomalies of muscular construction which have been referred to
necessarily add to the size of each individual muscle. But, on the other
hand, such a muscle appears to be more liable to become tetanic when
called into play by the act of will. .

Symptoms.—Typical cases of this disease exhibit in very early
youth, to a moderate degree, the disorder of movements, which becomes
more pronounced later in life. A history of a similar affection can be
found upon inquiry to have existed in some of the patient’s ancestry.
After a period of rest the patient experiences a peculiar tension and
stiffness of the muscles when any voluntary movement of the limbs is
attempted. This stiffness may be so marked in some cases as to com-
pletely arrest. the intended movement for a time. It gradually dis-
appears, however, and, by the aid of continued movements, the patient
after a time regains complete control over his muscles.

In addition to this peculiar muscular state, the patient is also
rendered unable to voluntarily relax the muscles quickly.

The muscles of the lower limbs are more frequently affected than
those of the upper. In some cases, the muscles of the tongue, face, eyes,
and also those of mastication, are affected. Involvement of the tongue
by spasms of this character gives rise to a peculiar hesitancy in speech.
Awkwardness in the mastication of food is observed whenever the
muscles which move the lower jaw are attacked.

When the muscles of the lower limbs are affected with this disease
the patient is very apt to experience great difficulty in attempting to
rise and walk, after a prolonged recumbent or sitting posture. Such sub-
jects have been known to fall as soon as efforts to walk were attempted.
Fibrilary contractions of the muscles may occasionally be detected.
Continued movement and the application of heat tend to diminish the
spasm, while mental excitement and cold usually aggravate it.

Again, the muscles in these patients show an abnormal excitability
to mechanical and electrical stimuli. Artificially produced contractions
are apt to be very much prolonged. Erb describes peculiar “ wave-like
contractions” in the muscles of the limbs, whenever galvanic currents
of sufficient intensity are employed upon the patient by the stabile polar
method. These contractions, according to this author, always tend to

pass toward the anode. After a time they subside “like waves of water

produced by a falling stone.” Any increase of the strergth of the
current, however, tends, as a rule, to reproduce them.
449, LECTURES ON NERVOUS DISEASES.

To test this reaction in the upper extremities, one pole may be
placed at the nape of the neck and the other in the palm of the hand or
at the annular ligament of the wristjoint on its palmar aspect. To test
it in the lower extremity, one pole should be at the neck and the other
may be placed adjacent to the patella or upon the tendo-Achilles. The
strength of the current employed varies from six to twenty milliampéres.
Jacoby has observed an absence of any fixed relationship of Ca.C.C.
and An.C.C, to each other, as exists in healthy muscle (page 190).

The duration of this disease is limited by the life of the patient;
although remission and exacerbations have been described by different
observers.

Diagnosis.—This disease is to be distinguished from muscular
hypertrophy by the presence of the spasms, and the peculiar electrical
phenomena already described. The reflexes give evidence, also, of an
unusually prolonged muscular response.

Treatment.—Gymnastic exercises, warm baths, and judicious electri-
cal treatment may possibly afford some relief.

ACUTE ASCENDING SPINAL PARALYSIS.
(Kussmaul-Landry’s Paralysis.)

This disease, as far as we at present know, is not associated with
anatomical changes in the nervous system. It consists of a tendency
toward progressive paralysis, which slowly creeps from below upward
in a more or less irregular way. There is an absence of atrophy; and
no sensory or trophic disturbances are observed. There is no paralysis
of the bladder or rectum. The irritability of the paralyzed muscles is
retained.

Etiology.—This disease is a rare one. It is more common among
males than females; and, as a rule, it affects middle life.

Its exciting causes are very obscure. It has been observed to follow
mental excitement, exposure to cold, suppressed menstruation, acute
infectious diseases, coitus in the standing posture. The syphilitic history
may be detected in a certain proportion of persons so afflicted.

Morbid Anatomy. — Little if anything is known respecting the
changes which occasion this disease. Westphal concludes from his
investigations that it is the result of some unknown infection; because
he detected changes in the intestinal follicles and the mesenteric glands
in a numher of cases.

Symptoms.—The paralysis may develop suddenly; or it may be
preceded by slight fever, pain in the back and limbs, tingling and other
forms of abnormal sensation. The paralytic symptoms do not always
follow a strictly ascending course. They may begin in one or both feet
and then skip to the upper extremities, the neck, chest, or abdomen.
ACUTE ASCENDING SPINAL PARALYSIS. 443

This, however, is not always the case. In rare instances, the impairment
of motion has apparently pursued a descending course; and, in one case
reported by Westphal, the nuclei of the medulla were alone iunplicated
and * bulbar” symptoms appeared at the onset.

In most cases, a paresis first appears; this subsequently deepens
into complete paralysis. A sense of fatigue in the limbs is first noticed
by the patient, and walking soon becomes extremely difficult. For this
reason these patients usually take to bed early.

When the back muscles become paralyzed, it is impossible for the
patient even to sit up. Paralysis of the muscles of the abdomen renders
coughing, sneezing, expiration, defecation and micturition difficult.
When the intercostal muscles are paralyzed, inspiration is seriously
disturbed, and the most marked difficulty in breathing may occur when-
ever the phrenic nerve becomes affected. Sooner or later the movements
of the upper extremities are rendered difficult or are totally lost.
Whenever the medulla is implicated, speech becomes very much impaired,
and the act of swallowing may be attended with great difficulty. It is
very rare to observe any paralysis in the nerves of cerebral origin,

No atrophy is detected in the paralyzed muscles, and they retain
their normal irritability to electrical stimulation.

In very exceptional instances only do the sensory functions give
any evidence of serious impairment. Cases have been reported, however,
where the sensations of pain and temperature have been imperfectly
conducted, and where the muscular sense has been somewhat diminished
Anesthesia and hyperesthesia have also been observed, There seems
to be a tendency to diminution or abolition of the skin and tendon
reflexes late in the disease.

In some cases a marked enlargement of the spleen and clinical
evidences of albuminuria have been detected.

Diagnosis.—This disease may he confounded with an ascending
myelitis, poliomyelitis anterior acuta, and acute multiple neuritis.

From myelitts of the ascending type, it may be recognized by the
absence of fever and sensory disturbances, by the fact that bed-sores
do not occur, and by the non-occurrence of vesical and rectal com-
plications.

From poliomyelitis, it may be told by its progressive character, and
the absence of rapid atrophy in the paralyzed muscles. The “ reaction
of degeneration ” is present in poliomyelitis ; while it is generally absent
in ascending paralysis.

From acute multiple neuritis, it differs in that marked pain and
sensory disturbances are usually absent, and in the fact that the affected
nerves and muscles do not rapidly lose their irritability to electricai

_ currents.
444 LECTURES ON NERVOUS DISEASES.

Prognosis.—This disease usually runs an acute and progressive
course; hence the prognosis is naturally grave, although recovery has
been observed. The development of “bulbar” symptoms generally
indicates the approach of a fatal termination. The more rapid the
development of paralysis of a complete kind, the more serious is the out-
look for the patient. The duration of the disease is generally a short
one. It may prove fatal in from four days to as many weeks.

Treatment.—If the disease can be shown to be connected with any
of the clinical manifestations of syphilitic infection, the remedies sug-
gested on page 291 should be administered. It is well to make use of
the actual cautery, dry cups, or ice-bags to the spine. The internal
remedies suggested by authors comprise the iodide of potash, full doses
of ergot, belladonna, and strychnia, The galvanic current may be applied
to the spine, preference being given to the polar action of the cathode.

ABNORMAL VASCULAR CONDITIONS OF THE SPINAL CORD AND ITS
COVERINGS.

Under this head I have included, in a previous table, spinal con-
gestion, spinal ansemia, spinal embolism, atheroma of the spinal vessels,
fatty degeneratian of the vascular coats, and aneurismal dilatations.

Of these, only the first two can be described as conditions which are
clinically recognized. The other four are pathological states which tend
when present to induce structural changes within the substance of the
spinal cord. They are more directly concerned, therefore, with the
etiology of organic spinal diseases than with their symptomatology.
One form of spinal anzemia has been already considered under the head
of ‘ spinal irritation.”

SPINAL CONGESTION OR HYPERMIA.

The distinction between congestion and hyperemia is one of degree
rather than of kind. In both conditions we encounter dilatation of the
vessels with an excess of blood. In hyperemia, the current is unusually
rapid; in congestion, it is unnaturally slow.

Clinically, the line of distinction between hypersemia and inflamma-
tion is very difficult, if not impossible, to draw. One may be simply
a precursor of the other. As the vessels of the pia are the chief
sources of supply to the spinal cord, hyperemia of the cord and me-
ninges usually go hand in hand. Its symptoms must, therefore, be of
necessity closely allied to those of spinal meningitis and myelitis.
When the pia is diseased, the spinal cord is almost invariably affected
simultaneously to a greater or less degree.

Etiology.—A sudden checking of the perspiration by draught of cold
air, bathing, etc., is generally regarded as tending to excite this condition.

 
SPINAL CONGESTION OR HYPERZMIA. 445

Excessive fatigue, violent excitement, unnatural indulgencies in
venery, suppression of the menstrual discharges, the effects of com-
pressed air, prolonged physical or mental exertion, blows and falls, ete.,
have also been mentioned by some authors as apparent causes of spinal
hyperemia.

Personally, I am inclined to believe that most of the symptoms
usually attributed by authors to this morbid state are dependent upon a
neuropathic tendency whose exciting causes will be discussed in full in
the section which relates to functional nervous diseases.

Symptoms.—These are to be attributed in a general way cither to
irritation or a state of depression of the spinal functions. They may,
therefore, vary with each case, and closely simulate the first symptoms
observed in spinal meningitis, spinal tumors, and myelitis.

Hammond, Browne-Séquard, Radcliffe, Ollivier, and others, who
have written upon this condition, describe among the symptoms many
clinical features which, in my opinion, are not always distinguishable
from those occasioned by the organic diseases mentioned. Thus, for
example, pain, disturbances of motility and sensation, the cincture-
feeling, a lowering of the temperature in parts below the lesion, inter-
ference with breathing and the action of the heart, a loss of control of
the bladder and rectum, a diminution of the electro-muscular con-
tractility, the development of bed-sores, etc., are what we are apt to
observe whenever the spinal cord is subjected to irritation or when its
functions are in any way interfered with. The clinical history of each
case, combined with prolonged observation of the patient, can alone
enable us to exclude organic spinal changes.

Respecting the pain of spinal congestion, it is claimed that the
recumbent posture increases it; and also that the standing posture adds
to the distress when the congestion is localized in the lower spinal
segments. This is attributed to the effects of gravity. It is also stated
that a sudden blow or shock, as a false step, for example, adds to the
pain in the spine.

Anesthesia, or a sense of tingling and formication, may exist in the
feet (chiefly in the plantar surface of the toes) whenever the dorsal or
lumbar segments are locally congested.

Paresis of the legs, or actual paraplegia, may be developed. The
patient can usually move the limbs when sitting or in bed, although
they may be incapable of supporting the body.

According to Hammond, the symptoms of spinal congestion are
always more marked on rising than as the day advances.

Diagnosis.—This condition may be confounded with spinal anzemia,
myelitis, spinal meningitis and spinal tumors.

In spinal anemia, the bladder, when aftected, is impaired before the
446 LECTURES ON NERVOUS DISEASES.

development of motor weakness in the legs, while the reverse order is
observed in spinal congestion. UHyperesthesia is developed in place
of anesthesia and formication. The effects of a recumbent posture tend
to cause an improvement in the symptoms.

In myelitis, the urine is apt to become alkaline, irrespective of
decomposition from retention within the bladder. Moreover, the
paralysis is more decided, the development of bed-scres more frequent,
the cincture feeling is more decidedly marked, and the pain in the cord
is more severe.

In spinal meningitis, the tendency to muscular spasm, the pain on
movement of the spine and of the paralyzed limbs, the febrile symptoms,
the muscular twitchings, and the tendency toward muscular rigidity are
all in contrast to the symptoms of simple congestion.

In spinal tumors, the loss of motility is most marked upon one side,
and sensory disturbances (anesthesia) upon the other. There is also a
history of tubercle, cancer, or syphilis. The spinal symptoms develop
very gradually, as a rule,

Prognosis.—There is a tendency in all cases of spinal congestion for
the disease to progress along the cord. Moreover, the development of
structural disease of the cord is liable to be a result of excessive vascu-
larity. The prognosis is not unfavorable, if the case be one of a
localized type and unaccompanied by organic or inflammatory disease of
the cord or its membranes.

Treatment.—In cases of an acute character, where the symptoms
develop rapidly, leeching the anus will indirectly deplete the cord, and
dry-cups over the spine may also tend to relieve the congestion.
Hammond also suggests the daily use of three drachms of the sulphate
of magnesia in divided doses to cause watery stools, which require a
determination of blood to the intestinal canal.

irgot should be administered in large doses. I have given it in
doses of a drachm of the fluid extract after each meal for many weeks at
a time to patients without any symptoms of ergot poisoning. Bella-
donna, in doses of fifteen drops of the tincture, may be given with
benefit three times a day.

The employment of the hot douche to the spine—the water being
poured froma height of two feet upon the bare back for five minutes
daily—is highly recommended by Hammond.

Electricity is of service in the treatment of this disease. I prefer’
the withdrawal of static sparks from the spine to galvanism or faradism.
I have also employed the same treatment to the paralyzed muscles with
good results.

Strychnia and phosphorus are strongly contra-indicated, according
to Hammond,
SPINAL ANZZMIA. 447

SPINAL ANEMIA.

One form of this condition has already been discussed under the
head of “ spinal irritation.” This disease is believed by some observers
to depend upon an anemia of the posterior columns of the spinal cord.

Another varicty is thought to affect the antero-lateral columns of the
spinal cord (Fig. 91). If this condition be recognized as a distinct
disease, the symptoms will be of necessity connected with motility ; and
possibly with exaggerated reflexes, contracture, and atrophy. It will
also cover all of the so-called “ functional paralyses ” whose pathology is
now unknown.

_ I cannot express my full concurrence with these views; but, with
deference to those advanced by others, I shall here give the main features
of the disease as generally taught.

Etiology.— Extreme cold, sleeping on damp ground, exhausting
diseases, spinal embolism, thrombosis or atheroma, and interference with
the circulation through the abdominal aorta; from compression, throm-
bosis or aneurism of that vessel, may cause spinal anemia. Moreover,
the spinal vessels may be influenced to contract through the agency of
the vaso-motor nerves, as an indirect result of peripheral irritation from
any cause, such as the ovaries, intestine, genitals, eye-strain, injuries to
nerves, etc.

Symptoms.—The affected segments of the cord give evidence of
deficient blood-supply early by paresis of certain muscles. It is claimed
that the anterior tibial muscles and the peronei seldom escape. The
paresis rarely prevents walking, although the gait is generally feeble and
the patient’s endurance slight. The upper limbs are seldom paretic,

The sphincters of the bladder and rectum are seldom affected ; and
the paresis of the limbs is not usually progressive in type.

Sensory disturbances are infrequent. The cincture feeling is not
developed.

The reflexes may be normal or exaggerated slightly. They are
never abolished.

Prognosis.—If the exciting cause can be removed, the chances for
a complete recovery are good; if not, the spinal cord may undergo
softening.

Diagnosis.—The chief points, which relate to the discrimination -
between this disease and spinal congestion, have already been given
(page 445).

Treatment,—The utmost care should be exercised in ascertaining
the cause. My remarks concerning the effect of “eyestrain” in a
preceding section should be carefully considered, and all necessary tests
Should be made early to determine the condition of this organ and its
448 LECTURES ON NERVOUS DISEASES.

muscles. In the light of late researches made in this direction, I am
inclined to discredit the value generally placed by the profession upon
many of the other reflex causes enumerated, although more than one
cause may exist in any individual case.

The general treatment should be directed toward improving the
vitality of the patient.
SRL Vs

- FUNCTIONAL NERVOUS DISEASES.

29 (449)
SECTION V.
FUNCTIONAL NERVOUS DISEASES.

Unper this heading I propose to discuss certain abnormal conditions
of body, in consequence of which some special form of disturbance or
derangement of the nervous functions may be exhibited, which has not,
as yet, been shown to depend upon any positively recognized pathological
state.

Among this class of conditions may, in my opinion, be included a
certain percentage of epilepsy, chorea, hysteria, and hystero-epilepsy. In
this percentage, the existence of organic lesions can be excluded. Again,
neurasthenia (with its endless variety of manifestations), typical attacks
, of migraine or * sick headache,” certain obstinate types of neuralgia,
and, in some cases, evidences of imperfect performance of some of the
functions of the abdominal and thoracic viscera, are unquestionably to
be regarded as functional neuroses. :

JT am aware that I am at variance with the majority of authors in
thus grouping so many diseased conditions that are apparently dis-
cordant under one head. I may be severely criticised possibly by some
for so doing. I may even be taken to task for the selection of the term
“functional nervous disease,” which is rejected by many enthusiasts in
pathological research.

To show, however, that I am not alone in the position taken, I take
the liberty of quoting the following paragraphs from the preface of a late
work* upon this special field :-—

“Pathological anatomy has exercised such an enormous influence
upon the advances made in practical medicine within the last twenty-five
years, that many pathologists sneer at the term ‘ functional ’ disease, and
deny its very existence.

“While we fully agree that there can be no morbid manifestations
without a change in the material structure of the organs involved, we
are nevertheless fully convinced, in view of the fruitless search of
pathological anatomists, that the diseases which we have considered in
this work present no primary anatomical changes which are visible to
the naked eye or the microscope; in other words, that the changes are
of a molecular nature.”

While the truth of this statement appears to me self-evident, I have,
moreover, other reasons than those urged by this author for including

* Putzel—‘ Functional Nervous Diseases,”’ 1880.

(451)
452 LECTURES ON NERVOUS DISEASES.

under the term “functional” nervous diseases, the abnormal states
specified by me, as will appear later. These will be more apparent when
I call attention to what I regard as of vital importance in some of these
cases.

THE RELATIONSHIP BETWEEN FUNCTIONAL NEUROSES AND
ANOMALIES OF THE VISUAL APPARATUS.

The study of defects in the adjustment of the eye-muscles and the
relationship which exists between such defects and nervous diseases, has
not been generally regarded as of very great practical importance until
of late. Many of our best text-books upon the eye do not deal with any
such muscular defects, except in relation to strabismus. Some give
directions for testing the ocular muscles, that are in direct opposition to
the views which are here advanced. A few are positively misleading ;
chiefly on account of errors of statement concerning points where
physiological optics come into play.

I may be pardoned, therefore, if I review, in a general way, a few
points which have a practical bearing upon a method of examination and
treatment of the visual apparatus, which is to-day exciting considerable
attention among scientific medical men, especially among those whose
interest centres in the study of nervous diseases and in ophthalmology.

What I have to say here includes the discussion of the following
points of inquiry —

(1) What steps may be deemed as essential to success in the diag-
nosis and treatment of certain anomalies of the visual apparatus.

(2) Why it is that observations in this direction, when too hastily
or imperfectiy made, are peculiarly apt to be untrustworthy.

The limits of a few pages will hardly suffice for me to cover more
than a few of the more important points comprised under these headings.
What I have to say will, therefore, be as condensed as seems to me per-
missible. A personal experience, derived from several years of
continuous research in this field upon a class of patients afflicted
exclusively with nervous derangements, and from more than five hundred
graduated tenotomies upon the recti muscles of the orbit, justifies me,
I think, in expressing positive convictions.

‘The views which I shall discuss here constitute the basis of a
systematic method of examination for and treatment of certain ocular
defects, whose relationship to functional nervous diseases seems to me
to be now established beyond dispute.

Since these views were first advanced by Dr. George T, Stevens,
they have attracted no small amount of professional attention. In spite
of the fact that his contributions in relation to this subject are
remarkably clear and succinct, considerable misapprehension still appears
FUNCTIONAL NEUROSES AND VISUAL APPARATUS. 453

to exist in the minds of the profession at large relative to the views
advanced by him.

I may be pardoned, therefore, if, as an exponent of these views, I
repeat in substance much that has already appeared in print. By so
doing, I hope to concentrate attention upon certain steps employed in
the examination of the visual apparatus, whose order is deemed by no
means unimportant, and in some of which the observer should exercise
no small amount of care.

The following statements are, therefore, deemed by me as worthy
of your attention :— :

(1) The view is held that errors of refraction (by which I mean
near-sightedness, far-sightedness, or astigmatism) often modify apparent
muscular anomalies to.such an-extent as to render the early detection and
correction of refractive errors imperative.

This point is of vital importance in the treatment of many patients.
Clinical observation has conclusively shown that one of the most
important steps in correcting what is commonly known as a “squint,” or
“ cross-eye,” is first to properly detect any existing error in refraction and
to properly correct it. Such defects should always be sought for early,
and the effect of a proper glass upon the deviation of the axes of vision from
their normal position which demands relief should first be carefully noted.
Many cases are observed by oculists where spherical glasses alone have
corrected a marked “squint.” The neglect of this important step may
prove to be a serious omission, as it may lead to an error in diagnosis
or treatment, Let me impress upon you the fact that each eye of every
patient must be separately examined for refractive errors, and rendered
as nearly emmetropic as possible, before any test relating to the ocular
muscular conditions can be considered as reliable. It is not enongh,
therefore, for a neurologist to provide himself simply witha set of prisms
with which to examine his patients’ eyes for suspected muscular errors.
Any tests so crudely made are certainly unscientific, and probably
inaccurate.

. (2) The view is held that errors of refraction can only be positively
determined after the full effects of atropine; hence the step of dilating
the pupil is deemed of importance in most cases.

‘There are two sources of error which are possible in all oph-
thalmoscopic examinations as a step toward the determination of
. tefraction.

The first of these is that the observer may not be able to perfectly
relax his own “accommodation” while using the instrument. Most
oculists of large experience believe that-they can do this with cer-
tainty,—a belief which, in my opinion, is perhaps not always well
founded. The second source of error lies in the “ accommodation ” of
454 LECTURES ON NERVOUS DISEASES.

the patient. This cannot always be relaxed by instructing the patient to
look at an object twenty or more feet distant from the eye.

I am satisfied that mistakes in the determination of refractive errors
by the ophthalmoscope are far more frequent than are generally supposed.

For the past four years I have examined the eyes of every patient
intrusted to my care by the aid of test-type both before and after the
pupils have been fully dilated by atropine. I am not aware that I have
ever lost a patient by the use of this drug. In my experience, intelligent
persons are always willing to submit to a temporary inconvenience for
the purpose of obtaining positive information respecting any point that
is deemed of scientific value in relation to themselves. I have personally
come to regard the ophthalmoscope as an unreliable instrument for the
determination of refraction. Its use is rendered compulsory, however,
in very young children, and in ‘those who, from ignorance or feeble-
mindedness, are unreliable in their reading of test-type.

It is generally accepted, furthermore, among our best oculists that
astigmatism (a recognized source of nervous perplexity) is always esti-
mated more accurately with the pupil widely dilated by atropine than
with the normal pupil.

The reasons which I have already given must suffice to explain why
the use of atropine constitutes a most important preliminary step to the
detection and estimation of any error in the eye-muscles, although many
other arguments might be brought forward to prove its advisability in
some subjects.

(3) The view is held that no examination for suspected muscular
error in the orbit should be regarded as conclusive for diagnosis, or as a
basis for any surgical procedure, until the eye has been proven to be free
from refractive error, or rendered as nearly emmetropic as deemed
advisable by properly selected glasses.

It is, of course, advisable during the first interview with each
patient to note and record any “ manifest” defect in sight. If such
exists, each eye should be provided with the glass which gives the best
vision for each eye (the two eyes being always tested independently of
each other). After such correction, the different tests employed to
detect muscular anomalies should then be made, and the results of each
test should be recorded as the “‘ manifest muscular error.”

At the second interview, with the pupils fully dilated by atropine,
the sine steps should be repeated. We thus learn, in many cases, the
existence of refractive conditions which the first interview did not reveal.
We record such as “ latent ” refractive conditions, By the aid of suitable
glasses, any latent refractive error found is then to be corrected ; subse-
quently, at this interview, the muscular movements are to be tested with
each eye temporarily adjusted to distant vision by suitable glasses.
FUNCTIONAL NEUROSES AND VISUAL APPARATUS. 455

(4) The view is held that all tests employed to detect muscular
anomalies must be made with the test-object (preferably a candle flame) at
a distance of at least twenty feet from the eye. In this respect, the
method of conducting examinations advocated here is somewhat at
variance with that commonly described in most text-books.

In the practical office work of many oculists the so-called “line and
dot” test is generally employed (at a distance of fourteen inches from
the eye).

It is usually advisable to employ this test in addition to the
“candle flame” test at twenty feet; but, when it is employed, the results
obtained by each test should be separately recorded, The words “in
accommodation”? have been suggested by Dr, Stevens as a suflix to
designate the results obtained when the test-object is placed at fourteen
inches from the eye.

While it is deemed desirable in most instances to record the results
of both tests described above, all operative procedures are invariably
based upon the results obtained by placing the test-object at a distance
of twenty feet from the eye.

To a lack of uniformity in the tests made by oculists to detect mus-
cular anomalies in the orbit many of the discrepancies frequently met
with between observations made by different men upon the same patient
are unquestionably due. For example, a patient may exhibit an in- -
sufficiency of the externi at twenty feet, and of the interni at fourteen
inches, in spite of the fact that all precautions have been taken to
previously rectify existing refractive errors. This field is too large to
discuss here, but it is a very important one.*

(5) The view is held that observations made for muscular anomalies
in the orbit, when the test-object is within the limits of accommodation, are
not usually reliable as a basis for operative procedure undertaken for the
relief of such anomalies.

Experience goes to show that deviations of the visual axes observed
when the test-object is placed at twenty feet from the eye more correctly
represent the muscular error which needs correction in any given case
than when made at a nearer point.

I have encountered several interesting cases where extremely
satisfactory results upon functional nervous phenomena of a distressing
type have followed an operative procedure upon the eye-muscles, which

/ would have been strongly contra-indicated if I had attached as much
importance to the results of tests made with the test-object at fourtecn
_ inches from the eye as the statements found in most of the text-books

* See articles by G. T. Stevens, in New York Medical Journal, December, 1886, and in
Archives of Ophthalmology, June, 1887; also a. paper read by the same author before the
Toternational Medical Congress at Washington, D. C., September, 1887.
456 LECTURES ON NERVOUS DISEASES.

would justify. These cases impressed me very strongly at the time.
They bear the strongest testimony in favor of the view that convergence
of the eyes is a factor which should be eliminated as far as possible in
searching for muscular anomalies of the orbit.

(6) The view is held that muscular anomalies in the orbit may be
partially or totally “latent.”

The amount of muscular error detected in any given case does not
necessarily indicate the full amount of error that actually exists,

The results of ordinary tests simply tell us how much eye-tension
exists which the patient cannot overcome by any effort of which he is
capable.

Upon this one point too great stress cannot be laid, as it sheds much
light upon the clinical history of many patients who suffer from eye-
strain. :

All authorities recognize the fact to-day that a patient may have a
very marked congenital shallowness of the eye, and apparently have
normal yision, or possibly appear to be even near-sighted, prior to the
use of atropine. Subsequently to its use, the same patient will, however,
show a high degree of far-sightedness (hypermetropia), because the ciliary
muscle (temporarily paralyzed by the atropine) cannot overcome, or (to
speak more technically) compensate for the abnormal shallowness of
the eye.

Unfortunately for science, we have as yet no drug which aids us in
determining the existence of a “latent” muscular error in the orbit.

Yet, are we justified in concluding that latent muscular anomalies do
not exist? Most assuredly not. There is the strongest clinical evidence
to the contrary.

Only a few weeks ago, I examined the eyes of a prominent physician
on three consecutive days, and I was unable to detect (either before or
after prismatic exercise of his eye-muscles) any change in his ocular
condition from the one noted at the first examination. His symptoms,
however, led me to believe that a greater muscular error existed than he
showed, although the anomaly detected was a very marked and im-
portant one.

I therefore instructed him to wear a prism, which nearly corrected the
error then detected, until the next examination. Less than two hours
later, I accidentally had the opportunity of again examining his eyes.
His muscular error was then exactly double what it originally appeared
to be. He was again given almost a full prismatic correction for the
defect detected. Twenty-four hours later he was examined for the fifth
time, and he still showed an excess of two degrees over the record of
the day previous. He was again given a further prismatic correction;
but from that time he failed to exhibit any further alteration in his ocular
FUNCTIONAL NEUROSES AND VISUAL APPARATUS. 457

tests. The relief afforded by prisms was so instantaneous and permanent
(while they were worn) as to prove conclusively that the prisms were
wisely selected, and that the “latent” insufficiency, which was developed
after and by means of their use, more accurately represented his true
condition than did the original observations made at the first interview.

I mention this case, not because it is at ‘all unique (for many such
instances have been observed) but because it illustrates admirably the
existence of latent insufliciency, which happened in this case to be
developed rapidly by the temporary use of correcting prisms.

In the second place, it is not at all uncommon to observe the
development of latent muscular anomalies in the orbit after a graduated
tenotomy has been satisfactorily and scientifically performed for the
correction of a ‘“‘manifest’”’? muscular error. Sometimes, quite a long
interval elapses before latent insufficiency shows itself. Again, it shows
itself almost immediately.

An epileptic, upon whom I operated for eye-defect, ane who has
now been free from attacks for over one year.and a half, in spite of the
cessation of all drugs, showed me originally only one degree of esophoria.
This defect would, I think, have been heretofore regarded’ by most
oculists as hardly worthy of correction—even by a prism. , The sub-
sequent treatment of this case demanded repeated partial tenotomies
upon both of the interni; and proved not only that I had a high degree
of “latent” trouble to correct (which a one-degree prism would not have
helped), but also that the attacks have thus far been totally arrested by
the relief of abnormal eye-tension.

In the third place, it has been proven that systematic daily exercises
of the various eye-muscles (accomplished by teaching the patient to fuse
images which have been rendered momentarily double by a prism held
before the eyes) will in some cases develop latent muscular anomalies of
the orbit.

In other words, a patient, after a week’s muscular drill, will often
show a greater flexibility of the eye-muscles and the existence of a lack
of equilibrium in the eye-movements, which they did not exhibit at the
‘earlier examinations. JI am aware that an injudicious use of such
prismatic tests in’ the hands of a novice might cause “asthenopia,”
and seriously affect muscular conditions; but this fact can hardly be
used, I think, by fair-minded critics, to explain the phenomena alluded
to here.

Finally, it may be stated, in this connection, that one examination
of the various eye-movements is not, as a rule, sufficient for a positive
diagnosis respecting muscular anomalies. Repeated tests have often to
be made before a complicated problem may be satisfactorily solved, even
by an expert in this line of examination.
458 LECTURES ON NERVOUS DISEASES.

(1) The view is held that prismatic glasses are not only inadequate
as satisfactory remedial agents in most cases, but that they may be posi-
tively injurious to certain classes of patients.

Few, if any, of our prominent oculists have perhaps ordered as
many prismatic glasses as has the chief advocate of the method now
under discussion. Yet, in spite of this fact, strict limitations upon their
field of usefulness (not generally taught) seem to be rendered probable
by late investigations.

A careful study of the different movements of the eyeball, and of
the combination of muscles required to produce some of them, must
impress even the most casual reader with the idea that an agent (such,
for example, as a strong prism) which tends to restrict the movements
of any one muscle, may do harm if persistently worn.

Some patients are peculiarly susceptible to such influences. I have
encountered a large number of patients whose eyes refused to tolerate a
prismatic glass. Their symptoms were at once made worse whenever
they attempted to correct an existing muscular anomaly by wearing a
prismatic glass.

On the other hand, many patients are benefited at once by the use
of prisms, and suffer no inconvenience of any kind from them.

What are we to infer from this statement? Are we to surmise that
the prisms were either injudiciously selected or improperly placed,
simply because the patient could not tolerate them? Ithink not. Such
might possibly be the case in the hands of a novice, but presumably it
is not the case in the experience of one skilled in eye-examinations.

My own experience in several such instances has shown me that a
properly graduated tenotomy of the muscle exhibiting the greatest tension
has been followed by a complete cessation of the nervous symptoms for
which the patient sought relief, in spite of the fact that prisms prescribed
to correct the same error have proved intolerable to the patient, and
have markedly aggravated the symptoms.

There is, however, a practical atid important field for prismatic
glasses. It is well to keep, as a part of a physician's office equipment, a
large number of prisms of different angles. These can be slipped into’
a frame with the base inward, outward, upward or downward, as the
exigencies of any case seem to demand. They may be loaned from time
to time to patients, for the purpose either of verifying a diagnosis or, by
giving relief to a “manifest”? ocular tension, of developing a latent
muscular error which the physician may be led (by repeated examinations
of the patient) to suspect. When they are well-tolerated, the physician
may often learn a great deal by their protracted influence. When they
are not well borne, it is advisable, as a rule, to discontinue their use at
once.
FUNCTIONAL NEUROSES AND VISUAL APPARATUS. 459

It is often wise to prescribe prismatic class, also, for a class of
patients who are unable (for one reason or another) to submit at the
time to a graduated tenotomy.

Sooner or later, I find that such patients usually return. Asa rule,
they do so for one of the following reasons: (1) because they have
developed an additional “latent” muscular error, which the prisms
naturally failed to correct; (2) because they do not tolerate them well,
and are made decidedly worse by their use; (3) because they prefer a
tenotomy to the inconvenience of a glass which has to be constantly
worn; and (4) because they suffer from eye-fatigue, on account of the
disturbance to codrdinate movements of the eyeball.

’ There is no doubt that very many cases of nervous diseases are
materially helped (if not radically cured) by the aid of prismatic glasses;
but the question naturally arises to my mind in this connection, “ Would
they not have been more rapidly benefited and permanently relieved with
far less inconvenience to the patient by tenotomy ?”

(8) The view is held that a graduated tenotomy is the only way of
satisfactorily and permanently relieving abnormal tension of a muscle in
the orbit.

There are only two ways of overcoming an abnormal tendency of
the visual axes to deviate from parallelism whenever the eyes are directed
upon an object more than twenty fect off. One of these is by the aid of
a prism; the other is by a graduated tenotomy of the muscle, which
directly aids in producing and perpetuating the deviating tendency.

Whenever prisms are prescribed, they afford relief practically in the
same way as a “rubber muscle” does in orthopedic surgery; in other
words, they compel the muscle which is opposed to the base of the prism
worn by the patient not only to overcome the antagonistic muscle, but
also to so adjust the eye as to compensate for the refractive effect. of
the prism. They practically act, therefore, as a “ pulley-weight ”—
mechanical device seen in all gymnasiums.

Now, if the wearing of prisms had no deleterious action upon those
particular muscles, which, in each case, are not at all at fault, and if
they invariably exerted only beneficial effects, this principle of treatment
could be more generally applied with benefit. Even then, the existence
of latent insufficiency might, unfortunately, remain unrecognized for a
greater or less period of time, possibly to the serious detriment of the
patient. On the other hand, if it be satisfactorily demonstrated that
the operation termed “graduated tenotomy ” has been rendered a safe
and accurate method of correcting muscular anomalies in the orbit, a
fact has certainly been noted that opens a new and shorter route to relief.
Such a step enables us, moreover, to decide the question of “ latent ”
mingealar defects in any given case.
460 LECTURES ON NERVOUS DISEASES.

(9) The view is held that the difficulties previously experienced in
attempting to correct so-called ‘muscular insufficiencies” in the orbit by a
surgical procedure upon the stronger muscles have now been satisfactorily
overcome.

Space will not permit of a discussion here of the demerits of oper-
ations previously devised for this purpose. Suffice it to say that the
operation first suggested and performed by my friend, Dr. G. T. Seevens,
preserves the normal line of traction of the muscle.

This igs a point of vital importance to the patient, and one which
cannot be claimed, in my opinion, for any other operation previously
devised for this purpose with which I am familiar.

Any disturbance in the proper adjustment of the eye-muscles, which
must ensue from an alteration in the line of traction of any one or more
of the six muscles which move the eye, cannot help but be a serious
matter.

The full details of the operation alluded to have sean been
published.* I quote from an article lately read before the Neurological
Society of New York by the chief advocate of this method :—

“In the main it consists of making a small opening through the
conjunctiva, exactly over the insertion of the tendon, when the tendon
is seized by extremely fine forceps, and divided in each direction,

‘preserving the extreme outer fibres, or, at least, the reflection of the
capsule of Tenon, which serves as an auxiliary attachment.”

It may be stated in this connection that this operation is absolutely
painless when done under the influence of cocaine; that stitches are
never employed; that no subsequent dressings are rendered necessary ;
and that patients frequently go from the operating chair directly to their
business, A slight amount of redness and irritation about the wound,
and occasionally some sub-conjunctival hemorrhage (both of which tend
to rapidly disappear) are all the inconveniences which this operation
commonly entails. I have personally performed this operation about
six hundred times up to the present date, and I have never known
suppuration to occur, or any complications to be induced which caused
me serious perplexity.

(10) The view is held that “eye-strain” from any cause (be it
refractive or muscular) 7s @ serious matter, and that its tendency is to
predispose to nervous derangements and to perpetuate them when once
developed so long as this factor exists.

This is one of the most important, if not the chief claim made.
It is substantiated by many carefully made and collected observations,

It is chiefly in those cases where, in spite of a muscular error, the
images of the two eyes can be blended by a great effort that the patient

* Archives of Ophthalmology, June, 1887.
FUNCTIONAL NEUROSES AND VISUAL APPARATUS. 461

begins to experience the deleterious physical influences of abnormal
muscular tension in the orbit. Placing a plain red glass before one eye
of a patient suspected of having a slight degree of strabismus will often
reveal to a patient a diplopia of which he or she may have been un-
conscious. Such cases do not belong to the class discussed here as
those of “ insufficiency of the ocular muscles.”

It is not hard to understand why it is that an animal too heavily
laden is unable to rise after a fall has occurred until the load is taken
from it.

So it is with many nervous patients. The incessant efforts made to
fuse the images perceived by the two eyes into a single image (when a
muscular defect renders such an act possible, yet one of extreme difli-
culty) are liable sooner or later to exhaust the nervous force of the patient
and to excite some form of functional nervous disturbance.

This is the line of argument, which apparently seems difficult to
understand. It is a train of reasoning which many enthusiastic patholo-
gists naturally prefer to discard, because it puts an end to a search fora
pathognomonic lesion which no human eye (even with the aid of a
microscope) has ever yet been able to detect in many hopeless and
chronic cases of chorea, epilepsy, insanity, neuralgia, headache, hysteria,
and neurasthenia. Itis a view which will probably be opposed by some,
because it comes into direct antagonism with the prolonged administration
of the various bromide salts; in spite of the fact that the injurious effects
of such administration are too frequently encountered to be ignored. It
is a principle relating to functional neuroses which is naturally combated
on general grounds, because it is new, and opposed to preéxisting views.

Respecting the views here advanced, I take the liberty of quoting a
few selected paragraphs from a singularly lucid paper lately read by the
pioneer in this field before the Neurological Society of New York.* 1
do so because they appear even yet to be misunderstood by some who
listened to the paper quoted from. The author of that paper says :—

“A doctrine so much at variance with ordinary beliefs must. of
necessity excite suspicion that the proposition has been based upon
insufficient data, or that observations have been imperfectly made. That
neither of these suspicions is correct it is hoped may be shown to the
satisfaction of reasonable inquirers. If the proposition appears extreme,
and tending at best to the recognition of a single class of causes to the
exclusion of others, let me recall the fact that the proposition fully
recognizes any and all causes of nervous irritation, and that the influ-
ences indicated are held to be preéminent, but not exclusive permanent
causes, If greater importance is conceded to the influences mentioned
in the proposition than to others, it is from no unmindfulness of the

* New York Medical Journal, April 16, 1887.
462 LECTURES ON NERVOUS DISEASES.

possibility of other conditions acting as irritating influences, or that cer-
tain known or unknown influences may give character to the results of
irritation arising from the causes mentioned. Let it be remembered
that it has been universally conceded that the nature of the neuropathic
tendency is unknown. If one preéminently important element is de-
monstrated, it is not to be rejected because it may not include the
whole.

“In the explanation of the etiology and treatment of disease, neither
settled thcorics nor novel doctrines are to be accepted only as they are
confirmed by undoubted facts. Nor can isolated facts, nor facts divested
of their natural environments, be accepted as valid evidence in support
of theories, old or new. The facts must be uniform, occurring so regu-
larly as sequences as to demonstrate that they are consequences.
Unless the skilled observer is able to predict, with a reasonable degree
of accuracy, the result of certain combinations of circumstances, such
result, when occurring, must be considered accidental.”

“The principle of ocular irritation is of wide application, and is not
to be compared with the occasional irritation set up by such accidental
and usually secondary causes as phimosis is, the presence of calculus, the
existence of a stricture of a passage, the effects of decayed teeth, and of
many other peripheral irritations which might be mentioned. All these
are of importance, and are not to be overlooked.

“The conditions to which I have especially called attention are,
however, in general, commensurate with the life of the patient, and exist
in a vastly greater number of instances than either or all of the condi-
tions belonging to the other class just mentioned. Not only are those
painful or irregular conditions, usually described as neuroses, in great
proportion responsive to the relief from ocular tensions; but a great
variety of conditions, commonly regarded as local affections, yield as
readily, and prove that they are in faet reflex phenomena.

“Tf it be said that the origin and prevention of nervous diseases is
to be found in a great variety of circumstances, I reply, let us find them
all, and adapt our measures to them all, but let us not neglect this
because there may be others.

“For myself, I do not think that another as important class of
causes of nervous disturbance will be found as that which attends the
anomalies of the parts engaged in the performance of the visual function.
In any case, our aim is to prevent the evils of nervous derangement by
the early removal of any known mischievous tendency, and our duty is,
when such nervous derangement actually occurs, to remove every per-

plexing cause. In the observance of such a principle, we may leave to ~

superstition and to ignorance the practice of expelling nervous diseases
by means either fashionable or obsolete.”
FUNCTIONAL NERVOUS DISEASES AND REFLEX CAUSES. 463

ARE FUNCTIONAL NERVOUS DISEASES FREQUENTLY REFLEX
MANIFESTATIONS ?

The view that a direct relationship exists in many subjects between
epileptic seizures (that are apparently not associated with organic lesions
of the brain) and abnormal muscular tension within the orbit seems to
have received most valuable indirect confirmation in the startling
experiments published by Drs, F, X, Dercum and A. J. Parker, of the
University of Pennsylvania,* According to these observers, convulsive
seizures were artificially induced in apparently healthy subjects by
prolonged muscular tension of a single muscle or groups of muscles in
the limbs.

I regard these experiments as perhaps the most important ones that
have yet been brought forward in support of the general view that
epileptic seizures are, in the large proportion of cases, simply one of the
many types of manifestation that a reflex cortical disturbance is capable
of exhibiting.

It is unquestionably true also that such reflex causes are too
. often not sought for by the profession with sufficient care or in the
proper way.

The methods of examination that have been generally regarded until
of late as conclusive, when defects in adjustment of the eye-muscles
have casually been sought for, were certainly most crude and unscientific;
and a modification of them appears to be most timely.

I take the liberty of quoting from the published experiments of
Drs. Dercum and Parker the following paragraphs :—

“The subject being seated, the tips of the fingers of one or both hands were so
placed upon the surface of a table as to give merely a delicate. sense of contact, 2.e., the
fingers were not allowed to rest upon the table, but were maintained, by a constant muscular
efort, barely in contact with itt Any other position involving a like effort of constant
muscular adjustment was found to be equally efficient. Any one object in the room was
now selected, and the mind fixed upon it, or some subject of thought was taken up and
unswervingly followed.

‘After the lapse of a variable period of time, extending from a few minutes to an
hour, and depending upon individual peculiarities to be noted, .... the subject was
frequently thrown violently to the ground in a general convulsion, preceded by tremors
which rapidly hecame more violent.

“Seizures equalling in violence a general convulsion were by no means induced in all
subjects, and were generally the result of experiments repeated many times during the
same evening. In the experimenters the convulsions became so easily induced that it was
thought advisable to desist for a long period.”

* Jour. of Nervous and Mental Diseases, 1884, pp. 579 and 636,
{ Italics my own.
464 LECTURES ON NERVOUS DISEASES.

Dr. Chas. H. Thomas, of Philadelphia, when speaking of these
experiments in a late contribution to this subject,* says :—

“The effort of constant muscular adjustment here spoken of appears not unlike
the condition found in the eyes in cases of insufficiency of the ocular muscles; and
it seems not unreasonable to infer that if such strain of the muscles of the forearm
would produce results of the kind reported by the authors just named, that the strain
upon ill-balanced ocular muscles (which must be continuous during the whole of the
time that the eyes are opened) should be productive of even more serious, and, indeed,
permanent results.”

Within the past year, an extremely valuable paper respecting
one of the much neglected and perhaps not infrequent causes of
epilepsy has been also published by Dr. A. P. Brubaker,t of Phila-
delphia, entitled “Dental Irritation as a Factor in the Causation of
Epilepsy.” The following extracts from this paper have an impor-
tant clinical bearing, and possibly shed some light upon the proper
treatment of convulsive diseases and other forms of reflex nervous
conditions :—

“In all the wide divergence of view as regards the nature of epilepsy there is a
general consensus of opinion that its essential feature is of the character of an explosive
discharge from the higher nerve-centres, the nerve-force: thus liberated bearing down upon
the centrifugal distributions of the motor nerve-tracks with such an excess of energy that
incodrdination of movement reaches the stage of convulsion and spasm. Owing to the
periodicity of the convulsive seizures, it has been assumed that in individuals predisposed
to epileptic attacks the higher nerve-centres are in a state of high tension, of unstable
equilibrium, and that it only requires a stimulus of a definite quantity or intensity to
excite the explosive discharge.

“The object of this paper is to direct the attention of physicians to a cause of epilepsy
which has not hitherto been estimated at its full value, inasmuch as in none of the standard
works upon neurology is the subject even alluded to,—viz., pathological states of the dental
structures. That dental inflammations and disorders are more often provocative of
epileptic seizures than is commonly supposed appears quite certain from the following
cases, and also from the character of the cause and its effect. Many reasons might be
given why dental disorders are peculiarly adapted to call forth this periodical discharge,
and why these disorders are habitually overlooked by the physician, but they need not be
detailed here. As exemplifying these phenomena, some interesting and instructive cases
are adduced.

“The interest aroused by the result of the preceding case led to an examination of
medical literature for reports of similar cases. I find that no less than sixteen cases,
entirely and immediately cured by the removal of an irritating tooth, have been
recorded by different observers, and which are here arranged in chronological order.
It is not supposed that this collection embraces all the recorded cases, but it is hoped
that it will elicit references to many others, and, what is more important, the reporting
of many new cases.”

* Trans. Phila. Co. Med. Soc., Mar. 14, 1888.
t Jour. of Nervous and Mental Diseases, 1888, p. 117.
FUNCTIONAL NERVOUS DISEASES AND REFLEX CAUSES. 465

In the light shed upon this subject chiefly by recent contributions
to medical literature,* the view is gradually being accepted by many in
the profession that certain nervous diseases (whose pathology, to say the
least, is still in doubt) are possibly not dependent in every case upon an
unrecognized organic lesion; and they are being led to coincide with
the statement that the term “functional” nervous disease may be
properly applied, in some instances at least, to the graver nervous
conditions,—such, for example, as epilepsy, chorea, hysteria, or other
manifestations of nervous exhaustion, and insanity. In other words,
the professional mind seems more willing now than in the past to discard
an apparently fruitless search for a pathognomonic lesion for each
intractable nervous condition, and to look more calmly upon tangible
clinical facts, even if they are radically opposed to preéxisting views.

If the view that eye-strain, dental irritation, or other causes of reflex
disturbance may be a frequent cause of functional nervous derangements
proves to be the correct one, beyond the possibility of doubt or cavil,
it is not difficult to see that a hope of marked relief or of ultimate
recovery is practically extended to many hopeless sufferers upon whom
drugs have exerted little or no benefit.

In order that those of my readers who have possibly not given
much attention to the views which most of my incorporated cases are
particularly selected to illustrate may properly understand the train of
reasoning that offered a solution to my mind of the symptoms here
recorded, I take the liberty of quoting a few paragraphs from a paper
which I lately read before the International Medical Congress at
Washington, entitled “ Does a Relationship Exist between Anomalies of
the Visual Apparatus and the So-called ‘ Neuropathic’ Predisposition ?”+
This paper was based upon a carefully tabulated analysis of the records

*The reader is referred to the articles by Dr George T. Stevens on ‘‘ Chorea”’
(Medical Record, 1876); on ‘“‘ Anomalies of the Ocular Muscles”? (Arch. of Ophthalmology,
June, 1877); and on ‘Ocular Irritations and Nervous Diseases”? (New York Medical
Journal, April, 1877); also to his work on ‘‘ Functional Nervous Diseases” (D. Appleton
& Co., N. Y., 1887); also toa contribution by Dr. H. D. Noyes, on ‘‘ Tests for Muscular
Asthenopia and Insufficiency of the External Recti,’’ read by him before the International
Medical Congress, Copenhagen, 1884; also to papers by the author on ‘“ The Eye as a
Factor in the Causation of Some Common Nervous Symptoms (New York Medical Journal,
February 27 and March 15, 1886); on ‘“ Eye-strain in Neurology”? (New York Medical
Journal, April 16, 1887); on ‘ Eye-strain in its Relations to Functional Nervous Diseases”
(Medical Bulletin, September, 1887); and an abstract of an essay read before the
Tuternational Medical Congress at Washington, entitled ‘Does a Relationship Exist
Between Anomalies of the Visual Apparatus and the So-called ‘Neuropathic Predisposi-
tion?” (Medical Register, November 19, 1887). The articles by Drs. Dercum and Parker,
Dr. C. H. Thomas, and Dr. A. P. Brubaker, of Philadelphia (already quoted), are worthy
of special notice in this connection,

tAn abstract of this paper was published in the Medical Register, Ncvember 19,
1887,

30
466 LECTURES ON NERVOUS DISEASES.

of one hundred consecutive cases of typical neuroses taken from my
private case-book.
In this paper I say :—

Until there is a uniformity in the methods employed for testing the eye-muscles,*
and of terms for the recording of anomalies so detected, the profession must unfortunately
continue to be more or less embarrassed in this line of research, I do not feel justified in
personally discussing this subject here, as it has only an indirect relationship with this
paper; but I can not refrain from saying, in this connection, that to defective methods of
examination, made venerable chiefly by their antiquity, we owe to-day, in my opinion,
much of our ignorance of anomalies of the ocular muscles.

Some time ago I was struck, on looking over a children’s magazine, with an illustra-
tion designed to teach the reader the dependence of the various organs of the body upon
the brain. It represented the brain as the head of a manufacturing establishment sitting
at his desk, and around him were the various departments,—as, for example, the liver-
department, the stomach-department, the eye-department, etc. These departments were
connected with the head of the establishment (the brain) by telegraph-wires, through
which each could make its wants known and receive information regarding them.

Probably the designer of this sketch (made for the purpose of illustrating to the
child the dependence of the organs upon the brain for their successful operation, as well
as their actual support) built ‘better than he knew.” He embodied in his drawing a
graphic representation of certain fundamental principles of physiology which are not
clearly understood even by many adult minds in their. bearings upon the general health,

The lungs do not make us breathe; except in an indirect way, by asking the brain
to start the necessary muscles into action, The stomach does not perform its functions
until ‘after the brain has been requested by it to turn on the blood-supply in sufficient
quantities to produce the requisite quantity of gastric juice. The intestine performs its
incessant worm-like movements by no inherent power of its own, The heart keeps up its
rhythmical beating only when permitted to do so by the great centre of nerve-force.

Now, is it at all inconsistent with physiological principles to advance
the view that any excess of nervous expenditure to one organ over the
normal amount which should be furnished ‘is done at the expense of
the others sooner or later?

No one can draw incessantly upon his reserve capital of nerve-force
without incurring a risk of ultimately exhausting it. A bankruptcy in
the reserve capital of nerve-force entails untold ills to the individual.

The day of reckoning is postponed in any given case in direct
proportion to the drafts made upon the reserve and the amount of the
reserve. This may help us to explain why some escape it indefinitely,
while others are precipitated into indescribable distress when life is
hardly begun.

In case the bearing of eye-strain upon the problem of nervous
expenditure is not very clear to some of my readers, I deem it wise to
quote here some extracts from a late brochure of mine upon this subject
(N. ¥. Medical Journal, Feb. 27 and March 13, 1886).

* See article by Dr. G. T. Stevens in the Archives of Ophthalmology, 1887 and 1888.
FUNCTIONAL NERVOUS DISEASES AND REFLEX CAUSES. 467
Speaking of hyperopia, I say :—

Fortunately for our nervous system, the normal eye takes pictures of surrounding
objects. without any muscular effort when the object is more than twenty feet away; hence,
during the larger part of each day the normal eye is passive, and is practically at rest,
although performing its functions. How different is the condition of the far-sighted or
“hyperopic” eye, however, from the normal! For this eye (since it is too short in its
antero-posterior axis) all objects have to be focused by muscular effort, irrespective of
their distance from the eye. Such an eye is never passive. It has no rest while the
body is awake. It is always straining more or less intensely to bring properly upon the
retina the images of objects seen.

The “hyperopic”’ condition of the eye, or ‘ far-sightedness,” as it is called, is a very
common defect. It is especially frequent in persons of tubercular parentage. It is well,
therefore, to suspect the existence of this defect in children or adults whose ancestors
have died of “ consumption.”

Again, speaking of muscular anomalies, I use the following illus-
tration :—

A high-couraged horse feels the will, as well as the support, of his driver through the
reins by means of the bit. Although his course and rate.of speed are changed from time
to time at the will of the driver, the reins are never slackened. The horse becomes
acquainted with the desires of his master by a sense of increased or diminished tension
upon the reins. He is guided to either side by a difference in the tension of the two,
although the driver does not entirely relax his hold upon the opposing rein while he uses
the guiding one, and the difference in tension may be very slight.

‘ So it is with the normal eye. It is both controlled’ and supported while performing
its movements within the orbit by the eye-muscles (which are its reins), The brain is the
driver. At its command the eye revolves, or remains ‘stationary at any desired point.
The tension of muscles, opposed to any movement of the eye required, is so modified by
the brain as to insure the requisite support to the eyeball, and to steady it as it moves.
Thus, a perfect equipoise is constantly established between opposing forces, adjusted with
the nicest care to meet the full requirements of the organ under all possible circumstances.
The normal eye does not tremble or wabble when it moves or the attempt is made to
hold it in any fixed attitude. It is a piece of machinery, perfect in all its parts, reliable
in its movements, perfectly controlled by its master.

The eye with “muscular insufficiency” is like a horse with an inexperienced and
incompetent driver; the proper tension upon the reins is not maintained at all times, as it
should be; there is no equilibrium between antagonistic muscles; fixed attitudes are
maintained with difficulty for any length of time; the brain becomes more or less
disturbed by its inability to properly control the eye-movements, and exhausted by the
continual strain imposed upon it by the efforts required to do so even imperfectly.

A point may now be raised concerning which some misapprehension
seems to exist among medical men (judging from remarks which I
occasionally hear expressed). I refer to the relationship of actual
squint to nervous disturbances.

No one can deny that people frequently live for long periods of
time in houses impregnated with sewer-gas and in the most malarious
regions without apparently suffering in consequence. Yet no intelligent
468 LECTURES ON NERVOUS DISEASES.

man would attempt to prove to-day that sewer-gas poisoning and
malarial infection were delusions simply because some people had escaped
their influence.

The argument has been advanced that, because some cross-eyed
people have escaped epilepsy, chorea, insanity, and functional neuroses
of the milder types, it is erroneous to maintain that eye-strain has any-
thing to do with these conditions. This is absurd upon its face. The
hint might, perhaps, be pertinently dropped in this connection that
cross-eyed people practically suffer but little from their muscular error,
simply because they have habitual double vision, which no effort on their
part can correct, These subjects learn very quickly to practically
discard one image (the one seen by the crossed-eye) and to use one eye
only for ordinary vision. In other words, they never try to blend the
images of the two eyes, except in certain attitudes of the head, which
result in a single visual image without an effort on the part of the
patient.

It is only in those cases where (in spite of a muscular error) the
images of the two eyes can be blended by a great effort that the patient
begins to experience the deleterious physical influences of abnormal
muscular tension in the orbit.

If we admit the proposition that eye-defects, or anomalies of the
ocular muscles, are liable to become causes of impaired nervous energy
(because they demand an excess of nervous expenditure), we are forced
to the conclusion that the earlier this source of physical depression is
removed the better are the prospects of the person so relieved of
escaping diseases which impaired nervous energy necessarily tends to
hasten or develop. We are naturally led to question if the so-called
“neuropathic predisposition” is not dependent (in a certain proportion
of cases, to say the least) upon “eye-strain.’ We might possibly also
be led to think that the so-called “tubercular tendency” (which is
present, as far as my observation goes, in nearly 50 per cent. of all cases
of marked functional nervous disease) might, in some cases, be modified,
controlled, or perhaps arrested before its physical results become
apparent by taking from the life of such subjects a load which their
small reserve capital of nervous energy particularly unfits them to
endure.

It is hard to give up the view, so universally conceded, that a
predisposition to disease means a “constitutional taint.” Yet, in many
cases, we are absolutely unable to demonstrate that any evidence of
physical weakness or disease has appeared until sufficient time had
clapsed from the date of birth for the development of a serious impail-
ment of nervous energy. What has caused it? Has it been deficient
nourishment, a lack of maternal care or solicitude during childhood,
FUNCTIONAL NERVOUS DISEASES AND REFLEX CAUSES. 4469

gross violations of the rules of hygiene, ora lack of prudence on the
part of the individual when of matured experience ? The history of
case after case answers ‘‘no” to such surmises, These, then, sre not the
all-important factors in every case. Phthisis, epilepsy, chorea, headaches,
neuralgias, hysteria, dyspepsia, obstinate constipation, nervous prostra-
tion, inebriety, and many other evidences of the neurasthenic state are
markedly hereditary. What is the load (if any) which many sufferers
of this type are carrying through life? Have they a congenital burden—
which is, perhaps, too often unrecognized? I leave these questions for
future research to solve.

In this section I will call attention to a few cases selected from my
own case-book where the relief of ocular defects produced remarkable
and unexpected benetit after all hope of recovery had practically been
abandoned by the patient.

I bring these cases prominently forward in the interest of science
only; because the improvement made by these patients is attributable
not to drugs, but solely to Nature, when a burden of which she could
not rid herself was taken away and recuperation beeame possible.

Did you ever see a tired horse fall prostrate under an excessive
burden? How long would he remain so, were the burden not removed ?

Now, it should constantly be borne in mind that no two cases
exhibit identical manifestations of nervous depression or irritation.
Some patients who are suffering from such conditions manifest the effects
in physical, others in mental disturbances. The heart’s action may be
alone disturbed in some cases, the stomach may give out in others,
some may complain alone of spasmodic muscular troubles, some may
notice its effects in the eyes, some are rendered sleepless, many suffer
from more or less persistent pains, a few complain alone of skin
disturbances, and so on throughout the different parts of the entire
human organism. :

‘We can understand how these apparently discordant facts may be
reconciled when we recall the fact that by means of the brain and spinal
marrow, and the nerves which unite these centres to the different parts
of the body, we are enabled to see, hear, taste, smell, appreciate touch,
swallow, breathe, and perform voluntary muscular acts. It is by means
of our nerves alone that the heart beats; the digestive processes go on
without our knowledge or control through the same agencies; the blood-
vessels contract and dilate in accordance with the demands for blood
telegraphed to the nerve-centre by different organs and tissues; and
every process pertaining to life is thus automatically regulated.

It requires no medical knowledge to see at once how a disturbance
of so complicated an electric mechanism as the nerve-fibres and the
herve-cells of a living animal are can upset all or any one of the
470 LECTURES ON NERVOUS DISEASES.

individual functions enumerated. Many of our houses are furnished
to-day with electric bells by means of wires distributed in the wails. In
some houses we light the gas-jets, and even the rooms themselves, by
means of the same subtle fluid. When the battery becomes weak, or when
the wires are disarranged or broken, what may be the results? Some of
the bells may cease to ring when the button is touched, while others
work properly. Perhaps the electric light may fail in some rooms and
burn with its accustomed brilliancy in others. The gas-jets may not he
properly ignited. So it is with the nervous apparatus of man. From
the same cause one patient may have nervous dyspepsia, another sleep.
lessness, a third headache or neuralgia, a fourth weakness of the muscles,
a fifth disturbances of sensation, a sixth hysteria, chorea or epilepsy. It
is needless to multiply illustrations.

The nervous system of man has been very aptly compared to a
mountainous region where any atmospheric disturbance calls forth a
“ series of echoes” at distant points. So it is with many of the so-called
“functional diseases.” They may be simply the manifestations of a
disturbance of the nervous system, entailed by causes which have been
overlooked or imperfectly relieved.

Before I leave this subject it is but proper to say that a few cases
reported by me in this chapter (while not a large number in the aggre-
gate) were, without exception, well-marked cases of typical and intractable
neuroses, The improvement noted in each case after well-directed
treatment of the eyes or the eye-muscles tends to cast a doubt upon the
existence of any organic disease. No other causes of reflex nervous
disturbances outside of the eyes were detected after a careful search in
any of these cases; otherwise it would have been my manifest duty to
relieve all that were found in my efforts to benefit the symptoms
manifested by each patient.

It is not to be expected, nor do I anticipate, that views so radically
opposed to the ordinary methods of treatment by medication, now gen-
erally advocated for functional nervous diseases, will be accepted at once
by the profession at large, even if correct and satisfactorily demonstrated.
No great advance in science has ever been made until time has tempered
prejudice and modified the prevailing tendencies of thought.

Of late years we, as a profession, have had our attention drawn,
however, more seriously than ever before to the clinical importance and
the necessity of detection of remote sources of irritation to the nervous
centres. We have already learned that the ovaries, the womb, the pre-
puce, the urethra, the rectum, the alimentary canal, ete., can, in some
instances, induce serious nervous conditions which closely simulate the
evidences of organic disease. Complete paralysis of both legs has been
known to be cured in a child by circumcision. The operation devised
FUNCTIONAL NERVOUS DISEASES AND REFLEX CAUSES. 471

by Battey for the removal of the ovaries in subjects attacked with
hystero-epilepsy is to-day sustained by the profession, and often
performed with the view of removing a merely suppositious source of
reflex disturbance. This supposition, in many cases, is based, unfortu-
nately, upon tests much less scientific and therefore less reliable than the
tests employed to detect anomalies of the visual apparatus. It is safe to
question, therefore, if the source of reflex irritation in many patients of
this class has been carefully sought for, and if it does not lie more in the
eyes than in healthy ovaries,* which are not infrequently sacrificed.
Personally, I should not feel justified in taking so serious a step with
any patient until every other possible cause of reflex disturbance had
been carefully sought for in vain.

There is no doubt that many physicians of prominence are devoting
more attention to-day in their practical office work to the determination
of latent refractive errors in the eye and disturbances of equilibrium in
the eye-muscles than was their habit in years past.

This long-neglected but important element in the “neuropathic
tendency ” (and perhaps also in the “ tubercular predisposition ”’) is now
receiving from many sides the most thoughtful consideration. Sooner
or later, in my opinion, our views of the causes of functional nervous
disease will no longer be those now advanced in most of the works
devoted to that field. We shall in time more elearly recognize the fact
that drugs do more harm in functional neuroses than good whenever any
exciting cause of such a morbid condition persists and can be removed;
just as we to-day rely, in case of a joint-disease, more upon mechanical
separation of the surfaces of the inflamed joint than upon anodynes to
relieve the pain. We shall learn to search more carefully and intelligently
for obscure causes of reflex disturbances, and ‘to try the effect of their

removal before we resort to drugs. Medication must eventually, in my
opinion, become the dernier ressort of the physician, in this particular
class of nervous diseases, rather than the haven of refuge.

We are now prepared to discuss some of the various forms of
functional nervous disturbances commonly encountered in medical
practice.

The term “disease” can hardly be applied to a condition whose
morbid anatomy is unknown (as is the case with epilepsy, chorea,
hysteria, hystero-epilepsy, migraine, and certain forms of peripheral
paralysis, and neuralgia). These abnormal states are, properly speaking,
but symptoms, the exciting cause of which may often be involved in
obscurity, and the removal of which must, of necessity, form a very
important factor in the treatment.

* Cysts in the ovary are seldom, if ever, wanting ; hence, they can scarcely be pro-
nounced (when small) an evidence of disease.
472 LECTURES ON NERVOUS DISEASES.

EPILEPSY.

Of all the so-called “functional” nervous diseases, this condition
merits attention first, because it is the most grave. It consists of
periodical convulsive attacks, associated, in typical cases, with a loss of
consciousness.

The paroxysms may vary in regard both to their frequency and
severity.

The extent of the coma, the duration of the fit, the parts con-
vulsed, the mental aberration, and the constitutional effects which follow
the attack vary also in different subjects. Among the ancients, this
condition was regarded with peculiar horror, and was attributed to the
“possession of a devil.”

Varirties.—Custom has established a classification of this con-
dition into types, as follows :—

(1) The “Granp MaL” or typical attack, where consciousness is
totally absent during the convulsive stage.
(2) The “petit MaL” or mild attack, in which consciousness may be
wholly or partially retained, and the convulsive movements may
‘be slight or absent.
(3) To these, may be added a condition known as “IRREGULAR
EPILEPSY.” :

These distinctions are not clinically accurate. Cases do occasionally
occur where consciousness may be wholly lost, and yet the convulsive
movements may be partial rather than general. Again, general con-
vulsions of a severe type have been observed in rare cases where con-
sciousness has been perfectly retained. I have encountered, moreover,
a few cases of petit mal where certain peculiar attitudes of the ex-
tremities and face have taken the place of convulsive movements and
consciousness has been only imperfectly lost.

I have frequently seen patients have an epileptic attack in my office
while sitting upon a chair without falling from it. One patient now
under my charge has had numerous attacks while walking in the street,
which, as his attendant assures me, did not demand any aid on his part
toward supporting the patient.

Etiology.—Heredity plays an important part in the history of many
cases. A record of epilepsy, hysteria, insanity, chorea, migraine, or
phthisis is commonly found to exist in some branches of the ancestral
line. Tnebriety may also have been frequently observed on the father’s
or mother’s side.

Some adults are apt to trace their first fit to masturbation; or
to excessive venery, some great mental excitement or strain, or some
infectious disease (prominently syphilitic infection).
EPILEPSY. 473

Most epileptics also give a history of some severe injuries received,
to which they attribute (too often erroneously) their convulsive attacks.
Investigation will usually show that these injuries are apt, however, to
be the result of an attack rather than cause, or to be a mere coincidence.
Traumatism may, unquestionably, in rare cases, prove an exciting cause
of epilepsy, but I believe the frequency of such cases to be greatly over-
estimated. ‘The same remark would apply to some organic brain-lesion.

In the third place, any condition which creates marked reflex
trritation—such, for example, as eye-defect, dental irritation, phimosis,
gastric or intestinal disturbances, cicatrices involving nerve-filaments,
foreign bodies or wax in the ear, ovarian irritation, uterine or rectal
diseases, the first menstruation or coitus, ete.—may, in some subjects,
induce epileptic seizures. A large proportion of the epileptic attacks
of infancy are unquestionably brought about by trivial reflex causes.* In
adults, however, the reflex causes enumerated (with the exception of
“eyestrain” and bad teeth) are, in my opinion, less apt to induce true
epilepsy than the profession generally suppose.

It is very uncommon, in my experience, to meet with male or female
adults (in whom attacks of epilepsy have commenced after the seventh
year) which fail to show some abnormality of refraction, or in whom the
condition known as ‘“ ocular insufficiency ” is not found to exist toa
marked degree.

Ihave one patient under my care at present who, for years, had
always been seized with an attack on suddenly going from the light into
darkness. Another (who, happily, has apparently about recovered after
partial tenotomies performed upon the eye-muscles) had the first two
attacks when exposed to the dazzling reflection of the bright sun upon
a rough sheet of water, and was rescued from drowning twice in conse-
quence. A third patient of mine, who had several attacks daily when
on land, would, strange as it seems, skip many wecks without a fit when
on shipboard, where his efforts to accommodate vision for near objects
were infrequent. He had very serious refractive and muscular anomalies.

Finally, it must be conceded that organic changes within the brain-
substance or irritative lesions of the cortex may, in a certain proportion
of cases, induce epileptic attacks. A depressed fracture of the cranium
or an exostosis, for example ; a meningeal thickening; an abscess within
the skull; parasitic deposits ; gummata, etc., have been shown to have
induced attacks of this character.

We may assume in cases of epilepsy that, as a rule, the condition
becomes more grave after the seventh year than in early childhood,
—especially if no well-ascertained cause of reflex irritation can be

* Worms, indigestion, phimosis, teething, etc., are often accompanied by epileptic
attacks in infancy or early childhood.
474 LECTURES ON NERVOUS DISEASES.

discovered. It is impossible as yet to express any definite knowledge
regarding the relative freyuency of such causes to the total number of
epileptics encountered ,—because the published records of such cases are
singularly imperfect in reference to the examination of the eye. The
following statistics (taken from Dr. Stevens’ prize essay) will, however,
prove of interest in this connection :—

Total number of cases reported, a ae ae include all cases up to

Total taken from the author's private practice, . 1882,

An analysis of 100 consecutive cases of typical epilepsy, from number

above mentioned, shows the following refractive errors to have existed :—

Hyrerorra or Hyprropic ASTIGMATISM, . . . present in 59 cases, or . per cent.

Myopra on Myopic ASTIGMATISM, . . . .. ee 23: a

Refractive errors of less than 1 dioptre, . . . e 1g © i3 “i
Total, 100

The condition of the eye-muscles was not sufliciently well reported
in many of these eases to allow of percentages being given in reference
to this important factor.

My own examinations up to 1887, of a much smaller number, show
that my private cases possess a much larger percentage of hyperopic
abnormalities (in excess of 1 dioptre), and a smaller proportion of
myopic defects. In fourteen cases carefully observed, prior to 1887,
nine were markedly hyperopic, four were myopic in excess of one dioptre,
and only one was emmetropic. In every case but one, a marked condi-
tion of esophoria was found. In five, hyperphoria existed in addition to
esophoria. In the remaining case, a hyperphoria of about 4 degree was
all that was detected. The following summary of these cases may shed
possibly some additional light upon this new field of inquiry :—

Total cases, 14. (All of the severe type.)

 

FREQUENCY OF THE AT- EXAMINATION ‘OF

 

 

7
MENTAL |
TACKS (IN SPITE OF; ioe 2 EYES: peteoep STATE t REMARES.,
ACTION OF BROMIDES) © Refractive Muscular | OF PATIENT.
WHEN FIRST SEEN. | | "2pyor. hrven
Seer ty ftp a ey hag

 

 

” Beophor ia, | Markedly af. | One of these cases
13cases. _ fected in 5 cases. had 52 convulsions

| in 8 honrs, after
Huperphoria, ‘Slightly affected : stopping the use of

ATER of over five ‘fits | H., 7 cases.
each day, 1 case.

Average of three per day, ‘Ha., 4 cases,

 

 

 

4 cases | 5 cases. In 8 cases. | the bromides.—each
Average of two per day, M., 4 cases. Exophoria, Unaffected in | fit lasting 3 min-
2 cases. ‘ 0 case. 6 cases. | utes.
4
Average a one per week, Ma., 1 case. | Heterophoria. | In all of these cases
cases, 14 cases, the frequency of
Average of one per! Em.,1 case. | Orthophoria, Pe ny
month, 3 cases. 0 case. ae th
discontinued the
Occasional attacks, 2 use of the bromides.
cases. “|
Total cases=11 | Total= 1 * * __ Total=lt at

 

 

*Some of these wvatlantis showe ‘la au more fan: one eye-defect ; Tene: these two columns
cannot be tallied.
+ The symbols used in this table are explained on p. 130.
EPILEPSY. 475

Morbid Anatomy.—In spite of the fact that much has been written
upon this subject, no primary changes of an anatomical character can be
asserted to be pathognomonic of epilepsy.

In this view, I think that most of the later authorities stand
agreed,

The view of Schroeder Van der Kolk (1859) that the vessels of the
posterior half of the medulla (those affecting chiefly the roots of the
vagus and hypoglossal nerves and the fourth ventricle) were unnatu-
rally dilated is not now accepted. That of Kroon (asymmetry of the
olivary bodies); of Solbrig (constriction of the spinal canal, with second-
ary atrophy of the medulla); of Lélut (sclerosis of Ammon’s horn); of
Cooper (compression of the carotid arteries) ; of Landois (venous hyper-
wmia of the brain and spinal cord); of Nothnagel (irritation of the
“convulsive centre ” in the region of the medulla and pons); and many
other equally fanciful hypotheses have been proven to be more or less
fallacious. .

The exhaustive paper of Hughlings-Jackson (1873), in which he
advocates the theory of “explosive discharges ” of the cells of the brain
in epileptic attacks, is rather physiological than pathological in its scope.
If, as he believes, a mal-nutrition of the brain-cells exists as a primary
state (which predisposes to these paroxysmal explosions) the importance
of the detection and removal of its cause becomes the more apparent.
The paper referred to aids us more in localizing an intra-cranial lesion
of an irritative type than in explaining the occurrence of genuine epilepsy
as we commonly encounter it.

In the light of later researches, it is, in the opinion of the
author, not necessary to discuss at length the view of Lasegue
(1877) that epilepsy proceeds from cranial asymmetry or mal-
formation.

Brown-Séquard has shown that animals can be made epileptic by
injuries to the spinal cord and peripheral nerves; but, as some weeks are

required to induce this result, these experiments seem to show that some
secondary changes in the nerve-tissues had probably developed as a
result of the injury inflicted.

Eccheverria claims to have discovered serious changes in the
cervical sympathetic ganglia and the sympathetic fibres in connection
with epilepsy. Similar changes have been observed, however, by Mayer
and others in connection with diseases of the brain associated with
vascular disturbances.

Symptoms.—The general character of a severe epileptic attack has
been partially described already in a previous section (page 155). Jt
will simplify description to consider certain features of the attack
separately.
476 LECTURES ON NERVOUS DISEASES.

GRAND MAL.

PremMonitory Symproms.— Most epileptics affected with “orand
mal’? have some peculiar sensations (the aurexe ) which indicate the
approach of an attack. Some subjects experience a marked change in
temperament for a day or two prior to the fit. They become either
gloomy, sullen, inclined to anger, or, in exceptional instances, more
cheerful than usual, Again, the skin of the face and neck may assume a
a dusky hue some hours before the attack, In others, headache, cardiac
palpitation, pain in the precordium, a sense of distension of the ab-
domen, a diarrhwa, attacks of vomiting, sensitive spots on the limbs,
attacks of agraphia, giddiness, unnatural loquacity, etc., have been
reported as forerunners of an epileptic fit.

Aure connected with the special senses are not uncommon. Some
patients perceive an unnatural color (usually red or green or blue) in
the field of their vision. Some patients of this class habitually see
objects enlarged or diminished in size—an evidence of eye-defect. Others
see a rising mist or various unnatural objects (as in a dream). To smell
bad odors, to hear strange or unnatural noises, to taste unexpectedly
obnoxious things, or to feel numbness, etc., are not infrequently a note
of warning to epileptics to seek a recumbent posture.

The muscular aure observed comprise an unexpected and un-
controllable spasmodic movement in some part of the limbs or body,
a sudden activity in the facial muscles, a sudden tendency to rotate the
body, or to break into a run while walking, and a sudden stiffness or
immobility of a part.

Vaso-motor aure are not uncommonly observed. They comprise
spots of pallor or flushing upon different portions of the skin, an
unnatural heat or coldness in some part, a tendency to. sudden local
perspiration, and flashes of heat or of cold shooting over the whole
body.

Psychical aure are occasionally exhibited in the form of delusions,
hallucinations, and illusions,

The Epileptic Cry.—In a certain proportion of cases, a peculiar cry
precedes the fit. It may be a shriek, or again it may be scarcely audible.
IT have known it to awaken all the patients in a hospital ward from deep
slumber. The patients are usually unconscious of having uttered it,
and it is probably due to a very forcible expiration through a partially
closed and rigid glottis.

Indications of Alarm.—Some epileptics have a facial expression of
great alarm just preceding the fit. This is more common in children
than in adults. In rare instances, the attitude of the hands and arms
express the same mental state.
GRAND MAL. 477.

Actua Symrtoms.—At the approach of the fit, it is common to
observe a marked facial pallor. KEyen in “petit mal” this is generally
present. In exceptional cases the face may appear congested.

The Stage of Rigidity.—If the fit is a severe one, the body
becomes at first as rigid as a board. The limbs are extended,
the feet inverted, the fingers and toes are commonly flexed, and
the head is thrown back and usually turned to one side. The
whole body may be twisted backward or laterally. The eyes are
fixed during the tonic stage, and the pupils are, as a rule, widely
dilated. The breathing is partially or totally arrested. Sensibility
is abolished. :

The Stage of Clonic Spasms.—After the tonic stage has lasted
for a short time (about two minutes or less), convulsive movements
begin, the whole body being alternately thrown into violent contraction
and relaxation. The face is distorted by terrible grimaces and assumes
a purplish hue. The breathing gradually becomes loudly stertorous ;
the saliva escapes from the mouth as froth, and is often bloody from
wounds inflicted by the teeth upon the tongue. ‘The urine, semen,
and feces are often passed involuntarily. The clonic spasms generally
subside by degrees, growing less and less violent until they entirely
cease, As the convulsions subside the face becomes less dusky. During
this stage the eyes may stand open and seem to protrude from the
socket; but they are generally turned upward, so that the white of
the eye only shows beneath the blinking eyelids. They sometimes
become intensely congested, so as to give the eye a resemblance to
raw beef.*

The pulse cannot be satisfactorily observed in this stage on account
of the muscular movements. ;

Stage of Recovery.—When the convulsive movements have entirely
ceased, and the breathing has resumed its normal character, the patient
lies limp and helpless for a short time and gives evidence of a desire to
sleep. If aroused, he acts as if dazed and stupid; answers questions
with reluctance or imperfectly ; looks about him in a semi-conscious or
frightened way; mutters to himself some unintelligible sentences; and
relapses into a lethargic sleep. Cases where complete epileptic coma
has lasted forty-eight hours have been reported. As a rule, however, a
sleep of a few minutes suffices to enable the patient to walk with slight
assistance.

The fit usually leaves a sensation of dull headache for several hours

and great muscular fatigue.

* Serious difficulties may occasionally arise from this intense congestion after a partial
tenotomy of the eye-museles has been performed. I have had two patients intensify the
effect desired from a graduated tenotomy by a fit occurring soon after the operation.
478 LECTURES ON NERVOUS DISEASES.

In very severe fits, the teeth, and even the jaw itself, have been broken
by the violent muscular movements, the tongue completely divided, the
clavicle fractured, and muscles torn across. One of my patients worked
his way through the ash-door of a furnace (12x16 inches) during an
epileptic fit, and the brick-work had to be removed to extricate him.
Fortunately no fire was in the furnace.

Many epileptics fall very violently when the fit comes on, because
of insufficient warning. It is very common, therefore, to encounter
scars on different portions of the body in these subjects. The edges of
the tongue usually give more or less evidence of previous attacks of
“orand mal.” They are badly scarred, or ragged, from imperfect union
of old wounds.

PETIT MAL.

The milder forms of epilepsy may assume a variety of types.
Personally, I do not regard any attack as one of true epilepsy unless
consciousness is more or less completely lost; hence, I do not usually
include among this particular class those subjects who suddenly have
some of the premonitory symptoms of grand mal, already described, and
still retain a perfect knowledge of their surroundings.

Subjects afflicted with petit mal often assume a fixed attitude without
any premonition of an attack, and stare unconsciously for a few seconds.
I once had a patient who would frequently do this at a card-table without
dropping a card or losing the run of the game. He played for very
heavy stakes and was usually a winner.

Occasionally, these subjects will stop in the middle of a sentence,
grow pale or red, and remain motionless for half a minute or more with
the eyes staring into vacancy. They will then finish the sentence and
be unaware of the intermission which had possibly alarmed the rest of
the company.

Facial grimaces or slight twitchings of the muscles may occur in
more severe attacks of this character, and the urine may be voided
unconsciously, ,

Some attacks of this type are exhibited by the patient walking about
in an aimless way, with inarticulate mutterings, as if in search of some-
thing.

Petit mal is usually associated with some ill-defined aura, which
leads the patient to suspect that he has had an attack accompanied by a
temporary loss of consciousness. Some subjects compare these attacks
to “a dream;” others feel dizzy or nauseated; a few suffer an in-
describable physical distress. I have had several patients of this class
who have told me that they “became blind” for a moment. An uncon-
trollable dancing of the eyes (nystagmus) occurs during these attacks
in one of my patients, of which he is conscious.
IRREGULAR EPILEPSY. 479

Momentary strabismus is not infrequently observed in epileptics.
It may occur independently of a fit or in conjunction with one.*

IRREGULAR EPILEPSY.

These attacks are of a peculiar kind, which are indicative of a
condition designated by Hughlings-Jackson as “mental automatism.”
Hammond classes them as aborted paroxysms.

Such attacks are characterized by acts on the part of the patient of
an impulsive and unnatural character, of which he is unconscious. ‘They
simulate in some cases attacks of momentary insanity. There are no
muscular twitchings, as a rule. These attacks may occur in subjects
who have never had either grand mal or petit mal. They are usually of
short duration (a few minutes only, as arule). Acts of violence are not
uncommon in these attacks. Patients often wander without proper
preparation through crowded streets, commit acts of immodesty or
indecency, utter lewd expressions, etc., during these attacks, without a
knowledge of doing so. Some suddenly find themselves standing or
sitting in unexpected places (as in a closet), or committing some act
which they had no will and often no motive to perform. These attacks
may occur at any time of the day or night, and cannot usually be traced
to any special cause. Kleptomania and other unconscious acts of crime
may be attributed (in some cases) to this particular form of epilepsy.

Diagnosis.—The various types of epilepsy may be confounded with
comatose states and with other convulsive attacks; such, for example,
as those of cerebral congestion ; alcohol- or opium-poisoning; the con-
vulsions of uremia, hysteria, apoplexy, cerebral organic lesions, and
feigned epilepsy. The table on the following page will aid the reader
in the diagnosis of some of the more important conditions mentioned.

COMPLICATIONS OF EPILEPSY.

Various forms of mental disturbance may develop in connection
with epilepsy. I have observed several cases where such disturbances
have assumed the condition of permanent insanity; but they are, as a
rule, of short duration. The condition described as “irregular epilepsy ”
is particularly liable to manifest itself in this way. It is stated by
Reynolds that one-tenth of all cases of epilepsy develop epileptic mania.
This proportion seems to me to be somewhat excessive.

* In this connection I may remark that the constant efforts which epileptics
commonly and unconsciously make to avoid being cross-eyed is, in my opinion, one of
the causes of their attacks. If they were actually cross-eyed, they would learn soon to
disregard the visual image of the distorted eye, and their diplopia would be clinically of
no account. As it is, they suffer in many cases from. a very high degrce of “latent 7
insufficiency, which they instinctively endeavor to overcome in order to prevent diplopia.
This subject has been discussed on a preceding page.
LECTURES ON NERVOUS DISEASES.

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PROGNOSIS OF EPILEPSY. 481

Epileptic mania may lead to motiveless and atrocious crimes in
some cases, and to acts of indecency and vulgarity in others. Again,
illusions of the special senses, melancholy, or preternatural buoyancy of
spirits may be evidences of this complication. Epileptic delirium is
therefore not always of a dangerous character; although it is liable to
become so, and deserves careful watching.

When idiocy is associated with epilepsy, the former is generally
congenital or the result of a prolonged use of bromides.

Prognosis.—Authorities differ respecting the indications for an
extremly unfavorable prognosis in epilepsy. Some assert that extreme
frequency of the paroxysms have a serious significance; while others
claim that the most intractable cases are those who have attacks at
prolonged intervals.

It is generally conceded that cases of long standing are more
rebellious to any form of treatment than in those where the “ epileptic
habit ” has not been developed to the same extent.

The criticisms which I would make, in the light of my preliminary
remarks to this chapter, upon the two former paragraphs would be this:
First, that it is difficult (in cases where the attacks are very infrequent)
to tell positively when all causes of reflex irritation are removed without
waiting a long time; secondly, that most cases of long-standing (irre-
spective of the frequency of the attacks) are usually thoroughly bro-
midized before reflex causes are searched for in a scientific way, and are
suffering as much from the deleterious effects of drugs as from the
epileptic state.

Although mental failure is generally regarded as a sign of evil
import in epileptics, I have seen several cases in private practice where
a tenotomy of the eye-muscles has been followed by marked recovery of
the intellectual faculties, after all drugs have been discontinued. Photo-
graphs of several patients operated upon by my friend, Dr. Stevens, in
the Willard Asylum, during the summer of 1886, seem to prove quite
conclusively that some cases of even chronic insanity as well as epilepsy
are capable of rapid improvement when the deleterious effects of eye-
strain and drugs are no longer borne by the patient.

One case of insanity recovered his full mental faculties in a few
weeks after I performed a tenotomy of his internal recti muscles, and he
has shown no tendency to relapses. An epileptic, in whom all convulsive
attacks ceased after I performed the same operation upon her, was very
deficient in intellect before that step and is now rather above the average:
in mental power. One of the most remarkable cases that ever came
under my observation was that of a combination of chorea, epilepsy, and
idiocy in a girl about eleven years of age, who completely recovered her
health, strength, and mental faculties when a refractive error in the eyes

; 31
482 LECTURES ON NERVOUS ‘DISEASES.

was corrected by glasses, and a serious combination of muscular defects
‘in the orbit was adjusted by tenotomy. This case was one that I saw
some three years ago, in connection with the practice of Dr. Stevens.
At the first examination, the child could not walk without being sup-
ported on both sides, drooled constantly, talked unintelligibly, answered
questions with apparently little conception oftheir import, could hardly
sit unsupported in a chair on account of chorea, had epileptic seizures
repeatedly during the day and night, and presented a most pitiable and
apparently hopeless aspect. I saw her again, about a year after the
operations were performed, at the request of Dr. Stevens. I found her
free from chorea and epilepsy, able to run and skip a rope unaided, rosy-
cheeked, and in full possession of her mental faculties. Photographs of
this case have been already published by Dr. Stevens.

That a persistence of epileptic attacks for years does not necessarily
render recovery impossible is proven by the fact that I have personally
had three cases where convulsive seizures have been thus far arrested by
tenotomies which I performed upon the eye-muscles. All of these cases
had been kept constantly under bromides for several years without
apparent benefit before they were placed under my care. Over a year
has now elapsed since two have taken any drugs or have had an epileptic
fit, and the third has passed several months without an attack. Dr.:
Stevens reports several such cases; which tend to prove that permanent
organic changes in the cells of the cortex do ‘not necessarily occur as a
result of frequent and long-continued epilepsies.

Finally, it may be said that little danger to life is to be apprehended
in epileptic seizures. I have never known of a case where death occurred
directly from the fit; although many cases may have met their death
indirectly from that cause, through suffocation, drowning, ete.

Treatment.—From what I have already said in the preliminary
remarks concerning functional nervous diseases, it must be evident that
medication in these affections constitutes with me rather a dernier ressort
than a harbor of refuge. In this view, I feel that I am, as yet, quite
alone among neurologists; but I am too sure of my position to doubt
that in time the views which I here advocate will not be without other
enthusiastic followers.

The first step in the treatment of epilepsy (and the same remarks
hold good for all functional nervous diseases) is, in my opinion, to
ascertain (by all scientific means yet noted and by careful observation
and record) if any cause for reflex irritation exists. While I believe
that such a cause will be found, in a very large proportion of such cases,
in the eye, I would not be construed as stating that the examination
of this organ should constitute the beginning and the end of such
a search. The womb and the ovaries in females, the genitals in the
TREATMENT OF EPILEPSY. 483

male, and the teeth and rectum in both sexes may require a careful
examination.

I should be very strongly led to suspect an eye-defect or an “insuffi-
ciency” of some of the ocular muscles in case (1) the patient was a young
adult; (2) if he had a tuberculous ancestry; or (3) if he gave a history
of epilepsy, hysteria, chorea, or insanity, in some branches of the ances-
tral line,

The conditions of the visual apparatus which seem to predispose to
these conditions are peculiarly liable “to run in families,” and to be
transmitted (as features and mental traits are) from parents to their
children. It will generally be found that “sick-headache” is another
“family ailment” among this type of subjects; in case a heredity to the
severer forms of functional nervous disturbance is not clearly brought
out on a careful line of examination. The close relationship which exists
between this common and excruciating form of pain and eye-strain is
now too well recognized to need further comment.

The next question which I should feel myself called upon to decide
in a case of epilepsy (provided the previous lines of inquiry respecting
reflex causes had been prosecuted with due regard to the details given
for such examinations and had yielded negative results) would be to.
determine if traumatic conditions did not exist, which might account for
the epileptic seizures. /

The steps indicated for the relief of such conditions would depend
entirely upon the nature and seat of the injury received. Cerebral
localization would then come into play, and surgical interference would be
justified or contra-indicated by the conclusions drawn from that source.

In the third place, it is always hest to examine with care in any case
for the symptoms of organie changes of a local character either in the
brain or its coverings. The hints furnished in Section II of this work
can be reviewed with advantage in this connection.

Finally, if all of these lines of investigation give us negative results,
medication must, of necessity, come to our aid,—as an empirical and
most unsatisfactory way to an inquiring mind of controlling or modify-
ing symptoms which we are unable to explain, and upon the cause of
which pathologists have shed but little if any light.

. A few illustrative cases may be cited .in this connection with possible
advantage to the reader :—

Casz I. Chronic Epilepsy —Male, aged forty-three, merchant. Began to have severe
epileptic fits when seventeen years of age. Had masturbated when a boy, and had been
addicted in later years to excessive venery.

Family History—One brother is a confirmed dipsomaniac; the father died of paral-
ysis: one sister is a victim to sick-headaches; no phthisis has existed in the family, so far
as could be ascertained.
484 LECTURES ON NERVOUS DISEASES.

The epileptic seizures of this patient varied in frequency from two or three a week to
one in'three months. He came under my care in 1871 (when twenty-eight years old),
and was treated by me for many years with enormous doses of the bromides of potassium
and sodium. These salts reduced the attacks to about four a year. Stopping the bro-
mides invariably increased the frequency of the attacks.

Lye-defects.*—In January, 1886, his eyes were examined after his return from an
extended residence in the South. He showed under atropine a latent hyperopia of 2.50 D.,
and also a manifest esophoria of 4°. Subsequently several degrees of “latent” esophoria
also manifested itself,

Partial tenotomies were performed upon both interni, and hyperopic glasses (+ 1.50 D.)
were given him. Since the first operation (January, 1886) he has taken no bromides and
has not had a convulsion, He has twice been ‘at death’s door” with fevers, but he has
shown at no time any epileptic tendencies.

Case II. Chronic Epilepsy —Female, aged twenty, unmarried.

Family History—The father died of apoplexy. No hereditary tendency to nervous
disease or phthisis could be discovered /

The epileptic seizures had existed for five years and developed after an excessive use
of the eyes in sewing upon a black material. Menstruation was regular. The epileptic
fits were, however, more frequent during the week prior to and following the menstrual
epoch. Under large doses of bromides and ergot she had once in her history passed six
weeks without an attack; but she averaged, when I first saw her, about six attacks each
month. An epileptic attack could usually be induced by firing the eyes for a- few minutes
intently wpon some near object. She had at one time as high as thirty severe fits in twenty-
four hours. When the bromides were withdrawn from this patient, the fits increased to
several each day (often as high as ten severe seizures). She had for years suffered from
czstinate constipation and pain during her menses.

Eye-defects —This patient was found to be absolutely emmetropic both before and after
the use of atropine. She showed, however, an esophoria of 5° and a very low power of
abduction. Subsequently, a large amount of latent esophoria developed.

Several partial tenotomies were performed upon the interni of this patient during an
interval of some four months until all latent esophoria was apparently overcome. After
the first operation, the lacrymal secretion, which was singularly defective, became normal,
her mental despondency disappeared, and her attacks rapidly diminished in frequency.
Since June 10, 1886, she has had no fits to my knowledge, nor to that of her physician so
far as I can ascertain. The case was lost sight of by both of us some months ago, much
to my regret. When I last tested her eyes, she showed no defect and was apparently in
perfect health. She had passed several menstrual epochs without any epileptic seizures.

In this case I would call attention (1) to the fact that emmetropia
existed; (2) to the fact that the eye was the apparent exciting cause of
her attacks; (3) to the fact that epileptic seizures could be induced by
excessive use of the internal muscles of the eye; and (4) that the
esophoria was “latent” to a very marked degree.

In addition to these points of interest, another fact is worthy of
passing remark, viz., that the relief of the “eyestrain” was followed in
this case by a total disappearance of the habitual constipation that

* For the meaning of terms employed in connection with muscular anomalies of the
orbit, the reader is referred to page 143.
TREATMENT OF EPILEPSY. 485

previously had existed, and that menstruation ceased to be accompanied -
by pain up to my last notes on the case. This experience, although
apparently a coincidence, is not by any means infrequent with female
patients, in my practice, after a partial tenotomy of an eye-muscle for
the relief of an abnormal tension within the orbit. It is probably to be
attributed to the fact that the nerve-power of the patient improves
rapidly after the excessive expenditure of nerve-force demanded by
abnormal eye-tension is arrested, thus allowing of an improvement in the
functions of the other viscera. The introductory remarks of this chapter
will, I trust, make this explanation clear to my readers and bring this
statement more into apparent harmony with physiological laws.

Case III. Chronic Epilepsy —Male, unmarried, aged twenty years.

Fanuly History —No consumption among the ancestors or immediate family. Several
members of the family suffer from headaches.

| Eye-defects—Hyperopic astigmatism (0.75 De. and 0.50 Dc.), esophoria (manifest) of
6°, and latent hyperphoria of a very high degree. The latter has proved very persistent,
and has only lately been satisfactorily corrected. ‘I'he progress of the case has also
demonstrated that a high degree of latent esophoria had to be corrected in excess of what
he at first manifested.

This patient was a victim to the severest type of chronic epilepsy. His attacks were
extremely frequent and severe. Going from light into darkness would invariably cause
an attack and a total loss of consciousness. I personally attended him, in connection with
Dr, G. W. Leonard, of New York, when he had fifty-two epileptic seizures in eight hours,
each fit lasting exactly three minutes. All medicinal treatment had proved inoperative.
His attacks began while he was at school as a child, and were preceded by a difficulty for
months of keeping his place on a page while reading. Le used to hold his finger on the
line to aid him in reading.

His improvement, after repeated tenotomies upon both interni and the left superior
rectus, has been most remarkable. His attacks have been decreased over 75 per cent.
He is still under observation, with a prospect of still greater improvement, if not of a
permanent cure. He has taken no bromides or medicine of any kind save an occasional
diuretic (tincture of iron) for sluggish kidneys.

The photographs of this patient, which I now possess, hardly show
the happy change which has occurred since the last was taken, in spite
of the complete cessation of the bromides for about eighteen months.

‘In place of the dull, apathetic, and sluggish features which indicate
the impaired mental state of the patient from the bromides, in the secone

‘photograph an animated expression and a shortening of the face can be
seen, which are much more apparent to-day even than when it was taken.
The change in his general health and physical strength has been even
more marked than his facial changes.

Casr IV. Chronie Epilepsy—Female, unmarried, aged nineteen years.

Family History —Paternal grandmother died of phthisis. The mother has migraine.
The brother hag migraine. A paternal aunt was insane.

Eye-defects—A high degree of myopia (3.75 D.) and myopic astigmatism (1.50 D.).
486 LECTURES ON NERVOUS DISEASES.

Ksophoria (manifest) of 9°. A high degree of latent hyperphoria was also discovered
* later.

Prior to my first examination this young lady was considered a hopeless epileptic.
She had been for years under the care of several of our most noted neurologists and oculists.
After a partial relief of her abnormal eye-tension by tenotomies, she went over seven
months without an attack, and regained her mental faculties, which had been somewhat
impaired by bromides. Within the past four months she has had six attacks of epilepsy,
two of which followed fright, one an imprudence in eating salads very late and immedi-
ately before going to bed, and the fourth after the excitement attending a departure for a
pleasure excursion. She has lately manifested a latent muscular defect which I have yet
to overcome. From a letter addressed me by her father not long since I quote the follow-
ing paragraphs :-—

“Nothing but an inability on my part to pay for your services would persuade me to
remove my daughter from your care, and if I could not pay I would ask you for charity

to keep her. /
“Her whole being has been altered, and her physical condition is better than for

eight years.” ,

The photographs of this patient show a very marked alteration in
her physical and mental states, as a result of the relief of the muscular
errors detected in the orbits. She is now allowed to enjoy privileges
which were considered impracticable prior to this treatment, such as an
unrestricted diet, horseback exercise, visits to the city unaccompanied,
attendance at social gatherings, ete.

As this case is well known to several prominent medical men of New
York City, it may be proper for me to state that since October 10, 1886
(some nineteen months), this patient has had but eight epileptic seizures.
Prior to that date my records go to show that, even when under bro-
mides, from one to six fits a day often occurred, and that the nocturnal
attacks (which were very frequent) were not always noted. It is safe,
therefore, to say that, had she received no medicinal treatment or correc-
tion of her eye-defects during the past nineteen months, the total number
of seizures would probably have been more than a hundred times this
number. She had been known to have as high as seventeen epileptic
seizures during one night, Her attendant has assured me that since my
treatment was commenced all nocturnal attacks have ceased.

The point may be raised that a report of any epileptic case, until
the full limit of three years has been passed without an attack and with-
out the employment of any medicine which would control the epileptic
tendency, must be considered as somewhat premature. In reply, I would
say that the cases I have brought forward are not represented as cases
of radical cure. They are adduced simply as:a clinical evidence that the
frequency of such attacks has been greatly modified, and in two instances
completely controlled for long periods of time, without the aid of drugs.
On the other hand, there are now to my knowledge several eases of
chronic epilepsy similarly treated that might be brought forward (did I
TREATMENT OF EPILEPSY, 487

deem if necessary to quote from the experience of another) which have
fulfilled all the requirements which would justify the belief in a radical
cure of chronic epilepsy. One of these patients has passed over seven
years without a fit, and several have exceeded the three-year limit.

We all admit, I think, that epilepsy is certainly the gravest of all
the functional nervous maladies, and that it is, as a rule, incurable by
drugs; hence, as I have remarked in a previous discussion concerning
this subject, ‘one radical cure of epilepsy without the aid of drugs ofisets
a thousand failures as a scientific proof of a discovery.”

It is impossible for any one not familiar with the difficulties encoun-
tered in the treatment of these subjects (already discussed) to appreciate
the fact that, in some cases of epilepsy, eye-defects may exist which can
not be thoroughly rectified; and that, even in favorable cases, time and
patience are important factors in the treatment.

Epileptics usually present, in my experience, in addition to errors
of refraction, anomalies in both the lateral and vertical movements of the
eyes;.and in some cases the oblique movements are probably at fault.
Moreover, experience with these subjects demonstrates clearly to my
mind that the muscular anomalies which exist are generally “latent” to
a marked degree.

It should be remembered also that a victim to chronic epilepsy who
is rendered by any treatment as free from attacks without the bromides
as he was when under their deleterious influence has been very markedly
benefited; again, that if a marked diminution of the attacks has been
effected, the patient has double cause for gratitude; finally, that if the
attacks are arrested in ¢oto without drugs, it is to-day one of the most
remarkable facts recorded in medical literature.

There is a point where opposition to carefully made clinical statistics
respecting new views ceases to be conservatism. True conservatism is
the brake upon the engine of progress. It is to be used in checking its
speed when going too fast, but not in preventing its advance, even if
the country is an unexplored field. Too often in medicine the term
conservatism has become a favorite synonym for bigotry and intolerance.

My own personal observations of epileptic subjects, since my atten-
tion was first drawn to the importance of a systematic examination of the
eyes and the eye-muscles in these cases, are not sufficiently extensive
perhaps to warrant any general deductions respecting the percentage of
such errors which would be accepted as conclusive; and those of Dr.
Stevens upon a larger number of cases might also be regarded as some-
what insufficient. As yet, no scientific records of the examinations of
epileptics in respect to abnormalities of the ocular muscles have been
systematically made, to my knowledge, in other quarters. Ophthalmc-
scopic tests have been published and errors of refraction have been:
488 LECTURES ON NERVOUS DISEASES.

repeatedly noted, but the tests to determine the existence of esophoria,
exophoria, and hyperphoria at twenty feet (and also at fourteen inches
if modified by accommodative efforts on the part of the patient) have
yet to be made on a large number of cases by competent experts before
this matter can be spoken of in an authoritative manner. I can only say,
in this connection, that I have yet to meet a case of epilepsy in my
private practice (which was not clearly the result of traumatism or
syphilis) that did not exhibit more or less muscular error connected with
the eye after the refractive error (if such existed) was corrected with the
proper glass. It is but natural, therefore, to expect that further records
of epileptic cases which will doubtless appear hereafter from time to time
shall give satisfactory evidence of care and skill in these important
examinations.

The opposite page shows the results of an eye-examination upon
sixteen consecutive cases of epilepsy which came under my care during
the early part of the past year in my private practice. It also has a
bearing upon some other points relating to epilepsy which have been
discussed in preceding pages.

It will be perceived that most of these cases are of several years’
duration,—enough to be considered chronic. In only two of these cases
was the eye emmetropic. All but one (a syphilitic case) showed a
departure from the physiological state of equilibrium of the eye-muscles.
Several had impairment of intellect. In most of the cases, the epileptic
seizures were very severe and of frequent occurrence, All but two had
been kept under the bromides for long periods of time.

After deducting from this list those cases which either refused to
have tenotomy performed, or who failed from other reasons to put
themselves under treatment, eight remain that have been operated upon
with the object of correcting some existing muscular error. Of these eight,
three have been thus far very markedly relieved of epileptic seizures by
partial tenotomies of eye-muscles ; and five are still under observation.
No medicines have been administered to any of these eight cases to aid
in controlling the epileptic attacks since they have been under my care.
Of the five that are still under observation, one has granular kidneys as
a complication ; and the remaining four have still some muscular errors
in the orbit that have not been perfectly corrected up to the time of
writing. One of the four has had epilepsy over twenty years, during
most of which time she has constantly taken large doses of bromides of
potash, soda, and ammonium.

The three cases which are to-day apparently relieved of attacks
were all of the chronic type. All had taken enormous doses of the
bromides, and had reluctantly been forced to abandon them, either at
my request or when they ceased to be efficacious in controlling the attacks.
489

TREATMENT OF EPILEPSY.

 

 

 

 

 

 

 

 

 

 

COMMENCE- EYE EXAMINATION.
‘ FREQUENCY OF MENTAL STATE AT DATE,
@ og | MENT OF SEX. REMARKS,
i hs 2%) i XAMI ;
4 g | sophia ATTACKS Res nonin Aiseltor Teron. OF EXAMINATION,
eae 9e =: '§ Esophoria, 10°. Has had attacks of epile -| Refused operation, Addicted to
1| 46 Atageof26, Has had 15 ina day. M. | H+an, — } Pppionoha, 2° peta Dee eee cabinets
2 18 Atage of 14. | Every 6 months. EF. w, | Esophoria, 6°. Normal. } atte Operation, Addicted to
3/43 | Atage of 14.| One in 4 months. M. | iH. Esophoria, 4°. Normal. \ Ape ora pnee aie
j oO
4°23 , Sincea baby.) Several daily. M. | H.+Ah. | toeerbota, 1°, i Fairly intelligent. Still under treatment.
.| . " a a ' § Bsophoria, 6% . . F 4 | Apparently relieved by operation..
5) 19° Atage of 13. | Has had 17 in a day.: FL | M.+Am. ’ Toworyhatid, 194, ; Markedly impaired. 5 i a histo consedittivé mentis.
| Has had 52 attacks in j | § Esopheria, 10°, 2 * Has granular kidneys. Attacks
6 | 21 | Atage of 12. one day. i M. | M.+Am. ( Liyperphoria, 1°. Markedly impaired. } | greatly lessened since operation.
| ei ‘ i
= a 4 ‘ A i y :
7 | 99 | Atageof 15. ans 10 attacks = F. | Emmetropic| Esophoria, 5°. Normal. ; | pearently coe by operation.
8 | 96 | Atage of 22.| Average of 1 a week. M. | H. Esophoria, 3°. } gore ansanejand idan: { Sent to an asylum,
9/19 | Atage of 11.| Average of 2 a week. F. | Am. Hyperphoria, 1°. Impaired. Refused operation.
10 | 30 Atage of 28. | Has 2 in a month. M. | H. Normal. Normal. | nS 1G Sens. Cured by specific
i Average of l a day wane sia. 13° : i i j | Still under treatment. Attacks
i} 19 pAtageor, 12. vee prowiles: M, | Emmetropic, Esophoria, 13°, Markedly impaired. very infrequent since operation.
' Esophoria, 9°. | No attacks since last operation;
12 17 ; Atage of 13. Average of 1 a month. M. | M.+Am. } Hyperphoria, 1°. { Normal. } | performed some 9 pee pe oe. 5
a: : Esophoria, 3°. . : Operated on. Has gone three
13 | 21 Atage of 8. | Average of 2a week. M. | H. } Hyperphoria, 1°. i Markedly impaired. | Taonghe-aationt & Hee
i : '§ Average of 8 a week Esophoria, 2°. . + Not operated upon as yet. Has
14 37 | At age of 16. i ee bromides. i F. | M.+Am. ' Hyperphoria, 1°, { Markedly impaired. i been 20 years under bromides.
ee a Average at first 2a da . Operation postponed on account of
15 ince a baby. ; aE eee suege: y i F. | H. Esophoria, 5°. Normal. } ‘uncertainty of tests made.
16 M. | H. Esophoria, 5°. Semi-idiotic and at times?) perused operation.
insane.

12 At age of 8. | Average 2a week.

|

 

 

 

 

The terms used in recording the eye examinations are fully explained in Section II of this work (pages 147 and 148). Photographs of all cases operated
upon were taken before surgical treatment was commenced. ‘ :

 
490 LECTURES ON NERVOUS DISEASES.

Onc had had epileptic seizures for nearly thirty years, one for six years,
and one for five years prior to the operation.

Finally, the cases reported by Dr. Brubaker of recoveries from
epilepsy after the removal of all sources of dental irritation, and of
many others which show that relief has followed the cessation of ovarian
irritation, should not be allowed to pass without notice.

Such cases as these have a very important bearing upon the question
which is now being most carnestly investigated by some of the leading
minds in the profession, viz., whether the present methods of medicinal
treatment of epilepsy and its allied disorders of the nervous system are
not destined to be superseded by more rational and scientific methods of
research for the underlying causes of their imperfectly solved problems.

In the preceding table, it will be perceived that the degrees of
insufficiency which existed in each patient is noted. It may be well to
state, in this connection, that the highest degree of error detected during
my observations of each case is noted (rather than the lowest), because
this probably indicates the closest approximation to the actual state of
the patient which we can scientifically record. Probably the “ latent”
insufficiency vastly exceeded in each case the amount actually noted (see
p- 456). In one of my cases (now apparently cured) one degree of eso-
phoria was all that was detected on the first examination ; yet, in spite
of this fact, a very free but incomplete division of both interni was
required to establish the physiological equilibrium. The attacks of
epilepsy then ceased, and have not returned, to my knowledge, for over
thirteen months.

Finally, it may be added, in justice to the views here advanced, that
it is not impossible that in some of these apparently successful cases
a latent insufficiency may still be lurking, which the patient may be able
to overcome fora longer or shorter period of time without producing
any abnormal nervous manifestations. Should such a recurrence of
ocular tension ever manifest itself, it ought to be corrected by a repe-
tition of tenotomy, even if the epileptic seizures should not reappear or
the patient apparently suffer from its presence. One such ease occurred »
under the observation of Dr, Stevens, where epileptic seizures were
arrested for several months by partial tenotomies in an apparently
hopeless subject. A return of the attacks led the patient to again seek
his advice, and it was found that a high degree of latent insufficiency
had manifested itself. This patient refused, under the advice of friends,
to continue the treatment (which had produced such marvellous results
but a few months before), and he returned to bromides. This case has
been used hy an opponent of these views as an evidence of the lack of
permanency of the results obtained. The injustice of such a conclusion
must be obvious to any intelligent reader.
 

TREATMENT OF EPILEPSY. 491

Clinical facts go to prove conclusively that in almost all epileptic and
choreic subjects the manifest insufficiency is much less than that which
actually exists. It is only after patient waiting, in some cases, that we
find we have more to deal with than the patient at first disclosed.
Whenever we find it, it should be rectified by proper methods and at the
proper time. It should be anticipated and persistently looked for, over a
period of many months. If it fuils to develop within a year, we may be
hopeful that we have overcome all that originally existed. If it develops,
we have simply noted a condition that it was reasonable to expect, and
the necessity for further operative procedures is clearly indicated.

In one of my successful cases no latent. insufficiency has thus far
shown itself, although over two years have elapsed since the last opera-
tion, In another I have not had an opportunity of examining the patient
for some months. In the third, a slight hyperphoria remains, which the
patient now tolerates, but which may require correction at a later date.

Dier TREATMENT.—Many cases of epilepsy are materially benefited
by a restricted diet. Perhaps the one which has given the best results
consists in depriving the patient of meat-foods of every kind and
description, Even soups are prohibited. Eggs and cheese are strictly
forbidden.

The principle involved in this diet is the withdrawal of nitrogen, as
far‘as it is practicable to do so, from the patient.

Milk is allowed, as are also its various preparations, such as butter-
milk, skim-milk, koumiss, etc. Vegetables of every kind, bread, oatmeal,
cracked wheat, ripe fruit of all kinds in moderation, and other non-
nitrogenous articles of food constitute (with milk) the best means of
nourishing these patients.

MeprcinaL TREATMENT or Eprnepsy.—No work would be complete
without some reference to the methods of treatment now generally
adopted for the purpose of holding these attacks in check, in spite of
the fact that all are more or less detrimental to health, and generally
unsatisfactory both to the doctor and patient. Personally, IT have never
traced up a reported case of cure of genuine epilepsy with drugs alone,
without finding that the cessation of the drug has been followed by had
results, The best authorities speak with extreme caution respecting the
permanent benefits which may be expected of medication.

In infants and children, epileptte seizures very Frequently get well if
let alone—a fact that is to be explained by the susceptibility of the young
to reflex nervous disturbances, and the multiplicity of causes of such
derangements. This fact is too often overlooked when the efficacy of
drugs in such subjects (affected with epilepsy) is called into question.

If, in spite of careful scrutiny into all the possible factors which
have been mentioned as liable to cause epileptic seizures, nothing can be
492 LECTURES ON NERVOUS DISEASES,

found; or, if (when all that may have been discovered have been either
satisfactorily removed or justly pronounced incurable) the epileptic
attacks persist, nothing, unfortunately, remains for such a patient but the
hope which drugs may afford of lessening or preventing subsequent
attacks. In such a dilemma we are left, as physicians, to choose from the
following list of drugs, such as seem best adapted to meet the indications:
(1), the bromides of potassium, sodium, ammonium, iron, arsenic, calcium,
etc; (2), preparations of zinc, preferably the oxide; (3), the various
preparations of arsenic; (4), the nitrate of silver; (5), belladonna, in
some of its various forms; (6), hyoscyamus; (7), osmic acid; (8), digi-
talis; (9), curare; (10), the nitrite of amyl; (11), strychnia; (12), the
hydrate of chloral; (18), the iodides of potassium, calcium, and iron
(especially if syphilis is suspected to be a factor in the case) ; and (14)
preparations of nitro-glycerine.

The bromides of sodium, potassium, lithium, ammonium, and calcium
probably stand first in professional estimation to-day as a remedy in
epilepsy. These salts are commonly given in doses which vary from
fifteen grains three times a day at the commencement to one hundred
grains, as the patient becomes tolerant of them. They are preferably
given in solution, and Seguin’s suggestion that Vichy water be used as
a solvent isa good one. Gower’s method is to give very large doses at
the beginning of treatment after breakfast in a goblet of water. He
advises that two, three, four, five, and six drachms of bromides be given
on successive mornings. He omits treatment fora week or two after the
patient has been carried to a state ‘of drowsiness or of mental sluggish-
ness. Subsequently, he gives doses of twenty grains or more three times
a day. '

Most authorities advise the continuance of the bromides for two
years at least. A late author says, ‘‘ Patients may take sixty to ninety
grains of bromide a day for six or ten years without injury.” I would
caution the reader against so extreme a statement. I have seen patients
brought to a state of insanity and idiocy by very heavy doses, and all
patients become more or less affected in mental power by its long-
continued use. Personally, I am inclined to believe that the apparent
benefits derived from the use of bromides is more than counterbalanced
in most cases by their disastrous effects upon the nervous system.

If a skin eruption (acne) appears, arsenic may be judiciously given
in connection with the bromides. The dose of Fowler's solution is from
three to five drops for such a purpose.

The bromide of lithium is said to be tolerated by weak stomachs
better than the other salts mentioned.

In connection with the bromide treatment, it is oftentimes important
that patients take iren, cod-liver oil, and quinine. It is also well to stop:
TREATMENT OF EPILEPSY, 493

indulgence in alcohol, tea and coffee to excess, highly-seasoned and
indigestible food especially of an animal kind), and cold bathing. <A
regular movement of the bowels should be had daily. This may be
aided by the drinking of mineral waters, or by the hot-water treatment
(p. 248).

In nocturnal epilepsy, the largest dose may be advantageously given
at night.

Hydrate of chloral is often combined with bromides. It should not
be continued too long, as it affects the general health. The dose should
not exceed fifteen grains, and it is well to combine digitalis with it, to
prevent the possibility of heart symptoms.

Belladonna was first recommended highly by Trousseau in the treat-
ment of epilepsy. Atropine is now generally used in doses of one one-
hundredth of a grain. This dose may be given three times a day until
the pupils become dilated and the throat unnaturally dry.

The salts of zine, chiefly-the oxide and the bromide, have been
extolled as a cure for epilepsy. The bromide may be given in simple
syrup and water, commencing with one-grain doses and increasing the
amount gradually as long as nausea is not produced. The oxide is given
in doses of from five to ten grains. If an eruption follows its use,
combine it with Fowler’s solution of arsenic.

The nitrate of silver is liable to produce’a permanent blue staining
of the skin. Its supposed benefits hardly warrant so great a risk;
hence, it should not be continued long, in case it be employed.

Curare has been given by the hypodermic method to epileptic
patients in doses of 0.03 grammes by Kunze and others. It is not to be
administered oftener than the fifth day. It shows its toxic effects early
in the eyes, sight being rendered dim and indistinct.

Osmic acid (in doses of 0.002 grammes) may be advantageously
administered in combination with the bromides, according to the late
publications of Wildermuth.

Finally, nitrite of amyl may be used by epileptics as a means of
warding off impending attacks. It is best carried in small bulbs of
thin glass (amyl-pearls) which may be crushed in the handkerchief
and the fumes inhaled by the patient as soon as the aura is perceived.
Two to five drops of this agent will generally prevent an attack for
a while.

Nitro-glycerine as a therapeutic agent in epilepsy was first employed
by Hammond and Weir Mitchell.. The favorable results claimed for this
agent seem to have fallen far short of general acceptance. The late
report of Osler respecting its effects in epilepsy seems to show that the
remedy rapidly lost its influence in those cases that, for a time, appeared
to improve.
494 LECTURES ON NERVOUS DISEASES.

It may be given in pilules of y}y of a grain, or in a one per cent,
solution in doses of mv. The susceptibility of different patients to this
drug varies, according to my experience ; hence, it is wise to begin with
small doses, and to slowly increase the dose until its physiological
effects are manifested by a flushing of the face, a sense of fullness in the
head, and a peculiar glow of the whole body.

Finally, when the condition known as the “ status epilepticus”
develops, during which the convulsive attacks are practically constant,
it is well to treat the patient, according to circumstances, by ice to the
spine, inhalations of nitrite of amyl or chloroform, repeated doses of
chloral, or subcutaneous injections of morphia.

CHOREA.

This form of functional nervous disturbance is most commonly
encountered in children. It may, however, begin in adult life; and it
has been known to develop in advanced age. It is commonly known
among the laity as “St. Vitus’ dance.”

Etiology.—This disease may be congenital. It is particularly
common in the offspring of tuberculous parents. The period of second
dentition (the sixth and seventh years) is one that is apparently very
susceptible to these attacks. I have several times observed it in adults
between the fifteenth and twenty-fifth year of age; and in old age it has
been often known to follow grief, fright and violent mental emotions. A
predisposition to chorea seems to exist in subjects that have had isolated
cases of hysteria, epilepsy, insanity and neurasthenia among different
branches of their family. -

Most authorities mention, among the exciting causes of this disease,
excessive joy or grief, severe fright, traumatisms to the head or back,
infectious diseases, rheumatism, anemia, onanism, reflex irritation aris-
ing from the genitals, the intestine, neuromata, dentition, pregnancy,
ete.; and, finally, certain atmospheric conditions, It seems to be some-
what more common among girls than boys. It may be acquired by
imitation.

In the light afforded by the latest researches in reference to the
existence of eye-defect as x cnuse in producing chorea, as well as
the so-called “ predisposition” thereto, the following deductions of
Dr. Stevens’ seem to prove quite conclusively that hyperopia (often
latent) exists in an enormous proportion of choreic subjects, and that
muscular error in the orbit frequently coexists. From the prize essay of
that author the following deductions are taken :—

In 118 eases of chorea, 78 had simple hyperopia (or about 67 per
cent.); 13 had hyperopic astigmatism (or about 11 per cent.); 5 had
mixed astigmatism (or about 4 per cent.); 6-had unequal myopia in the
CHOREA. 495

two eyes (or about 5 per cent.) ; 11 had myopic astigmatism (or about 9
per cent.); 5 had no marked refractive error, but a marked muscular
defect existed in the orbit (or about 4 per cent.).

It will be seen from these statements that nearly eighty per cent. of —
the subjects examined by this author (and they were consecutive cases)
exhibited either simple hyperopia or hyperopic astigmatism, and that
four per cent. more had mixed astigmatism, which entitles them to
belong to this class of refractive error. Only fourteen per cent. had
myopia or myopic astigmatism. Only four per cent. had no refractive
error; and these had a sufficient degree of ocular insufficiency to justily
the view that reflex irritation from the visual apparatus was markedly
present. In not a single case were the eyes perfectly emmetropic and
the ocular muscles in the state of physiological equilibrium.

My own personal experience with choreic patients of a persistent
type leads me to sustain in a general way the accuracy of these observa-
tions, They are oftentimes difficult subjects to examine with satisfiue-
tion, partly on account of their age, and partly on account of the
spasmodic movements of the head and body. I have found “latent”
hyperopia of a high degree in all of my later cases whose eyes I have
examined, not infrequently associated with esophoria and hyperphoria.
This subject will be more fully discussed when the treatment of this
disease is reviewed.

Morbid Anatomy.—The changes which exist in the brain or spinal
cord in connection with chorea are unknown. It is very doubtful, to my
mind, if any exist. All theories in relation to it are either pure
maanmptions, or are based upon insufficient data.

Symptoms.—Various prodromal symptoms of this disease are men-
tioned by authors. Among these the following may be given:
Anorexia, a disinclination toward mental or bodily pursuits, headache,
restlessness, pains in the limbs and joints, irritability of temper, weak-
ness of the memory, and many others.

As the disease develops, the patient gradually begins to exhibit a
certain awkwardness of movement in the extremities. Objects fall
frequently out of the grasp. The child spills his food while cating. It
becomes difficult for the child to stand still. Attempts to write, sew or
draw are imperfectly performed. Such children are very often punished
for supposed ill behavior or careless habits.

Later on, the symptoms become so unmistakable that the presence
of actual disease is no longer doubted. The patient may become inca-
pable of dressing. The limbs or face are no longer under the control of
the will. Involuntary movements of extension and flexion of the fingers,
pronation and supination of the hand, shrugging of the shoulders,
dancing of the legs, grimaces of the face, and distortions of the body
496 LECTURES ON NERVOUS DISEASES.

become more or less constant. These patients may be unable to sit upon
a chair without feeling a sense of danger from falling. I have knowna
child to be thrown out of bed by the violence of the spasmodic
movements.

Speech, mastication, and swallowing may be seriously embarrassed,
and the teeth have been known to be broken by the uncontrolled
movements of the jaw.

The thoracic and abdominal muscles may, in rare instances, be so
seriously affected as to produce cyanosis and a sense of impending

suffocation; but I have never seen any affection of the heart, the bladder,
or the rectum in chorea. Even the glottis may participate in the
convulsive movements,

During sleep, the convulsive movements usually italy cease,
They are, however, sometimes very severe just preceding repose; hence
these subjects often regard bed-time with a peculiar horror.

Strange as it may seem, these movements seldom ereate fatigue ;
although they may be incessant.

The whole body is not usually affected until late in the disease.
Often a condition (known as “ hemi-chorea ”), in which the muscles on
the right or left side are alone uncontrolled, is developed. Again, one
arm and the face, or the face alone, may be affected. The left side is
usually more severely attacked than the right.

The mental state of these subjects is generally far below the normal
standard. They are prone to laughter over trivial things, or to attacks
of weeping without apparent cause. They may develop idiocy or mania.
Irritability of temper, a stupid demeanor, and impairment of memory
are frequently observed.

Any unusual excitement of the mind or body is apt to intensify the
muscular twitchings. Severe mental application, the reading of exciting
books, the witnessing of dramas or other entertainments of that char-
acter, excessive indulgence in sports, etc., are to be discountenanced,
therefore, in cases of chorea.

Choreic subjects are apt to be pale and anemic. It is not uncom-
mon, therefore, to detect an anemic murmur over the heart and the
jugulars. Sometimes the second sound of the heart is intensified.

It is difficult to carefully observe the pulse in chorea on account of
the spasmodic movements. It has been stated that the arterial tension
is diminished in the height of the disease.

I have never observed any change in the bodily temperature which
might be regarded as directly due to chorea. An elevation of the
temperature of the parts affected has been noted by some observers in
hemi-chorea ; but, in my experience, this is not always present.

In serious cases, insomnia may develop.
CHOREA. 497

Complications.—Basedow’s disease may be developed in connection
with chorea. Aphasia has been observed as a complication of this
affection; and, in rarer instances, paralysis of a transient character has
been known to develop. The joints may become swollen and painful.
The pupils may be rendered sluggish to the etfects of strong light, and
be unnaturally dilated. Disturbances of the intellectual faculties have
been known to occur during chorea, and to cause permanent idiocy or
insanity.

Diagnosis.—This disease may be confounded with athetosis, post-
paralytic chorea, hysteria, convulsive tremor, paralysis agitans, mul-
tiple spinal sclerosis, and some other forms of organic disease of the
brain and spinal cord. The table on the following page will aid
the reader in distinguishing between chorea and most of these
affections.

The age which is generally attacked in chorcie subjects practically
removes all the difficulties of diagnosis. It is only in adult cases that
we are called upon to discriminate closely between it and hysteria,
convulsive tremor, paralysis agitans, and multiple sclerosis.

The chief point in all of these discriminations bears upon the relation
of choreic movements to willed muscular movements of the extrem-
ities. In chorea, willed muscular action is unexpectedly opposed by
spasmodic movements which carry the part in some unnatural direction.
In this respect the disease simulates incodrdination of movement (which
is prominently encountered in locomotor ataxia), Thus, for example, a
choreic subject while eating will jerk a spoon away as it is about to enter
the mouth; or, he may possibly strike the ear or nose with the fork.
Such accidents are seldom observed when tremor exists, or when even in
athetosis.

Prognosis. — Although fatal cases of chorea have been recorded,
the prognosis is, as a rule, extremely favorable. Quite a large pro-
portion of cases recover under judicious medication within ten weeks.
Obstinate insomnia is a symptom of evil import. I have seen some
very persistent cases of chorea in the adult which have withstood
all medication, and have subsequently made a complete recovery
when the eye-muscles have been properly balanced by partial tenoto-
mies; and I regard the correction of refractive errors in all cases of
chorea as a step of vital importance. It certainly tends to prevent
relapses, woich are particulariy prone to occur in chorea, I believe
the mental impairment often noted in connection with this disease
to be due in a large proportion of the cases to “eve-strain’ un-
corrected, A hyperopia or hyperopic astigmatism in a child is cer-
tainly a defect of sufficient ne to merit early recognition and

correction.
, 32
LECTURES ON NERVOUS DISEASES.

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CHOREA. _ 499

The following case illustrates the importance of correction of
anomalies of the visual apparatus :—

Chronic Chorea of Thirty-one Years’ Duration, affecting the Head, Face, and all the
Extremities.—Female, aged thirty-three, unmarried.

Family History——The father had pulmonary hemorrhages for muny years. One
paternal aunt died of “hasty consumption.’ Sick-headaches are very common among
both paternal and maternal ancestors. Neuralgia is a frequent complaint among the
paternal ancestors,

When two years of age, this girl developed chorea. The spasmodic twitchings
steadily grew worse, in spite of the fact that her father was a physician, and that she had
the services of the most skillful medical men from time to time. The twitchings began on
the right side; but they subsequently involved the left side, and also the head and face.

She has suffered some from sick-headaches, as has also her sister. The hands have
gradually become so contractured that all attempts to use them are more or less distressing.
Her fingers could not be extended farther than would suffice to grasp small objects.

When I first saw this patient she was unable to write except by grasping the pencil

_ with all the fingers and the palm of the left hand, and holding the left hand with the right
hand as the spasmodic movements of writing were made. She walked with a peculiar
unsteady and crab-like gait, ate with difficulty, and ‘suffered great pain between the
shoulder-blades and over the first lumbar vertebra (two points, by the way, which are
very frequently attacked, in my experience, when eye-strain is present). She had never
written with ink. Prior to menstruation (which occurred at seventeen years of age) the
patient had experienced attacks (probably epileptic) which she describes as “those of
numbness, followed by a loss of consciousness.” She has had chronic constipation all her
life. The memory and mental faculties are perfect.

When I first saw this patient the spasms were very violent, especially about the face
and neck. The limbs were jerked about, the fingers too'tightly clinched at times to grasp
anything, and the speech was rendered peculiarly spasmodic and almost unintelligible at
times. She sputtered, and at times ejected drops of saliva, when endeavoring to converse.

At the first examination she exhibited no refractive error; but, under atropine, a high
degree of hyperopia (1:75 D.) was detected, and proper spherical glasses (+ 1 D.) were
at once provided. In order to test her eye-muscles, the services of Professor J. Williston
Wright, of New York city, who saw ker with me by invitation, were invoked to hold her
head. This he did with no small effort by clasping the head on either side, and firmly
pressing her head against his body as he stood behind her chair. During this examina-
tion she whistled shrill notes on two occasions, and underwent the most violent facial
and body contortions. os

The results of this imperfect’ examination (necessarily so under such conditions)
indicated to me that a high degree of hyperphoria existed ; and, as I could not again see
the patient for some months, I decided to perform a free but incomplete division of the left
inferior rectus muscle. I then instructed the patient to try and get a photograph taken, if
possible, before she saw me again. She laughingly said that she had never been able to
have a picture taken, but she would do so if she could. She then departed for home
with instructions to return to me for treatment in the antumn. The first picture receiver
of this case was one that she was able to have taken three weeks after the operation, when
her head and shoulders had become comparatively calm, as a result of the relief afforded
by it. This photograph was deemed at that time a great success by herself and friends,

“You can see in it the blurred outlines which indicate that the movements were still some

what active.
500 LECTURES ON NERVOUS DISEASES.

During the past autumn this patient has been under my care for some eight weeks. I
have partially divided the right superior rectus and both externi in order to overcome a
high degree of left hyperphoria and exophoria, and I have administered static sparks daily
to thespine and limbs, The second picture will give, better than words can describe it, an
idea of the wonderful improvement which has taken place. Prior to her departure for home
(some weeks since) she could thread the finest cambric-needle, and pass her fare to the con-
ductor of a street car without attracting the notice of passengers, or throwing it out of the
window, as she certainly would have been apt to do two months previously. She can fully
extend her fingers, walk several miles a day, write with far greater certainty and ease, and
eat at a boarding-house table without exciting comment. Her limbs still twitch somewhat
immediately before going to sleep, and, in the presence of strangers or when unduly
excited, she still shows some spasmodic movements of the face and shoulders, When calm
she is, however, perfectly composed, and almost entirely free from convulsive movements,
She considers herself as practically cured; but I suspect that time and some further
operative work upon the eye-muscles will be demanded before complete restoration to
health is effected.

As I regard this case as one of the most distressing and typical
cases of chronic chorea ever reported, it may be well to state that the
patient is well known to Professor A. M. Phelps and Professor J. W.
Wright, of this city, and Professor Woodward, of Burlington, Vt., and
. that she has been seen by many members of the profession, both from
this city and distant States, during her treatment in my oftice.

During the whole treatment of this patient no drugs have been
employed, and the photographs are from untouched negatives. I
attribute to the static applications the rapid relief of the contractured
state of the fingers and the improvement in her general strength; but,
from many facts observed during my treatment of her, I am convinced
that the relief of the eye-strain is alone deserving of whatever credit
may be claimed for her recovery. Four weeks before she was dismissed
from my care she read and sewed continuously for several days, and was
immediately precipitated into a relapse, which as rapidly subsided when
the cause was ascertained and its recurrence prevented.

Treatment.—My remarks concerning the causes of chorea and those
which treat of the surgical relief of epilepsy bear strongly upon the
cure of this form of functional nervous disturbance. I have not yet
encountered a case for the past three years in my private practice where
I have failed to find either a refractive error or an insufficiency of some
of the eye-muscles. It has been my custom for some time past to care-
fully examine the eyes of these cases under atropine, and to correct all
refractive errors (so found) subsequently with a glass that the patient
could comfortably wear after the effects of atropine had subsided.

‘In previous pages of this work, I have combated the view (too
commonly held by oculists) that the ophthalmoscope furnishes as positive
information in respect to hyperopic defects as the ordinary type-tests
made when the eye is fully under the effects of atropine. I have time
CHOREA. 501

and time again found the best experts to be in error, when they have too
implicitly relied upon ophthalmoscopic tests.

All that any one can determine with this instrument is based, of
necessity, upon the presumption that the patient’s accommodation as well
as that of the observer is velaxed. This factor in the case is therefore
two-fold; and is not always overcome, on the one hand, by an “acquired
taculty ” of the oculist, or, on the other hand, by directing the patient to
look at an object over twenty feet from the patient’s eye. To be sure of
your results you must be able in any case to state positively that no
accommodative efforts are made by the patient. This is positively
ensured by a free use of atropine, and by no other recognized method.

Again, the tests for suspected errors in the eye-muscles are valueless,
unless the refractive errors be intelligently corrected first. Moreover,
if any muscular defect is detected, and confirmed by repeated examina-
tions, the use of prismatic glasses does not fully meet the indications ;
because we have no way (yet known to science) of estimating the amount
of “latent ’ insufliciency which may exist in each case.

The results obtained by partial tenotomies prove the truth of this
statement beyond the possibility of its denial.

Respecting the relationship of chorea lo anomalies of the visual
apparatus I would make the following suggestions :—

(1) Choreic subjects belong to one of two classes: (4) Those who
tend to get well under almost any treatment or even without treatment,
and (b) those who fail to get relief from any medicinal aid. The thes
tend to run a chronic course, usually one of unfavorable progression.

(2) The chronic form of chorea is one of the most serious and
hopeless of nervous maladies. It is not infrequently associated with
epilepsy or with mental impairment.

(3) Both forms of chorea are based, as a rule, upon a well-marked
neuropathic or tubercular predisposition.

(4) The pathology of chorea is not known. No one has ever proved
that it was a “ constitutional disease,” in the sense that an organic lesion
was essential to its development.

Now, the remarkable case which I report belonged, without question,
to the class which I think is generally regarded by neurologists as
incurable, and as offering but little hope of marked improvement under
any form of medication. In this girl, at least, all such attempts at relief
had proved of no benefit. The convulsive movements had persisted for
over thirty years, and the condition of the patient has steadily grown
worse in spite of the best medical care. She had probably had a few
epileptic seizures in girlhood, but her mind had remained unimpaired.

When Dr. G. T. Stevens read his paper on the relationship between
refractive errors and chorea in 1876, he advanced views that were new
502 LECTURES ON NERVOUS DISEASES.

to the profession. Within a year, a paper on the same subject was
published by another,* in which the view of Dr. Stevens, that hyperopia
constituted an important element in most cases of chorea, was very
strongly combated. The latter paper has been quite extensively quoted.
It may not be inappropriate for me, therefore, to carefully analyze the
paper referred to in this connection, as I feel that the conclusions of the
critical reviewer are misleading, and certainly not in accord with my
own observations.

This observer drew his conclusions from an examination of thirty-one
cases of chorea, most of which, if not all, were taken from dispensaries.
It is safe to infer, therefore, that the patients were not well educated,
They may not have even known their letters sufliciently well to i
regarded as accurate in reading test-ty pe.

In the second place, the ages of the thirty-one patients reported
show that twenty-two were less than twelve years of age. Four were six
years of age, and one was only three and a half; one was seven, three
were eicht, three were nine, four were ten, and six were eleven years old.
The question naturally arises whether (at these ages) the tests of vision
usually made by the aid of test-types, when the patient is well under
atropine, are reliable in children that are presumably ignorant.

In the third place, seventeen out of the thirty-one patients were
found to be emmetropic in one eye or both when atropine was used by
this observer. This is certainly a very remarkable fact, as it is a
proportion which is contradicted by statistics gathered by equally
competent observers from the examination of children’s eyes under
atropine.f

In the fourth place, the percentage of hyperopia and hyperopic
astigmatism combined constitutes, according to this observer, about 55
per cent. of the total number. No myopia or myopic astigmatism was
detected in any of the thirty-one cases. The latter fact is remarkable,
and seems to cast further doubt upon the cases reported as ‘‘ emmetropic.”

Again, nineteen of the thirty-one patients are reported as having
had “insufficiency of the interni.” Now, I have examined within the
last three years the eyes of a very large number of patients who were
afflicted with various nervous disorders, and I have given special
attention to the state of the eye-muscles detected by appropriate tests in
these cases. I have found the condition of “insufficiency of the interni”

*Dr. C. 8. Bull, Med. Record, June, 1877.

{ Cohn shows that, in 299 eyes under atropine, no-case of absolute emmetropia was
detected. Hausen found but 26 emmetropic eyes in 1610, and Darr but 30 in 414. A.
Randall states, in his article on “‘ The Refraction of the Human Eye, a Critical Study of,
the Examinations of the Refraction, especially among School-children’? (Am. Jour, of the
Mea, Sci., July, 1885), that only 7 #5 per cent. of 1834 eyes of infants and school-children
were found to be emmetropic.
CHOREA, 503

to be a comparatively rare one when Graefe’s test was employed with
the test-object (preferably a candle-flume), at twenty feet from the eye,
It is reasonable to infer, therefore, that the tests made by this observer
were such as to require accommodative efforts (pr: obably the line-and-dot
test at fourteen inches). Such tests, if made under atropine, are cer-
tainly open to criticism and probable correction. Even if not made under
atropine, this form of test is only of value in connection with the other.

The critical reviewer mentions a certain “ Martin family ” as a proof
to his mind that a “neurotic taint’ exists in choreic subjects, Now, the
four choreics of this family were all hyperopic, while five who were not
so had no chorea. This fact would seem to confirm Dr, Stevens’ view.
No one disputes the fact that a “neurotic predisposition ” is present in
most choreic subjects; but the view that eye-defect ‘tends to create this
tendency seems to be less generally accepted.

Finally, the paper here referred to notes a failure to relieve the
chorea by the use of glasses, in a few cases where the patients were able
to purchase them. If other serious defects existed besides the hyperopia
(to the extent shown in the examinations reported by this observer),
this is not to be wondered at. Hyperopic glasses will not relieve

“insufliciency of the interni ” (frequently noted by this observer in his

' choreic subjects); and the latter is certainly a well-accepted cause of

reflex disturbance when it exists, as well as the latent hyperopia that
was alone corrected.

In preparing this section, I have looked carefully over the records
of all cases of chorea which I have personally tested for anomalies of
the visual apparatus. I have not found a single case where either
“manifest or “latent ” hyperopia did not exist. I do not mean to assert
that this statement proves anything—but it certainly seems a very
strange coincidence, if such it is.

Respecting the “neurotic taint”? to which this reviewer attributes
the origin of chorea, I would respectfully refer my hearers to a study of
this question and its dependency upon anomalies of the visual apparatus
in a paper previously quoted from,* and also to tables of a similar
purport published (since that article was read at the International
Medical Congress) by G. 'T. Stevens, in his work an “ Functional Nervous
Diseases.” +

Every patient whom you examine for defective equilibrium in the
eye-muscles instinctively strives (not by mere volition) to get binocular
vision, under the nearest approach to physiological conditions of which
he is analile,

We are forced to admit, therefore, that what we detect in any
patient and record as an error is in reality only what the patient cannot

* Med. Register, November 19, 1877. {D. Appleton & Co., N. Y., 1887.
504 LECTURES ON NERVOUS DISEASES.

conceal, not necessarily all the defect in the muscles that actually
exists.

Because a patient can momentarily perform a feat of eye-balance
which approaches the normal state, by the aid of his reserve power,
it is by no means proved that the eyes are habitually in equilibrium.
An over-taxed muscle may, and often does, become preternaturally
shortened or “ contractured,” so long as its utmost exertions are habitu-
ally demanded. Why, then, may this condition not exist in the eye-
muscles, when the antagonistic forces are unequally balanced? Ifit may
do so, does this view not tend to shed some light upon the fact that
patients often show a higher degree of “ insufficiency ” after a tolerably
free division of the stronger tendon than before the operation? May
not a contractured muscle relax when relieved of the irritation caused by
the over-taxed condition of that muscle? May not the development of
“ latent ” insufficiency be attributed (in part at least) to the relaxation
of a muscle in the orbit, which has been thrown into a state of abnormal
spasm by its efforts to overcome an antagonistic force disproportionate
to its inherent strength? I propound these questions because many
facts have been observed by me after partial tenotomies upon the eye-
muscles, which seem to me to add confirmatory evidence in support of
this view. If there exists in any case a tendency on the part of the visual
axes to deviate from their normal condition of parallelism when the eyes
are directed at an object twenty feet or more from the eye, may it not
indicate that an inherent defect (probably congenital) exists in the
weaker muscles, either in respect to their actual development or their
contractile power? If this view is admitted, why may not such a
muscle, by endeavoring to antagonize a stronger muscle, become con-
tractured in consequence of the development of the state of excessive
nervous irritability ?

Clinically, as I have remarked before, we are forced to recognize two
classes of choreic patients,—those who get well within a short time
(usually in less than four months) by the aid of tonics, good food, ete., and
possibly without any medication; and those of a chronic type, in whom
the choreic manifestations persist in spite of every form of medication.

There is no nervous disease known which has apparently been cured
by so many different and often antagonistic lines of treatment. Some
get well under iron, some under arsenic, some by the aid of good diet and
good air. All the remedies which have been extolled as curative agents
would, if compiled, exceed even those suggested for the relief of epilepsy ;
the difference between the two diseases being that one generally gets
well and the other seldom if ever does, no matter what drug is used.

Now, it may pertinently be said in this connection that the cure of
a typical chronic case of chorea without the use of drugs is a fact worthy
CHOREA. 505

of record. Ifit can be shown that correction of a refractive error in the
eye, or the relief of an existing “ insufficiency” of some eye-muscle by
partial tenotomy, has cured most obstinate cases of chronic chorea
where medication and all other lines of treatment have proved of no
benefit, the value of the method must be recognized.

I have seen choreic symptoms disappear in several instances within
a week or two when an existing hyperopia has been relieved by convex
glasses, with the frames well fitted to the child, so that each pupil is
opposite the centre of the glass. It is not enough to tie a pair of glasses
with frames made for an adult onto a child’s head, and expect that com-
fort to the child will follow such a procedure. Neither is it right to
expect that glasses are all that is demanded, when a child has esophoria,
exophoria, or hyperphoria, in addition to a hyperopia or hyperopic
astigmatism or refractive errors of the myopic type. The case reported
on page 499 was one of the worst that I have ever encountered, and yet
a practical recovery ensued when the muscles of the eye were properly
adjusted. The photographs of some cases of chronic chorea published
by Dr. Stevens illustrate more forcibly than words the results of such
treatment when skillfully employed. ,

Finally, certain precautions are to be exercised in reference to the
child by its parents and associates. Study should be interdicted,
plenty of good food and fresh air should be provided, and encouragement
and praise should be freely bestowed as aids to the child in its attempts
to conquer the choreic habit.

Anything which disturbs and annoys the patient does harm,—such,
for example, as mimicry, confinement to the house, deprivation from
reasonable pleasures, etc.

Arsenic is a valuable remedy, in a large proportion of cases.
Fowler’s solution may be given to a child after eating, beginning with
doses of three drops three times a day, and sindwilly increasing the
amount by the addition of one drop each day until the patient takes ten
drops after each meal, provided that nausea, cedema of the eyelids, or
other toxical effects of the drug do not appear. I do not believe that
arsenic should ever be pushed to the poisoning point, in spite of views
advanced to the contrary. Iron, cod-liver oil, and quinine may be
employed in a combination with the arsenic, if the condition of the
patient is anemic, or if good results do not follow the use of arsenic
alone.

The judicious use of chloral, combined with digitalis, may be of
great benefit in cases where persistent insomnia exists.

Ice-bags or ether spray to the spine, static electricity administered
by the insulation or spark methods, and general galvanization are w orthy
of atrial in refractory cases.
506 LECTURES ON NERVOUS DISEASES.

A few months ago, I was asked by Dr, Stevens to meet a patient:
then under his care, whose subsequent recovery possesses great, clinical
interest in this connection. I give the details of this case as the patient
stated them to me at our first meeting :—

Mr. C., minister of the gospel. Mother died of phthisis. No nervous diseases had
existed among his direct ancestors, or in remote branches of his family.

About twelve .years before this interview, his family had noticed frequent facial
contortions which he was unable to control. A trip to Europe, and parish labors ina
district where he spent most of his time in a carriage and wrote but little in his study,
prevented its increase for about four years. He then became the pastor of a church and
began active labor in hisstudy. The facial contortions grew rapidly more aggravated in
character. Every feature would become horribly distorted; the eyes would close, the
forehead become terribly wrinkled, and the nose and mouth would assume attitudes
which no one could possibly imitate by volition, and which it is difficult to describe. The
hour of retiring was particularly dreaded, because the facial spasms would become terribly
persistent and severe as soon as the eyes were closed and a recumbent posture was
assumed. The facial contortions were always least severe in the morning, and grew more
severe as the day progressed. No medicinal treatment had ever benefited the patient.

An examination showed hyperopia of a high degree, esophoria of 6°, and hyper-
phoria of right eye of 3°. IIe had been wearing prisms with the base inward, as the
suggestion of an oculist.

A partial tenotomy was first performed to correct the hyperphoria. The facial
spasms ceased within an hour; and no sign of chorea was observed for two entire days.

On the third day a very slight twitching about the mouth developed. A partial
tenotomy of the internal rectus of the left eye was then performed. This completely
corrected the esophoria.

Subsequent to the second operation, the patient had few, if any, choreic movements.
He stated to me that “unless excited his face remained absolutely quiet,” and that for the
first time ‘he had that day been able to attend a meeting of ministers and look them in
the face without facial spasms while discussing church matters.” During his recital of his
various symptoms, ete., to me, his face only showed one very slight convulsive movement.
Thus, in less than one week, were the convulsive spasms of his face almost completely
arrested by correcting a hyperopia and two muscular defects associated with the eye.

Such a case is rarely encountered. The patient was an adult. The
duration had exceeded twelve years. The spasmodic movements were
terribly severe. All medication had failed even to ameliorate them.
They became greatly aggravated as soon as the patient was compelled
to use his eyes in study or writing. Ile could not even “look out of a
ear window” without heing thrown into a most distressing state; yet,
in spite of all these unfavorable facts, he was apparently perfectly well
when I last conversed with him.

HYSTERIA.

A form of functional disturbance of the brain. spinal cord, or the
sympathetic nervous system, in which the patient gives evidence of
“an abnormal susceptibility to external impressions, and a deficient
HYSTERIA. 507

power of the will to restrain its manifestations,” is generally termed
“hysteria.”

It is encountered chiefly in women. In the male, cases are some-
what rare.* The allied conditions known as “ catalepsy ” and “ hystero-
epilepsy ” will be discussed also under this head.

Etiology.—A very large proportion of cases of this type develop
symptoms of nervous derangement at the age of puberty (twelfth to
twentieth year). Girls reared in luxury and idleness, especially in cities
where excitement and dissipation are cultivated, suffer more than those
who have to labor and those who enjoy country life. Cases of genuine
hysteria are sometimes encountered in children under twelve years of
age. It is very uncommon for hysteria to develop after the age
of forty.

Psychical influences frequently seem to excite this condition,
especially when the patient is predisposed to hysteria. Among such
influences, fear, jealousy, love, disappointment, anxiety, care, remorse,
etc., are more liable to cause hysteria than pleasurable emotions or states
of mind. ,

The sexual organs are liable to be found deranged in many hysterical
females. Displacements of the womb, ulceration of the cervix, diseases
of the ovaries or vagina, scanty menstruation, or irregularity of the
periods, leucorrheea, excessive irritability of the vulva or clitoris, ete.,
may be often detected on examination. Self-pollution, or the frequent
occurrence of erotic dreams, in females is not uncommonly met with in
hysterical subjects.

Heredity plays an important réle in hysteria. A phthisical pre-
disposition is extremely common. Again, hysteria may be directly
transmitted, or it may alternate with epilepsy, insanity, sick-headaches,
neuralgias, chorea, and allied conditions.

In this connection, my remarks concerning eye-defects and muscular
insufficiencies in the orbit when discussing epilepsy and chorea might be
repeated here. Hysterical subjects are almost invariably thus affected,
and an examination of the eyes and the eye-muscles will generally
shed light upon this disease, as well as upon its allied diseases. The
reader is referred to the introductory pages of this section, and to the
views advanced respecting the causes of epilepsy and chorea.

Finally, imitation has been known to cause hysterical attacks in
schools and convents. In such cases the afflicted probably suffered from
one or several of the predisposing causes mentioned, the attacks being
actually developed by the mental impression made by witnessing an
attack in another.

* According to Briguet about fifty males were attacked to nine hundred and fifty
females,
508 LECTURES ON NERVOUS DISEASES.

Morbid Anatomy.—The existence of any organic lesion of the nerve-
centres may be considered extremely doubtful in any case of hysteria,
unless some other symptoms of a strongly diagnostic character are
detected. I have on my case-book the records of one case of hysteria
where a calcified state of the falx cerebri and the adjacent dura was
found after death. A few cases have been reported where other organic
changes have been shown to have existed, and to have unquestionably
caused the hysterical phenomena. These cases must be regarded,
however, as exceptional.

All authorities seem to be in accord in the statement that no
pathology of hysteria has, as yet, been recognized as proven.

Symptoms.—These are so varied as to require classification. The
following table will bring the more common symptoms of hysteria
prominently before the mind of the reader :—

 

HYSTERICAL PHENOMENA.

 

(1. Hyrrer#s- ( One entire side.
THE SIA. | Occipital region,
(Rarely of J The back, thorax, or abdominal walls.
the whole ) Individual joints.
body.) It | The muscles,
may affect... | The special senses.
Generally of left side.
May na touch, temperature sensations and pain (anal-
gesia).
2. AN ESTHE- SenetDuiey may remain intact in spots scattered over the
SIA. anesthetic area.
A r ; ‘i
‘ One or more of the special senses may be lost or impaired.
ash Ss Joints and even bones may be deprived of sensation.
Sunsony 4 Muscles may lose their electro-contractility.
APPARATUS.
3. Loss OF { Hysterical patients sometimes cannot tell if they move a
MuSCULAR limb, or, if it is moved, in what direction, unless they
SENSE, observe it with their eyes.
( Coceydynia (at tip of spine).
Sciatica (in lower limb).
Dike a Co, nese seventh rib).
vumbar (in small of back).
4. NEURAL- Brachialgia (arm).
i raat AL: | Omalgia (neck).
Lous nerves) Cephalgia (headache). This is a very common symptom.
: aoe ene (confined to one side of head).
‘ardialgia (pain over heart). .
a pain over ovaries). This is a valuable diag-
nostic sign.
S Ranhiaipie (spinal pain).
{ Facial spasm.
OF larynx, la and csophagus (the so-called “ globus
hystericus”’),
Paroxysms of uncontrollable laughter. r F
‘B. Opontre | Paroxysms of uncontrollable weeping or convulsive cries
DISTURBANCES Tysrrrican 2 ~ (barking, howling, etc.). |
a THE MOTOR SPASMS. . Paroxysims of uncontrollable hiccough (due to diaphrag-
PPARATUS. : matic spasin).
. ILysterical asthma (due to bronchial spasm). 2
eet Ror yawning (due to spasmodic action of inspiratory
muscles}.
| Hysterical cough (due to irritation of the laryngeal nerves).

 

* Anesthesia of the larynx and pharynx is a very common symptom of hysteria. In many
cases, the finger ur a probang may be introduced into the larynx without exciting coughing or
vomiting.
HYSTERIA. 509

HYSTERICAL PHENOMENA (continued).

1. Vaginismus (often preventing sexual intercourse).
e Spasm oe pi aee, and rectum,
- 7 . Goose-flesh (due to erection of the papilla of the derma).
2. oe rn 4, ee el ee cn the ected (resulting in a
‘ ormity—usually at the knee, wrist, fingers and toes).
SPASMS. 5. Torticollis or  wry-neck.” ; pie :
6, Strabismus or “‘cross-eye.” This may be permanent or
transient.

B. CONVUL-
DISTURBANCES SIONS (hys-
OF THE MOTOR terical type).

APPARATUS 4¢ ;
(continued).

Constituting ‘“hystero-epilepsy.”” These may be partial or
general, and with or without a loss of consciousness).

3: re

. Of face. May exist in combination with hemiplegia of
the same side.
Of eye. Ptosis and alternating strabismus are occasion-
aliy observed.
Of esophagus and pharynz,
. Of larynx. (Causing “hysterical aphonia.”
Of diaphragm. _ (The voice is lost. The thorax contracts
PARALYSIS during expiration and the abdomen rises.)
(hysterical a lst ae sey accompanies hysterical hemiplegia
r paraplegia.
L type). 7. Of rectum. (Accompanied by constipation, tympanites
and rectal anzesthesia.)
8. Hemiplegia or paresis. (Usually developing after ex-
citement or a general convulsion.)
9. Paraplegia or paresis. (Usually associated with para-
anzesthesia, )
10, Monoplegia or paresis, (Generally affects arm or leg.)

4. MOTOR

eo Pop

 

 

(1. Abnormal respiration. (Usually increased in frequency.)
2. Abnormal heart's action. (Palpitation or anemic murmur.)
3, Impaired digestive functions, (Capricious appetite, fasting, vomiting,
Cc belching, ete.) .
Visceran 4% Unnatural craving for food. (Boulimia.)
Disturpances. | > Irregular or scanty menstruation. It may be suppressed (amenorrhea),
: * | 6. Vicarious menstruation by the lungs or the rectum.
7, Retention of urine. (Requiring the regular use of a catheter.)
8. Abolition of sexual excitement.
[ 9. Increase of sexual excitement. (Nymphomania.)
Morbid desire for sympathy or for attracting attention.
¢ Premonitory Apathy to external surroundings, e
manifestations Obstinaey to all influences exerted upon the patient.
Sudden transition from gayety to sadness, or vice versa.
Hallucinations.
D Acute manifes- | Delirium.
Psy. CHT can 4 tations. { Ecstasy.
DISTURBANCES, Mania,
Melancholia.
Ecstasy. : .
Somnambulism (usually followed by convulsions, if the
Chronie mani- patient is awakened while out of bed).
festations. Nymphomania. .
Lethargy or stupor. (Has béen known to last for months
without any interruption. )
Trance, (It may simulate death very closely, in some cases.)
Elevation of temperature. (Sometimes preceded by a chill.)
BR Salivation, (erocably due to irritation of the central origin of the chorda
Vaso-MorToR tympani nerves. )

D Polynria. (The urine being very light in color and deficient in salts.)
ISORDERS. | edema: (Usually appearing suddenly without cause and disappearing as
suddenly.)

After a perusal of this table, the thought may occur to the reader
that it would have been easier to mention the symptoms which do not
occur in hysteria than those that may be encountered. It is safe to say
that no nervous <isease (if such a term is applicable to hysteria) pre-
Sents a greater variety of forms, or may more closely simulate the effects
of organic lesions of the nerve-centres. The diagnosis of hysteria is
510 LECTURES ON NERVOUS DISEASES.

almost invariably made by the exclusion of more serious conditions
which the symptoms exhibited by the patient might lead a physician to
strongly suspect. The best diagnosticians are sometimes misled by
hysterical subjects.

Diagnosis.—To the practiced eye, there are certain symptoms in
almost every case of hysteria which materially aid in making a diagnosis ;
although it is difficult to state in a general way exactly what the particu- |
lar points in a given case may be. Certain hints may be given, however,
in this connection with advantage to the reader.

In the first place, the history of the case may aid you. If the
patient has from childhood been very impressionable; if she has been
subject to periods of unnatural excitement; if the existence of similar
conditions in the family can be traced; if epilepsy, insanity, chorea,
neurasthenia, severe and recurrent headaches, or neuralgias have ex-
isted in her relatives; if anesthesia, hyperesthesia, painful points, or
a sense of compression in the region of the epigastrium persist after the
suspected hysterical paroxysm has passed away, and if transient par-
alyses have appeared at any time, the diagnosis of hysteria is more than
probable. :

Again, whenever the paroxysm assumes the convulsive type, the
irregular character of the fit, the length of its duration, the occurrence of
hiccough or of laughing or weeping after the convulsions have subsided,
the fact that the convulsions seldom occur at night or when removed
from the possibility of sympathetic attention, and the passage of large
quantities of pale, clear urine, deficient in salts, point to hysteria or
hystero-epilepsy. Energetic pressure upon the ovaries may also modify
hysterical convulsive seizures, while in epilepsy this test is negative in
its results (Charcot). If the larynx or pharynx is anesthetic, so that
coughing or vomiting cannot be induced hy introducing the finger or
a probang after the attack, hysteria is almost positively indicated.

The so-called “globus hystericus,” the sensation of a ball in the
throat, the absence of any appreciable rise in temperature (when taken
in the rectum), and the absence of albumen or casts in the urine point
rather to hysterical attacks than to true epilepsy, urzemic convulsions,
or organic lesions of the nerve-centres.

Hysterical paralyses may generally be distinguished from the paral-
yses of cerebral or spinal lesions by the gait (page 165), the history of
its onset, the absence of tremor, the testing of the reflexes (page 174),
the results of electrical tests (page 194), and the history of the case.

The diagnosis from trismus ov true tetanus is easily made by the
absence of a history of some injury received, the method of extension of
the convulsions, the facial expression, the attitudes assumed, and the
typical relaxation and termination of attacks of tetanus.
HYSTERO-EPILEPSY. 511

The diagnostic table given on page 498 will aid the reader in making
a discrimination between hysteria and other diseases which it may
closely resemble. As Hammond very aptly remarks, “careful watching,
with thorough skepticism, will either result in detection, or in the
patient’s defeat from sheer weariness.”

Let us now pass to the consideration of hystero-epilepsy, catalepsy,
and eestasy, which belong to the hysterical type of nervous affections.
The prognosis and treatment of these conditions will be considered later.

HYSTERO-EPILEPSY.

This condition is characterized by peculiar combinations of the
symptoms of hysteria and epilepsy.

 

Fig. 121.—Hystero-Errtersy. (Froma photograph. Case of C. K. Mills.)

These attacks are usually preceded by some of the prodromal mani-
festations of hysteria.

The various manifestations of this form of attack have been classified
by Richer into four distinct periods, as follow :—

(1) The epileptoid period.

(2) The period characterized hy contortions.

(3) The period of emotional attitudes.

(4) The period of delirium.

The symptoms of each of these states may be arranged in a tabular
form, which admits of a contrasting of the chief peculiarities of eack by
the reader,
512 LECTURES ON NERVOUS DISEASES.

SYMPTOMS OF THE FOUR PERIODS OF HYSTERO-EPILEPSY.

Tremor.

Pupils contracted.

Rapid winking of the lids.
Rapid respirations.

Pupils dilated.
Face pale at first and con-
gested later,
Loss of consciousness.
2. Convulsion, characterized by...-..

(1, Premonitory symptoms.........+++

Rigidity.

Slow bending. of of body and
twisting of he

Distortion of the cenenires,

Pronation of the hands.

Adduction and slow move-
ments of the legs.

Inversion or eversion of the
- feet.

THE First oR EPILEP- |
TOID PERIOD.

3. Stage of secondary rigidity (patient lies in a fixed attitnde).

Unilateral.

Sonnet ne one limb
Resemabling an epi-

General leptic attack.

3 7 ete
4, Stage of clonic convulsion.......++

Stertorous breathing.
Frothing at mouth.
Stupor,

 

5, Stage of recovery.....------. slevese

ness.

Extreme opisthotonos.

Piercing shrieks.

Forcible and rapid movements
of the limbs (usually of
flexion and cee

Striking of the bod

Tearing of the glotbiug and
the hair.

Face not turgid.

No foaming at the month,

Duration, o to 10 minutes.

3 Jn this stage the following symptoms
THE SECOND oR Con- exist aa the movements are very
TORTION PERIOD. forcibly made............ intaheseterateio aie"

| Tncomplete loss of conscious-

 

Fic. 122.—ANorHER ATTITUDE OF SAME CASE.

ees of general sensibility to touch, pain, or temperature usually
exists
The special senses may be in abeyance.
. Various forms of hallucination exist.

TuHE THIRD OR PERIOD | The patient may answer questions unconsciously.

OF HALLUCINATIONS. ) Various expressions are uttered and certain gestures are made which
scam the form of hallucination that exists (usually that of
sigh

Eyes Stilt’ anesthetic.
Pupils may be contracted or dilated.

he atient promoeny passes into this stage.

Tur FourtH or upils may be dilated

PERIOD OF DELIRIUM. ARE Gens: SWRDRERS, laughs, weeps, or shows mental excitement ip
The patient frequently passes large quantities of urine. ‘
HYSTERO-EPILEPSY: 513

The second and third periods described are of especial interest. The
contortions observed in the second stage are often horrible to witness.
The arms and legs may be placed in the most revolting of attitudes.

 

Fic 123,—Tusrp ATTITUDE OF SAME CASR.

In the third stage, the expressions of the patient often indicate the
greatest alarm. Hallucinations of sight are very common and the
patients see horrible sights. To quote from Hammond, they “ hurl
invectives at imaginary persons,—Scoundrels! robbers! brigands! Fire,
fire! Oh, the dogs, they bite me!”

Sometimes it becomes necessary to feed these subjects through a
tube and to draw the urine at regular intervals; because the pharynx
and the bladder are occasionally paralyzed after the attack.

 

Fic 124,—Convursion oF Hystero-Epritersy. (Froma photograph, Case of C. K. Mills.)

During the intervals which elapse between these attacks of hystero-
epilepsy, many of the symptoms enumerated as hysterical develop; such,
for example, as paralysis, anesthesia, hypersthesia, and diminution of

the special senses.
33
514 LECTURES ON NERVOUS DISEASES,

CATALEPSY.

Catalepsy can be classed as a condition closely allied to hysteria.
It is a functional neurosis, with no recognized pathology. It is char-
acterized by attacks of partial or complete loss of consciousness, which
ure accompanied by a peculiar rigidity of the muscles. During these
attacks, the limbs remain in any position in which they chance to be at
the onset, unless they are passively moved into some other position by
outside influence or until the limb falls from exhaustion of the muscles,

Although the muscles appear tense and unyielding, a slight amount
of force suflices to cause them to yield and to assume any posture which
an investigator may desire. They will then remain fixed until the atti-
tude ts again changed in the same manner. ‘This state of the muscular
system has been termed ‘“ waxy flexibility.”

These attacks usually begin suddenly, but they are frequently pre-
ceded by prodromal symptoms, as, for example, by yawning, eructations,

 

Fic. 125.—Casz OF CATALEPSY, EXHIBITING THE PROLONGED MAINTENANCE OF AN
ARTIFICIALLY INDUCED ATTITUDE, (From an original sketch.)

a sense of pressure in the head, palpitation of the heart, vertigo, a
change in the disposition, ete.

When the attack develops, the patient is suddenly rendered
incapable of altering the position in which he or she may be at the
moment. The eyes are either open or closed. The patient may occasion-
ally understand questions and yet be unable to respond or move. The
features are immobile, and the whole body remains as if suddenly petrified.

Sometimes one limb is affected at first, but the rigidity soon extends
over the entire body. The respiration is often slower than normal.
The leart’s action is regular. The power of swallowing is preserved.
The sensibility of the skin is greatly diminished or absolutely lost. The
pupils are usually dilated and respond slowly to light. Occasionally, the
temperature falls below the normal point and the skin is pale and cold to
the touch. The reflex excitability of the muscles is abolished in some cases.
CATALEPSY, 515

Hither sex may be affected. I observed with great interest in 1872
an attack in the male, which came under my notice while a resident
surgeon in Bellevue Hospital. The details of this case are given in full
by Hammond, from notes furnished him by my friend, Dr. Early. The
cataleptic state persisted in this case for several days. The temperature
rose to 100° F.

The duration of cataleptic attacks varies from a few hours to several
days. They generally subside with sighing and a desire for food. A
tendency to recurrence of these attacks is often observed.

Among the reported causes of this condition the following may be
mentioned: Pregnancy, mental excitement, grief, anxiety, mental

disease, hysteria, chorea, fevers, narcosis from ether or chloroform, and
anemia,

 

Fic. 126.—A CaTALeptic PATIENT SupporTED BY Hgap AND Feet. (From asketch made
at the time.)

These patients can be easily nourished if food is made to pass the
fauces. Death may be simulated during cataleptic attacks; but the
heart’s beat and respiration can be easily detected by a careful observer.

Catalepsy may be induced in “ hypnotic ” subjects by suggesting to
their minds the state of rigidity of the muscles. Charcot has supported
a patient in this state by resting the nape of the neck and the ankles upon
the hacks of two chairs placed about five feet apart. I witnessed a sim-
ilar condition of muscular rigidity in a cataleptic during my connection
with Bellevue Hospital in 1872, and also in another cataleptic subject
during the winter of 1885. (See Fig. 126.)

TREATMENT OF THE HYSTERICAL STATES.

The management of hysteria, hystero-epilepsy, and catalepsy will
now be considered. I would suggest, in the first place, that before
any medication is begun a thorough search be made for eye-defects
516 LECTURES ON NERVOUS DISEASES.

which have been discussed in the introductory pages of this section,
and also in Section II, and in relation to epilepsy and chorea. In case
they be found, they should be corrected by glasses or partial tenotomies.
My records do not show any cases of hystero-epilepsy and catalepsy in
which such examinations have been scientifically made; hence, I cannot
vive any personal experiences in reference to the beneficial results of
this treatment except in hysteria. Among the latter class, I have
observed several very marked examples, where a close relationship
between eye-strain and the attacks existed.

I could quote many cases from my case-book if I deemed it neces-
sary. The records in all go to show that eye-defect existed, and that
partial tenotomies gave marked relief in a very large proportion of the
whole number operated upon by me.

The examination of the eyes of hysterical subjects tends, in my
experience, to lead me to the conclusion that a defect in the eye or its
muscles is too often disregarded or unrecognized. It is well known that
heredity plays a very important part in hysterical cases, as well as in
other functional diseases; hence, it is advisable to investigate this pos-
sible factor in any case early, and, if it exists, to remedy it without delay.

In hysterical anesthesia, the employment of the secondary coil of a
faradaic machine by means of the wire brush often acts in a magical way.
Daily applications over the entire area of anesthesia with as strong a
current as the patient can comfortably bear will generally cure this
symptom ina short time. The negative pole of a galvanic battery may
also be einployed with decided benefit upon the area of anesthesia.

Hysterical paralysis yields in my experience most quickly to heavy
indirect static sparks. Strychnia and phosphorus are valuable aids in
effecting a rapid recovery, in some cases. Persistent daily attempts to
use the limbs should be urged upon the patient.

Hysterical contractures are often cured by static sparks and passive
motion. The galvanic current applied through the positive pole to the
alfected muscles (with the cathode on some neutral point—see p. 186)
often gives excellent results. I prefer “stabile ” applications to “ labile”
in case the positive pole is indicated. Massage may be employed with
marked benefit in certain forms of hysterical contracture. It should be
practiced daily by one well instructed in the art; and it is well in some
cases to use a faradaic current for from three to five minutes daily in
connection with massage.

Hysterical paroxysms, when particularly ‘severe, are controlled and
often entirely relieved by the inhalation of ether or chloroform. These
inhalations may be repeated as often as the symptoms seem to warrant.
It is generally advisable to push the administration of anzesthetics at
first to a point where the patient is rendered insensible by them, This
TREATMENT OF THE HYSTERICAL STATES. 517

rile of treatment applies with equal force to emotional paroxysms as
well as to those where spasm is the prominent feature of the attack.

Hysterical venting is sometimes obstinate. Hydrocyanic acid, sub-
carbonate of bismuth, blisters over the epigastrium, strychnia, phosphorus,
and cocaine have been used by me with great benefit in such instances.
The valerianate of caffeine in three-grain doses, repeated ina half hour if
necessary, has been highly recommended by Paret, Hammond, and others.

According to most authors, the so-called “ hysterical state” may be
controlled or eradicated, in some subjects, by long-continued medication.
While I am inclined to believe that some form of reflex irritation exists
ina very large proportion of hysterical subjects, and that its detection
and removal constitutes the first duty of a physician, still I am not
prepared to state that there may not be a certain proportion of this class
of subjects that must be medicated before the hysterical tendencies are
fully eradicated. I do not believe, however, in any medicinal specifics
for hysteria.

Among the REMEDIES which have been suggested for the relief of
these cases, the following may he cited :—

(1) Lhe monobromide of camphor may be given either in an emul-
sion or pill in doses of from three to five grains every hour or two as the
symptoms seem to indicate (Hammond). This drug seems to be partic-
ularly of service when the inhalation of ether or chloroform is contra-
indicated during emotional paroxysms or attacks of hysterical convulsions.

(2) The antispasmodics. Musk, valerian, asafcetida, and the vari-
ous bromides are highly recommended by authors generally. Valerian
is best administered in the form of the tincture, extract, or as the
valerianate of zinc. The nauseous taste of the latter preparation is
best overcome by giving it in capsules.

Castoreum is held in high favor by some authors. It is somewhat
expensive, however, and is not always procurable. Ten drops of the
tincture may be given on a lump of sugar.

The bromides of sodium, potassium, calcium, or zine may be given
in large doses until the full effects of the drug are obtained in cases
where hyperesthesia or mental disturbances are prominent manifesta-
tions of the hysterical state.

(3) The mineral tonics. Arsenic stands at the head of this list,
in my opinion, It may be administered in pills of the arsenate of iron,
or as Fowler’s solution. It acts well when anemia is markedly exhibited
by the patient.

Various combinations of zinc, copper, silver and gold have been
given to some cases with apparent benefit.

(4) The narcotics. This class of drugs has been quite extensively
employed by some observers. Opium may be administered cautiously
518 LECTURES ON NERVOUS DISEASES.

by the hypodermic syringe or by the mouth or rectum. Belladonna
must be administered with extreme caution ; especially if its active prin-
ciple (atropine) is employed. It sometimes acts well when hiccough
exists, or when convulsive seizures are frequent.

In closing, I would mention certain suRGICAL PROCEDURES which have
been suggested as a means of cure of hysteria :—

(1) Cauterization of the clitoris, according to Friedreich, often
yields good results in hysteria.

(2) Removal of the ovaries is now frequently practiced in severe
forms of hystero-epilepsy (Battey’s operation).

(3) The removal of the clitoris has been reported as having led to
good results.

(4) Partial tenotomies may be performed upon the ocular muscles,
in case any abnormal tendency to deviation of the visual axes inward,
outward, or upward can be detected in the patient. I am able to bear
strong testimony to the eflicacy of this step in several instances in which
I have deemed it wise to operate.

(5) An application of the actual cautery may be made to the spine
and the nape of the neck. This procedure, in my experience, has given
very marked relief to several patients of the hysterical class. Such
applications may be repeated as often as the symptoms seem to demand
them. The heated platinuim-tip should not be allowed to blister or burn
the skin. It should simply be brushed lightly over the surface.

Before we leave the subject of hysteria and its allied conditions
(hystero-epilepsy and catalepsy), it may be well te give some general
directions respecting the general steps which should be taken in the
management of such a case.

It is very essential, in the first place, that the doctor has the respect
and full confidence of the patient. The impression made upon the mind
of the patient by the personal characteristics of her medical attendant
has often a great deal to do with the eflicacy of the steps employed for
the relief of the symptoms. Possibly this accounts for the fact that
recoveries have occurred under lines of treatment which could have
had little, if anything, to do with the benefits derived. We are all
too apt to think that any given patient recovers in consequence of some
medicinal agent that we may have administered, when perhaps the mind
of the patient has simply been forcibly influenced.

In the second place, we must make such subjects believe that their
symptoms are perfectly understood, that all the points of the case have
been thoroughly noted and examined, and that there is strong reason to
hope for a complete recovery. Ridicule or the implication that the
symptoms are purely imaginary is apt to destroy the physician’s
influence over the patient.
NEURASTHENIA, 519

Again, the use of the term “hysteria” is often construed by the
patient or her friends as a slur upon the patient’s integrity of character ;
hence it is well to avoid it in discussing the case outside of medical
circles,

Patients of this class generally do better when removed from the
influence of sympathizing friends, or surroundings that tend to recall the
original exciting cause of the attacks. Pleasant and cheerful surround-
ings, travel, amusements of a non-exciting Character, ctec., are often of
great advantage to such patients. A married woman will frequently
improve faster when taken away from her husband; and it is often well
to free her also from the care of her household by removing her from
her home.

No effort should be spared to improve the general health of the
patient. Tonics, good hygiene, regular exercise or massage, and even
the so-called “rest treatment” (first suggested by Mitchell) may be
required to establish this end. Some cases of hysteria are close to the
border-lines of insanity, and must be treated with due regard to their
condition.

Above all, do not fail to examine for all possible conditions which
may exert (through reflex irritation) a deleterious influence upon the
nervous centres of the patient. Every organ in the body should be
examined before this question be decided in the negative.

Children of hysterical mothers should be brought up by a healthy
wet-nurse, and given every possible chance to grow strong and robust.

Ice-bags or a pressure-pad may be placed over the ovaries (if de-
cidedly hyperaesthetic) with benefit to some patients. The use of cold
should not be employed for more than an hour ata time to the ovary.
The actual cautery or blisters have been suggested as a substitute for
the ice-bag, since both tend to contract the blood-vessels by influencing
the vaso-motor system of nerves.

Static insulation (see subsequent section) often acts charmingly
with hysterical patients, in my experience. The patient should be very
highly charged with static electricity for twenty minutes daily.

NEURASTHENIA.

By the term newrasthenia we have been taught to include all mani-
festations of the condition commonly known.as “ nervous exhaustion.”

It may be manifested in a variety of ways. Its symptoms will
depend upon the type which exists—cerebral exhaustion or spinal
exhaustion—and also upon special idiosyncrasies of the patient.

Neurasthenia has been brought, in my opinion, too strongly into
prominence as an independent condition, chiefly through the writings of
Beard, Mitchell, Playfair, and Clark.
520 LECTURES ON NERVOUS DISEASES.

To my mind, neurasthenia, while not in reality a disease in itself, con-
stitutes the basis of many of the functional diseases which have already
been described in this section; hence, much that has been said in rela-
tion to the causation of epilepsy, chorea, hysteria, hystero-epilepsy and
catalepsy might pertinently be repeated here.

Patients probably always develop the neurasthenic state, to a
greater or less degree, prior to the appearance of certain symptoms
which are characteristic of the special functional diseases already dis-
cussed,

When the condition of neurasthenia is not accompanied or followed
by convulsive or emotional manifestations, it tends to manifest its
presence by many other morbid phenomena. These have been classified
by Beard, who, in various monographs which he issued upon this subject
prior to his death, has minutely described the abnormal conditions most
frequently encountered. =

Etiology.—The more common evidences of functional nervous
derangements which we so often encounter to-day (among which may
be mentioned sleeplessness, muscular twitchings, nervous dyspepsia,
sick-headache, hay-fever, morbid fears, sexual debility, melancholia,
etc.) were uncommon, and are still so, in certain climates and among
certain classes.

The reasons why functional nervous derangements are more common
now than of old, and why the American race is particularly disposed to
them, has been made the subject of much scientific thought and discussion.
It may be well to refer toa few of the causes which tend to promote
nervous debility. Practical suggestions may be afforded by so doing.

Dryness of the atmosphere is one of these factors.—In all cold
climates the humidity of the atmosphere is less than in the warmer
latitudes. This is because cold air condenses moisture, while warm air
will carry a large amount of it without depositing it as rain. It is well
known that dry climates predispose to nervous excitability by absorbing
the natural fluids of the body. Since dry air is a poor conductor of
electricity, it tends, moreover, to cause the body to become overcharged
with electricity, and thus to render the nervous organization abnormally
susceptible to any form of external or internal irritation. In very dry
climates, the hair becomes stiff and brittle on account of a want of the
natural moisture and oil. Sparks of electricity may be elicited under
such circumstances from the hair by drawing a comb through it, and
even from the clothing in some instances. Men and animals of all kinds
become fretful and irritable when exposed for any length of time to dry,
cold winds, so often encountered in the Western States. The vegetation
is frequently shrivelled and parched by an abstraction of its moisture,
and its vitality is quickly destroyed.
NEURASTHENIA. 521

Extremes of heat and cold tend to cause nervous diseases.—In the
southern climates, and in the small islands surrounded by salt water
which are known as health resorts, marked extremes of temperature are
uncommon ; hence we find less susceptibility to nervous excitability in
the inhabitants of these climates, when contrasted with those of the
Northern States, in which bitter winters are followed by a high range of
temperature during the summer months. The freezing blasts of winter
compel the inhabitants of the Northern States to live in-doors, in homes
filled with a dry and over-heated atmosphere. On the other hand, the
heat of the summer months does not encourage out-of-door exercises
and athletic sports as a popular pastime. Now, in England, for example,
the climate is more equable and moist than in America. Athletic
exercises can be indulged in there during all seasons of the year, and are
of the greatest benefit to the inhabitants. While I am glad to sce a
growing love for similar sports on this side of the water, the peculiarities
of our climate will never permit of the highest development and general
popularity of the hunt, tennis, cricket, foot-ball, etc., with the masses.
Thousands may attend exhibitions of this character, but those who
participate must of necessity be few.

The heating of our houses is an innovation upon the past.—Our
grandfathers brought up their families to rely on food and exercise
for warmth. In the Northern States the log-fire on the hearth was
the only way of keeping warm when in-doors. Now, any one who
has had experience in that style of heating will accord with the state-
ment that in extremely cold weather it is impossible to heat a room
to a temperature above 60°. I have personally known water to freeze
in a corner of a room in New England, which was illumined by the
blaze of a roaring fire. The bed-rooms in olden times were cold, and
feather-beds with an abundance of clothes were used to protect the
body during sleep. The hostess of olden time was accustomed, more-
over, to have the bed warmed for the guest immediately before his
retiring.

, In some parts of the country this method of heating is still
employed; but, as a rule, the use of stoves, furnaces, and steam has
superseded the hearth—much to the injury of the inhabitants. Most of
us are now baked and dried all winter in a temperature which varies
between 70° and 80°. We shiver when a slight draught enters the door
or window casement. We pass into the air with our skin-circulation
active, our pores open, and our bodies lacking the proper amount of
fluid, since it has been abstracted by the heat of our houses. Is it to be
wondered at, therefore, that an extreme of cold checks our perspiration,
drives the blood from the surface to our lungs and digestive viscera,
whose vessels become thus over-filled, and causes pneumonia, pleurisy,
529 LECTURES ON NERVOUS DISEASES.

liver and kidney diseases, and thousands of ills to the nervous organiza-
tion whose development is not at once perceived?

Our habits of eating are often detrimental to health.—It was the
custom of our ancestors of a century ago, if inhabitants of a northern
climate, to eat salt pork three times a day and nearly every day in the
year. I vividly recall, during a residence of four years in New England,
the dish of salt pork that was invariably put upon the table. It had a
constant claim to recognition as much as its:companion, the castor. A
prominent medical author humorously remarked, in an address delivered
some years ago before a convention of doctors, that “ Pork, like the
Indian, flees before civilization.” He says, furthermore, “ The history
of the rise and fall of pork as a food is itself instructive in relation to
the first effects of civilization upon the nervous system, In all the great
cities of the East and among the brain-working classes of our large cities
everywhere, pork in all its varieties and preparations has taken a
subordinate place among the meats of our tables, for the reason that the
stomach of the brain-worker cannot digest it. This dethronement of
pork has had, and is still having, a disastrous effect upon the American
people; for, as yet, no article of food with a ‘sufficient amount of fat has
been generally substituted. Fat in our dietaries is one of the most
imperative hygienic needs of our time, which has come to be felt, both
instinctively and rationally, and which, on all hands, we are trying to
meet by the use of cream, cod-liver oil, eggs, fish, and the fats of fresh
meat.” r

It bas been my custom for years to allow babies suffering from
nervous debility to chew upon a well-cooked rind of salt pork. I believe
that this form of food must of necessity always be the main article of
animal food for the community at large.

I would eall attention, in the second place, to a habit which is com-
mon among brain-workers, viz., of eating irregularly and too rapidly, and
the drinking of large quantities of fluid during their meals. It needs no
argument to prove that both conduce to destroy or impair the powers
of digestion. Who would think of placing a bucket of water by the side
of a horse every time it was fed. If food is properly masticated, the
saliva should suflice for all lubrication necessary to the act of swallowing.

Our systems of education may conduce toward ill health.—lIt is a well-
recognized fact among scientific medical men that a defective construc-
tion of the eye is present from birth in quite a large percentage of
children. As long as the child and its parents are ignorant of such a
defect, or until the defect. is remedied by glasses properly adjusted to the
eye, serious harm may be done to the nervous system by the strain to
which that important organ is constantly subjected. Most children in
the larger cities are now compelled to spend from five to six hours each
NEURASTHENIA. 523

a day, for ten months in the year, ina school-room; and to use their
eyes as well as their intellect after school hours in preparation for the
exercises of the ensuing day. It is not infrequent for medical men to
encounter adults who have been rendered victims of countless nervous
maladies by defects in vision which have never been corrected by the
use of glasses.

A far-sighted child becomes easily fatigued when attempts at read-
ine, writing, or study are made; hence he quickly develops tastes for
out-of-door amusements in which he usually excels. Children of this
type are often punished for a willful neglect of their studies, whenever
impaired vision from a tired ciliary muscle renders it impossible for
them to accomplish the allotted task. On the other hand, near-sighted
children cannot indulge in out-of-door sports because their vision either
prevents it entirely or makes them awkward in their attempts ; hence
they are generally fond of reading, and are too often regarded as preco-
cious beyond their years. The steady increase in the functional dis-
orders of the eye, which is proven by all of the carefully prepared
statistics, may be attributed, in part at least, to the neglect of parents
in having the eyes of children examined by a competent oculist before
they are sent reeularly to school.

One of the most frequent symptoms of nervous exhaustion in adults
is a weak condition which manifests itself in a sense of pain and weariness
whenever the eyes are used. This condition is known as ‘ asthenopia.”

Our hygienic surroundings should be conducive to health.—A very
large proportion of the patients who are referred to me for advice
respecting functional nervous maladies owe their troubles in part to
defective hygiene. Most of the large cities are imperfectly sewered, and
few dwellings are built with a proper regard for the requirements of
health. The business offices in cities are often so dark as to be con-
stantly damp and filled with the vapors arising from the consumption of
illuminating gas. They are,asa rule, over-heated, ill-ventilated, deprived
of sunlight, and often imperfectly protected against sewer gases. This
statement is true also of all of our stores, and of some of our dwellings.
It is one of the natural results of economy of space entailed by the high
value of land.

While it is difficult to obviate this element of disease in cities, it is
well to impress the minds of laymen with the fact that sunny bed-rooms,
perfect ventilation, and pure air are of vital importance to health, Large
cities are not the best places for people of moderate means to live in.
Their business offices may be in the city, but their homes from choice
should not be. A person may breathe impure air for a few hours each
day with comparative impunity, if he can have its effects counteracted by
pure country air during his hours of rest and the Sabbath.
524, ‘LECTURES ON NERVOUS DISEASES.

slleohol, tobacco, and other stimulants are often used to excess.—
There is a deeply rooted opinion among some of the laity, and medical
profession also, that tobacco and alcohol are.the most prominent factors
in producing the steady increase of nervous maladies which is generally
recognized as existing. It is not my intention to discuss the question
of temperance here from a social or moral aspect. What remarks I feel
myself obliged to make on this point are of a purely medical character.

From information gathered by personal observation and careful
inquiry and research, I am convinced that our ancestors were fully as
induigent in the consumption of tobacco and alcohol as are those of the
present generation, and probably very much more so. Many of our
grandfathers and grandmothers can be shown to have used both alcohol
and tobacco to excess, without developing any of the functional nervous
derangements of to-day. Ladies of the Southern States formerly indulged
to excess in the habit of snuff-dipping. Men and women were habit-
ually addicted to the use of snuff as a stimulant to the mucous mem-
brane of the nose, during the epochs when it was fashionable. The open
sideboard is certainly less common to-day in private residences than in
the past. People do not now, as a rule, take their ‘ night-cap ” before
retiring ; but it was once the universal custom. Bulwer happily remarks
that ‘it requires a very strong constitution to dissipate,”

Now, it is very common for me to have nervous patients tell me
that they have been obliged for years before they sought my advice to
discontinue the use of alcohol and tobacco. Some of my patients are
unable to drink tea or coffee; others are abnormally susceptible to
stimulating narcotics, such as opium; while a few are unable to tolerate
many of the drugs which they could previously use with impunity. On
the other hand, I ain satisfied that nervous exhaustion is a cause of
confirmed inebriety in many instances.

It seems to me that we are forced by what has thus far been said,
without further illustration, to the following conclusions: (1) that the
tendency of the age is toward nervous excitability and debility; (2) that
the brain-workers (in contradistinction to the muscle-workers) are more
susceptible to external and internal disturbances than in past genera-
tions; (3) that many of the factors enumerated can be justly included
among the elements which have produced this result; (4) that the
American race is particularly prone to nervous derangements; and (5)
that we are ourselves partly responsible for the modifications which
have taken place in the constitutional vigor of man as civilization has
progressed.

Betore I pass to the consideration of the-more prominent symptoms
of functional nervous derangements, I may state that the premature
decay of the teeth has heen brought forward by Beard as one of the most
NEURASTHENIA. 525

striking evidences of the steady increase of the constitutional impair-
ment which has followed our present methods of living. It is common
to hear dentists account for this fact on various grounds, amony which
may be mentioned the use of acids, the eating of sweet things to excess,
alack of scrupulous cleanliness, and the elimination of such foods as
require thorough mastication. While I do not deny that there may be
a justification for these views, still I would draw the attention of my
readers to the fact that the teeth of the negro race, of the Indian, and of
all semi-barbarian tribes are proverbially perfect. This is the case in
spite of the circumstance that they are extremely fond of sweets. It is
also true that they seldom if ever clean their teeth, and that they never
suffer from cavities except in old age. Neitlier are the tecth of these
races nor of animals irregular; yet how common are such deformities
among the descendants of intellectual and refined ancestors! We should
remember in this connection that the nutrition of all parts of our frame
is controlled by the nerves. Is it not rational, therefore, to regard im-
perfect bone nutrition and development as a result, in some instances at
least, of an impairment of the nervous functions ?

Morbid Anatomy.—In the early stages no pathological lesions can
be detected in many neurasthenic subjects. Later on, sclerosis may
possibly be developed in exceptional instances, and many other varieties
of structural change. Doubtless, these abnormal conditions are either
induced or hastened by a state of nervous debility ; but they cannot be
said to be more than mere coincidences.

Symptoms.—Neurasthenia may affect the cells of the brain or of the
spinal cord separately. Hence we are forced to clinically recognize two
types of neurasthenia,—the cerebral and spinal.

Cerebral neurasthenia (brain exhaustion) may be indicated, according
to Beard, by one or more of the following symptoms: Tenderness of the
scalp; pains in the head; fleeting neuralgias; sleeplessness; vertigo; a
tenderness and pallor of the gums; abnormal sensitiveness of the teeth;
blanching of the hair; flushings of the face; dilatation of the pupils;
idiosyncrasies in regard to food and external irritation; mental depres-
sion and melancholia; defects in memory; a morbid craving for alcohol ;
a decrease in intellectual capacity; a buzzing or ringing in the ears;
specks before the vision; abnormal and imaginary impressions of taste
orsmell; morbid fears of various kinds; sick-headache; dryness of the
skin and the mucous surfaces; weakness of the muscles; numbness in
the limbs; thickness of speech; and mental excitability, irascibility or
loss of emotional control.

These symptoms, in many cases, are but the manifestations of weak-
ness. The electric batteries of the brain (the minute organs known as
the “brain-cells”) are feeble or uncertain in their action. They are
526 LECTURES ON NERVOUS DISEASES.

incapable of performing the offices for which they were created. They
are not diseased (in a medical sense), but they are weak and liable to
become so sooner or later. I have kuown sufferers of this type to be
precipitated into a condition approaching incurability by mental alarm;
excited, in some instances, by an opinion of an unfavorable kind made
by physicians respecting a prospect of recovery. Again,it is well known
that insanity may arise as a consequence of the loss of sleep often experi-
enced by these subjects, and by “brooding over their symptoms” whose
significance they fail to properly understand. I recall several cases
where a patient was with difliculty convinced that some special type of
malady was not about to attack him, because in reading a medical work
his attention had been called to the significance of some special symptom,
which he was sure he had personally experienced. If medical students
who possess vivid imaginations can become (as they often do) victims to
imaginary diseases whose symptoms they have been studying, is it to be
wondered at that the weak and highly-organized sufferers from neuras-
thenia are especially prone to become impressed by this form of
delusion?

Spinal neurasthenia (spinal exhaustion) signifies an exhausted state
of the cells which help to form the spinal cord. The cord itself, although
only about the size of an ordinary lead-pencil, is composed of millions of
nerve-cells and distinct bundles of nerves. Some of these nerves pass
through it to reach the brain above, while others become united to the
spinal cells and pass no further. The cells of both the brain and spinal
cord are practically electric batteries ; and the nerve fibres are the wires
by which they are connected with the different organs of the body, the
muscles, skin, joints, and viscera. This wonderfully constructed organ is
under the control of the brain; but is capable of exerting, under certain
circumstances, a control over all acts, which are termed “ reflex acts”
because they are to a greater or less extent independent of the will.

Now, when the cells of the spinal cord become exhausted, the symp-
toms produced differ markedly from those already mentioned as indica-
tive of brain-exhaustion. Among its chief manifestations, may be
mentioned the following: A general tenderness of the skin to touch or
pressure; tenderness along the spine or over certain limited portions of
the spine; irritability of the breasts, ovaries, and the womb in females;
flecting pains of a neuralgic type in various parts of the body; an
extremely rapid or slow pulse, which fluctuates widely during periods
of excitement or fatigue; attacks of palpitation of the heart; dryness
of the skin, or in many cases the reverse; excessive perspiration of the
hands and feet; sudden startings on going to sleep; muscular twitchings
in one muscle or a group of muscles; chilliness and creeping sensations
along the spine; numbness or abnormal sensations of heat in the skin
NEURASTHENIA. 527

of the body or limbs; itching of the skin; eruptions upon the skin,
chietly of the type of eczema; frequent gaping, yawning or stretching ;
frequent seminal emissions; weakness of the bladder and rectum; and
disturbances of the digestive functions.

The distinction between cerebral and spinal neurasthenia, which has
been stated by many observers to exist, cannot be made in each and
every case, because various combinations of the symptoms of the two
are often encountered in the same individual. A prominent author upon
this type of diseases very aptly compares the nervous system of man to
certain mountainous regions,—since it causes so many echoes and rever-
berations. He says, “ An irritation at one point may be transferred to
any other point, following the paths of least resistance, and making itself
felt in those parts that are least able to resist molecular disturbances.
Thus, for example, seminal emissions and spermatorrhawa, when they
arise through abuse or through spinal-cord disease, almost uniformly
react on the brain,—robbing the sufferer of courage and manliness,
exciting various phases of morbid fear (of which I shall speak), with
aversion of the eyes and countenance.”

Thave known a decayed tooth to cause persistent earache, and in
one case to cause the corresponding eyebrow to become white. In male
children, a tight foreskin not infrequently creates sufficient irritation of
the sexual organs to induce spasms or paralysis of the lower limbs by
an indirect effect upon the spinal cord. I have frequently cured patients
who have come to me for relief from persistent and excruciating attacks
of neuralgia, by a correction of some defect in their eyes. The extrac-
tion of a tooth has frequently, in my experience, relieved facial and
orbital neuralgia.

It may be well to consider a few of the more prominent manifesta-
tions of nervous exhaustion separately.’ Among these, sleeplessness, a
defect in vision known as asthenopia, sexual weakness, headache, an
unnatural dryness of the skin and mucous surfaces or profuse sweating
of the hands, and morbid fears or melancholia, deserve special mention.

Insomnia.—Sleeplessness may assume different forms. Some of
those afflicted have difficulty in getting asleep; some awake after a few
hours of slumber and remain so until daylight; a few find themselves
overpowered with a desire for sleep during their working hours, when
their business will not admit of it, and at night cannot: obtain sleep
except under narcotics. I have had patients who have told me that
they spent most of their nights for years in writing to friends,
riding in the horse-cars, or walking the streets for amusement because
they could not sleep. It is safe to assert that persistent insomnia,
extending over a period of weeks or months, indicates in most cases
a persistent cause of neurasthenia or organic disease of some kind.
528 LECTURES ON NERVOUS DISEASES.

In patients who have passed the age of fifty, or in younger persons
who have indulged to excess in alcohol, it is often due to a type
of kidney disease, to detect which repeated examinations of the urine
are required. This form of trouble is known as the “ granular” or
“contracted kidney ;” and insomnia, frequently combined with headache,
is one of its most prominent symptoms. Obstinate sleeplessness is the
cause of many a suicide, too often the starting point of the opium and
chloral habit, and surely the destroyer. I would caution my readers
against allowing this symptom to remain uncontrolled in a patient for
any length of time; to avoid the use of all forms of narcotics as long as
possible; and to keep the patient from acquiring a habit of using them
without medical authority. The chains of intemperance are but silken
threads when compared to those of the opium or chloral habit.

Asthenopia,—This type of defective vision cannot be relieved by
ordinary glasses; nor does it respond quickly to the customary sugges-
tions of gymnastics, horseback-riding, etc. It is due, as a rule, to a
defective equilibrium in the muscles which control the movements of
the eyeballs, and it manifests itself chiefly as a sense of extreme weariness
when the eyes are steadily employed for short periods of time. It is an
indication of neurasthenia, and is of great diagnostic value. In many
cases it becomes necessary to partially divide the tendons of the stronger
muscles of the eye, in order to relieve the weaker ones of a strain. I
haveseen patients who could not sew for five minutes ata time from this
cause, and others who would be made sick by attending a theatre, picture
gallery, or other places of amusement. The reader is referred to pre-
ceding pages, which deal with this subject at greater length.

Headache.—Many attacks of this character are undoubtedly to be
attributed to imprudences in eating, exposure, or fatigue. But I believe
that most of those who are periodically afflicted in this way owe their
suffering to a lack of tone in the muscular coat of the blood-vessels of
the brain, consequent upon some of the causes of neurasthenia mentioned.
[ have seen a large number of instances where the eyes were the cause of
such headaches, and where the adaptation of glasses has brought imme-
diate relief. The medical profession are rapidly becoming enlightened
upon this fruitful cause of pain. It is well also to examine the urine
when persistent or periodical headache occurs, as it may be a symptom
of kidney-disease. Some neurologists believe that the so-called “ sick-
headaches” sre to he regarded as but a modified form of that condition
which produces epilepsy. This condition will be considered separately
in subsequent pages,

Pryness or Unnatural Moisture of the Skin.—Some nervous patients
suffer from an unnatural dryness of the skin, the throat, and the nose.
They are also liable to experience dyspeptic symptoms at the same time,
NEURASTHENIA. 529

which are probably due to similar changes in the lining of the stomach.
This dryness may be accompanied also by an itching of the affected parts
oran attack of eczema. A burning sensation is sometimes produced. I
was once consulted by a patient who had been in the habit of encasing
himself in flannel and putting on flannel stockings before he retired
for years, in order to overcome a sense of burning in the skin which
followed the contact of cotton or linen with any part of his body. I
recall a case where the feet were once frost-bitten, and the patient has
never been able since to walk upon a carpeted floor on account of a
burning sensation which immediately follows. He takes off his shoes as
the last step before retiring.

On the other hand, many patients afflicted with neurasthenia suffer
from a profuse sweating of the palms of the hands. This is accom-
panied in some instances by a flushing and redness of the face, neck,
and ears. The nails may become unnaturally soft or brittle.

Morbid Fears.—This peculiar manifestation of nervous exhaustion
may assume one of several types. Attempts at classification of these
morbid fears have been made by some authors, such as fear of lightning,
of places, man and society, solitude, accident, etc., and special names
have been applied by them to each of these types. Fears of this kind
may be present without any other manifestation of mental impairment.
They are usually uncontrollable, in spite of the fact that the patient may
exhibit a knowledge that they are groundless and absurd. They seem to
take full possession of a being, and to cause mental torture of an extreme
kind. :

Finally, melancholia is not an infrequent symptom of neurasthenia.
It may be accompanied by paroxysms of laughing, weeping, and
hysterical phenomena.

Prognosis.—I have never observed a case of neurasthenia where
death has occurred, save through some intercurrent disease; and I doubt
if such an occurrence has ever been noted by a competent observer. I
have, however, seen organic disease develop in the brain and spinal cord
(apparently as a sequel to the neurasthenic state) in several instances.
Melancholia, delusions of various kinds, and even mania have been
known to develop in subjects who had previously suffered from symp-
toms of nervous exhaustion. I am not inclined to believe that these
cases are extremely uncommon. Quite a large proportion of insane
subjects give a history which leads to a different conclusion than that
given by most authors.

A very large proportion of neurasthenic cases drag out a miserable
existence for years; become hopeless invalids; and eventually die of
some intercurrent disease. It is a daily experience with me to encounter
both males and females who are totally unfitted for the active duties of

34
530 LECTURES ON NERVOUS DISEASES.

life from neurasthenia. To many of them the possibility of death would
be robbed of its terrors, because life has ceased to be a source of comfort
or of usefulness.

Treatment.—In this class of cases, my experience has convinced me
that “eye-strain ” constitutes one of the most important factors in the
causation of the symptoms, and that the detection and relief of the defect
which exists in any individual case is of the greatest importance. I
could quote case after case, if space would permit, to prove this asser-
tion. One of the most remarkable instances of this kind which ever
came under my personal observation may be worthy of record here :—

Case I, Cerebral Neurasthenia, Gastralgia, Persistent Tremor, ete.—Mrs. , aged
forty-three. Her father and mother died of phthisis, as well as several blood relatives. Has
two children; was ‘very nervous” asa child. For the past sixteen years has been more
or less:of an invalid. For some years the patient has not been able to spend her evenings
with her family or to see company. She reads without fatigue, has suffered but little with
headaches, and has never had marked asthenopic symptoms. She had suffered greatly
for some years with recurring attacks of gastralgia, a loss of emotional control, severe
palpitation of the heart, and an inability to endure physical exertion or any form of
excitement. Has always been regular in menstruation.

When I first saw the patient, she trembled violently, had moist palms, and could not
without great effort control her emotions. Her eyes were constantly averted while in
conversation, being generally directed toward the floor. Her voice was feeble and tremu-
lous, and at times scarcely audible. Under any excitement, she would experience a
choking sensation. During one interview in my office, she was so attacked, and suffered
like a person in the height of a paroxysm of asthma.

An. examination of her eyes under atropine showed :—

 

Emmetropia.
Esophoria of a high degree (6°).
Power of abduction 4°; of adduction, 28°.

Daily applications of static insulation gave her but little relief; although they were
persisted in for some weeks. Prismatic glasses annoyed her and yielded negative results.
Her tremor and emotional excitability persisted, and her condition remained practically
unchanged. Finally, she consented to allow me to perform partial tenotomy upon her
internal recti muscles. Within twenty-four hours, her trembling ceased and has not
returned. In less than two weeks she was able to attend places of amusement, entertain
her friends and perform all the duties of life as well as when agirl. She has remained
absolutely free from attacks of gastralgia and cardiac palpitation since the last operation
(nearly two years ago), and looks at least ten years younger than when I first saw her.

This case illustrates admirably the following points: (1) that no
asthenopic symptoms had ever existed, in spite of the eye-defect; (2) that
prisms failed to relieve the patient; and (8) that tenotomy cured her of
tremor, gastralgia,and cardiac palpitation, besides a host of other neuras-
thenic symptoms. It is needless to add that the patient had tried
medicinal agents without number during the many years that she had
been an invalid.
NEURASTHENIA. 521

Another equally striking case of cerebral neurasthenia is illustrated
in the following history :—

Case II. Cerebral Newrasthenia, Constant Pain in the Head of Five Years’ Duration,
Asthenopia, etc—Female, unmarried, aged twenty-one years.

family History—Maternal aunt and five paternal relatives died of phthisis; two
cousins had chronic chorea,

Eye-defects.—Patient had hyperopia, (latent) of 1.25 D. and exophoria (manifest) of 2°.
A latent hyperphoria of 2° was subsequently discovered.

This young lady was brought into my office by two assistants, who were obliged to
carry her from the carriage. For several years she had been carried daily from her room
to the library of her father’s house, and, after reclining in a chair for a few hours, she
would be again carried to her bed-room. She could manage with difficulty to walk slowly
across.a room. She had not been able to write, read, sew, or see her most intimate
friends for five years on account of a constant pain in her head, which was rendered
intolerable by any use of the eyes or excitement. Her symptoms began while at
boarding-school, from which she was removed to her home in a recumbent posture and by
easy stages.

L used static electricity upon this patient for some weeks with a slight improvement
in her power of walking, but no relief to her head. I then persuaded her to consent to a
relief (by partial tenotomies) of her abnormal eye-tension. Tenotomies were then per-
formed upon her left superior rectus and both externi within the space of two weeks.
From that date her improvement was very rapid. She was sent home a few weeks later
practically cured,

A letter from her physician, lately received by me, says :—

“Your patient is the wonder of this region. She rivals the ‘ Jersey Lily’ in her feats
of walking.”

Before this patient was sent home she ascended and descended five flights of stairs
daily, and averaged over a mile’s walk each day without a companion to assist her.

In case the eye be found to be entirely free from abnormalities of
refraction or accommodation, and the ocular muscles to be normal, I
would advise rest as a valuable step toward a cure. The plan first
suggested by Dr. 8. Weir Mitchell (now generally known as the “ rest-
cure”) has proven of great value in some of my cases. It consists of
perfect isolation, a prolonged confinement to bed, and a total cessation
of bodily or neil pursuits, combined with vaerular and systematic
feeding, massage, and electrical applications. It is especially adapted
for females; but, in a modified form, is useful in male subjects.

With males, it is usually well to advise early a total withdrawal
from business for a time, and retirement to some quiet place where out-
of-door sports can be indulged in. I seldom advise travel, because it
involves too much excitement.

Sleeplessness may usually be controlled by a judicious use of the
bromides, some preparations of valerian, chloral, hyoscyamus, conium,
or opium. I seldom employ any drug, however, for the relief of this
symptom until I have thoroughly cauterized the back of the neck (over
532 LECTURES ON NERVOUS DISEASES.

the point of entrance of the vertebral arteries) with the white-hot
platinum tip. Such an application is often immediate in its effects.

Sweating of the hands and feet is generally relieved by atropine and
friction of the parts after bathing them in very hot water.

Disturbances of the digestive functions are often greatly benefited
by a prolonged use of’ hot-water drinking (see p. 248) and the adminis-
tration of tonics. Stimulants may be given in some cases directly after
eating. In occasional instances I am compelled to restrict patients for
a time exclusively to a milk diet.

Statice electricity, by the spark method, the static breeze, or simple
insulation often acts as a great aid in the cure of these cases. General
faradization or general galvanization are excellent methods of employing
electricity upon these subjects, in case a static machine is not attainable, or
as a substitute for static applications when the patient fails to respond to
its influence.

MIGRAINE—SICK-HEADACHE—MEGRIM.

This distressing condition is characterized by paroxysmal attacks
of pain in the head (usually unilateral, but not always so), accompanied
by nausea, eructations of gas from the stomach, and vomiting. Between
the paroxysms, the patient generally enjoys more or less perfect health
and is free from pain. /

There is perhaps no form of pain that is more commonly encountered
by. the physician than this; unless it be “neuralgia” in the common
acceptation of that term. Sufferers from sick-headaches are to be found
in every large city and country town, especially among the brain-workers
in contra-distinction from the muscle-workers. No clime or atmospheric
condition seems to confer immunity from ne attacks to those who are
congenitally predisposed tc them.

I approach the discussion of this subject with more than ordinary
interest, because for nearly thirty years I was personally a victim to the
most severe form of these attacks. Within the past ten years, I have
treated a very large number of these cases with the most satisfactory
results ; hence, my convictions are strong in reference to their causation
and their treatment.

Etiology.— Migraine runs in families. Hereditary predisposition is
perhaps more strongly marked in this affection than in most of the
so-called functional nervous maladies. In all of this class such a pre-
disposition is very marked, and particularly so in migraine.

Most authorities classify migraine under the “ vaso-motor neuroses ;”
but, in the light of my own observations in this special field, I prefer to
discuss it under the head of functional nervous diseases, because I
believe that reflec irritation of the oculo-neural type lies at the bottom
of the attacks. |
MIGRAINE—SICK-HEADACHE—MEGRIM. 533

It is quite remarkable how often the family history of this class of
patients points to a ¢ubercular predisposition. It is, in my experience,
very rare to find typical attacks of migraine in a male or female who has
not had some relatives die of phthisis.

For many years I have taught in my lectures that I had yet to meet
acase of typical migraine in which an examination of the eyes or the
eyemuscles would not show the existence of a marked error. All
observations to date confirm me in this view. Latent hyperopia is
an extremely common cause of reflex disturbance in these cases; and
esophoria or hyperphoria (p. 143) are not infrequently found.

No one in the profession, as far as my information goes, has ever kept
such careful records of the condition of the eye and its muscles in de-
scendants of “* consumptive ” ancestry as has my friend, Dr. G. T. Stevens.
His investigations in this particular direction have been noted carefully
in several thousand patients. They go to confirm my own researches in
the conclusion that a hyperopic eye exists in an extremely large percent-
age of these subjects, and that ocular insufliciency is also very common
among them.

To avoid repetition, I would refer the reader to some pertinent
remarks upon the generally accepted views respecting the causes of
sick-headache which I have made in the second section of this work
(p. 127).

The age varies at which patients experience their first attack. Gen-
erally they develop during childhood, provided the occupation of the
child requires much eye-work, as in the case of educational pursuits. If
they begin after the twenty-fifth year, I generally am led to suspect some
intercurrent disease in addition to “ eye-strain.”

Symptoms.—Attacks of sick-headache are always paroxysmal and
peculiarly “explosive ” in character. They come without known cause,
as do epileptic seizures; although all persons so afflicted, as well as
their doctor, usually think that they know the particular exciting cause
of each paroxysm. (See p. 128.)

Premonitory symptoms, as a rule, warn the patient of the approach
of an attack. They awake with a peculiar “ heavy feeling” in the head,
or a sense of languor, or a disinclination to eat, or to smoke (if addicted
to tobacco). They are often constipated, and feel a peculiar aversion to
mental effort or to gayety. Sudden movements of the head or body are
often followed by pain in the head. Stooping is liable to produce
unpleasant sensations. They are apt to yawn frequently, and eructations
are not uncommon. In rare instances, these attacks are preceded by a
marked buoyancy of spirits on the preceding day.

As the day progresses, pain of a decided character begins to be felt
in the head. It may be unilateral or bilateral. If unilateral, the left or
534 LECTURES ON NERVOUS DISEASES.

the right side are equally apt to be the seat of pain. The special senses
‘become abnormally acute. The temporal arteries are swollen on the
affected side and feel like whip-cords beneath the skin. The patient
begins to experience pulsations within the head, which send shooting
pains with them of a severe character. The region of the stomach often
feels unpleasantly, as if distended with gas. Light becomes painful, and
the eye of the affected side gradually changes in its appearance, It is
usually dull, retracted, and not widely opened. The pupil may be
slightly dilated.

The seat of pain may be at first in the occipital region or over
the forehead or temple; but it tends to spread gradually over the
affected side as the paroxysm increases in severity. The cervical
region of the spine is apt to be more or less affected with an aching
sensation.

Toward the close of the day the patient is obliged to give up busi-
ness and retire to absolute quiet and a dimly-lighted room, provided the
attack is a severe and typical one. The pain becomes more and more
intense until it culminates in vomiting. This often closes the attack and
the patient falls into a heavy sleep closely resembling that which follows
an epileptic seizure. Several fits of vomiting are generally experienced,
accompanied by retching, sweating, pallor and extreme physical prostra-
tion, -before entire relief from pain comes.

No one who has never experienced a severe attack of this kind can
conceive of the torture which such a patient endures. It deprives him
of all power of performing the simplest mental processes and takes away
the ability to endure suffering. In addition, the patient is harassed by
all-forms of visual disturbances, even when the lids are closed. Such
patients may be rendered partially or totally blind during the attack.
The hearing and smell are so acute as to detect things which would
otherwise be unnoticed, and to cause them to suffer acutely in conse-
quence of such perceptions. Bright zigzag lines of light often seem to
flit across the vision ; or luminous spots may appear, which grow in size
and brilliancy till they become intolerable. Sensation may be abolished
in some well-defined area of the skin.

The frequency of the paroxysms varies in different individuals.
Some have them once a week, others once a month, others much less
frequently.

Between the attacks the patient usually feels perfectly well and
generally suffers from no nervous symptoms. There are exceptions to
this rule, however, which are well illustrated in the few cases cited.
These are taken from my own records. They represent but a small
fraction of similar cases which I am constantly observing in my practical
office work.
MIGRAINE—SICK-HEADACHE—MEGRIM. 535

‘Casz I. Inherited Sick-headache, Vertigo, Loss of Emotional Control, ete—Mr. ;
aged twenty-eight; has had severe headaches at least once cach week since the age of six.
Consumption very frequent in his maternal ancestry and immediate relatives, Has suffered
with diplopia at times; especially when fatigued by the use of the eyes for near-work. Has
lately had # marked increase of the headache. The attacks are excruciatingly severe
and almost constant. Has tried almost every known drug, but has found all more
or less unsatisfactory. Within the three months preceding the examination of the eyes
has had, in addition to the headache, ‘extreme nervousness,” with a loss of emotional
control, attacks of vertigo, which have been distressing, and an inability to use the eyes
steadily for any length of time without great fatigue. Has used a + 1.00 D. glass at
times for reading.

 

Examination of the eyes shows :-—

 

PAO DS Weer Becta Secs by cae ee bok Saami he hk, 3 aw g
OsBs Ve. sa cerGe ai Hope & @ $b RW a aoe oe Hay 3
DBIMGG5 "Vid songs cy ten ape oe ee ee ee 20
Without atropine . External insufficiency (esophoria) . 2... ee, 79
Addiction: . 2% 2-4 a5 Ree we a Be Ered ue the 20°
Abduction . 2... 0... EB ew Bt kee ah 4°
Visual field... 2... O40 a eee HBS normal.
| Reading power: No. 1 type read easily by + 1.50 at ten inches.
Os De Gs a ee RE Ae made 22 by + 3.00
Os, Bi giles eae ee wes 2... + made 2% by + 3,00
“ ; Binoey ee Soa bob ek kek be we made 3° by -|- 3.00
With atropine External insufficiency 5°, but totally relieved by + 3.00 glasses,
without prisms.
| Reading power: test type, No. 1, read with ease with + 4.00.

Ordered }- 1.75 glasses for each eye, in spectacle-frames; these to be worn constantly,
for both distant and near vision.

The correction of this ocular defect made a complete cure, The patient did not have
a headache for over eight months, and all the nervous symptoms disappeared immediately.
During the past five years, the attacks of headache have not exceeded two a year. They
invariably follow excessive mental effort and a protracted use of the eyes. This case
illustrates well the acuteness of vision which existed before the use of atropine, in spite of
a high degree of hyperopia.

 

Casz II. Headache, Mental Depression, and Insomnia.—Mr. , aged forty-nine;
lawyer. Phthisis common among maternal ancestry. Has had more or less headache,
but no periodical attacks of migraine. Has begun to suffer for the past two years with
extreme headaches, insomnia, inability to use the eyes, great mental depression, and vertigo.
Has never required glasses even to read,

Examination of the eyes shows :—
A “manifest” myopia of — 0.75 existed before atropine was used,
Hyperopia under atropine corrected by + 1.50.
External insufficiency (esophoria) of 1°.
Adduction, 10°; abduction, 5°.
Marked ciliary spasm (as shown by the effects of atropine).

An uncontrollable trembling of the head, and severe pain at the occiput invariably
occurred during the testing of the eyes for insufficiency, before atropine was used.
536 LECTURES ON NERVOUS DISEASES. ©

This was one of the most interesting cases I have ever seen. Any
attempt at convergence of the eyes gave intense occipital pain and a
shaking of the head which would dislodge the spectacle-frame. Although
he exhibited, under atropine,a latent hyperopia of a marked degree, he was
apparently myopic before its use, on account of an existing ciliary spasm.
The total muscular power of adduction and abduction was extremely low.

The use of atropine arrested all the reflex nervous phenomena in
this subject at once. He was kept under its influence for a week; was
given + 1.50 glasses for reading and all near-work. By the use of pris-
matic, daily exercise for the muscles, he recovered the normal power of
convergence and divergence in about three weeks. In this case, static
sparks were administered daily to the occiput and cervical region of the
spine for several weeks, as it gave the patient a great sense of relief in
the head. Although all pain had ceased from the first administration of
atropine, a sense of “fullness in the head” remained, which was over-
come entirely by the static spark and ergot.

Case III. LHysteria and Morbid Fears, associated with Headache.—Mrs, , aged
twenty-seven ; wife and mother of two children. Has a well-marked phthisical ancestry.
Patient has had scrofulous joint-disease. Prior to the examination she had been growing
hysterical, with a tendency to cry constantly. Has had repeated ‘sinking feelings.” Has
an aversion to crowds, and morbid fears. Suffers greatly from sick-headaches. Has had

 

' amenorrhea for many years at intervals,

Examination of the eyes shows :—
Without atropine, O. D. V8 . ce ak ee ee we es with atropine, 29 imperfect.
it Mm Os Sy Vat a ab a A BR RR ws . oe Re
“ “ Esophoria, 4°.
fi “— Adduction, 12°.
tf “Abduction, 6°
Hyperopic astigmatism of a high degree (+ 1.50) in each eye.

This patient did not wait in the city to have her visual apparatus

corrected. The case, however, illustrates well the existence of a marked
hyperopic defect and muscular insufficiency as a cause of headache.

Case IV. Excruciating Headaches, Chronie Diarrhea, and Neuralgie Parorysms—
Female, aged twelve. :

Family History.—The father is somewhat eccentric and intemperate; pulmonary
consumption was extremely common among the paternal ancestry; one brother is an
epileptic and is partly idiotic; all the paternal side of the family are very excitable and
nervous people.

This little patient was a great sufferer. Whenever attempts were made by her parents
to send her to school, she would “ break down” at once with peculiar attacks, characterized
by obstinate vomiting, chronic diarrhea, intractable headache, and neuralgic pains in the
spine, limbs, and chest. All medical treatment had proved of no permanent benefit. So
long as study was not attempted, the child suffered only at intervals with these severe
attacks, but she remained weak and delicate,
MIGRAINE—SICK-HEADACHE—MEGRIM. 5387

Eye-defects—An examination of her eyes showed a latent hyperopia of nearly 3 D.
and esophoria of 8°. Prior to the use of atropine she had normal vision (22). The wear-
ing of spherical glasses (2 D.) and prisms (4° over each eye with the bases out) caused all
her distressing symptoms to disappear within two weeks.

A letter, lately received from her mother, says: “I thank you next to the dear Lord
for removing this burden of anxiety about my child, which was becoming unbearable.”

Prisms were ordered in this case because the parents decided to postpone a radical
correction of the muscular error. This step I expect to undertake very soon,

Case V. Orbital Neuralgia and Sick-headaches—Mr. ——, aged forty-séven. Patient
isalawyer, Mother has had sick-headaches every week for her life-time, confining her
to bed. Sister is ‘‘ very nervous.’ Patient has suffered personally either with orbital
neuralgia or sick-headaches nearly every week for nearly thirty years. The attacks usually
last two days and require from one to three grains of morphia to control them. They seem
to be independent of any known exciting cause. No remedy has ever been found. Patient
has consulted several of our best physicians.

Examination of the eye shows :—

Normal vision before atropine was instilled.

A latent hyperopia of the right eye, corrected by a + 1.50 glass
A latent hyperopia of the left eye, corrected by a + 1.50 glass
O.D, = + 4.25
0.8, = + 4.25

} ander atropine.

Reading test for No. 1 Jaeger’s type, under atropine= j

External insufficiency (esophoria) of 3°,

I ordered this patient at first glasses of + 1.00 for distance, reading, and all near-
work, The insufficiency at first appeared to be corrected without prisms by his “distance”
glasses. Subsequently I was obliged to add 3° of prism, as he refused surgical interference.

Patient experiences great relief from the glasses and is still under galvanic treatment.
The neuralgic attacks are apparently occurring at less frequent intervals.

Cast VI, Excruciating Neuralgic Headaches—My. , aged thirty-nine. Patient
for years had had attacks of neuralgic headache, usually hemicranic. They have occurred
with increasing frequency and severity for the past few years. They have of late become
almost constant and have rendered the patient entirely incapable of following his profession
with pleasure or profit.

 

Examination of the eye shows :—

A latent hyperopia of each eye, which requires a -+- 2.75 glass to correct it when the
eye isunder atropine. Without atropine, V. = #$ in both eyes.

External insufficiency (esophoria) of 6°.

With corrected vision, by means of + 1.50 glasses and 3° of prism over cach cye,
this patient has almost entirely regained his health. His neuralgic attacks are very
infrequent and are usually traceable to excessive use of the adductor muscles. Patient
still wears prisms and refuses surgical relief for his esophoria.

Case VII. Cerebral Neurasthenia, Pseudo-ataria, and Chronic Headache—Male,
married, aged forty-three.

Family History—Two brothers died of phthisis, one uncle ‘of paralysis; maternal
ancestors are nervously predisposed; two children of the patient suffer from nervous
disturbances,

. Eye-defects —Hyperopia (latent) of 2D. Esophoria of 7° (manifest).

This gentleman was a great sufferer. Had been forced to give up his business from

constant distress in the head, which was aggravated by any mental labor. He walked
538 LECTURES ON NERVOUS DISEASES.

with difficulty on account of a feeling of great insecurity, and closely simulated the gait
of an ataxic. He ate poorly and slept badly. No organic disease could be found, and
electrical treatment was thoroughly tried, and proved of little benefit. Within twenty-
four hours after a tenotomy of his internal rectus was performed he ceased to have pain
in his head, walked with greater ease than for many months, and left for his distant home
within a week, provided with + 1 D. spherical glasses. The last report from him noted
a slight tendency toward a return of his bad feelings, and he was advised to have his eyes
again examined to ascertain if any latent esophoria remained to be corrected,

In his last letter he says: ‘‘I have not had a sick-headache since leaving New York,
and much less of the neuralgic pain in the neck and other parts.”

Cases VIII anp IX. Asthenopia and Sick-headaches—Mr. and Mr. ——
unmarried, aged respectively twenty-one and twenty-two. Both were college students.

Family Histories.—Headaches were common in their immediate relatives and ancestors,
and in one phthisis was found to have affected the ancestry.

Eye-defects —Both had slight latent hyperopia and‘esophoria (manifest) of a moderate
degree. , :

These were typical cases of asthenopia and sick-headache. Both wore prisms for a
while with benefit, but they found that a latent esophoria showed itself, and required a
change of the strength of the prisms. The stronger prisms caused them some distress in
walking. They both underwent an operation for the radical correction of the defect, and
have remained entirely free from asthenopic symptoms and headache up to the present
time. The necessity of wearing glasses, which was thus dispensed with, is a matter of
delight to both.

In one of these cases, a marked tendency to dyspepsia and chronic constipation has
apparently been entirely overcome.

The last tests made of the eyes of these patients showed an entire absence of muscular
defect in the orbits.

CasE X. Chronic Neuralgic Headaches of Twenty-six Years’ Standing —Mrs. —,
widow, aged forty; has had two children,

Family History—Father died of paralysis. Mother had “suffocating spells” all her
life. -One sister was treated for vaginismus. Dyspepsia is a “family ailment.” No
phthisical tendencies, as far as known. Her oldest child is ‘very nervous.”

Eye-defects —Myopia (—2.50 8.); hyperopic astigmatism (+ 0.75 c, and + 1.50c.);
hyperphoria of 4° (manifest); adduction, 24°; abduction, 8°.

Since a child, this patient has had terrible headaches. They are often preceded by
blindness. Since her marriage they have increased in frequency and severity. She has
(on an average) two each week. She has frequently been in complete coma for twenty-
four hours from pain, and “it generally takes forty-eight hours to recover her strength
sufficiently to get about the house.”

She has had twenty-six teeth drawn, in the vain hope of getting rid of the head-
aches, which have been pronounced as “ neuralgic.”

Prior to her deliveries, while pregnant, she would oftentimes become suddenly uncon-
scious several times a day. These attacks were apparently “epileptoid” in character. No
uterine disease or deflection has ever been found, although repeatedly sought for.

This patient was treated at the first interview by a partial tenotomy of one superior
rectus muscle, as her hyperphoria was of a very marked character, even after the correction
of her refractive error by glasses.

On the following day, some two degrees of latent hyperphoria developed and was
corrected by a second operation. She was sent to her home in a distant state within a
week, provided with proper glasses for constant wear,

 
MIGRAINE—SICK-HEADACHE—MEGRIM. 539

Since her return, some six months have elapsed and she has had but two headaches,
both of which she attributes to very marked excitement and physical fatigue. She states
that her physical condition has improved to a remarkable degree.

Such cases as the last one narrated certainly justify an earnest
inquiry regarding the cause and proper methods of cure of chronic head-
ache. This hopeless sufferer recovered without drugs and with little or
no inconvenience. ;

Treatment.—In my opinion, the first step toward a cure in these
cases is to examine the eyes when fully under the influence of atropine,
and to carefully ascertain the amount of refractive error which exists.
(See p. 146.)

If a high degree of hyperopia, with or without hyperopic astigma-
tism, be detected, it is often well to keep the patient’s eyes under atropine
for a period varying from one to several weeks.* During this period,
the patient should wear constantly a glass that corrects the hyperopia
(less one dioptre—a glass of about thirty-six inches focus}); and a
stronger glass may be ordered while the patient is under atropine for such
near-work as he is obliged to perform with his eyes. This glass takes
the place of the normal accommodation, which is paralyzed by atropine.
For example, if a hyperopia of three dioptres is found, the patient should
wear a + 2.00 glass for distance, and while under atropine his power of
accommodation must be temporarily furnished by the use of a convex
glass of sufficient strength to enable him to read ordinary type with ease
at fourteen inches. When atropine is discontinued, the latter glass must
be dispensed with as soon as the ciliary muscle begins to assert itself;
hence, these patients, unless presbyopic, need but one glass, which
answers both for distance and near-work after the effects of atropine
have passed away. If the patient be simply astigmatic, the full correc-
tion will generally be tolerated by the patient, after the effects of atropine
have subsided. These cases do not require a prolonged use of atropine,
as a rule.

If the muscles of the eye are found to be out of balance, prisms may
be added to the glass which is selected to correct the refractive error;
in case the patient absolutely refuses to have a partial tenotomy per-
formed. I am personally opposed to the constant use of prisms, save as
a dernier ressort; partly because all patients cannot wear them with

*This step is taken to ensure a decrease in the power of a hypertrophied ciliary
muscle, which would oppose attempts to correct a high degree of hyperopia which had
been ‘‘ latent.”

+ A glass of one dioptre is in reality about 40 inches focus. Practically, the subtrac-
tion is necessary of 1-36 from the glass, which affords full correction of the refractive
error. It is tolerated by the patient if he wears such a glass constantly, and afford. g.eat
comfort when the ciliary muscle ceases to exert its action in viewing objects beyond the
20-foot radius.
540 LECTURES ON NERVOUS DISEASES

comfort, and also from a knowledge of the fact that the “manifest us
insufficiency which the prisms correct is not usually all that actually
needs correction. Prismatic glasses frequently render the appearance
of the sidewalk or floor apparently concave to a patient when first worn.
This effect soon tends to pass away. It is very annoying to some sub-
jects, and they should be prepared for it by timely explanation.

Considerable difficulty may be experienced in getting patients to
persevere in the wearing of glasses for a latent hyperopia, after the
effects of atropine have already subsided. ‘The ciliary muscle of each
eye invariably fights the glass to a greater or less extent, because it has
long been accustomed to excessive action in bringing the eye to a focus
both for distant and near objects. This accounts for the fact that these
patients often experience a dimness of vision at times through the
glasses (which passes off as soon as the glasses are removed). I have
known vertigo, nausea, and even vomiting to occur from this conflict
between the ciliary muscle and the glass.

Patients should be told that these difficulties are apt to arise for
some weeks or months at intervals, and that they must persevere in
wearing the glasses ordered, even if they have to remove them for a few
minutes at a time whenever they become particularly annoying. It is
not enough for them to use their glasses for reading or writing only.
The “eye-strain”? must be overcome without interruption, if we are to
expect a cure. These patients will very often tell you “that they can
see better without their glasses than with them;” and they may narrate

_ina complaining tone all the inconveniences of wearing a glass constantly,
such as irritation of the nose, the-trouble of cleaning them, the accumu-
lation of moisture or snow upon them, the disfigurements, etc. With
such complaints I constantly have to deal by impressing them with the
benefits derived from the glasses, the difference between seeing without
effort and seeing with eye-strain, the necessity of strict compliance
with my directions, ete. The wearing of spectacles or nose-glasses
constantly is at best a nuisance, and to ladies they are sometimes very
repulsive; but when the choice between sick-headaches and glasses is
intelligently discussed before this class of sufferers, it is very uncommon
to find a rebellious patient.

During a paroxysm, what is to be done for the patient? In the
prodromal stage, give a good purgative or an emetic early. If you delay
it until late in the day the paroxysm will reach its height. I frequently
give compound cathartic pills (three or four at a dose), and follow it in
two hours with warm water as an emetic.

Sometimes full doses of bromo-caffeine, or the fluid extract of
guarana in drachm doses (repeated if necessary), or large doses of
quinine (ten to twenty grains), or copious draughts of very hot water,
NEURALGIA. 541

will cut an attack short. Antipyrine, in doses of two to five grains every
hour, will often cure an attack, even when excessively severe. These
remedies, however, are liable to prove ineffectual when most uceded,

When the pain becomes very severe, immersion of the entire body
ina very hot bath will almost always give relief. A bag partially filled
with hot water placed at the back of the neck after the bath is very
agreeable to most sufferers of this class and frequently induces sleep.

The patient should be placed in a darkened room and all noises
should be excluded. Finally, a full dose of morphia may be required in
extreme paroxysms. Of all the remedies that my personal experience
has proved to be effectual, a brisk purgative and the hot bath are the
most liable to relieve the patient promptly.

I have never observed any decidedly curative effects from medica-
tion or electrical applications during the intervals between the par-
oxysms. The intervals may be prolonged somewhat, in some cases, by
tonics, out-of-door sports, or exercise, a regular life, care in the diet, ete. ;
but the paroxysms tend to return with severity in spite of every known
precaution, until the eye-strain is removed.

Of late, considerable attention has been given to the dependence of
headache in certain cases upon a partial or complete obstruction of the
nasal passages due to hypertrophy of the mucous covering of the turbi-
nated bones or deflections of the nasal septum. These conditions are
more commonly encountered than one would at first imagine.

Probably deflections of the septum are due in part to blows received
upon the nose during childhood.

The explanation of the development of headache, in consequence of
an obstruction in the nares of sufficient extent to interfere with the
oxygenation of the posterior nares in the vault of the pharynx, seems to
be that of reflex irritation of the nerves distributed to that part, which
probably induces vaso-motor disturbances within the cranium.

While my experience in the removal of such obstructions by means
of the nasal trephine, the nasal saw, and applications of chromic acid or
the actual cautery is not extensive, I can bear testimony to the fact that
I have encountered cases where this step has led to marked relief of
headache. I believe that in typical sick-headache occlusion of the nares
is less frequently observed than in those cases which suffer from tie
so-called “catarrhal ’ headaches. These are less paroxysmal and severe
than typical attacks of migraine.

NEURALGIA.

In view of the fact that different authors include under this head
widely varying conditions which are associated with paroxysmal pain,
it may be well to state early what my conception of the term embraces.
542 LECTURES ON NERVOUS DISEASES.

It seems to me that the term “neuralgia” cannot be properly applied to
paroxysms of pain which are clearly traceable to organic changes in the
brain or spinal cord, On the other hand, it is equally clear to my mind
that typical attacks of neuralgia of a very persistent and obstinate kind
may occur without the existence of organic changes in the nerves
themselves.

I have for some time regarded most neuralgic attacks rather as a
symptom of an existing “neuropathic predisposition,” which has been
either created by or subjected to some marked reflex irritation, than as
clinical evidence of existing disease in the nerves. This condition of
reflex irritation is encountered not alone in subjects who have fleeting
attacks of pain in various nerves at different times. It is met with often
in those who suffer from paroxysms of severe pain with more or less
periodicity in some special nerve-trunk or its branches. It is my opinion
that a very large proportion of neuralgias are totally independent of
pathological lesions either in the nerves or the nerve-centres; and that
but a small proportion are the direct result of morbid changes. This
subject will be discussed further when the causes of neuralgias are
considered. :

Neuralgia must not be confounded with neuritis. The latter condi-
tion is an inflammatory one; in which the symptoms are not paroxysmal
but constant while they last, and are not infrequently accompanied by
marked disturbances of motility and sensibility, and also of muscular
nutrition.

Although the existence of certain tender points in the course of a
nerve (where pressure is acutely felt’ and usually accompanied by pain
along the nerve—the so-called “ puncta dolorosa” of Valleix) is generally
considered as peculiarly diagnostic of neuralgia, there may be cases of
typical neuralgic paroxysms, in my opinion, where these tender points
are not to be detected after a careful examination.

The “puncta dolorosa” are to be sought for, as a rule, near the
orifices of bony canals or foramina through which the affected nerve
escapes, or where the nerve subdivides, anastomoses, or pierces a fascia.
In my work, “The Applied Anatomy of the Nervous System,” I have
described the situation of these tender points for the more important
nerves of the body. Space precludes a full discussion of this field here.

Etiology.—The causes of neuralgia may be classified as follow: (1)
The predisposing; (2) the modifying; and (3) the exciting.

The predisposing causes of neuralgia (like those of other functional
neuroses) comprise all constitutional or acquired conditions which tend
to create the so-called “ neuropathic tendency.”

It is generally recognized that in this particular class of nervous
subjects, hereditary influences may be observed in a very large proportion
NEURALGIA. 543

of cases when carefully sought for. We find, not infrequently, that
neuralgia has been present in different branches of the family for several
generations; or that some other evidences of a nervous taint have occa-
sionally appeared,—such, for example, as hysteria, epilepsy, chorea,
insanity, etc. Again, a tubercular tendency is very commonly detected
in the ancestry of neuralgic subjects. Finally, neuralgia may be shown
in some cases to be indirectly a result of general anzmia, chlorosis,
neurasthenia, and other similar states, which may have been induced by
excesses, over-exertion of the mind or body, prolonged anxiety, diarrhea,
or lactation, and many other similar causes.

Now, I believe, from a somewhat extended research into the probable
factors which tend to induce the “neuropathic tendency,” that ‘eye-
strain” and “abnormal eye-tension” are perhaps more closely related to
this obscure and imperfectly understood condition than any other factors
which have as yet been observed. Dental and ovarian irritation are also
peculiarly liable to induce neuralgic paroxysms.

It is safe to assert that comparatively few cases of neuralgia are ever
subjected during their lives to eye-tests made in a scientific manner by
competent observers, It can be shown, I think, that until recently the tests
made by many of the best observers in this field have been more or less
superficial in reference to the state of the eye-muscles; and that the
method described in this volume (p. 145) is far more complete and
thorough than that given by most authors on ophthalmology. It is not
hard, therefore, to understand why this statement is not more generally
accepted by the profession at large. The medical mind is now rapidly
becoming awakened to the necessity of such tests in nervous disturbances;
as well as to the importance of more care regarding the details of the
methods employed by those who make the tests. Many of the profession
(who are not oculists) are to-day beginning to make their own tests for
suspected refractive and muscular anomalies. To such we shall soon
owe perhaps more valuable information respecting the relationship
between errors in the orbit and functional nervous maladies than to
oculists, because nervous diseases are more commonly observed in general
practice. |

The modifying causes of neuralgias come next in order. They
comprise all forms of infectious, toxic, and depressing conditions which
tend to exert a deleterious influence upon the general health of the
patient. In this way, malarial influences, the germs of the various fevers,
poisoning by lead, mercury, alcohol, tobacco, ete., syphilis, exposure to
cold and dampness, over-fatigue, and many other similar causes may
have a bearing upon the cansation as well as upon the relief of neuralgias.

It should be borne in mind, however, that these causes are usually
engrafted upon some one or more of the predisposing causes mentioned.
544 LECTURES ON NERVOUS DISEASES.

It is rare, in my experience, to observe cases of neuralgia where a pre-
disposing tendency cannot be demonstrated. I think we are all apt to
attach too much importance to the modifying and exciting causes of
functional nervous attacks. I believe future investigation will justify
this conclusion, and that the views of the profession must undergo a
marked reformation respecting this painful and distressing malady,

The exciting causes of neuralgias are sometimes very difficult to
determine. I quote from Rosenthal, who aptly says: “ The arrangement
of the central mosaic (7.e., the intermingling of nerve-roots and cells)
determines the law of peripheral manifestations.” It is often a matter
of difficulty to ascertain (even by a careful examination of the patient)
whether some local cause may not exist; or,if it is not discovered,
whether some form of reflex irritation is not helping to keep the neuralgic
manifestations active.

Trouble with the teeth may start up either a trigeminal neuralgia,
or an earache, or some other reflex disturbance, which often proves
obstinate until the cause is removed or ameliorated. Perhaps a perios-
titis near to a foramen through which a nerve passes may light up a
neuralgia in that nerve. Again, in inflammatory exudations, cicatrices,
tumors of all kinds, and other conditions may occasionally press upon
a nerve and cause neuralgic manifestations. Finally, reflex irritation
from the eye, nose, mouth, uterus, ovaries, intestine, bladder, clitoris, or
rectum may prove to be exciting causes of paroxysmal pain far removed
from the actual cause.

Of all these reflex causes, I regard the eye as probably the most
common, and certainly the most important one to search for early in the
examination. So generally do I find palpable evidences of eye-defect in
these cases, that I have many times questioned whether this factor does
‘not surpass in its frequency all others combined. Congenital errors of
refraction and anomalies in the eye-muscles are, in my opinion, the chief
factors in producing the “neuropathic predisposition.” Their continu-
ance without relief tends also under certain physical conditions to act as
a reflex cause for pain; as well as for the more serious neuroses, when
the subject becomes unable to endure the eye-strain which such con-
genital defects entail. That this conclusion is not irrational, the effects
of removal of this factor in many cases which I have personally observed
clearly demonstrates.

Morbid Anatomy.—As a rule, it may be stated that neuralgias are
seldom dependent upon pathological changes. In a few exceptional
cases, however, the nerves and the nerve-centres may reveal in a variety
of ways the existence of a morbid state. These morbid conditions may
usually be diagnosed. after a thorough examination of the case and &
careful study of the symptoms has been made.
NEURALGIA. 545

In the nerve-trunks, the following lesions have been observed in
reported cases where neuralgia has been a marked symptom: (1), con-
gestion and thickening of the sheath of the nerve; (2), neuromata; (8),
sclerosis and atrophy of the nerve; (4), granular degeneration of the
axis-cylinders; (5), inflammation or degeneration of the ganglia on the
posterior spinal nerve-roots; (6), similar changes in the ganglia of the
sensory cranial nerves; (7), simple atrophy of the nerve, following
pressure upon it from one or more of the causes previously mentioned ;
and (8), capillary hemorrhages in the nerves themselves.

In the spinal cord, Anstie has claimed theoretically that morbid
processes (atrophy or degeneration) in the posterior nerve-roots or in
the gray matter of the posterior horns probably exist in neuralgia.
Unfortunately for this view, pathological research has failed to verify
the hypothesis. Like many pure hypotheses, it is probably without
foundation.

In the brain, we find that tumors, softening, inflammatory ex-
udations, tubercle, hemorrhagic clots, and many other morbid con-
ditions may, under certain circumstances, irritate the roots of some
cranial nerve, or the trunk of the nerve itself. These morbid conditions
are, however, in no way to be considered as pathognomonic of neuralgia.

The cranial nerves may in some instances. be independently affected
with any of the changes already mentioned in connection with the
nerves.

My friend, Dr. C. L. Dana, of New York, has lately contributed an
article to the literature of neuralgia based upon the clinical study of
458 cases. Some of his deductions are of value in this connection, and
therefore quoted.

Respecting the percentage of the various types, his statistics show .
that 41 per cent, were of the trigeminal type; 23 per cent. of sciatic; 13
per cent. of the intercostal; 4.5 per cent. of cervico-occipital; 2.5 per
cent. of lumbo-abdominal; 2 per cent. of articular; and about 2 per cent,
of brachial.

Respecting the season of the year which is.most frequently attended
with neuralgic attacks, he shows that winter and fall have a larger pro-
portion than spring and autumn.

Regarding the age of patients so afflicted, he shows that 45 per cent.
developed before the thirtieth year.

‘The influence of sex seems to be apparent. Females are shown to
be attacked more commonly than men in the proportion of 5 to 3.

In this paper, migraine is classed as a type of neuralgia. Un-
fortunately, in my opinion, while admitting ‘the neuropathic predis-
position” and marked “ family-tendency ” to neuralgia in any or all of
its forms, this author does not bring into prominence the common

35
' §46 LECTURES ON NERVOUS DISEASES.

relationship between eye-strain and these attacks which is now being
very generally recognized.

In summary, it may be said that we are forced to admit that the
pathology of neuralgia is as yet undetermined. It has been sought for
by a host of enthusiastic pathologists without any satisfactory results.

The morbid conditions which have been previously enumerated as
having been found in exceptional cases are probably the last to be clin-
ically suspected, whenever the paroxysms of pain are unassociated with
motor, sensory, or trophic disturbances between the paroxysms, All
of the later observations of Dr, Stevens and myself go to show that
neuralgic attacks are curable in a large proportion of cases when treated
by the relief of eye-strain. This fact is incapable of explanation if the
presence of pathological lesions of the brain, spinal cord, or the nerves
affected with neuralgic paroxysms is admitted. Like other purely
functional neuroses, the detection of the cause and the removal of an
irritation (generally of a reflex type), which a thorough examination of
the case will usually reveal, results in permanent benefit to the patient
and a more or less complete cessation of the attacks.

Symptoms.—-The chief symptom of this affection is pain. This
symptom is characterized by the following peculiarities :—

(1) It is very acute, paroxysmal, and usually intermittent.

(2) If remittent, the remissions are very distinctly marked.

(3) The pain is generally unilateral.

(4) It follows the course and distribution of a nerve.

(5) Tender points ( puncta dolorosa) are generally present.

(6) The general health is but little affected.

(7) Inflammatory symptoms are absent,

(8) Abnormal phenomena of a sensory, motor, and trophic kind may
be associated with the attacks of pain, but do not exist between the
paroxysms.

The table on the opposite page will aid the reader in distinguishing
the diagnostic points which are to be clinically observed in cases
afflicted with various types of neuralgia. Some other diseases which
simulate neuralgia will be contrasted with it later.

Clinically we are forced to recognize two creat classes of neuralgic
patients, viz., those who have mild and infrequent attacks, and those
whose sufferings are almost without intermission.

A careful scrutiny of this table will make the prominent features of
tic-douloureux, cervico-occipital neuralgia, cervico-brachial neuralgia,
intercostal neuralgia, mastodynia, lumbo-abdominal neuralgia, and
sciatica more apparent than a long description. Such a table aids the
reader, moreover, in contrasting the chief symptoms of the special types
of neuralgia most frequently encountered in medical practice.
d47

NEURALGIA.

REGION OF PAIN...

SYMPTOM.

TRIGEMINAL
{ Prosopalia)
TIC-DOULOUREUX,

CERVICO-DCCIPITAL.

TYPES OF NEURALGIA.

CERVICO-BRACHIAL
(Neuralgia of Brachial
Plesus).

PORSO-INTERCOSTAL
(Ulutercostad Neuralgia)

MAMMARY
(Mastodynia).

LUMBO-ABDOMINAL.

SCIATICA.

 

PRESSURE-POINTS ......

 

 

(During paroxysm.)

CuiInicaAL HIstor¥ OF
THE ATTACK......0s000

OccastonaAL TROPHIC
VASO-MOTOR

  

Motor PHENOMENA...
(Which may . coexist
with the pain.).

| awe il, Ophthalmic.

\Ss
SS

 

Supraorbital fora-
men.

Parietal eminence.

Inner angle of eye.

Infraorbital
men.

Malar region.

Upper lip.

Alveolar processes.

fora-

|

 

Mental foramen.
Side of tongue.

Dependson branch of

   

maxillary.

Most frequent in fe-

males. Oplithalimic
branch most often
affected. Entire

nerve rarely attack
ed. Generally uni-
lateral.

Skin eruptions;
blanching of hair;
glaucoma; iritis;
choroiditis.

Convulsive spasms of
the face, and occa-
sionally of the neck.

The limbs may becon-
vulsed in rare cases.

 

nerce involved—the
ophthalmic, supra-'
ma ury or infra-

 

 

|
|

 

Behreen mastoid pro-
cess and Ist cerv.

 

pr bertehyee,

Cervical spinous pro-
cesses.

Occiput and back of
neck,

May extend to ear,
scapule, and ehest
(in severe cases).

Most frequent in fe-
males from twenty to
fifty years of age.
Occipitalis major
nerve generally
attacked.

Generally unilateral.

Redness of a Jateral
[ half of the face: in-
jection of conjune-
tiva; contracted
pupil; excessive
secretion of tears.

|] Movements of head

seriously interfered
with during por-
oxy ams.

 

Vary with the branch-
es of the brachial
plexus attached.

Near infernal condyle

4 Near head of ulna.

Bivipital depression.

Lower ang of scapula

Avrillary fossa.

Spinous processes.

 

May be confined to
area of distribution
of the median, ulea,
meusetulo- spiral, sub-
sepilar, and sepra-
elavicular branches
of brachial plexus.

Most frequent in
males. Right side
usually attacked.

May follow trauma.
tism, lead poisoning,
joint diseases, ete.

Generally unilateral.

Pallor or redness of
skin; profuse sweat-
ing; skin eruptions;
excessive growth of
hair; changes in
nails; glossy skin.

Fibrillary twitchings;
tonic or clonic
spasms; paresis or
paralysis; | perma-

[ nent extension of the

ne

fingers ; contracture
of muscles.

' Close to spinous pro-
cesses of thevertebrae
{vertebral pwint).
Axillary line of chest
over aflected nerve
(ateral point).

Edge of sternum (ster-
nal point).

Rarely in dorsal
branches of theinter-
costal nerves.

oth tu Gth nerves most
often attacked.

May extend into arm.

Most frequent in fe-
males. Followsmala-
ria, injury, chlorosis,
exposure, pleurisy,
phthisis, ty phoid,
lead poisoning, ete.
Most frequent on left
side. Generally uni-

L lateral.

Herpes zoster.
Offensive perspiration
Cardiac neuroses.
Localized anzsthesia.
« hypereesthesia,

Body often bent to-
ward painful side.
Breathing superficial.
Voice feeble.

 

 

Are inconstant,

| Nipples very tender.
Sore spots may be
detected over the
breasts.

Most marked in the!
breasts. 2d to 6th
Infercustals are at-!
tacked. Nipjle very
sensitive. May radi-
ate into neck, shoul-
der or back.

 

 

Exclusively in fe-
males. Develors,
after puberty. Nodu-;
Jar indurations are
net infrequent du
ingparoxysm. Isapt
to be persistent and
obstinate. Often bi-
lateral.

 

Secretion of milk!
after paroxysms, in}
some cases.

Vomiting frequent (at
height of paroxysm).

 

Near spines of lumbar
vertebrae.

Middle of crest of
ileum.

On serotum or labium.

1, Region of hip and
hypogastrium. ey
Groin and inner part |
of thigh. 3. Scrotum
and testicle. Several
nerves often attacked
simultaneously.

Affects
equall:

May follow spinal
caries, spinal menin-
gitis, ete.

Most frequent on left
side,

Generally unilateral.

both sexes

Profuse sweating.

Affects areas of dis-
tribution of the lamn-
bar plexus :—

|

} Skin eruptions.

{ Seminal emissions.
Spasm of cremaster
muscle (retracted
testicle).
Vesical tenesmus.

ee se,

 

Apt to be inconstant
or wanting.

Lower border of glu-
teus maximus.

Behind trochanter of
femur,

Middle of back of
thigh.

Bend of knee.

Below head of fibula.

Behind the malleoli.

 Dorsum of foot.

May affect individual
branches of the
nerve. Ifwhole nerve

! is attacked, pain is

{ felt in buttock, pos-

terior part of thigh,
Jeg, and all the foot
but the inner side.

 

Most frequent in
males (20 to 60 years
of age). Follows

traumatism, ex pos-
ure, gout,

rheuma-
 mala-
Generally

   

unilateral.

Abnormal redness of
skin; excessive
growth of hair: ex-
cessive sweuting;
Herpes zoster; boils;
paresthesia; atro-
phy of muscles.

Vomiting (at height
of paroxysm ).
Toniear cionic spasms
of leg.

Paresis.

Posture in bed (usu-
ally on healthy side,

affected Je,

AE

with
flexed at thigh an
L knee).

 
548 LECTURES ON NERVOUS DISEASES.

A few points may be mentioned separately, however, which have more
than ordinary diagnostic importance in these affections.

(1) The discrimination between neuralgic attacks which follow the
development of some organic cerebral lesion and ordinary neuralgia, is
clinically of great importance. It modifies materially the prognosis and
the treatment.

(2) The pains of the first stage of locomotor ataxia are very often
mistaken for neuralgia and rheumatism. In my experience, it is rarely
my privilege to encounter a case of this spinal disease where the subject,
through an incorrect diagnosis, has not been medicated for the relief of
one of these conditions for a longer or shorter time before he is brought
to my notice. The peculiarities of ataxic pains have already been quite
fully described.

(8) Organic spinal lesions of the “non-systematic” type are very
apt to be mistaken for neuralgia.

(4) Vertebral caries is a prolific source of pain in the young which
may be referred to parts which are remote from the spine. I recall a
case where persistent pain over the stomach (produced indirectly by
caries of the spine) was treated for many months by medication, to the
serious detriment of the child.

The table opposite may aid the reader in making the discriminations
mentioned.

In trigeminal neuralgia the situation of the pain and the locality of
the “pressure points”? varies with the branch of the nerve which is
affected. It is very rarely bilateral, and seldom alternating in character.
The ophthalmic branch is most often attacked. When accompanied by
spasm of the facial muscles, it is known as “tie convulsif.” Muscular
movements increase the pain of neuralgic attacks; hence, chewing,
laughing, talking, etc., are apt to be studiously avoided during these
attacks.

In sciatica we have one of the most common and rebellious types of
neuralgia. Exertion of any kind, such as sitting or walking, is apt to
increase the severity of a paroxysm or to hasten the approach of an
attack. It is most common in middle life, and very rarely encountered
in childhood. It may be associated with a neuritis. If so, the intervals
between the paroxysms are apt to be associated with an aching, burn-
ing, or bruised feeling in the leg. The muscles not infrequently undergo

atrophy in cases of long standing.

The skin eruptions which follow or accompany neural attacks
comprise herpes, pemphigus, psoriasis, erythema, and urticaria.

The duration of neuralgic attacks varies from a few minutes to
several days. Paroxysm generally follows paroxysm with more or less
rapidity during the attack; while pain of a less severe type is often felt
 

549

SYMPTOMS.

CEREBRAL NEURALGIAS. |

LOCOMOTOR ATAXIA.

SPINAL NEURALGIAS.

VERTEBRAL CARIES.

 

Pain Pati clarceascenescesaeanaue

SPECIAL SENSES...........00665

NEURALGIA.

SYMPTOMS OFTEN ASSOCIA-
TED WITH PAROXYSMS
OF PAIN....... deeanamiananesd

Tropuic DISTURBANCES....

 

All the branches of the I,
fifth nerve are liable |
to be simultane-
ously affected (in-.
frequent in neural-

 

gia).
No puncta dolorosa |
exist
Headache is apt to
z exist. J

( These are liable to'}
show more or less

impairment. The |
seat of the lesion
modifies these
symptoms.

‘“‘Choked disk’? may |
exist if intracranial |
pressure is exces- |
sive. |

Pupils may be af-|

L fected. :

 

 

[

Vertigo.
Mono-anesthesia.
Hemi-anesthesia.
Monoplegia.
Hemiplegia.

 

L

Are infrequent.

The pain of this dis-
ease has typical pe-
cultarities (p. 397).

No puncta dolorosa
exist.

Head-pain is absent
as a rule.

Robertson's pupil (p.
120) may exist.

Diplopia may be de-
veloped.

Incoordination of
movement.

Anesthesia (an early
symptom).

Exireme susceptibility
to east winds or

damp atmosphere.
Decrease or abolition of
reflexes.
No actual paralysis.
Common, late in the
disease.

 

 

Paroxysms of pain
may attack different
nerves from time to
time.

Pain in the back may
be constant.

Intercurrent diplopia
may develop.

Pupils may be un-
equal.

Paresthesie generally
exist.

Anesthesia.

Hypereesthesia.

Altered reflexes.

Paralyses of various
kinds.

Girdle-sensation.

Bulbar symptoms may
develop.

} May develop.

 

Neuralgic pains are
apt to be more or
less constant as the
deformity develops.

in

oe back is

J marked.

Not affected.
Deformity.
Paralyses.

! Various disturbances

of sensation.
Altered gait.
Psoas abscess.

Are generally absent.

 
300 LECTURES ON NERVOUS DISEASES.

during the intervals. Sometimes the approach of an attack is indicated
by certain prodromata, such as formication, tingling, or a feeling of
stiffness in a part.

The frequency of neuralgic attacks depends upon the exciting
cause and the susceptibility of the individual to reflex irritation. In
malarial cases they occur with marked periodicity, and sometimes begin
with a chill and end with sweating.

Neuralgic attacks, when once developed, are very apt to be more or
less frequent and obstinate to treatment. If the attacks are very severe
and prolonged, the general health of the patient may become impaired.
The digestion is apt to be imperfect in these subjects, the hours of sleep
cut short, the ability to take exercise lessened, the mental power more
or less weakened, the disposition rendered irritable, and many other
manifestations of the neurasthenic state may become apparent to the
patient or his friends. Personally, I regard these symptoms as due,
in most cases, rather to the exciting cause of the neuropathic predis-
position than to the attacks of pain.

Extremely protracted or very frequent neuralgice attacks tend to
impair the functions of the nerve so affected. In some instances, we
encounter hyperalgesia, anwesthesia, paresthesia, paresis, motor palsy,
etc., as a result. Twitchings, tremor, or convulsive spasms may also
precede or accompany severe neuralgic attacks, The trophic functions
of the nerve will be shown to have been disturbed in case the skin gets
glossy or affected with eruptions, when the hair becomes excessively
long or thick, when the nails appear to be altered in appearance, or when
the muscles undergo marked atrophy.

Diagnosis.—Sufficient has already been said to aid the reader in
clinically recognizing the various forms of neuralgia from each other,
and in distinguishing typical neuralgic attacks from organic lesions of
the brain, spinal cord, or vertebra, which may induce paroxysms of pain
that may closely resemble such attacks.

The tables previously given may prove of utility in making these
discriminations.

Prognosis.—Like other functional disease, neuralgia of a mild or
severe type is seldom if ever a cause of death. Still it must be
admitted that the terrible sufferings of many of its victims: not in-
frequently lead either to suicide or the morphine habit, because many
cases are extremely intractable to medicinal treatment, and the vital
forces of the sufferer become exhausted in consequence of the recurring
paroxysms of pain. When the treatment of this malady shall have been
discussed, it will be shown conclusively, I think, that the correction
of its reflex causes (chief among which I would mention eye-strain)
leads to happier results in the treatment of the obstinate type of
NEURALGIA. 551

neuralgias than any of the remedial agents commonly extolled by
authors of repute.

Treatment.—My views upon this head are somewhat at variance with
those which have previously been advanced by most authors. If the fact
can be substantiated, that serious eye-defects exist in a very large pro-
portion of those subjects who suffer from frequent and obstinate neuralgic
attacks, we must naturally look to the eye for beneficial results which
may be anticipated from the relief of this exciting cause. Both of these
conclusions are, to my mind, susceptible of proof which is conclusive.

In the prize memoir which Dr. Stevens presented before the Royal
Academy of Belgium, he reports careful deductions drawn from eight
hundred and eighty-five neuralgic subjects which he had examined with
special reference to the existence of eye-defect or muscular errors in the
orbit. The effects of his treatment (directed exclusively to the correction
of such errors) are shown to be as follow in one hundred consecutive
cases selected from this large number :—

After eliminating fifteen cases (in which, for various reasons, he had
been unable to obtain complete records of the results of such treatment)
eighty-five cases are reviewed by this author in which the eye alone was
subjected to remedial measures for the relief of neuralgic paroxysms of a
more.or less persistent and obstinate type. Of these eighty-five subjects,
seventy-one, or 834 per cent., were absolutely cured; ten, or 113 per
cent., were markedly benefited; and four, or 4? per cent., were not
materially relieved.

Although an analysis of so small a number of eases is not sufficient
to warrant any positive deductions respecting percentages of cases in
which permanent relief may be expected by this method of treatment
when skillfully employed by competent experts, it cannot be denied that
the results obtained by this author are very remarkable and entitle his
views to thoughtful consideration. The total number of persons exam-
ined by him for eye-defect, in which neuralgia was a prominent symptom,
was avery large one. His observations go to show that it is a rare
occurrence to-find a typical case of neuralgia in which anomalies of
refraction or a lack of equilibrium in the eye-muscles does not exist,
provided the history of the case renders the presence of organic changes
in the nerve-centres highly improbable.

In my own practice I have examined during the last three years
over fifty victims to neuralgia with reference to the existence of eye-
defect as an exciting cause of the attacks. I have found in almost every
case satisfactory evidence of anomalies, which I have deemed of suffi-
cient importance to require correction. In some, the correction of a
latent hyperopia by convex glasses has been followed by immediate
relief; in others, astigmatism has existed to a high degree and cylindrical

\
5d2 LECTURES ON NERVOUS DISEASES.

glasses have been required; in a third class, the eyes have been dissim-
ilar in reference to their refractive conditions; in a fourth class, the eye
has given undisputable evidence of a tendency to deviate from the con-
dition of physiological equilibrium. Persons of the fourth class have, in
the majority of cases noted by me, given no external evidences of
strabismus or a tendency thereto. They have, however, been greatly
benefited in almost every instance in respect to their neuralgic habit,
after partial tenotomies have been performed upon the eye-muscles for the
correction of the abnormal muscular tension, In several instances I have
been unable to persuade a patient to submit to surgical relief for this
defect. Under these circumstances I have resorted to prismatic glasses.
The results so obtained have not been as satisfactury as I might wish.

The following table will give to the mind of the reader a clear
conception of the results of these observations :—

A TABLE SHOWING THE RESULTS OF EYE-TESTS* MADE IN FIFTY CASES
OF TYPICAL NEURALGIA.

 

ASTIGMATISM. | MYOPIA./HYPEROPIA. EMMETROPIA. MUSCULAR ERRORS,

 

., Hyper-| yy; £so- Exo- | Hyper-
Myopic. opic. Le phoria. aha phoria,

 

 

 

 

 

 

 

38 5 2 10 24 9 26 | 5 16

 

Such a table shows conclusively to my mind the necessity of sub-
jecting neuralgic subjects to a systematic method of eye examination as
well as a complete physical examination (prior to medicinal treatment,
if possible); and it certainly offers some forcible suggestions respecting
certain steps which may be taken for its relief.

Tf, after a satisfactory correction of all existing defects so dis-
covered, the neuralgic paroxysms persist, further search should, in my
opinion, be made for conditions which may create reflex irritation;
such, for example, as nasal, dental, rectal, uterine and ovarian disorders,
which might have escaped notice in the earlier examinations of the
patient.

Probably no nervous malady depends, in a larger proportion of
cases, upon reflex disturbances than does neuralgia; hence, neither time
nor trouble should be spared in ferreting out the cause. That this cause ©
is not always to be sought for along the course of the affected nerve, all
authorities agree. That it may be far removed from the seat of pain is
indisputable. The admirable work of Hilton on “ Rest and Pain” may
be read with profit by those who seem to despise scientific methods of
research, and who are ever ready to grasp at any new medicinal agent
which is presented to them,

* Many of the cases had more than one error. For example, one case had hyperopia,
astigmatism, csophoria, and hyperphoria,
NEURALGIA. 553

I would not be construed as denying én toto the influence of debili-
tating influences in certain cases of neuralgia, such as malaria, rheuma-
tism, syphilis, gout, anaemia, etc. Any of these may constitute a factor
in estein cases, which eerily demands our best efforts at its remov al;
yet, on the otter hand, our first duty should always be to detect antl
remove, if possible, any local cause which may materially assist in pro-

longing if not in creating the neuralgic tendency.

If malaria exists, quinine in large doses, arsenic, or Warbure’s
tincture will usually aid in the recovery.

When rheumatism is present, salicylic acid in some of its various
preparations, iodide of potash, the carbonates of soda and potash and
the oil of wintergreen may be employed with good results. Colchicum

may be given if gout is present.

If the existence of syphilis is disiatigilee suspected, mercury by the
mouth or skin and the employment of the iodides and tonics will be
indicated.

In anzmic subjects, it is well to give cod-liver oil, iron, arsenic, and
strychnia,

Among the special drugs which have been highly recommended for
the relief of neuralgia per se may be mentioned: (1) phosphorus, in large
doses every four hours for forty-eight hours (Thompson); (2) gelsemi-
num, in doses of from five to twenty minims for trigeminal neuralgia;
(8) aconitia (Duquesnil’s crystallized alkaloid) in doses of one one-
hundred-and-fiftieth (;45) of a grain (Seguin); (4) atropia, by the
mouth or hypodermically in one-fiftieth (j5) grain doses (Anstie);
(5) osmic acid, in a one per cent. solution by the hypodermic method
(Eulenberg) ; (6) carbolic acid in solution of two parts to two hundred
of distilled water, by the hypodermic method in doses of half a drachm
(Schultz); (7) syrup of hydriotic acid; (8) oil of turpentine, in doses of
a half ounce.

Many of these drugs are exceedingly poisonous; hence, they must
be administered with extreme caution, and their effects should be care-
fully noted while being given to the patient.

During the paroxysms of pain, or following them, the following
methods of treatment may be tried in case previous suggestions prove
of no value :—

(1) Blistering over the nerve. This may be readily done by hoiding
chloroform upon the nerve under a watch-glass. Several spots should be
blistered simultaneously.

(2) The administration of morphia (by the mouth or by means of a
hypodermic syringe). This is our main-stay during the paroxysms.

(8) The application of ice-bags to the spine (Chapman). They may
be employed for from a half hour to an hour several times a day.
554 LECTURES ON NERVOUS DISEASES.

(4) An application of the actual cautery over the affected nerve at
several points. This gives less pain and better results than blistering.

(5) The employment of the “static spark,” or the positive pole
(anode) of a galvanic battery over the seat of pain (see Section VII).
I have seen wonderful results follow these methods of treatment.

(6) Rapid percussion over the puncta dolorosa by means of the
rubber percussion hammer. This will not be borne well by patients
during the paroxysm.

(1) Stretching the affected nerve. Opinions differ respecting the
permanent value of this procedure.

(8) Acupuncture or electro-puncture over the affected nerve. A
needle is thrust slowly and carefully through the skin and as near to
the nerve-trunk as possible. When the point touches the nerve (told by
a peculiar feeling on the part of the patient) it is best to withdraw the
needle. If the galvanic current be employed, care must be taken to
prevent electrolysis of the nerve.

(9) Application of aconitia ointment (one grain to one ounce of lard)
to the seat of pain during a paroxysm. This is very dangerous if the
skin is abraded. It should be applied only with gloved hands and kept
away from the eyes, nose, or mouth.

(10) Continued applications of hot water to the part affected. This
remedial measure is often of great benefit during the paroxysms.

(11) Hot water may be injected subcutaneously over the nerve (as
a substitute for morphia) during the paroxysm.
SECTION VI.

TOXIC AND UNCLASSIFIED NERVOUS DISEASES.

(555)
SECTION VI.
HYDROPHOBIA.
(Rabies in the Human Race.)

Ts disease tends to occur in the human subject after inoculation
with the saliva of an animal affected with rabies. Of all animals, the
dog is most commonly affected with rabies; although the wolf is
frequently so attacked, as may also be cats, cows, and probably other
domestic and wild animals.

Morbid Anatomy.—In the spinal cord of patients who have died of this
condition, as well as in the brain, the blood-vessels appear to be dilated,
and their walls more or less thickened. Amyloid degeneration and an
increase of the nuclei in the cells of the neuroglia have also been observed.
Small hemorrhages may be occasionally detected in the cord. According
to Ross, the median and central groups of cells in the anterior horns of the
cord may be shrunken and atrophied ; and the nuclei of the pneumogas-
tric and spinal accessory nerves in the medulla may be similarly affected.

_ Marked congestion and a tendency toward hemorrhages scem to be
the morbid. phenomena most generally detected. A tendency to the
formation of cavities in the brain and the substance of the spinal cord
(probably due to degencration of the nerve-tissue) has been noted by
several observers.

It must, however, be confessed that we are as yet more or less
ignorant of the exact character of the morbid changes which are
peculiarly typical of this disease, as well as of the nature of the poison
which seems to excite it. It has even been claimed by some late
observers that hydrophobia cannot be regarded as a distinct disease.

Etiology. From a study of reported cases, the saliva of a rabid
animal seems to be the vehicle by which the poison is conveyed in most
eases of hydrophobia. Patients who are bitten upon portions of the
body which are not protected by the clothing are apparently more
liable to develop the symptoms of hydrophobia than when the teeth of
the animal pass through the clothing. It has not, to my mind, been
positively proven as yet that the poison of rabies can be transmitted by .
any other secretion than the saliva; not even by inoculation with the
blood of the infected animal. The saliva of hydrophobic patients has,
however, been known to induce a similar condition in other persons,
after coming in contact with a wound or an abraded mucous surface.
Cases are recorded, also, where the symptoms of this disease have
occurred from a rabid dog licking the hand or face of a human being on
which there were pimples or sores (Hammond).

(557)
558 LECTURES ON NERVOUS DISEASES.

Symptoms.—A wound made by a rabid animal usually tends to heal
in the ordinary way. An interval then occurs, which is rarely shorter
than a month, and probably never longer than five years, during which
time the patient may be totally free from any evidences of ill health. In
warm climates, hydrophobia has been known to occur within a few days
after the bite. In the vast majority of cases recorded, however, the
symptoms have occurred within a period of six or seven months.

During the period of incubation, there may occasionally be some
unnatural sensations in the region of the wound. These sensations
commonly include shooting pains in its vicinity, or a peculiar sense of
distress in the parts which the patient can with difficulty describe. It
is stated that the scar may, occasionally, become more or less livid. The
respiration may become sighing in character and somewhat irregular as
the onset of the attack approaches. There may also be a sense of
oppression or of constriction in the chest; very often accompanied by a
sense of anxiety and disturbed sleep. The patient’s disposition may
show a change. As a rule, these subjects become more or less moody
and irritable. The skin may be dry; and chilly sensations, followed by
flashes of heat, are occasionally observed.

The onset of the attack is usually accompanied by a sense of.
uneasiness in the epigastrium, accompanied by a feeling of constriction
in the throat and a difficulty in swallowing. On attempting to swallow,
the muscles of the throat are attacked with irregular spasms. The
patient cannot be induced on account of these spasms to partake of
liquid or solid food. Speech may be embarrassed in some instances
by a peculiar and painful stiffness of the tongue. I have seen food
ejected from the mouth with considerable force, during an attempt to
swallow, by one patient whom I was called upon to attend.

The tendency to spasm and the reflex excitability of the patient
soon becomes intensified. The whole body may become convulsed from
the mere suggestion of food or drink, or by any sudden sound, a draught
of air,a bright light, the sight of water, etc. The patient generally shows
physical exhaustion early. He may also be affected with trembling,
weeping, excessive perspiration, delirium, hallucinations and delusions.

The spasmodic phenomena generally tend to increase in severity
‘and frequency as the disease progresses. Vomiting may occur; and
intense headache is not infrequent. A severe pain in the spine and
muscles of the back and abdomen may develop. The mouth often
becomes excessively dry and parched. The saliva may be very tenacious
and frothy, and expectorated with difliculty. Moistening of the lips or
mouth not infrequently tends to excite convulsions. In one of the cases
which I observed some years since, the constant attempts of the patient
to rid the mouth of tenacious mucus was the first symptom observed. It
HYDROPHOBIA—RABIES IN THE HUMAN RACE. 559.

preceded the convulsions, and lasted several hours. Within five hours from
the time when I first saw the patient, general convulsions of a severe
character developed and continued uninterruptedly until death occurred.

In three patients which I have personally been called upon to treat,
I have never observed any efforts on the part of the patient to snap or
bite or to make any noise which could be compared to the barking of a
dog. I am inclined, therefore, to regard published statements that such
symptoms have occurred as due rather to the imagination of the
attendants than to accurate observation.

The termination of this disease is usually due either to physical
exhaustion, the frequent convulsive attacks, the loss of sleep, the in-
ability to take food, or to great emotional excitement. It is stated that
paralyses have been known to occur during an attack of hydrophobia,
but I have never observed it.

The temperature of the body is markedly elevated, as a rule, at the
beginning of the disease, and is usually highest at the height of the
paroxysm or during their subsidence. Hammond states that it may rise
to 110°.

The duration of the disease seldom exceeds three days, when the
symptoms are well established. Death generally occurs during a spasm.
It is stated that the power of swallowing sometimes returns before death.

Diagnosis.—Some of the manifestations of hysteria (usually follow-
ing severe fright occasioned by the bite of some animal not affected by
rabies) may closely simulate genuine hydrophobia. It is stated that
such cases can usually be distinguished by the fact that the convulsions
do not invariably follow slight forms of external irritation, such as those
already mentioned. Moreover, attempts at swallowing are not always
accompanied by spasmodic action of the muscles of the throat. Ham-
mond states, for example, that “the hysterical patient is apt to be loud
in the expression of apprehension, while the real hydrophobic one,
though intensely anxious and terrified, endeavors to prevent others
perceiving the state of his mind.”

The diagnosis of hysteria will be rendered probable if the attack
comes on too soon after the bite to allow of a period of incubation ; and
if the patient can be shown to possess hysterical tendencies. Simulation
of hydrophobia is not confined to females. It may prove fatal,

An attack of tetanus may be confounded with hydrophobia. It
should be borne in mind, however, that tetanic spasms are of the tonic
variety; that they affect chiefly the jaws and the back (not the throat
primarily); that the mind is unaffected at all times; that atmospheric
influences often predispose to tetanus; that the facial expression shows
less terror on the part of the patient; and that there is no relationship
between the convulsive attacks and excitability of the special senses.
560 LECTURES ON NERVOUS DISEASES.

Prognosis.—After hydrophobia has once developed, there are, in my
opinion, no well-authenticated cases of cure. On the other hand, the
prevention of attacks by the method of inoculation lately advocated by
Pasteur, seems to have been quite well proven in some of his cases.
The bite of the rabid wolf seems to be more uniformly followed by
hydrophobia than that of the rabid dog. Those subjects who are bitten
by a rabid animal first are more liable to develop hydrophobia than are
those who are subsequently bitten; a fact that tends to prove that the
poison becomes to a certain extent exhausted, even in the rabid animal.
Moreover, a wound which bleeds very freely is less liable to be followed
by hydrophobia than one in which the poison is not washed away.

Treatment.—When any one is bitten by’a rabid animal, or even by
one that is suspected to be rabid, the wound should be at once sucked by
the patient; or, when not so, by an attendant as soon after the injury as
possible. There is no danger in this step, if the mucous membrane of
the mouth or lips be not broken or abraded.

The wound should also be thoroughly cauterized, either by caustic
potash, the nitrate of silver, or by the ignition of gun-powder in the
wound. A complete excision of the wound may also be performed
immediately after the accident, the part being tightly constricted after
the accident to prevent the circulation carrying the poison away from
the wound.

During the attack the treatment is purely symptomatic, If ether or
chloroform be inhaled by the patient, food may be introduced into the
stomach by means of a tube. Milk is preferable to any other form of
nourishment, combined with alcoholic stimulants. Stimulants and
nourishment may also be given to the patient as enemata.

Among the drugs which have been employed during these attacks,
the following may be mentioned: (1) Hypodermic injections of morphine
and atropia during the paroxysms. (2) Large doses of chloral (twenty
grains), and one ounce of brandy with two ounces of beefjelly every
three hours as enemata. This treatment resulted in an apparent cure, in
the experience of Broadbent. (3) The tincture of cannabis indica has
been administered in doses of from six to fifteen drops every few hours.

A continuous application of the galvanie current from the soles of
the fect to the forehead during the attack has been suggested by Schi-
vardi, of Milan. In one of his cases, such a current was maintained for
fifty-eight consecutive hours from twenty-two Daniel’s cells. Life was
thus prolonged for over seven days,

The late researches of Pasteur seem to have been attended by some
extremely favorable results, although inoculation by his methods have.
not thus far been proven to be an absolute specific against the poison
of rabies.
MULTIPLE NEURITIS. 561

MULTIPLE NEURITIS.

Before we consider in detail the various forms of toxic neuroses, it
may be advisable to discuss a condition which has attracted considerable
attention of late, first, because its existence seems to be positively deter-
mined, and, furthermore, because its pathology tends to shed much light
upon many reported cases that have heretofore been probably incorrectly
interpreted. I refer to the disease now known as “ multiple neuritis.”

Under this term may be classed all toxic and a few spontaneous
cases in which a peculiar combination of abnormal motor, sensory, and
trophic phenomena may have existed during life in consequence of
morbid changes in the peripheral nerve-trunks.

Morbid Anatomy.—In multiple neuritis, the ultimate nerve-fibres
appear to undergo certain alterations in their structure which vary
‘somewhat in their degree and type, but which are embraced under the
general terms ‘“ degeneration” and “ regeneration.”

During the former process, the myelin and axis-cylinder of the
affected fibre becomes at first segmented; subsequently more or less dis-
integrated and studded with new nuclei; and finally absorbed to a greater
or less extent, leaving the sheath comparatively empty save the presence
of scattered nuclei and some débris. The terminal plates in the muscles
are simultaneously afiected. They tend to become granular and to undergo
absorption. It is also probable that the terminal sensory organs become
simultaneously altered in their structure; but the changes which they un-
dergo are less positively determined than those in the muscular apparatus,

Should the process of regeneration follow after the extensive
changes already enumerated have taken place, a new axis-cylinder and
myelin sheath is slowly formed. This is probably effected either by the
aid of the nuclei which remain in the sheath.of Schwann or by a direct
growth of the axis-cylinder from the proximal end of the nerve. Reven-
eration is, as a rule, an extremely slow process. From six to cighteen
months may be required to insure a complete restoration of a nerve
after the fibres have been seriously impaired by a degenerative process.

In multiple neuritis, the morbid changes observed in the nerve-
trunks attacked are so closely allied to those which experiment has
proven to result from compression of a.nerve-fibre with destruction of
its axis-cylinder—the process of ‘‘nerve-degeneration "—that they may
be considered as practically identical.

The dependence of these changes in mutiple neuritis upon a spinal
lesion seems to be disproved by the fact that the nerves are not affected .
throughout their entire length, but only in their distal portions. M. A.
Starr, in his late lectures upon this condition,* before the New York

* Medical Record, February 5, 1887.
36
562 LECTURES ON NERVOUS DISEASES.

Pathological Society, lays great stress upon this point, as well as upon
the fact that the sensory nerves as well as the motor are affected (cen-
trifugal degeneration of sensory nerves being never observed as a sequel
’ to a spinal lesion). He regards the morbid condition as one of “ primary
parenchymatous inflammation of the nerve-fibres.”

This author classifies the conditions observed in the nerves of
subjects attacked with multiple neuritis as of three types :—

In the first, the nerve-fibres exhibit no fatty metamorphosis. They
undergo degeneration in their distal segments and terminal plates
according to the normal formule.

In the second, the presence of fatty changes is very apparent. He
regards this class as possibly dependent upon the pressure exerted upon
the nerve-fibres by the exudation resulting from a primary interstitial
inflammation.

The third class sonomilied by him is that originally described by
Gombault as typical of lead-poisoning. It consists of a segmental
degeneration of a nerve, with normal nerve-segments being interposed.
He states that this condition has been observed also in. diphtheria by
Pitres and Vaillard.

Finally the muscular fibres exhibit an increase of their nuclei, a
fatty degeneration of the sarcous elements, and a progressive atrophy
proportionate to the destruction of the nerve-plates,

Etiology.—The many conditions which have been imperfectly
recognized and interpreted in times past, and which the light of recent
investigations seem to connect strongly with an existing multiple
neurosis, offer some practical deductions respecting the etiology of this
morbid condition, There is, probably, no doubt that many cases which
have heretofore been reported as dependent upon a spinal lesion (chiefly
those of supposed polio-myelitis anterior), and, in addition, some of the
so-called “ functional neuroses” have at times been wrongly diagnosed.
The following classes of cases are enumerated by Starr as particularly
liable to be induced by inflammatory conditions of the peripheral
nerves :—

(1) The “ numb fingers” observed in women about the Branetente
period (first described by I. I. Putnam as a disease); intermittent
paralyses ; and the endless train of obscure subjective symptoms clin-
ically encountered; such, for example, as pain, formication, numbness,
muscular weakness, which is not far removed from paresis, tremors
and slight convulsive attack, flashes of heat and cold, ete.

(2) Toxic Cases.—Among these may be prominently mentioned the
paresis and tremor encountered in chronic alcoholism, and the symptoms
of arsenic, lead, and bisulphide of carbon poisoning.

(3) Infectious Cases.—These include the results of diphtheria, the
MULTIPLE NEURITIS. _ 563

eruptive fevers, tubercle, malaria, and ‘“beri-beri” (an epidemic disease
due to a recognized bacillus),

(4) Spontaneous Cases.—These apparently follow exposure to damp-
ness, cold, or over-exertion; but their exciting causes are not, as yet,
well understood.

Of the toxic class, alcohol and lead are the most prolific causes.
Paralysis is, as we all know, not an infrequent result of chronie alcohol-
ism; and it is also a typical symptom of lead-poisoning. The question
whether syphilis can directly excite multiple neuritis does not seem to
be yet well determined.

Symptoms.—In multiple neuritis, we are apt to encounter a peculiar
train of symptoms in which are combined abnormal motor, sensory, and
trophic phenomena. This clinical fact is of great value, since it may
enable the observer to exclude the existence of a spinal lesion that might
otherwise be strongly suspected to exist. In the main nerve-trunks the
motor, sensory, and trophic fibres are so intermingled that a lesion of the
entire nerve could hardly fail to involve each, and thus cause three
distinct sets of sy mptems.

From an analysis of all the reported observations to date, the deduc-
tions ade by Starr relative to the symptomatology of this imperfectly
understood disease are of special interest. The following tables will
present the views of this author in the fewest possible words :—

( Paresthesie of various kinds occur at the onset. These tend to dis-
appear as the disease advances.

Occur only below elbows and knees, save in very rare instances,

Moderate pain. Not continuous. Less severe than in ataxia,

Tenderness in nerves and muscles is constant, Tt renders manipulation
painful and interferes with massage and electrical applications.

Anesthesia is rarely complete, but occurs late in the disease.

Delayed transmission of pain-sensations and temperature-sensations is
generally observed.

Impaired pressure-sense is usually to be detected.

Muscular sense may be impaired, but is often normal.

| Special senses are not affected, as a rule.

SENSORY SYMPTOMS, -

( Progressive muscular weakness and a sense of fatigue occur early.
This becomes true paralysis within the space of a few weeks, as a
rule.

The paralyzed muscles are chiefly those which move the feet and hands.

he distribution of the paralysis depends on the nerve-trunks
which are most involved. :

Facial muscles and cranial nerves are not usually attacked.

Svasmodic phenomena are rarely observed. .

‘ Tendon reflexes are abolished. The muscles lose their natural tone and

Motor SYMPTOMGS.... < tend to atrophy. .

The so-called ‘reaction of degeneration” is detected by galvanic tests,
and very strong galvanic currents are required to cause muscular
contractions early in the disease. This fact is in contrast with the
condition observed in poliomyelitis. M, :

Faradaie contractility is often abolished early in the disease. It may
not be entirely lost, however, in some cases.

The so-called “ d7op-wrist” and *drop-foot” are characteristic deform-
ities. They are very often encountered,

L The ‘claw-hand” and various forms of talipes may also be developed.

=

Gdema may be a marked and early symptom. It may affect the feet,
hands, and joints. It is usually temporary.

Excessive perspiration of the feet and hands, possibly with an offensive

TROPHIC SYMPTOMS. 4 odor.

z Glossy skin. This may develop early and be persistent. Its disappear-
ance usually indicates regeneration of the nerves.

| Ulcerations, bed-sores, and eruptions are rarely encountered.

 
564 LECTURES ON NERVOUS DISEASES.

The onset of multiple neuritis, like that of some spinal disease, may
sometimes be sudden and characterized by marked febrile symptoms.
The temperature may occasionally rise to 103° or even 104.5°, but it
probably has a lower range, as arule. The pulse is generally somewhat
accelerated, but it may rise in exceptional cases as high as 140. Starr
states that such an increase with marked irregularity probably indicates
degeneration of the vagus nerve. -

The sphincters are never affected in multiple neuritis; nor are the
automatic acts associated with them.

Dr. Il. D. Chapin, of New York, has lately reported some cases
observed among children in which the symptoms closely simulated those
of infantile paralysis, save that sensory symptoms coexisted with paralysis
and muscular atrophy. These cases were surmised by him (probably
with correctness) to be examples of multiple neuritis. No autopsy has
ever, to my knowledge, confirmed such an observation in a child,
although the literature of this disease is still somewhat limited.

A disease known as “ KAKKE,” or ‘ BERI-BERT,” has existed among
the Chinese for centuries. It is now recognized as an epidemic variety of
multiple neuritis, and its bacillus has lately been not only discovered, but
cultivated. HE. C. Seguin has lately published quite an interesting con-
tribution to this subject, and M. A. Starr gives in some detail the history
of this disease in his admirable lectures, to which the reader is referred.
It usually begins with a coryza, an inflammation of the palpebral and
ocular conjunctiva, and some febrile symptoms. Following these symp-
toms, those of a typical multiple neuritis are developed more or less
rapidly. It has proven to be at times a very fatal type of epidemic.

Diagnosis.— As multiple neuritis occasionally so closely simulates
some organic spinal diseases that a diagnosis‘is rendered extremely ditl-
cult, I have deemed it advisable to present its chief symptoms in contrast
with those of poliomyelitis anterior, locomotor ataxia, and diffuse mye-
litis. These three diseases are particularly liable to be confounded with it,
and, in the case of the two latter, it is believed that multiple neuritis can
occur -as a complication. According to the statements of Leyden, who
disagrees with many other observers, the existence of diffuse myelitic
without a coexisting multiple neuritis is rendered highly improbable. It
is certain that the symptoms of these two diseases present many points
of similarity which might easily mislead any one in making a diagnosis.

In connection with locomotor ataxia, there seems to be a growing
tendency among French neurologists to regard the serious trophic
disturbances which are occasionally encountered during the final stages
of tabes as dependent upon a complicating multiple neuritis.

The table opposite may aid the reader somewhat in making a
differential diagnosis :-—
565.

MULTIPLE NEURITIS.

 

MULTIPLE NEURITIS.

POLIOMYELITIS ANTERIOR.

LOCOMOTOR ATAXIA,

DIFFUSE MYELITIS.

 

ONSET iccesseemidceereceesesweencs

ATAXTA. .cassinsssamiaosamenieaes

 

PARALYSIS. ccctecceseres

MUSCLES ATTACKED...c-+.seeee

ELECTRICAL TESTS....

 

BLADDER AND SEX’L ORGANS..

HISTORY OF PATIENT.......0...

BEV UMRES 4 sis ci vacinmexceenss

TROPHIC DISTURBANCES.......°

CINCTURE-FEELING......-.00005

Gradual, preceded and
attended by numbness,
pain, marked muscular
hyperesthesia, and tend-
erness along the affected
nerves.

§ Ataxia and loss of muscular
{ sense may occur early.

“Advances gradually, and
tends to deepen rather
than to subside. Affects

| the legs first, as a rule.

Grouped according to their

nerve-distribution. Legs
affected below knees, and
arms below elbows.

Reaction of degeneration.

Not affected.

arsenic, infectious dis-

Poisoning by alcohol, lead,
eases, etc., in most cases.

Knee.-jerkmay be abolished,
and subsequently return,

i
sores.

Absent.

 

RRCOV REY ccc crsansecerneaesanens | May be complete.

 

Sudden, with no abnormal
sensory phenomena,

i Ataxia does not develop.

{Subsides more.or less rap-
idly after its onset.

Its distribution depends
upon the spinal segments
altacked. |

Are apt to be grouped phys- |

iologically, t.e., according °

to their function.

Reaction of degeneration.

Not affected, as a rule

No toxie history. Cause
may often be very obscure.

i The reflexes may be normal.

Muscular atrophy. Nobed-
sores.

 

Generally absent.

Is seldom complete.

Characterized by abnormal
sensory phenomena, such
as the typical ‘lightning
pains,” moderate anzes-
thesia, pareesthesize, etc.

§ Develops late in the disease,

¢ asarule.

True paralysis or paresis |

» does not develop. Inco:
ordination of movement
may seriously * disturb
locomotion, however.

Legs usually affected first.
he arms may become
ataxic later.

No reaction of degeneration.

Very often affected.

{ The cause may be very

obscure. Toxic conditions
(save syphilis) are not
detected.

Knee-jerk is usually abol-
ished early in the disease,
and seldom, if ever, returns.

Nomuscular atrophy. Bed-

sores may be developed,
Charcot’s disease, in-
lesions, ete.

Well marked.

ever occurs,

 

Spinal tenderness to heat
or pressure is apt to be
present.

The nerves and muscles are
not hyperzsthetic.

Is a rare disease.

\ Not present, as a rule.

Not confined to the distal
portions of the extremities.
Develops progressively.

All the extremities and even
the muscles of the trunk
may be attacked.

may be detected.

Are generally affected.
Cystitis commonly observed.

Toxic causes are usually to
be detected.

abolished,

1

May occur.

Generally present.

i Is usually fatal.

 
566 LECTURES ON NERVOUS DISEASES.

Prognosis.—A complete removal of the toxic condition which gen.
erally constitutes the underlying cause of multiple neuritis tends, as a
rule, to aid in establishing a more or less complete regeneration of the
nerves. Time is an essential factor in this step, however; the process of
regeneration often extending over a period of from two to sixteen months.

In the majority of non-epidemic cases, a complete recovery may
reasonably be anticipated. In epidemics, the proportion of recoveries is
less, The evidences of a commencing regeneration are shown first in a
stationary condition, followed by an amelioration of the symptoms and an
alteration in the galvanic formule of the nerves and muscles affected, and
a return of furadaic contractility. The cases which ofler the most serious
prognosis are those which are due to an excessive toxic condition, and,
according to Starr, those in which the disease ‘begins with great
suddenness, advances rapidly, and involves the phrenic and pneumo-
gastric nerves.”

Complications may occasionally arise in connection with multiple
neuritis and materially modify the prognosis. Among those to be
anticipated, the following may be mentioned: (1), myelitis ; (2), cerebral
and gastro-intestinal symptoms (chiefly in alcoholic patients) ; (8), ataxia;
(4), paralysis of the cranial nerves (chiefly in diphtheritic subjects) ; and
(5), where tuberculosis or syphilitic lesions develop in the nerve-centres
or viscera.

Treatment.—The pains should be controlled by a judicious use of
hot or cold applications, and also by morphine, whenever excessively
severe. The tenderness of the limbs often renders the employment of
evaporating lotions of real service. The internal administration of the
salicylate of soda in large doses is said to exert a specific action upon
the disease in its early stages, Starr recommends also the employment
of cold douches, lotions of carbolic acid (5 per cent.), enveloping the limbs
in cotton and oil-silk, and rubbing of the limbs with cocoanut oil.

The suggestions previously made in relation to the treatment of
syphilis (p. 291), and those which are subsequently given relative to the
treatinent of lead-, arsenic-, and alcohol-poisoning, are applicable to
certain types of this disease. In alcoholic patients, every precaution
should be taken to prevent the pxtient from surreptitious indulgence.

In chronic cases, strychnia (in doses of jy to 5 of a grain), phos-
phorus (chiefly in some preparation of the hyperphosphites), iron, and
Fowler’s solution of arsenic may prove of benefit whenever the patient
is anemic or exhibits low vitality. It is also well to stimulate the
circulation of the limbs by alternating hot and cold douches, warm
baths at night, systematic daily massage, and electrical applications.

Respecting electrical applications, the employment of galvanism or
static electricity is often rendered imperative when faradaic contractility
CHRONIC LEAD-POISONING. 567

is abolished by the degeneration of the affected nerves. This subject
will be discussed more fully in a subsequent chapter. The reader is
also referred to the tests for nerve-degeneration given on page 189.

CHRONIC LEAD-POISONING.
(Plumbism—Saturnine-poisoning.)

Lead may be taken into the system (1), by means of the skin in
certain occupations; (2), by the drinking of water which has remained
too long in lead pipes or tanks; or (3), by its inhalation in the form of
dust. A case of a peculiar character came under my observation some
years since, where a child swallowed a lead toy and was subsequently
affected by recurring attacks of lead-poisoning. It eventually proved fatal.

Etiology.x—In some of the manufacturing processes, the workmen
are constantly exposed to the deleterious effects of lead. Thus, for
example, the manufacture of paint, of colored papers, of rubber, of
enamel, etc., predisposes the workmen employed to this disease. Many
of our foods which are preserved in tin cans may become impregnated
with lead. A child of one of my intimate friends was thus fatally
poisoned. The drinking-water of suburban residences is particularly
liable to become poisonous in case it is allowed to stand during the
winter months in lead pipes or in cisterns lined with lead. Some of the
mineral waters, as well as ale, beer, etc., are liable to contain lead from
being stored in improper receptables.

Morbid Anatomy.—The morbid changes observed in all toxic paral-
yses are closely allied to those of multiple neuritis. The nerves which
supply the paralyzed muscles frequently undergo atrophy and degener-
ation.

In the spinal cord, changes have been observed in the cells which
compose the anterior horns.

The extensor muscles of the upper extremities and the musculo-spiral
nerve are most frequently affected when lead is the exciting cause.

The affected muscles exhibit a marked increase of nuclei of the
sarcolemma, a gradual wasting of the muscular fibres, an increase of the
interstitial tissue, and oceasionally an increase of fatty tissue. Accord.
ing to some authors, the changes in the muscles are primary; those of
the nerves and the spinal cord being developed after the muscles. It is
maintained by others that the peripheral nerves first exhibit a degenera-
tive form of atrophy.

In some instances, the brain has been found to, exhibit induration
and atrophy; and also marked evidences of inflammation and softening.

Symptoms.—The effects of lead-poisoning may be indicated by the
following conditions: (1) Lead-colic; (2) lead-paralysis; (3) brain
symptoms; (4) lead-anesthesia; (5) lead-hypereesthesia.
568 LECTURES ON NERVOUS DISEASES.

Lead-colic.—The presence of pain of a very severe character in the
region of the umbilicus, the epigastrium, the hypogastrium, or the entire
abdomen, should always give rise to a suspicion of lead-poisoning, in case
the abdomen is found tc be unusually hard or retracted during the height
of the paroxysm. Such attacks are usually accompanied, moreover, by
nausea and vomiting and the most marked constipation.

The pain is generally relieved by firm and uniform pressure. The
duration of the paroxysm varies from a few minutes to an hour or more.
The paroxysms tend to return, and are generally most severe during the
night. Patients usually lie upon the abdomen or press firmly upon it
with their hands.

The distress of the patient during a paroxysm is intense, and the
respiration is somewhat more frequent than normal and often quite
irregular. The pulse is seldom accelerated. This form of lead-poisoning
is particularly liable to occur in painters.

Lead-paralysis.—This is one of the later symptoms of lead-poisoning.
A blue line on the guins and more or less frequent attacks of lead-colic
usually precede development. An excessive use of alcohol and the
persistent use of the muscles of the forearm are said to predispose
to it.

Asarule, this form of paralysis develops gradually. In exceptional
cases, however, a sudden onset may be observed. The muscles supplied
by the musculo-spiral nerve are more often attacked than those of the
lower limbs, the back, or those of the chest. It may occur in one arm
or in both. The common extensor of the fingers and the extensor to the
wrist, little finger, and index finger are usually attacked first. The
muscles of the “ball of the thumb” and the first interosseous may be
involved later. The triceps usually escapes. In the lower limbs, the
muscles of the peroneal group are usually first attacked.

The onseé of this form of paralysis is usually accompanied by a
slight numbness and a tendency to tremor in the muscles affected. The
patient notices a progressive loss of strength in one or both hands, and
a marked difficulty in extending the wrist and the fingers. The circula-
tion in the affected limbs is imperfect, and the joints may be more or less
painful and swollen.

The “ reaction of degeneration” develops in the paralyzed muscles.
Faradaic irritability of the muscles is gradually abolished.

Fibrillary contractions in the affected muscles are often observed.

The cutaneous and tendon reflexes are decreased or abolished in those
regions where the muscles are affected.

The peculiar cachexia can generally ‘be observed. The disease
tends to run a chronic course. Occasionally relapses are observed,
without any fresh exposure to lead.
CHRONIC LEAD-POISONING. 569

Trophic disturbances may occasionally be noted, chiefly in the
form of an enlargement of the sheaths of the tendons and of the
phalanges.

Brain Symptoms.—These are comprised under the condition known
as “ lead-encephalopathy.”

The symptoms of this condition, if of a@ mild character, include
dizziness, headache, an abnormal irritability or depression, an incapabil-
ity for mental exertion, disturbed digestion, tremors in the hands, and
disturbed sleep. The tremulous condition of the hand exists when the
limbs are at rest; but itis greatly aggravated whenever the muscles are
actively employed.

When this condition is of a more severe type, delirium, convulsions,
and coma may develop. The convulsive attacks may closely resemble
those of genuine epilepsy. Repeated convulsions of this type may
occasionally follow each other.

If coma develops, the loss of sensibility is only partial.

The breath usually has a peculiar odor. As is noticed in all severe
forms of lead-poisoning, the complexion of these patients is usually
pale, and marked emaciation is present.

Lead-anesthesia.—This commonly affects the optic nerve, and causes
more or less complete blindness. It may occasionally be observed both
in the skin and muscles of the extremities and the trunk. Its onset is
usually rapid. Hammond states that it reaches its height in a few hours.

Lead-hyperxsthesia.—Lead-poisoning may create pains in the limbs,
chiefly in the flexures of the joints of the leg. The groin and the pop-
liteal space are generally atiected when the leg is attacked; and the
axilla and bend of the elbow, when the upper extremity is attacked.

These pains occur in paroxysms and appear to be excited by move-
ments, exposure to cold, or marked emotional disturbances. They are
usually relieved by firm and uniform pressure over the seat of the pain.
There is no redness, swelling or heat in the affected region. The char-
acter of the pain presents many variations. It may be an ache, a sense
of heat, or a sharp twinge of acute pain.

The use of cosmetics may be the cause of lead-poisoning. From
such a cause, the muscles of the face may be paralyzed ; an occurrence
which is extremely rare under other circumstances. The use of certain
hair-dyes containing lead is said to result in lead-poisoning in occasional
instances.

Diagnosis. —The diagnosis of lead-poisoning is usually not difficult.
A careful investigation of the case will show that the patient has been
exposed to the poisonous action of lead in some way. The muscles
affected by paralysis are so often those which are supplied by the
musculo-spiral nerve (with the exception of the supinators) that it can
570 LECTURES ON NERVOUS DISEASES.

searcely be confounded with a local affection involving that nerve;
because the supinators would in that case be paralyzed as well as the
extensors, and sensory disturbances, moreover, would probably coexist
with the motor symptoms.

In peripheral palsy of the musculo-spiral nerve, a local cause can
generally be demonstrated, such for example as a traumatism, sleeping
upon the arm so as to affect’ that individual nerve, crutch-injury, ete.
It is stated that Russian coachmen frequently get paralysis of this nerve
from winding the reins about the arm while they fall asleep upon the box.

The histury of the patiené will usually show that attacks of lead-
colic have existed before the paralysis appeared; and the appearance of
the gums may also indicate the existence of the poisonous effects of lead
in the system. Lead may almost invariably be detected in the urine.

' Poliomyelitis may in some cases resemble lead paralysis. The dis-
tribution of the paralysis is, as a rule, very different from that which is
due to lead ; and, in the history of the patient, nothing can be detected
which points toward a toxic condition. The urine would also be found
free from lead-salts.

Acute cerebro-spinal meningitis may be recognized, from the brain
symptoms which follow lead-poisoning in some cases, by the fact that
there is a marked rise in temperature in the former, while there is no
increase in temperature, as a rule, when the symptoms are referable to
lead.

Prognosis.— Unless the patient takes precautions to prevent subse-
quent pvisoning by this agent, relapses are very liable to occur. Even
without renewed poisoning, relapses are not infrequent. The prognosis
depends, in individual cases, upon the extent of the paralysis and the
reactions of the affected muscles to electric stimulation. If the muscles
shall have entirely lost their excitability to the faradaic current, a com-
plete recovery cannot reasonably be expected inside of several months,
if at all.

The brain symptoms which sometimes accompany plumbism are the
most serious of its clinical manifestations. In these cases death may
occur.

Under proper treatment, I have never observed a fatal result from
lead-poisoning.

Treatment.---Whenever a patient is known to be exposed to the
poisoning influence of lead, it is the duty of the physician to warn him
of his danger and of the serious consequences which are apt to follow.
His urine should be examined for lead from time to time. If an
attack of lead-colic should occur, the patient should at once remove
himself from such a danger; even if the attack should yield promptly
to treatment. ;
ARSENIC-PARALYSIS, 571

_ In the construction of factories where lead is employed too much
stress cannot be laid upon the proper protection of the workmen
employed. Again, patients who are known to be addicted to the use of
cosmetics and hair-dyes should be instructed to discontinue their use in
case they are found to contain lead.

The internal administration of the iodide of potash, in doses of from
ten to fifteen grains three times a day, has been shown to set free the
lead that is in the system, by causing a decomposition of the albuminates
with which that metal becomes united. The iodide of lead is thus
formed, and this salt is rapidly excreted from the system, chiefly by the
kidneys. Under its use, a disappearance of the blue line around the
gums will usually take place rapidly.

When there is great debility the administration of tron, quinine, or
strychnia, may often be advisable.

The hygienic surroundings of a patient suffering from lead-poisoning
should be carefully regarded, and nutritious and casily digested food
should be given.

Attacks of lead-colie frequently demand the use of ‘aeepiking pref-
erably by the hypodermic syringe, to control the pain, An occasional
purgative may also be given with advantage, preferably castor oil.

Warm baths, particularly sulphur baths, are said to greatly assist
the recovery of the patient: they should be given for from fifteen to
thirty minutes daily.

Lead-paralysts is best treated by the use of the faradaic or galvanic
currents. The latter current is particularly indicated as long as the
former fails to produce muscular contraction. The applications should
be made daily for a duration not to exceed five minutes.

When galvanism is employed, a labile application of the cathode, with
the anode upon the nape of the neck or the sternum, yields the best results.

I have employed the static spark to these muscles with very marked
benefit in many cases. The instrument must be of considerable power
if employed for this purpose.

Frictions to the part, systematic massage, and passive exercise are
valuable adjuncts to electrical applications.

Mechanical appliances may be employed to the paralyzed limb, with
advantage to the patient, in some instances.

ARSENIC-PARALYSIS.

This form of paralysis generally occurs after acute poisoning. It
usually develops rapidly, and, like other toxic paralyses, is probably to
be attributed to a multiple neuritis which has been endused,

It may be distinguished from lead-paralysis by the fact that the
lower limbs are more apt to be affected than the upper, by the rapid
572 LECTURES ON NERVOUS DISEASES.

atrophy which occurs in the muscles paralyzed, and by the presence of
marked sensory disturbances.

Violent pains usually precede the paralysis and atrophy. Among
the sensory disturbances noticed, numbness, analgesia, and formication
are prominent.

Symptoms of incodrdination of movement have been observed to
follow arsenical poisoning.

The condition of the reflexes, and the alteration in the electrical
excitability of the muscles are similar to those observed in lead-poison-
ing.

Treatment.—This is similar to that already described in connection
with plumbism.

PHOSPHORUS-PARALYSIS,

This form of poisoning may be of the acute or the chronic type.
In connection with both forms, monoplegia, paraplegia, and peripheral
paralysis have been observed.

In the paralyzed parts, all forms of subjective sensory disturbances
(paresthesia, see p. 354) and pain may be experienced by the patient.

Little is positively known regarding the morbid changes which are
induced in the nerves or nerve-centres by arsenic or phosphorus. The
evidences of multiple neuritis are generally detected in all forms of
toxic paralyses. Experimentation made upon dogs by Vulpian seem to
show that changes in the peripheral nerves,-as well as in white matter
and anterior horns of the spinal cord, take place.

The history of the case will usually suffice for a diagnosis. The
treatment of the symptoms is not unlike that employed in lead-poisoning.

ALCOHOLIC POISONING.
(Alcoholism—Delirium Tremens.)

. The ingestion of a large quantity of aleohol produces effects which
are modified by special idiosyncrasies of the patient, as well as by the
habits of the patient in respect to alcohol.

ACUTE ALCOHOLISM.

The condition which is here described does not include simple intoxi-
cation, which is too often seen not to be recognized, but rather a state
which is induced by the poisonous effects of very large quantities taken
at once or gradually established after a prolonged and excessive
indulgence.

“Delirium tremens,” or acute alcoholic poisoning is most commonly
observed after a prolonged debauch, or after an excessive indulgence in
alcoholic liquors by one who has been an habitual drinker for a sufficient
ACUTE ALCOHOLISM. 573

length of time to seriously undermine the general health. It is claimed
that it may also occur in habitual drinkers from the sudden cessation of
the habit. This fact is probably attributable (if it really ever occurs) to
a condition of system which is so thoroughly under the toxic influence
of alcohol that its ingestion is no longer possible, because it is refused
by the stomach. If this view be a correct one, the development of alco-
holismus is due rather to the depressed systemic condition than to the
stoppage of alcohol. It is well known that many habitual drinkers eat
sparingly and irregularly, sleep but little, and undergo more or less
exposure. These circumstances are probably conducive to a condition
of physical weakness, of which this disease is but a manifestation.

Symptoms.—Preceding the actual onset of an attack, it is not
uncommon to observe more or less tremor of the hands and tongue, and
a marked unsteadiness in the upper limbs when voluntary movements
are attempted. The muscles of the lower limbs and trunk are sometimes
similarly affected, causing an unsteadiness of gait. As a rule, these
phenomena are most marked on arising, and they tend to disappear to a
greater or less extent after the patient has taken several drinks to
develop an appetite for breakfast. The feebleness of gait in some of
these patients and the unsteadiness of the hands and upper limbs are
too frequently spoken of by such patients as ‘“ nervousness.” Respecting
this point, Hammond very aptly remarks: ‘“ From this feebleness, or
paresis, the distance to paralysis is not great.” It may indicate the
beginning of multiple neuritis.

Prior to the onset of' an attack vomiting is often a prominent symp-
tom, The patient may also exhibit sudden startings and a peculiar
watchfulness and distrust of his surroundings. Morbid fears of various
kinds may be developed. The expression may be markedly altered, and
the eyes may be peculiarly watery or red. Perspiration is sometimes
excessive. The fingers may be observed in some instances to be more
or less constantly employed in some aimless pursuit. Finally vertigo,
headache, and confusion of ideas may be encountered in such patients.

As the onset approaches, these symptoms tend to increase in inten-
sity, and other morbid phenomena appear. The face of the patient gives
evidence of more or less alarm. This is frequently due to the fact that
they experience illusions, hallucinations, and delusions which are of an
alarming type. Many eases of suicide have occurred among this class
of patients in their endeavor to escape from some horrible object which
they believe is pursuing them. They see demons, snakes, lizards, cats,
etc., about the room and menacing their safety. Sleep is no longer
possible on account of these visions. The patient is liable to become
more-or less uncontrollable and to form bitter dislikes toward his friends,
relatives, or attendants The temperature is generally elevated, although
574 LECTURES ON NERVOUS DISEASES.

the body may be bathed in a profuse perspiration. The pulse is markedly.
accelerated, small, and weak. The bowels are constipated. The patient
talks incessantly concerning various illusions or delusions which disturb
him. The pupils are small, and the retina may be congested in the region
of the disk. Convulsions sometimes occur, usually of the epileptiform
character. When these are developed, they are liable to be frequently
repeated. They area grave symptom, and death may occur in one of
these paroxysms.

The duration of such an attack varies from three days to a week or
more.

When the attack produces dangerous exhaustion, a low muttering
delirium takes the place of the loud ravings of the patient. The fingers
pick aimlessly at the bed-clothes. Gradually the pulse becomes almost
too rapid to count and very weak. A state of coma develops. The
patient then either gradually sinks or dies in a convulsive attack.

CHRONIC ALCOHOLISM.

This form of alcoholic poisoning differs from the acute chiefly in
the absence of a marked onset and the characteristic phenomena of
delirium tremens already described. In cities, it is more often encoun-
tered among the idle and wealthy classes than the acute form. These
are prone to indulge in alcohol to great excess during the hours spent
at the club, the gaming table, and social festivities.

Symptoms.—The manifestations of chronic alcoholism differ in
individuals. It may be well to describe them under the following
heads: (1) That in which tremor predominates. (2) The anesthetic
type. (8) The convulsive type. (4) The paralytic type. (5) The
mental type.

Alcoholic Tremor.—This may precede an attack of delirium tremens
in occasional instances. If, has been already described, therefore, among
the premonitory symptoms which occasionally indicate the approaching
onset of the acute variety of alcoholism. It chiefly affects the hands,
and is liable to be accompanied by unsteadiness of the legs and truank—
particularly in subjects who are victims to chronic alcoholismus. On
account of this tremor, such patients are often prone to drop thirgs
from their grasp unless they constantly watch the object. When their
eyes are withdrawn, the grasp is unexpectedly relaxed.

The muscles of the legs and trunk suffer from more or less PAresis, AS
the condition progresses. I have repeatedly known such patients to lose
in time their ability to walk without the aid of an attendant. For a
while they get along by the support of a heavy cane.

Vertigo and dimness of vision are sometimes experienced as the
result of chronic alcoholism. Various disturbances of sensation may be
CHRONIC ALCOHOLISM. 575

developed, such as numbness, formication, analgesia, etc. These will be
discussed under the next variety.

The paresis and abnormal sensory phenomena are probably to be
attributed to morbid changes in the peripheral nerves. In many cases
of this type, the pathological evidences of multiple neuritis are
unmistakably present.

The Anesthetic Type.—Oceasionally, from the very onset sensibility
may be perverted or entirely lost in chronic alcoholism.

The presence of anesthesia may be limited to one lateral half of
the body (hemianesthesia), Hammond speaks of this condition as
peculiarly characteristic of chronic alcoholism,—a view which he states
to be in accord with the observations of Magnan and Virenque.

In addition to this loss of sensation, the same observer states that
the sight of one eye, the hearing of one ear, and the functions of one
nostril and one lateral half of the tongue are often abolished. He
mentions one case cited by Magnan, in which the sensibility of the
cornea was totally lost in one eye.

Asa result of anzsthesia, the patient has imperfect conceptions of
the “feel” of objects; and the sense of pain may be totally lost both in
the skin and the muscles. These patients may thus be rendered personally
unconscious of tests made with a view to determine their appreciation
of touch, pain, or temperature.

A more or less marked loss of motor power invariably accompanies
the abolition of sensation.

The Convulstve Type.—It is not uncommon to observe, in patients
who are suffering from chronic alcoholism, convulsive seizures of an
epileptiform character. These may occur as early symptoms, or they
may follow some of the other symptoms alreacly described. As a rule,
they are usually accompanied by marked and permanent derangements

of sensibility, and more or less paresis during the intervals between the

convulsive attacks.

The convulsive seizures may or may not be accompanied by loss of
consciousness,

According to Huss, the frequency of convulsive attacks tends to
diminish as the condition of chronic alcoholism increases.

The Paralytic Form.—In connection with the previous types of
chronic alcoholism, paresis has been mentioned as a symptom which is

' generally present. In some cases the loss of motility progresses to such

an extent as to render locomotion impossible and to constitute true
paralysis. One very marked case of this character has come under my
observation.

In connection with the paralysis of the limbs, the muscles of the
eye are occasionally observed to suffer from paralysis. In this way the
576 LECTURES ON NERVOUS DISEASES.

development of strabismus and ptosis is to be explained. Again, the
muscles of the organs associated with speech and swallowing may be
paralyzed.

The Mental Type.—In connection with chronic alcoholism, the
mental condition of the patient is liable to be seriously impaired. Illu-
sions and hallucinations are not uncommon, and the power of intellect
and will are generally lessened in a marked degree.

Emotional manifestations, chiefly those of a “sorrowful type,
very frequently observed. A large proportion of these subjects are
prone to weep easily over imaginary troubles, and to exhibit a disposi-
tion to greatly exaggerate their business cares and perplexities. Those
who are naturally inclined to be vicious may be rendered still more so
by this form of alcoholic poisoning. It has not been my experience,
however, to encounter any exhibitions of mental disturbance in this class
of patients that would justly create alarm. They are far more apt to
become extremely irritable, peevish, and lachrymose. They are very
liable to take offense easily, and to misconstrue unintentional acts of
their friends and companions as personal slights and insults.

Suicidal tendencies may occasionally be observed in these patients
as the results of melancholia or imaginary fears. One of my patients,
who was a very rich man, was constantly haunted by the fear of beggary,
and was with difliculty restrained from acts of violence to himself.

The capabilities of the patient for mental application or for accurate
reasoning in respect to the ordinary affairs of life is liable to be seriously
impaired. Their sense of comprehension is often very much blunted, and
their judgment is often seriously in error. Hammond states that the
memory is the first faculty which shows impairment, and that the sense
of right and justice which the patient may have had in health is often
weakened or destroyed. This author lays stress upon the fact that lying,
stealing, and even serious outrages without known provocation, may be
committed by these patients; and he regards the existence of any motive
for such acts as extremely infrequent among this class of sufferers,

Tlallucinations and delusions in chronic alcoholism, as in the acute
form, tend to assume a peculiarly painful ‘and distressing character,
These patients are frequently the victims of fear of personal violence
either to themselves or those to whom they are attached. There are
exceptional instances, however, where the delusions assume a more
pleasant character.

Prognosis.—In the acute form recovery usually occurs, provided the
attacks have not been frequent. Convulsions in this form give a grave
aspect to the case. A failure of the digestive organs to assimilate food
after the symptoms have subsided to a greater or less extent is also an
unfavorable sign.

” are
CHRONIC ALCOHOLISM. D5TY

The chronic form may be recovered from when the symptoms are
not of a severe type, and when the patient’s appetite for liquor can be
effectually controlled.

Treatment.—An attack of delirium tremens demands active medica-
tion to induce sleep, and careful attention to the nourishment of the
patient. It is my custom to administer thirty grains of the bromide
of potassium and ten grains of chloral, combined with ten drops of the
tincture digitalis, to a patient suffering from delirium tremens, every
hour or two as the circumstances seem to demand, until sleep is induced.
The digitalis is added as a preventative of heart-failure, which sometimes
occurs from chloral-poisoning. When sleep is not induced by this pre-
scription within five or six hours, a hypodermic injection of a quarter of
a grain of morphine may be given and repeated in two hours.

The monobromide of camphor has been recommended in doses
of four grains every hour for several hours. I have had no personal
experience in its use.

Sometimes the administration of capsicum by the stomach acts
charmingly in inducing sleep. <A teaspoonful of the tincture may be
given at a dose.

During the attack, the patient should be carefully watched by an
attendant in order to guard against danger to the patient, as they are
very prone to jump from the window, or do themselves some personal
violence in their efforts to escape from the imaginary objects which
haunt them. It is well to remove from the room all articles of china
and other utensils which might be employed by the patient as a
weapon. One of my patients committed suicide by breaking the
handle from a heavy earthen pitcher and cutting his throat with its
Tagged edge.

The patient should be nourished at regular intervals with milk,
beef-tea, gruels, and other liquid foods. During convalescence, quinine,
iron, and strychnia may be indicated.

The treatment of chronic alcoholism consists in an entire cessation
of alcoholic liquors. If the bowels are deranged by constipation or
diarrhoea, they should be regulated. ;

When insomnia is a prominent symptom, the bromides alone, or a
combination similar to that used in delirium tremens, may be employed.

The oxide of zinc, in doses of from one to three grains three times a
day, has been highly recommended in this affection. Hammond suggests
the use of bromide of zinc in doses of two grains three or four times a,
day. This drug may be given in solution with water or syrup. The
dose should be gradually increased (up to four or even six grains at a
time) as rapidly as the stomach will permit.

The infusion of digitalis, in doses of a tablespoonful three times a

BV
578 LECTURES ON NERVOUS DISEASES.

day, is often indicated to increase the power of the heart and indirectly
to stimulate the action of the kidneys.

Electrical applications to the affected muscles may be administered
daily for from five to ten minutes. The faradaic or galvanic currents may
be employed, and also the static current in the form of spark or static
insulation. I have great faith in static sparks as a curative agent in
alcoholic tremor and paresis. When anesthesia exists the faradaic
current is best applied by means of the wire brush.

Careful regard to the diet of these patients should be observed. All
highly seasoned food should be countermanded, and large quantities of
milk should be taken by the patient. I have great faith in the curative
effects of an exclusive milk diet in these cases. Three quarts of milk a
day are amply sufficient to nourish an adult without a particle of solid
food. The addition of a slight quantity of lime-water or some of the
admirably made preparations of pepsin may assist in its digestion in
those exceptional cases where milk is not well tolerated by the stomach.

MERCURIAL POISONING.
(Hydrargysm.)

Mercury may be taken into the system not only by the stomach and
intestines, but also through the skin and lungs.

This med is often taken to excess in the form of blue mill and calo-
mel. Mercury is used extensively in some of the manufacturing arts,
such as the silvering of looking-glasses, the making of artificial flowers,
the manufacture of bronzes, some of the photographic processes, certain
forms of dental work, etc. Some of the cosmetics for the removal of
facial eruptions contain mercury. I have observed several cases of mer-
curial poisoning from an injudicious use of the vapor of mercury in a
bath given for medicinal purposes. This is particularly apt to occur
when calomel is employed, or when the vapor is inhaled into the lungs.

Symptoms.—In chronic mercurial poisoning, tremor is peculiarly
apt to be developed.

When salivation is thus produced, the gums will appear very much
swollen, sensitive, liable to bleed easily, and more or less separated from
the teeth. The breath is extremely fetid, and the teeth are apt to become
loosened from their sockets. The patient complains of a metallic taste
in the mouth. In severe cases, the tongue becomes enormously swollen,
often to such an extent as to protrude from the mouth. The saliva
flows in a stream, so that the patient has frequently to hang the head
over a bowl, which catches it as it escapes from the mouth. The coun-
tenance may be pale or livid. Severe nose-bleed sometimes oc¢urs, The
physical strength is very rapidly lost, and marked mental debility may
be exhibited.
BROMISM. 579

In some cases, cartes and necrosis, especially of the lower jaw, with
ulcerations of the soft parts, may develop.

Finally, convulsions of the epileptiform type and paralyses of
various parts of the body have been reported, :

Diagnosis.—The symptoms of this form of poisoning can hardly be
mistaken for those of any other disease.

The tremor, the peculiarly fetid odor to the breath, the characteristic |
appearance of the guins, the loosening of the teeth, the swelling of the
tongue, the enormous increase of saliva, and the bone-complications
frequently encountered, are met with in no other condition.

It is claimed that the diagnosis may be rendered certain when the
symptoms are not fully developed, by the administration of the iodide
of potassium to the patient in large doses for two days, and then
subjecting a few drops of the urine on a bright copper plate to a drop of
hydrochloric acid. If mercury is present, a bright metallic spot will be
found on the copper plate.

The history of the patient will usually reveal the fact that he has
been exposed to the poisonous influences of mercury.

Treatment.—During an attack of salivation, tannie acid may be
employed as a gargle, with very great relief to the patient. The admin-
istration of the iodide of potassium in doses of from 15 to 80 grains
three times a day, aids in the elimination of the poison.

When mercurial tremor is the prominent symptom in the ease, the
use of the iodide of potassium is often followed by a very rapid cessation
of that symptom.

The administration of iron, quinine, and strychnia in tonic doses
may prove valuable as adjuncts in the treatment of this form of
poisoning. The patient should be warned against further exposure to
mercury.

BROMISM.,

The bromides which are chiefly administered as drugs in the treat-
ment of most of the functional nervous diseases comprise those of
potassium, sodium, calcium, lithium, ammonium, zinc, and camphor.

The extent to which these drugs are employed probably exceeds
to-day that of any known class in the treatment of nervous diseases ;
hence, I feel it my duty to raise my voice here in protest against the
view too commonly held by practitioners, that these bromide preparations
are harmless, and that they are indicated in every functional nervous
disturbance whose cause may be obscure.

I believe that more harm has been done to the human race by the
bromides than good. In epilepsy, for example, the continued adminis-
tration of very large doses of the various bromide salts unquestionably
assists in bringing the mental state of the patient to a deplorable
580 LECTURES ON NERVOUS DISEASES.

condition, in depressing the digestive functions, in weakening the general
muscular tone, and in seriously delaying (if it does not sometimes pre-
vent) the recovery of the patient in many instances.

I have known of several epileptics where recurring dislocations of
the shoulder could, in my opinion, be attributed to a relaxed state of the
muscles, which had been induced by excessive and long-continued admin-
istration of the bromides. I have seen a very large number of patients
precipitated into a condition closely bordering upon imbecility from the
same cause.

Personally, I have for some years avoided the use of bromides as
far as possible in the treatment of functional nervous diseases; and I
believe that by so doing I have greatly added to the comfort and health
of my patients. The prevention of convulsive neryous phenomena by
the continued use of a drug whose poisonous effects are well-known and
generally recognized, cannot be considered in any light as a cure. It is
a question to my mind if epileptics, for example, do not improve as much
under a well-regulated diet from which nitrogen is eliminated as far as
possible, and the use of other drugs than the bromides whose poisonous
effects are far less marked if not totally absent, than by the use of
bromide-salts, which tend in time to render their mental condition, if not
their physical, a deplorable one in many cases.

Symptoms.—The poisonous effects of bromine may be developed in
some adults and often in children, from very small quantities of the drug.

The evidences of its poisonous effects may be manifested in a
variety of ways. I shall consider some of these effects in detail.

Excessive somnolence is an early symptom. The patient may sleep
or remain in a drowsy condition not only during the night, but also
during the day.

A feebleness in the legs and in the arms, may tend to develop.
This is shown by a marked alteration in the gait and a loss of the grasp-
ing power of the hand.

The heart’s action may be markedly weakened, and the pulse propor-
tionately accelerated. Frequently the skin is:rendered cold and clammy,
and the pupils may be occasionally widely dilated and rendered insensible
to the action of strong light.

Pustular eruptions may develop upon the skin—chiefly upon the
face, neck, and trunk. Boils and carbuncles have been known to follow
the abuse of the bromides.

The digestive organs are very often seriously disturbed. This is
shown by a coating, unnatural dryness, and occasionally an excessive
soreness of the tongue. The bowels are usually constipated and the
breath has a fetid odor. The mucous membrane of the mouth and fauces
may become covered with aphthous patches, and show a markedly con
TETANUS. 581

gested state. A similar condition is probably induced in the mucous
lining of the respiratory passages; as evidenced by accelerated respira-
tion, cough, and the physical signs of bronchitis.

The mucous lining of the pharynx, larynx, and the bladder may lose
its normal sensibility. Specialists on the throat employed this agent often
for the purpose of rendering the introduction of instruments into the
pharynx and larynx possible without exciting nausea or efforts to vomit.

In severe cases of bromism, walking often becomes impossible; the
patient lies in a deep stupor; the sphincters are no longer controlled;
the heart’s action is excessively weakened; lung complications are
developed; and death may occur.

Treatment.—When bromism has developed, the administration of
the drug should be immediately discontinued. Digitalis may be given
to increase the power of the heart and thus to excite the action of the
kidneys. The patient should be stimulated judiciously, and nourished
at regular intervals. ‘Tonics may be given during convalescence,

TETANUS.
( Trismus— Lockjaw.)

This disease is characterized by an exaggerated excitability of the
motor and reflex functions of the spinal cord. It manifests itself by
convulsive seizures of a tonic character. Its course is usually a rapid
one. Consciousness remains intact throughout the disease.

Etiology.— Tetanus is commonly divided into four varieties, viz.,
the traumatic, rheumatic, toxic, and idiopathic. To these varieties some
authors add the hysterical, inflammatory, intermittent, and that of the
newly born (trismus neonatorum),

Lock-jaw, or “ trismus,” is considered by some authorities as a dis-
tinct disease. With this view I am not in accord, since spasms of the
jaw-muscles are nearly always combined with spasms of the trunk and
limbs. I regard typical trismus as but « modified form of true tetanus.

The traumatic variety is the most frequently encountered. It seems
to occur in some regions more than in others. The atmosphere of some
localities apparently renders any wound particularly dangerous on this
account. Contused and torn wounds about the hands and feet, especially
if they injure nerves or tendons, are peculiarly liable to be followed by
tetanus. It is thought by the laity that a wound inflicted by a rusty
piece of iron is particularly apt to cause this condition.

Tetanus may follow immediately after a wound, or it may develop
after a lapse of several days or weeks.

Among the predisposing causes to tetanus may be mentioned certain
psychical influences, irritation of the wound, epidemic influences, atmos-
pheric conditions, concussion of the head or spine, pyemic poisoning, ete.
a
CO
iS)

LECTURES ON NERVOUS DISEASES.

The exciting wound may be extremely insignificant in some cases.
Tetanus has been known to follow the sting of a bee, tie pulling of a
tooth, the piercing of the ear, ulcerations, ete.

Among other forms of injuries received of a more serious character,
which have resulted: in tetanus, may be mentioned the wounds of the
surgeon’s knife, lacerations of the cervix uteri, the exposure of an
abraded mucous membrane (as in the puerperal state), and accidental
traumatisms of various kinds.

A variety of tetanus is not uncommonly observed between the fifth
and twelfth days of life, which is known as “trismus neonatorum.” It
may be attributed in many cases to disease of the umbilicus, frecal stasis,
and mechanical irritation of the medulla oblongata from strong extension
of the head during delivery.

 
 
  

  
 

popes
mana ey

oe

  

Fic. 127.—A Markev Paroxysm oF Tetanus. (After a drawing by Sir Chas. Bell.)

The rheumatic variety of tetanus isa rare form of disease. Many
authors of to-day express a doubt as to whether genuine tetanus is ever
dependent upon exposure to cold or dampness, or an excess of lactic
acid in the blood.

The toate variety of tetanus may occur in certain forms of poisoning
by drugs, chiefly from an overdose of strychnine or picrotoxine. It is
stated by some authors that clonic muscular spasms are more often noted
than the tonic in this variety of tetanus.

The tdiopathic variety of tetanus comprises all cases in which no
exciting cause can be discovered. In many such cases the presence of
an epidemic, due probably to some atmospheric influences, exists.

Symptoms.—A fter a wound, the onset of tetanus is usually preceded
by more or less pain in the region of the wound, or an unnatural appear-
ance of the injured part. These pains frequently shoot along the course
of some adjacent nerve. Local symptoms are often accompanied by a
TETANUS. 583

peculiar restless, excited, or anxious condition of the patient. Insomnia
may be a marked symptom.

As the onset of the disease approaches, movements of the jaw are
associated with more or less pain and stillness, as are frequently also

-movements of the neck and attempts at swallowing. The first signs of
muscular spasm generally appear in the face and in the back of the neck.
Later, a similar condition develops in the muscles of mastication, in the
pharynx, and in the muscles of the back and limbs. In many instances,
the extremities are but slightly affected.

The facial expression of tetanus is characterized by a peculiar
wrinkling of the forehead, an expansion and elevation of the nostrils,
and an attitude of the mouth which exposes the teeth, giving to it the
expression termed the “risus sardonicus” because it resembles that of
laughter. Respecting this peculiar condition of countenance, Eichhorst
very aptly says: “The features express the most antagonistic feelings.
While the upper half of the face has a cheerful though tired expression
(due to diminution in the size of the palpebral fissure), the lower part is
sad, and the mouth has the expression of one who is sobbing. On
account of the uncovering of the teeth, the expression has been com-
pared to that of laughing.”

The ability to open the mouth is partially or completely lost by a
tonic state of the masseter muscles. This interferes seriously with the
ability of the patient to take food. Infants, when attacked by tetanus
are unable to retain the nipple between the jaws. Any attempt to open
the mouth is so strongly resisted that a danger of fracture or dislocation
of the lower jaw might be created before the spasm could be overcome.
The nutrition of the patient is, furthermore, embarrassed by a similar
state of the muscles of the pharyx, in some cases. The tortures of
hunger and thirst may therefore constitute an important part of the
sufferings of the patient.

During the paroxysm the head is drawn forcibly backward, and
the muscles of the back distort the trunk so that the patient muy rest
upon his shoulders and hips. In occasional instances, the trunk may
be bent toward one side (pleurosthotonus) ; or the body may be drawn
forward toward the thigh (emprosthotonus). Cases have been reported
where the trunk-muscles have rendered the spinal column rigid without
distortion.

The respiratory movements are seriously embarrassed when the
diaphragm and the intercostals are affected. Under such circumstances
extreme cyanosis may develop, and death may occur from a lack of
ability on the part of the patient to breathe.

The muscles of the limbs may participate, to a greater or less extent,
in the tonic rigidity so commonly observed in the trunk and neck.
584 LECTURES ON NERVOUS DISEASES.

Flexion of the upper limbs and extension of the lower are generally
observed. The contracted muscles stand out with great prominence
beneath the skin, and, in severe cases, the patient may be raised from the
bed so that he rests upon his head and heels.

In very exceptional instances the third cranial nerve, in addition to
the seventh and ninth, may be affected and cause a strabismus. Eye-
symptoms in tetanus are justly regarded as of evil import.

The frequency and duration of tetanic spasms vary. During sleep,
they generally tend to subside or entirely disappear. In some cases,
distinct paroxysms are observed ; beginning, as a rule, with clonic con-
tractions, which gradually tend to assume the tonic type. In other
cases, the tonic contraction of muscles is persistent. Such a condition
may continue for days without intermission.

The reflex excitability of the spinal cord is very markedly exag-
gerated in some cases. The slightest noise or disturbance of the patient
in any way may excite a paroxysm.

The force of the tonic contractions of muscles has been known to
break off the teeth, and to fracture and dislocate the long bones. During
a paroxysm, the development of fibrillary twitchings in the rigid
muscles may occasionally be observed.

The onset of a paroxysm is looked forward to with great terror by
the patient on account of the extreme pain which is generally experi-
enced while the muscles are thrown into rigidity. In severe cases, the
patient is unable to obtain sleep or to quench his thirst or hunger.
Occasionally, del!rium sets in late in the disease; but, as a rule, the mind
of the patient is perfectly clear. Profuse sweating is apt to occur during
the paroxysms. The sensibility of the skin ‘is unaffected, as a rule, and
little; if any, febrile excitement is usually observed.

Diagnosis.—The only disease which could be confounded with
tetanus is spinal meningitis. The character of the spasms, the stiffness
or complete fixation of the jaws, the facial expression observed in
tetanus, and the difliculty in swallowing produced by spasms in the
muscles of the pharynx are suflicient to distinguish tetanus from an
inflammatory affection of the spinal meninges.

Prognosis.—The duration of tetanus, as well as the character of its
symptoms, vary in individual cases. A case is reported where death
occurred in a negro fifteen minutes after the accident; while, on the
other hand, the duration may extend over a period of weeks or months.
Paralysis and paresis have been known to occur as sequel of tetanus.

The mortality in infants is enormously large. In adults, the severity
of the symptoms and the exciting cause of the attack materially modify
the prognosis. Ina large percentage of cases it is unfavorable. A long
duration of the disease without rise in temperature or marked insomnia
TETANUS. 585

indicates a favorable termination. The idiopathic variety is more often
recovered from than the traumatic. The prognosis is also more favorable,
in case the attack be of the traumatic type, when a long interval elapses
between the exciting injury and the development of tetanic phenomena.

Treatment —The indications for treatment are modified by the
exciting cause and the symptoms. When an open wound exists, perfect
cleanliness and antiseptic dressings should be employed. The patient
should be placed in a darkened and quiet room; and every precaution
should be taken to avoid a recurrence of the piros yams,

The patient may often be nourished by means of a tube passed
behind the last molar tooth and through the phar yux into the stomach.
When this is impossible, the patient may be put under the influence of
ether or chloroform and a tube introduced between the teeth; or, when
that is impossible, through the nostril into the stomach.

Among the drugs which have been highly recommended, the follow-
ing may be mentioned: Calabar bean, cannabis indica, conium, anzs-
thetics, chloral and bromide of potassium in large doses, gelsemium in
doses of from ten to forty drops every two hours, paraldehyd in doses
of from thirty grains to two drachms during the twenty-four hours,
belladonna, and aconite.

Ice-bags and counter-irritants may be applied to the spine. Ether
spray and leeches have also been employed over this region.

Certain surgical procedures have been recommended. Among these,
stretching of the uerve leading to the wound may be mentioned as having
given satisfactory results in a few cases. Accumulations of pus may
demand an incision in the region of the wound, and care should be taken
to free the wound from the presence of any foreign substances which
may have entered at the time of the accident.

Hammond has carefully analyzed the results of treatment in
reported cases which were obtained by most of the drugs enumerated ;
and by surgical procedures in typical cases of tetanus. The conclusions
of this author go to show that some cases apparently recover rather in
spite of drugs than by their direct aid. Perhaps it may be said that
large doses of chloral, combined with large doses of the bromide of
potassium, give as much relief to the patient as any known treatment.
The application of ice-bags to the spine. combined with the internal
administration of half a grain of the extract of cannabis indica every
two hours, may be attended with good results.

T have been awaiting for some time an opportunity to test the effects
of strong static sparks upon a patient in a paroxysm of tetanus, on
account of the remarkable effect which such an electrical application
seems to exert upon muscular contracture. Thus far I have been
unsuccessful in obtaining an opportunity of this kind.
586 LECTURES ON NERVOUS DISEASES.

TREMOR
AND

PARALYSIS AGITANS.

Intermittent clonic spasms of the muscles, of a persistent type, are
not infrequently observed in connection with any condition which
increases the susceptibility of the patient to central or peripheral
irritation, or renders the action of the nerve-centres more or less
imperfect.

Etiology.—In the human race, the presence of persistent tremor
usually indicates a condition of irritation in the nerve-centres.

This condition may be dependent upon a morbid lesion; such as
inflammatory processes, tumors, sclerosis, Ganges in the vessels, ete.
It may also be apparently due to some excessive mental strain or excite-
ment in subjects predisposed to nervous disturbances; hence, it has been
known to follow sorrow, fright, prolonged anxiety, protracted mental
application, religious excitement, etc. Again, degenerations of the cord
or brain, which may or may not follow or accompany an attack of paresis
or paralysis, may cause persistent clonic spasms in the limbs or trunk.
Finally, nervous and easily-excited individuals, who inherit the so-called
“neuropathic predisposition,” may develop tremor in some of its forms
simply as the result of peripheral irritation. In this class of patients,
my experience leads me to believe that eye-strain exists more frequently
as an exciting cause than is generally suspected. (See my remarks
respecting chorea and other convulsive diseases.)

It has been noted, in connection with some of the toxic neuroses,
that tremor is often induced by the introduction of poisons into the
general system. Under this class of causes, chronic alcoholism, the
opium habit, excessive use of tobacco, and mercury or lead-poisoning
may be prominently mentioned. In such cases, the morbid evidences of
a multiple neuritis can often be detected.

Finally, the weakness of old age is often manifested by the develop-
ment of persistent tremor.

PARALYSIS AGITANS.
(Parkinson’s Disease—Shaking Palsy.)

This form of tremor was first carefully observed and described by
Parkinson in 1817. It is characterized by a tendency to steadily pro-
gress both in extent and severity, and to be accompanied by evidences
of enfeebled motor power or general paralysis.

Morbid Anatomy.—The anatomical changes which occur in this
disease ure unknown. By some observers, morbid changes (pigmenta-
tion, hypertrophy, etc.) have been detected in the ganglionic cells of the
PARALYSIS AGITANS. 087

brain'and spinal cord, chiefly in the pons, medulla, and Ammoun’s horn.
Our knowledge of these changes is, however, so imperfect that we are
as yet forced to consider this disease as a purely functional one.

Etiology.— Among the causes of this affection which have heen men-
tioned by authors of note, the following conditions seem to predispose
to it: Exposure to cold, injuries, excessive fright, prolonged mental
excitement, excessive venery, certain infectious diseases, heredity,
excesses in alcohol, gout, ete.

In many of these subjects, an inquiry into the health of the patient’s
blood-relations will often show that corea, epilepsy, hysteria, insanity,
neuralgia, or phthisis has existed in some branches of the family. Per-
sonally, I regard the question of heredity as one which should always
be thoroughly investigated. It tends to shed much light upon the
possible factors which aid in creating diseased conditions,

Among the traumatic cases, injuries to nerve-trunks are more
frequently followed by this condition than other forms of accident.
This disease has, however, been known to follow the opening of a car-
buncle, a severe burn, and other peripheral injuries.

Symptoms.—Shaking palsy is very rare before the age of twenty
years. I€ usually occurs in advanced age, chietly between forty and
sixty years of age. It seems to affect both sexes equally.

The onset of this disease is usually so gradual (except in cases
where it originated after a severe fright) that the patient cannot
accurately locate when the first symptoms were observed.

Prior to the development of the onset, the patient may have suffered
from marked insomnia, unnatural irritability, temporary weakness of
the limbs, vertigo, neuralgic pains, and paresthesia.

The disease first manifests itself by slight trembling in the muscles
of the fingers and hands; later in the muscles of the arms; and still
later in the legs. It is claimed that the right arm and the corresponding
leg are markedly affected before those of the left side. While this may
be generally true, it is not in my experience an universal rule. Some-
times the muscles in the head and face may be attacked with tremor; in
which case the tongue is also liable to be involved.

The trembling of the muscles is present during repose; and does not
seem to be affected by voluntary movements. They are intensified,
however, by any form of mental excitement. Although at first the
patient may partially control them by an act of will, the tremulous
movements soon become uncontrollable, and persist even during sleep.
In the latter stages of the disease, the tremors tend to become exces-
sively violent. Cases have been reported where the floor as well as the
bed have been set in vibration by the shakings of the patient. It is
needless, perhaps, to state that the ability to perform delicate movements
588 LECTURES ON NERVOUS DISEASES.

of the fingers is rapidly lost; and that the patient sooner or later may
become unable even to dress or feed himself.

The development of paresis and a rigidity of certain muscles
generally accompany or follow the onset of tremor. In exceptional
cases, paresis may precede the development of tremor.

An abnormal attitude of the fingers is very frequently observed in
connection with this disease. Sometimes the fingers assume the attitude
commonly employed in holding the pen; again, the constant movement
of the thumb against the extended fingers gives to the patient the appear-
ance of rolling a ball in each hand between the thumb and forefinger;
finally, the fingers may assume an attitude characterized by flexion of the
first phalanges, and over-extension of the second phalanges, and a flexion
of the third phalanges. The latter deformity very closely resembles that
observed in connection with arthritis deformans.

As arule, the upper extremities are flexed also at the elbow, and the
elbow is carried away from the chest. The admirable drawing made by
Charcot (Fig. 128) illustrates this point.

The gait of these patients is very peculiar. It has been described on
a preceding page. As they trot along, the knees are apt to rub against
each other and the feet to become crossed. In some reported cases the
friction made by the rubbing of the knees has given rise to eruptions,
ulcerations, and even gangrene. Deformities of the toes and pseudo-
talipes may be detected in these patients. The head is thrown exces-
sively forward, causing a prominence of the seventh cervical spine ; and
the body is also inclined very markedly forward. A prominent author
speaks of this attitude as one which indicates to the observer a danger
to the patient of tumbling head over heels. When these patients
attempt to walk, if it can be called walking and not running, they
experience great difficulty in suddenly stopping or in turning around
suddenly to either side (propulsion). I have known them to catch hold
of objects in order to stop when called upon to do so. Occasionally,
when a patient is requested to walk backward, he continues to do so
more and more rapidly, until he falls or is stopped by an attendant.
This condition is known as that of “ retropulsion.”

There are no evidences of atrophy or trophic changes in the muscles
of the limbs, even in the advanced stages of the disease. The sensory
functions are seldom affected, nor is the electrical irritability of the
muscles materially altered. In some cases an increase of the deep
reflexes has been observed.

A peculiarity of facial eapression is commonly observed in victims
of paralysis agitans. It is described as comparable to a mask, because
there is so little play of the features. Very often the mouth is kept
wide open and the saliva drools constantly from the lips. Articulation
PARALYSIS AGITANS. 589

and deglutition may be embarrassed. The voice is generally high pitched
and tremulous, The speech is liable to be slow and monotonous. Dis-
turbances of vision are observed in many of these patients, which are
exhibited by a difficulty in following the lines on a printed page.

The bladder and rectum are not usually impaired. In many cases,
constipation exists.

Diagnosis.—The tremor of this disease differs from that of multiple
sclerosis in the fact that it is not excited by voluntary movements ; that

   

  
   
   

\e an ms |

tet
CST a

Fic. 128.—Paraysis AGITANS, oR SHAKING Paxsy. (Charcot.)

it is not accompanied by symptoms of oscillation of the eyeball; that
sensory disturbances are wanting; and that it begins usually in the
upper limbs. The characteristic gait is also a prominent feature in
paralysis agitans.

From chorea, it can be told by the marked regularity of the spas-
modic movements; the persistence of the tremor, even during sleep;
the violence of the shaking; and the fact that voluntary movements do
not increase the tremulous condition of the limbs.
590 LECTURES ON NERVOUS DISEASES.

From the tremor of alcohol, mercury and lead, the history of the
patient would render the diagnosis easy, and the characteristic gait
would confirm it,

Prognosis.—No immediate danger to life is created by this disease.
From the period of its onset, many years may elapse before death occurs
from exhaustion. In some cases the tremor may exhibit intermissions ;
but, as a rule, the disease tends to steadily advance. Whenever the tremor
has not become general, or when the spasmodic movements are compara-
tively slight, recovery lias heen known to occur in exceptional cases.

Treatment.—The preponderance of medical testimony goes to show
that this disease is seldom permanently benefited by treatment. Ham-
mond states, however, that he has succeeded in curing eight out of
twenty-five cases, and partially curing five others. Such a remarkable
result might lead to the suspicion that all of these cases were not of a
typical character. The treatment which this author adopted comprised
the employment of the primary current to the spinal cord, sympathetic
nerve, and the affected muscles, together ‘with the internal administration
of strychnia and phosphorus. Four out of the eight cases, which were
entirely cured by this treatment according to the observations of the
author cited, recovered within two months.

The first point in the treatment of all cases is to remove the exciting
cause, if possible, provided it ean be ascertained. The value of the con-
stant current in this disease is not regarded by all authors as highly as
by Hammond. Static electricity has yielded satisfactory results in a
few reported cases,

Internal administration of Fowler’s solution of arsenic yielded
favorable results in the experience of Eulenherg.

Hyoscyamine, in doses of one-twentieth of a grain three times a day,
is stated to have produced a very marked improvement in some cases
reported by Oulmont. The phosphide of zinc, in doses of one-twelfth
of a grain, prepared in pill form and administered after eating, has also
been highly recommended.

As a rule it is safe to consider most cases of this disease, that
have become well established, as practically ‘incurable. The tremulous
condition may be improved by the various remedies suggested in many
cases; but, after the cessation of treatment, the patient is apt to relapse
to his former condition.

Due regard should be paid to the avoidance of all mental excitement
and excessive fatigue of the muscles. The diet of the patient should be
as nutritious as the digestive powers of the patient will allow of.

The persistent insomnia which these patients are apt to suffer from
may be controlled by the use of a combination of chloral and the bromide
of potassium,
POSTERO-LATERAL SPINAL SCLEROSIS. 591

POSTERO-LATERAL SPINAL SCLEROSIS (GENERIC ORIGIN).

(Friedreich’s Disease—Hereditary Ataria—Generic Ataxia.)

The term that I have selected by which to designate this peculiar
form of ataxia that shows a marked tendency to affect family groups has

been lately suggested and strongly advocated
by Dr. W. Everett Smith, in an admirable essay
on its nomenclature.*

Friedreich was the first, in 1861, to de-
scribe certain cases which he had encountered as

those of a type of ataxia which seemed to select.

its victims from lines of direct consanguinity.
He believed that they presented special points of

distinction from the clinical history of ordinary

locomotor ataxia. Since his first description of
these cases, others have published a sutticient

number of similar cases, accompanied by the

results of an autopsy, to warrant our acceptance
of this condition as a distinct disease.

Among those who have contributed to the
literature of the subject may be mentioned
Friedreich, Carré, Topinard, Immermann, Ruiti-
meyer, Carpenter, Kelloggs, Power, Hammond,
and Smith. Respecting some of the cases
reported, however, there is apparently ground
for doubt as to whether they are to be regarded
as typical representatives of generic ataxia.

This form of disease was observed by Fried-
reich to affect nine persons in three families ;

Carré, of Paris, reported seven cases in one °

family ; eleven cases in two families have been
_ described by Immermann and Riitimeyer (as
quoted by Eichhorst); and six in one family
have been observed by Dr. W. E. Smith. I
have in my possession some beautiful sections
of the spinal cord taken from a patient who was

 

Fic, 129.—Morbsm APPEARANCES
PRESENTED IN HeREvITARY
Avaxia. (After Friedreich.)

8o affected (in common with several members of his family) by Dr. W.
Everett Smith (late of Framingham, Mass., but now of Boston), and

kindly presented to me by him.

Morbid Anatomy.—In this disease, a degeneration (more or less
systematic) not only of the posterior columns of the spinal cord and

* Boston Med. and Surg. Jour., March 1, 1888.
592 LECTURES ON NERVOUS DISEASES.

the posterior nerve-roots, but also of the lateral and anterior columns,
has been observed. Our knowledge, however, rests upon only eleven
autopsies. In the spinal sections which I possess, the crossed
pyramidal and the direct pyramidal fibres of both sides are somewhat
affected; although not to so great an extent as the columns of Goll
and Burdach. Unlike in true locomotor ataxia, females seem to be
somewhat more frequently affected than males. Although it seems

 

Fic. 130.—PHoToGRAPH oF Case. (Reported by W. E. Smith.)

to be a systematic disease of both the motor and sensory columns of
the spinal cord, the question is still unsettled regarding the proper
classification of this affection.

Symptoms.—These may begin during childhood, usually between
the fourth and seventh years, or at the period of puberty. The lan-
cinating pains (which are typical of true ataxia) may be wanting; or, in
some cases, they may develop late in the disease. From the very onset,
marked incodrdination of movement or a sense of weakness is developed
POSTERO-LATERAL SPINAL SCLEROSIS. 593

in both the upper and lower extremities. In some cases reported, the
ataxic symptoms have been confined to the upper limbs. The disturb-
ance of codrdination is very rapidly developed. It may affect the
movements of the head, the muscles of speech, and possibly those of the
eyeball. Changes in the pupil and defects of vision are not commonly
observed,—a fact which is a marked contrast to the course commonly
observed in tabes dorsalis.

=z

 

Fie. 131.—PrHotTocrary or Case. (Reported by W. E. Smith.)

According to most observers, the tendon reflexes are usually
abolished. The sensory functions are less disturbed than in ataxia of
adults ; although tactile anaesthesia is generally developed. The muscular
sense is usually retained to a greater or less extent. The plantar reflex
may often be retained, in spite of the complete abolition of the knee jerk.

Some time after the symptoms of incodrdination appear, paralysis
and contracture tend to develop in some cases, these symptoms are
usually more marked in the lower limbs than in the upper. The patients

38
594 LECTURES ON NERVOUS DISEASES,

cannot walk, as arule; and free movements of the hands or arms may
become impossible.

Bed-sores do not occur in this disease. The sphincters are not
affected. The mental faculties seldom exhibit any marked impairment.
The speech, however, tends to become of a drawling kind, and often
more or less unintelligible.

Vaso-motor disturbances may be observed ; chiefly in the form of
polyuria, salivation, and excessive sweating.

The two foregoing figures (Figs. 130 and 131, taken from photo-
graphs made by Dr. Smith), together with the two sections of the
cord of one of these patients (Figs. 132 and 133), which have been
very accurately drawn by Dr. H. P. Quincy, present some very
interesting points in relation to this rare atfection.

/ The involvement of

the posterior spinal nerve-

B FED z Se GC ASS, AR roots was very marked in
aan = F, this case. The anterior .
ae nerve-roots were found to

. \ be perfectly healthy. The
\ ' a clubbed feet shown in the
i
photographs of two mem-
bers of this family con-
stituted a very marked
deformity.

In Dr. Smith’s six
_ cases, a sense of weakness
Fic. 132—Szction or Dorsat Recron. (After Smith and and uwneertain ty of MOvVE-
Quincy.) AR, Anterior nerve-roots (healthy). L, :

Lateral column (diseased). PR, Posterior nerve-roots ment of the limbs pre-

(diseased). P, Posterior columns ‘(diseased). C, Central

‘canal, ceded by the development
of ataxia and girdle-

pains; and likewise abnormal sensory phenomena in five of the subjects.

Incoérdination of movement was an early symptom.

In two cases “ wrist-drop” developed. In the two fatal cases reported,
death was preceded by symptoms of spinal meningitis and myelitis.

The movements of the head were attended with “irregular oscilla-
tions,” which were aggravated by voluntary attempts at movement of
any part of the body.

The limbs became greatly distorted by progressive atrophy and con-
tractures. Attacks of extreme dyspnea and impending collapse were
frequently noted.

In the case shown in the photographs, epileptic attacks had |
frequently for fifteen years prior to the published notes upon her con-
dition, She had developed right lateral curvature with kyphosis; also a

4

     
POSTERO-LATERAL SPINAL SCLEROSIS. 595

talipes equino-varus ; and extreme flexion of ‘the hands, wrist, forearm,
and head. She could neither pick up objects from her ion nor fed ehiani
when placed in her grasp.

Differential Diagnosis.—This disease might possibly be mistaken for
lead-poisoning, cerebellar disease, cerebro-spinal sclerosis, lateral spinal
sclerosis, amyotrophic lateral spinal. sclerosis, locomotor ataxia, chronic
myelitis, and progressive muscular atrophy.

Many of the tables given in connection with these diseases will aid
the reader in making the necessary discriminations.

I take the liberty of quoting, however, in this connection, several
paragraphs from a late brochure of W. E. Smith, respecting the clinical
distinctions which seem
to be regarded by him
as justified by the some-
what scanty literature of
this subject. He says :—

“ Now, although it is
true,as Ormerod has said,
that there have been cases
of Friedreich’s disease,
so-called, where paralysis
of the lower limbs has
been reported, ‘in no case
has it been observed until
the disease had existed
for a period of years, and
in some Very carefully Fic, 133.—Secrion of Dorsat Recion. (After Smith and

 

Quincy.) AR, Anterior nerve-roots (healthy). AL,

observed cases there has Antero-lateral column (diseased). PR, Posterior nerve-
. roots (diseased), P, Posterior columns (diseased), C

been no paresis at all, but Penalens . oe

simply ataxia. Again,

although in some cases diminution of sensibility has been noted, it is
usually for the earlier periods in quite an insignificant degree, and in
many cases every abnormality of sensation has been thoroughly excluded.
We have, therefore, in this disease an illustration of ataxia pure and
simple, apart from motor or sensory paralysis.’

“Clinically speaking, the difference between the classic locomotor
ataxia and the so-called hereditary ataxia may be distinctively arranged
into three general groups. In the first place, ordinary tabes does not
run in family groups, while Friedreich’s disease clearly does. Yet the
cases are few where, even in the latter disease, a strict heredity can be
claimed. It attacks, as a rule, members of the same generation in the
same family, although occasionally successive, as well as simultaneous,
outbreaks have been observed in the same family, as, for example, in
596 LECTURES ON NERVOUS DISEASES.

Carré’s cases, where the mother of the seven ataxic patients, her brothers.
and sisters to the number of eight, and her mother were all ataxic; in
Brousse’s case, where the mother was ataxic; in one of Rutimeyer’s
cases, where a male ancestor five generations back was ataxic; and in my
series:of cases,* where the father of the five affected girls clearly developed
the disease late in life. More often, however, a remarkable proclivity to
other forms of disease has been observed in these family forms of ataxia:
‘on the side of the nervous system, to chorea, paralysis, hysteria, mental
affections, intemperance; on the side of general diseases, to phthisis.’

Hf Patni, ordinary tabes is a disease of middle age or of later life,
while the family form of ataxia develops usually in early childhood.
Friedreich held that its development was connected with the changes of
puberty, and that females were particularly prone to it; while Ormerod
believes that the onset of an acute disease may have a possible influence
in its production. The disease is unquestionably due to a lack of proper
development of the nervous elements of the cord and their consequent
atrophy, and it is worthy of notice that the ataxic families are generally
large; so that it may be that the rapid production of children may have
caused an imperfect development of some of them. At any rate, enough
cases have now been reported to show that sex has nothing to do with
either the development or the occurrence of the disease.

“Nor do I believe that puberty is a potent or a common cause.t
The majority of cases thus far reported began to show an evident lack
of development at as early an age as five or seven years,and I very much
suspect that if these cases had been more carefully watched, they would
be found never to have been as steady in their movements as were other
children. At the age, however, when they would naturally begin to
romp and run, the parents may possibly observe that they cannot carry
themselves as well as their playmates can, but think little of it perhaps,
until the onset of an acute disease, or the extra demands which puberty
makes upon the system has allowed the incodrdination to develop to
such an extent that it can no longer be unnoticed.

“Thirdly, the absence of sensory derangements in the hereditary
forms of ataxia is of great diagnostic value. In typical tabes, as is well
known, the lancinating pains are usually a prominent symptom, espe-
cially in the early stages, and are rarely absent throughout the entire
history of the disease, while other sensory disturbances, such as numb-
ness and local anesthesia, frequently accompany the incodrdination of
movement. But in the majority of cases of family or ‘hereditary’ ataxia
pain is conspicuous by its absence, until at least the disease is very far
advanced ; although it is true that cases have been observed, such as those

* Boston Med. and Surg. Journal, October 15, 1885, p. 361.
{ Ibid., February 16, 1885, p. 175.
POSTERO-LATERAL SPINAL SCLEROSIS. 597

of Carré and Dreshfeld, where it occurred as an initial symptom. The
absence of the knee-jerk is, indeed, common to both of the forms of
ataxia which we are discussing, but the curvature of the spinal column,
which occurs so early and so markedly in the family form of the disease,
does not belong to the history of locomotor ataxia. Another critical
diagnostic symptom is the affection of the speech in the hereditary form
of ataxia. ‘From a mere drawl, stammer, undue confluence or undue
separation of syllables, the affection may advance till speech becomes
wholly unintelligible.’ ;

“The highest level to which the hereditary disease extends is marked
in its clinical aspect by the symptom of nystagmns, Bilateral and
transverse in its action, it is observed only when the patient looks at or
follows an object intently. Being a very late symptom, its absence in a
given case need not tell necessarily against the diagnosis of the family
form of the disease. Bed-sores and visceral disturbances never occur,
as they so commonly do in locomotor ataxia.

“ Seeing, then, how marked the contrast is between the two diseases,
it is not in the least surprising that some authors should have denied
altogether the existence of relationship between them. Thus, on the one
hand, Hammond maintains that Friedreich’s cases are not examples of
primary disease of the cord at all, but of disease of the medulla or cere-
bellum, extending secondarily to the cord; while, on the other hand,
Vulpian, Charcot, and Bourneville regard them to be simply a variety
of disseminated sclerosis. Although the affection of speech and the
nystagmus would seem to lend some plausibility to the latter theory, the
morbid anatomy of the cases, as revealed by autopsies, must be our final
test, and by this we find conclusively that the disease is spinal, and not
cerebral, in its origin; that whatever cerebral degeneration there is is
late and entirely secondary in its development; and that, moreover, the
spinal sclerosis is systematic, and not disseminated, in its character.

“Nor does the suggestion of Erb that cases of tabes may be grouped
under two types, the classical type and the type described by Friedreich,
seem entirely appropriate when we come to look at the pathology,
although the occurrence of forms apparently transitional between the
two may give some reasonable support to the idea. Such cases are
those reported by Carré, where there was a well-marked affection of the
speech and a distinct heredity, yet where the disease began with pains
and numbness in the legs and feet; and those reported by Dreshfeld,
where there were pains from the onset, and no affection of the speech
reported. In three of Friedreich’s own cases, also, these early pains
were noticed, and in Powers’ case there appear to have been vomitings
at an early period. Other aberrant forms are the two cases of Seelig-
miiller which Friedreich refused to recognize as of the same type as his
598 LECTURES ON NERVOUS DISEASES.

own cases, chiefly because of some mental peculiarities and the persistence
of the knee-jerk.”

Treatment.—The remarks already made when the treatment of
locomotor ataxia was considered are equally applicable to this disease.

The only unexplored field that suggests itself to my mind relates to
a question of its possible causation. ‘The accurate determination of the
presence or absence of some marked abnormality in the visual apparatus
(the eyes themselves or the ocular muscles) of the patients so afflicted,
and algo of all of the members of the family who have escaped, might
possibly shed some light upon a factor which, if present as a family
defect, might act as a cause of serious impairment of the nervous
energies of those who had thus far escaped any of the serious manifesta-
tions of organic disease.

The proclivity of other members of the families, into which this
disease has entered, to functional nervous diseases,—such, for example, as
chorea, hysteria, intemperance, mental disturbances, ete..—would cer-
tainly justify us in investigating this point very carefully.

EXOPHTHALMIC GOITRE.
(Graves’ Disease—Basedow’s Disease.)

A peculiar combination of an abnormal irritability of the heart, a
protrusion of the eyes from their sockets, and the development of an
enlargement of the thyroid gland (goitre), has been considered as a dis-
tinct disease since the original publications of Graves and Basedow.
The term ‘ exophthalmic goitre ” is now commonly used in speaking of
this affection.

Morbid Anatomy.—The pathology of this disease is to-day, as it
always has been, a subject upon which authors of note differ. Various
morbid conditions in the brain, spinal cord, and sympathetic nervous
system have been observed in connection with this train of symptoms.
In some instances, however, no marked changes of a morbid character
have been found after death. Many of the symptoms observed during
life seem to point to some form of disturbance of the centres situated
within the medulla, a view which is sustained by Panas, Hammond, and
others. Basedow considered this disease to be a manifestation of an
abnormal state of the blood analogous to chlorosis. Piorry, Bouillaud,
and others have attributed many of the symptoms to a compression made
by the enlarged glands upon the vessels and ‘sympathetic nerves of the
neck, The hypothesis advanced by Stokes, that the symptoms depend
primarily upon hypertrophy of the heart has to-day few, if any, supporters.

The symptoms of this disease are believed by many authors to
depend primarily upon the morbid state of the sympathetic system, On
the other hand, the opponents of this view bring forward imany justifiable
EXOPHTHALMIC GOITRE. 599

objections to this conjecture, and urge that such a conclusion is not
supported by pathological investigation in many cases.

The view seems to be gaining ground that we are justified in regard-
ing this form of disease as the result of a disturbed action of the medulla
oblongata, and possibly of some of the higher centres of the brain.

The prominence of the eyeballs is probably attributable to several
factors. Among these may be mentioned an unnatural turgescence of the
vessels of the orbit, an increase of the fatty tissues of the orbit back of
the eyeball, and a degeneration or lack of power of the ocular muscles
which allow the eyeball to bulge forward.

Etiology.—Among the factors of causation of this disease, undue
excitement of mind and physical or mental over-exertion may be promi-
nently mentioned. It has been known to follow blows upon the head.
It may occur also in connection with any condition which tends to
impair the quantity or quality of the blood; :and it is not infrequently
associated with evidences of hysteria and neurasthenia, A large propor-
tion of such cases seems to occur among women, a fact which is explained
by some authors as a result of the frequency of debilitating diseases,
hemorrhages, and nervous depression in the female sex. It occurs most
frequently between the twentieth and fortieth years of life.

Symptoms.-—The first symptoms of this disease are usually noticed
asa disturbed action of the heart, and an acceleration of the pulse of a
very marked character (120 to 160 beats per minute). At first the
heart’s action is apt to be irregular only when the patient is excited or
fatigued, but, later on, this is observed to occur during repose and inde-
pendent of any known exciting cause. There are no physical signs of
organic disease, but, in many cases, carotid pulsation and a “bruit” in
the vessels of the neck may be detected. Occasionally, a systolic murmur
and evidences of cardiac hypertrophy may be observed after the disease
has existed for some time.

After a lapse of several weeks or months, the patient notices that
the thyroid gland is gradually becoming enlarged. ‘This enlargement, as
arule, is at first apparent on one side only. The arteries which supply
the gland may often be seen to be more or less enlarged and tortuous,
and a blowing murmur may be sometimes detected over the gland. The
gland tends to gradually acquire an abnormal hardness. It may be seen
later on to rise and fall in rhythm with the pulsations of the carotids.

Simultaneously with or following the enlargement of the thyroid
‘gland, the eves of the patient begin to be more or less prominent and to
assume a peculiar fixed look that has been compared to the expression
seen in the eyes of a bull. The size of the palpebral fissure is more or
less increased by the protrusion of the eye, and, later in the disease, it
often becomes difficult or impossible for the patient to close the lids over
600 LECTURES ON NERVOUS DISEASES.

the eyeball. The power of divergence of the eyes is generally more
impaired than that of convergence. The upper lid participates imper-
fectly in the vertical movements of the eyeball. The cornea may lose its
sensibility and appear more or less glazed and opaque. Ulcerations of the
eyeball have been observed. The secretion of tears may be rendered
excessive. An unnatural redness and swelling of the conjunctiva is at
times observed. The power of vision and of accommodation is not
generally disturbed.

In consequence of the enlargement of the thyroid gland, the voice
may be altered and respiration may be somewhat embarrassed.

The general system is apt to be more or less deranged. A loss of
appetite, dyspeptic symptoms, diarrhea, marked emaciation, and chlo.
rosis are not infrequently present in these cases. It is not uncommon
to observe the development of dysmenorrhea or a complete cessation of
the catamenia. Unilateral sweating has been recorded in quite a large
number of cases. ,

The course of this disease is an exceedingly chronic one. It may
last for many years.

Diagnosis. —In those cases where the ‘chief phenomena are not
very pronounced, some difficulty may be experienced in forming a
definite opinion respecting the character of the disease. Whenever the
eyeballs are at all prominent on both sides, if the thyroid gland trans-
mits to the hand of the observer when placed upon it a peculiar thrill,
and the heart’s action is accelerated and somewhat irregular, we are
justified in suspecting the existence of this affection even in cases where
none of these symptoms alone are very well pronounced.

Prognosis.—Cases of this character seldom prove fatal. Some of
the later publications upon this subject seem to justify the statement
that under proper treatment quite a large proportion of patients so
afflicted may be cured. In almost every case, there is reasonable ground
to anticipate marked amelioration of the symptoms.

Treatment.—The internal medication of these patients should he
directed toward the improvement of the blood by iron; the quieting of
the nervous symptoms by a judicious use of the oummaplesis the improve-
ment of the heart’s action by digitalis; and the dontraction of the blood-
vessels by ergot.

All of these ingredients may be compounded in one prescription,
such as that recommended by Hammond :—

BR. Ferri pyrophosphatis, zinci bromidi., . ,......-- aa 3.
Digital HINGEUTE. 6 od mk a OP Re a a a 3v.
Hrgoleiext:. 2b SG 2 ae Sodom RR hee BE Om Bw Biv.

M. Ft. Mist.

Dose, a teaspoonful three times a day.
In connection with this prescription, it is well to instruct the
MYXCiDEMA. 601

patient to eat plentifully of animal food, and to indulge in moderation
in malt liquors.

Hammond suggests that after this prescription has been taken for
several weeks, it be changed for a combination of strychnia and
phosphorus, or of the extract of nux vomica and the phosphide of zine.

The electrical treatment of these patients is, perhaps, more important
than the medicinal. A constant-current battery should be employed.
The positive poles should be applied at the nape of the neck, and the
negative poles connected with a medium-sized electrode should be placed
in contact with the thyroid gland for about five minutes, and afterward
stroked up and down the neck so as to influence the sympathetic cords
and the pneumogastric nerves of either side. The latter application
should not exceed five minutes. The strength of the current should be
as great as the patient can comfortably bear during the application to
the thyroid, and somewhat less intense during the labile applications to
the sides of the neck.

Cases of cure by means of the galvanic current have been reported
by Rockwell, Bartholow, and others,

Deep injections of ergot and alcohol have been employed in treating
the enlargement of the thyroid gland, with results which seem to haye
been markedly beneficial Hammond reports multiple injections into
the substance of the gland of from twenty to thirty minims of the fluid
extract of ergot daily. I have had no personal experience with this
form of treatment.

MYX@DEMA.

(Cachexie Pachydermique.)

This disease seems to consist of an abnormal condition of the skin,
which is associated with a deposit of a mucoid substance and a degener-
ation and proliferation of the connective tissue.

Morbid Anatomy.—The changes observed in this disease are prob-
ably confined at first to the skin and the connective tissue which binds
it to the muscles. The changes in the skin are most frequently observed
in the face; prominently in the forehead, eyelids, cheeks, nose, and lips.
Moreover, the fingers and toes, and occasionally the limbs and trunk,
may also be affected. The mucoid deposit has been observed not only
in the skin, but also in the central nervous system. By some authors it
is believed that the primary changes are probably confined to the cells
in the gray masses of the brain and cord, although the exact character
of such changes is largely a matter of conjecture.

Etiology.—This condition occurs chiefly among women. It seldom
develops prior to the period of puberty or after the fiftieth year. It is
thought to be dependent upon pregnancy, lactation, parturition, exposure
602 LECTURES ON NERVOUS DISEASES.

to cold, anxiety, mental shock, atrophy of the thymus gland, sexual
excitement, and the “ neuropathic tendency.”

Symptoms.—A peculiar swelling, which closely resembles cedema, is
first noticed in the face. It becomes diflicult to close the lids on account
of their extreme thickening. The expression of the face tends to assume
a coarse and animal appearance. The features become more or less
stolid, and fail to express the emotions of the patient. The tears and
saliva are secreted in excess in some cases. The mucous membranes
which line the mouth, pharynx, digestive track, and larynx may also be
markedly thickened. The voice tends to become more or less hoarse and
nasal, and the articulation indistinct and monotonous.

When the upper extremities are affected, the hands are usually more
or less enlarged and distorted. The fingers are rendered bulbous at their
tips,and clumsy in their movements. The ability of the patient to write
or sew is materially interfered with, and often entirely lost.

The feet may be affected in the same way as the hands, and the
swelling of the skin may, in some cases, extend up the leg and even
involve the trunk. The gait of these patients is rendered slow and
laborious when the lower limbs ave seriously involved.

The swelling which affects the limbs and the trunk differs from that
of edema (for which it might easily be mistaken) by the fact that
pressure made by the fingers does not leave a pit after the pressure is
removed, as in the case of cedema. The reason why “ pitting” is absent
is that the skin and the cellular tissue beneath it have a semi-solid con-
sistence from the deposit of musin. The color of the skin has been
compared to that of alabaster, or of a yellowish wax. The bodily
temperature is not elevated. In many cases reported it has been some-
what lower than normal.

The secretion of perspiration and sebacious material is often
markedly decreased, and the skin may appear to be unnaturally dry and
more or less wrinkled. Occasionally the hair is lost. The nails may
become furrowed and extremely brittle.

These patients are apt to suffer from a sense of coldness in the
affected parts. Other forms of subjective sensations, such as numbness,
the creeping of ants, the feeling as if the parts were asleep, tingling, etc.
These are less common than the sensation of coldness. Occasionally the
skin may present a livid color or isolated reddened patches.

The mental condition of these patients is more or less affected as the
disease progresses. They may exhibit somnolence, apathy, a loss of
memory, and inability to converse as intelligently as before the attack,
or to solve the simplest mathematical computations. Delirium and
hallucinations may also develop. An indifference to the surroundings
and a peculiar slowness of speech in answer to questions propounded to
MYXC@DEMA. 603

the patient are frequently observed. These symptoms may he attributed
in many cases to the fact that the brain and spinal cord participate in
the changes observed in the skin.

The digestive functions of these patients are usually disturbed to a
greater or less extent. Especially in the latter stages of the affection,
we are apt to encounter constipation and dyspeptic symptoms.

The course of this disease is progressive, and essentially chronic.
Its average duration is said to be about sixteen years.

The special senses are not infrequently impaired. The patient may
state that objects are seen with a blurred outline, or as if surrounded with
ahalo. In some cases, double vision has been’ observed, together with a
slowness of movement of the pupils to the effects of light. The sense of
hearing may be diminished, and the smell and taste may be very seriously
affected. These symptoms may be explained by alterations in the mucous
membranes of the nose, throat, and mouth.

Diagnosis—This disease might possibly be mistaken for general
edema. The presence of aluminuria (which sometimes exists in con-
nection with myxcedema) might tend to further mislead the physician
regarding the diagnosis of this affection. The absence of pitting upon
pressure over the swollen parts, the clubbing of the fingers, and the
peculiar distortion of the features, are so diagnostic of this disease that

_itean hardly be confounded with the @dema which is observed in con-
nection with kidney disease, arsenical poisoning, or diseases of the right
heart that seriously interfere with the return of blood from the veins.

A condition of body, known as “ scleroderma,” in which there is
an actual hypertrophy of the skin, might be mistaken for this affection.
In seleroderma, however, the surface of the skin is hard, and a peculiar
“sense of tightness ” exists in the affected parts. We do not encounter,
moreover, in scleroderma abnormal mental conditions, nor any permanent
reduction in the temperature of the body. Besides, it is encountered at
a much earlier age than is myxcedema, cases being seldum observed after
the thirty-fifth year, according to Hammond.

Prognosis.—Myxcedema may terminate fatally, although in most
cases its progressive course covers so many years that death is apt to
supervene from some intercurrent affection, There is little hope in any
case of arresting the disease.

Treatment.—It is well in these cases to support the general health by
the use of mineral and vegetable tonics, and the judicious employment of
electricity, massage, and hot-air baths. In spite of the fact that medication
seems to exert little if any influence upon the actual symptoms of the dis-
ease, the preservation of the strength of the patient and the regulation of
the digestive functions may possibly postpone the development of the
More serious manifestations which are apt to occur late in the disease.
SECTION VIL

ELECTRICITY IN MEDICINE.

(605)
SECTION VII.
ELECTRICITY IN MEDICINE.*

In the diagnosis and treatment of nervous diseases, no agent is more
generally applicable than electricity, Its brilliant and often instantaneous
effects and the prevalent belief among the laity that electricity is prac-
tically identical with the vital forces of the human body have conduced
largely to the general use and frequent abuse of this important agent.

Thousands of electric batteries are sold yearly by the various manu-
facturers to persons both in and out of the medical profession. Many
who buy them are utterly ignorant of the principles of their construction,
and equally so of the indications for their use. A very large majority of
the medical profession possess only a faradaic battery or a magneto-
electric machine. They employ such a battery upon every case which
to their mind requires electricity. A few, in our larger cities, own a
galvanic battery ; but, as a rule, those who do so are unable to repair it
themselves when the connections become oxidized or when it fails to act
from a multitude of other causes. In my experience, it is very uncom-
mon to meet a medical practitioner (outside of those who are specially
interested in neurology) who thoroughly understands electro-physies
and many important facts relating to the uses for which special forms of
batteries are best adapted. I have deemed it wise, therefore, to include
in this section a terse and practical statement of the more important
facts which should be mastered before the treatment of disease by
electricity is attempted, and to shed some light upon the forms of
current which are indicated in the treatment of many of the nervous dis-
eases commonly encountered. I shall include in these remarks some
practical suggestions respecting the selection of batteries and the care
of them. The uses of electricity in diagnosis,as well as its therapeutical
properties in the treatment of nervous diseases, will be also presented in
as concise a form as is comportable with clearness of statement.

PART I.
ELECTRO-PHYSICS.

Under this heading we shall first discuss the varieties of electric
currents which may be produced (the faradaic, galvanic, magneto-
electric, and static). We shall also consider the construction of a galvanic

* A part of this section has been issued as 2 separate yolume by D. Appleton & Co.,
New York, 1886.
(607)
608 LECTURES ON NERVOUS DISEASES.

cell and its many modifications. It is important that physicians know
the principles of construction of the various galvanic cells offered to the
profession for medical uses, as well as the advantages and disadvantages
of each as a part of a medical outfit. In the third place, the reader
should be made familiar with many new terms which are commonly used
to-day in electrical literature, and also the application of Ohm’s law to
electrical problems. Finally, he should acquire a familiarity with the
many attachments to a battery. These are essential to its proper use, and
their purposes should be well understood. Under this heading I shall
give some practical hints respecting the selection, care, and repair of an
electrical outfit for medical purposes.

VARIETIES OF ELECTRIC CURRENTS.

A few of the more important facts relating to this agent (which we
are constantly called upon to employ in the treatment of various types
of disease) should be thoroughly understood by all who intend to use it.
Time will not permit of a detailed description of the different properties
of electric currents. These can be acquired from any of the standard
works upon physics. It is necessary, moreover, that such points as are
presented here should be briefly and simply stated.

The GALVANIC CURRENT (called also “ voltaism,” the “ battery.current,”
and the ‘constant current”) is one which is derived by chemical decom-
position or heat from one or more pairs of elements directly. When the
body is placed between two electrodes connected with such a battery in
action, the current traverses the part of the body embraced between the
electrodes before it returns to the battery—starting at the positive pole
(the anode), circulating through animal tissue, and returning to the
negative pole (the cathode). The polarity remains unchanged under all
circumstances.

Muscular contractions are produced only when the current ts closed
or broken, or when its intensity is increased. A very weak current fails
to produce muscular contractions.

In connection with the description of the tests employed in the
diagnosis of nervous diseases, suggestions have been made by me which
may be reviewed in this connection with advantage. (See Section IT
of this volume.)

By peculiar arrangements of the elements of a battery, the galvanic
current can be modified as follows: (1) To produce heat (cautery bat-
tery); (2) to insure chemical changes in living tissues (electrolysis) ;
and (3) to aid in many of the mechanical arts, such as electro-plating,
electric lighting, telegraphy, ete.

The FARADAIC CURRENT (called also the “induced” or “interrupted
current”) differs from the galvanic in that it is an induced current of
VARIETIES OF ELECTRIC CURRENTS. 609

high tension, which is produced by the magnetizing and demagnetizing
of a bar of soft iron or a bundle of soft-iron wires by means of a galvanic
current.

The circuit of the generating cell is made to pass through a coil of
insulated wire, known as the“ helix,” which surrounds the iron to be
magnetized, but i does not iself pass to the electrodes and thus to the
patient.*

When the current of the generating cell passes through the helix,
the soft iron is magnetized and draws the interrupter in contact with it.t
This breaks the circuit and demagnetizes the iron. The interrupter is
then returned to its former place by a spring. This step reconnects the
generating cell with the helix, and again allows the iron to be magnetized.
The interrupter is again drawn in contact with it. Thus the eurrent
is constantly broken and restored by a simple device known as the
“interrupter,” or “automatic circuit-breaker.” An induced current
within the iron core of the helix is thus produced. This is the current
which passes through the electrodes to the patient.

Much ingenuity has been shown in the construction of the “inter-
rupter” of a faradaic machine. It is very desirable that slow and rapid
interruptions may be produced at the will of the operator. If a machine
only insures rapid interruptions, the slow interruptions can be effected
by the use of an “interrupting electrode.”

The power of producing electrolysis, and some other chemical
properties peculiar to the galvanic current, are wanting in the faradaic.

Never attempt to combine a galvanic and a faradaic batlery. Separate
cells should be employed for each, as the faradaic battery requires a cell

* This is a point which cannot be too strongly impressed upon the minds of the pro-
fession. Its accuracy can be readily proved. If the binding-posts of the primary coil of a
faradaic machine be united by means of a large copper wire, the current generated in the
galvanic cell which runs the interrupter will pass through the wire rather than through
the helix which surrounds the iron core (because the wire affords less resistance). The
interrupter will then remain stationary, as the iron core is no longer magnetized. Again,
the interrupted or faradaic current has no chemical properties. This would not be the
case if the current of the generating cell passed to the binding-posts of the faradaic
machine. Finally, the external resistance of the human body is far in excess of that
afforded by the helix, and this alone would prevent the galvanic current of the generating
cell from traversing the animal tissues (the circuit of the greatest resistance).

It is not uncommon for agents of the various manufacturing companics to show a
prospective purchaser of a faradaic machine the galvanic cell which works the ‘inter-
Tupter,”’ and to endeavor thus to leave the impression that a galvanic current (as well as
the primary and secondary faradaic currents) can be conveyed by a faradaic machine to a
patient. Such a statement is untrue, and, if made, indicates either ignorance or dishonesty.
Subsequent diagrams will render the mechanism of a faradaic machine intelligible to the
reader,

t The expression ‘in contact.’’ is not strictly correct. The interrupter never actually
touches the iron core, because its magnetic action ceases before it reaches it. :

39
610 LECTURES ON NERVOUS DISEASES.

of greater capacity than those used in portable galvanic machines.
They may be placed in the same case, but each should be perfectly
independent of the other. If a battery is designed for transportation,
it is best to have one of each rather than two combined in one case.

 

 

 

Fre. 134.—One or tHE Many Forms op Farapaic MAcuine.—B28, connecting rods attached
to the elements of the exciting cell; D.adrip-cun, in which the zinc element is placed when
not in use (it should contain mercury); £, primary and secondary coils, /, adjusting screw
for the interrupter (¥): G,binding-posts: A’, plunger; ZL, 1/7, rheophores: O, P, electrodes.
The next figure will explain the action of the different parts ‘The faradaic instruments of
different manufacturers vary more or less in their mechanical devices and perfection of work-
manship, but the principle of all is the same.

The faradaic current ts an alternating current,—i.e., one which goes
in opposite directions at each make and break of the circuit. It is

strongest when, the current is broken. These facts are not generally
recognized by the profession. The polarity changes with each interrup-
VARIETIES OF ELECTRIC CURRENTS. 611

tion. The so-called “ cathode ” of a faradaic battery is felt the strongest
by the patient.

The helix of a faradaic machine is usually surrounded by a secondary
coil of wire, known as the “ secondary helix,”

This coil has no connection with the elements of the generating cell.
The current produced within it is induced by the passage of the current
(formed within the generating cell) through the “ primary helix,” which
magnetizes and demagnetizes the iron core. It is therefore called the
“secondary current.” It has high tension, is alternating, and_ is
employed in telephonic lines, chiefly on account of its high intensity. It

 

 

 

 

 

 

 

 

 

 

 

Fie. 185.—A DIAGRAM DESIGNED BY THE AUTHOR TO ILLUSTRATE THE CONSTRUCTION AND
Action oF A Farapaic Macuink.—Z, zinc element; C, carbon element; P, binding. posts
for the primary coil; $, binding-posts of the secondary coil; @, the interrupter when the
circuit is passing to the helix; 4, the interrupter when the circuit is broken. The screw
(shown in contact with a) allows of the adjustment of the interrupter to the bundle of soft-
iron wires within the primary helix, thus making the interruptions fast or slow at the will
of the operator. ‘The patient is connected with the battery in action by means of cords
attached to the binding-posts at Por S. These cords are not shown in the diagram, but are
shown in Fig. 134, The arrows show the direction of the.currents. The zinc is marked as
the negative element (—) and the carbon as the positive (+) element of the battery. Note
thatthe wireof the primary coil is represented as coarser than that of the secondary; that
the secondary coil has no connection with the elements of the cell; that the current going to
the primary binding-posts is generated by the iron core, and is not that which originates in
the galvanic cell; and that the interrupter has a small piece of platinum soldered upon it
where it comes in contact with the screw, so as to prevent oxidation at that point. Patients
feel the current made by the “break’’ more than that from the ‘*make’”’ of the circuit;
hence, one electrode apparently gives astronger current.

is modified in strength by regulating the amount of the secondary coil
which overlaps the primary—the smaller the extent of the overlap, the
weaker the current. <A sliding tube of metal is sometimes made to pass
over the primary coil, or between it and the primary coil. This accom-
plishes the same results as if the helix was movable.

The primary and secondary coils of a faradaic machine are made of
wire of different thickness and length. Many of those sold are poorly
constructed. They are the most important features of the instrument,
and should be made with the greatest care and of the best materials. A
fine finish of brass mountings and varnish does not always indicate good
workmanship in the coils themselves.
612 LECTURES ON NERVOUS DISEASES.

Induced currents develop in the individual coils of the wire forming

the primary spiral (as well as in the iron core which it invests) and also
in the secondary helix. These currents are of no therapeutical value
without the iron core, as they lack sufficient intensity.
If the secondary helix is composed of very fine wire, the current
induced within it is extremely painful. The number of coils and the
thickness of the wire selected for the primary and secondary helix
should be graduated to a proper relation to each other and the electro-
motive force of the generating cell employed.

 

Fic. 136.—A Static Macuine 1N Use.—The “direct spark’’ is here represented as being
drawn, z.¢., the patient being charged positively and the electrode being connected with the
negative pole of the machine, No Leyden jars are employed in this form of administration
of static electricity. The “indirect spark’’ is more commonly employed than the direct,
one pole being attached, in this case, to the insulated platform, the other being grounded by
a brass chain, and the electrode being grounded by a chain attached to a gas-pipe, a water-
faucet, or the like.

The term “primary current” is often used as synonymous with the
galvanic, It is incorrectly applied by some authors to that faradaic
current which is induced by the magnetizing and demagnetizing of the
soft-iron core of the helix.

STATIC ELECTRICITY is derived from friction. A revolving plate, or
by preference several plates, of glass may be employed as a generator.
Static electricity is sometimes called franklinism.

This form of current has high tension, but it possesses few, if any,

chemical properties. When a patient is charged with it, it is necessary.
VARIETIES AND CONSTRUCTION OF GALYANIC CELL. 613

that the chair upon which he sits should be insulated by glass or rubber
under the legs. When highly charged, sparks may be elicited from the
body of the. patient through the clothing.

Static electricity will be quite fully discussed, as to its physics as
well as a therapeutical agent, in subsequent pages. ’

Experimentation has shown that this form of electricity is accumu-
lated upon the periphery of the object charged (as explained in all works
upon physics). It apparently does not permeate very deeply below the
surface.

The MAGNETO-CURRENT (called also the dynamic current”) is derived
from a permanent or electro-magnet, in front of which an armature ts
made to revolve. The armatures are composed of a core of soft iron
wound with insulated wire, and the currents produced are formed within
them by breaking the lines of magnetic force.

The stronger the magnet, the more rapid the breaks made in the
current by the revolving armatures, and the greater the number of turns
in the spiral wire of the armatures, the more intense is the current,

This form of current possesses great electro-motive force or intensity.
Currents of this kind are of an alternating character. By means of an
automatic commutator (polarity changer), they may be carried, however,
in one direction, and, when so, they assume properties similar to those
of galvanic currents, Electric lighting, electro-plating, and many other
similar applications to the mechanical arts, are to-day accomplished by
means of dynamo machines at a minimum cost as compared with battery
currents. They are practically obsolete as a machine for medical pur-
poses, as the current is unsteady when hand-power is employed.

“Magneto-current ” machines (which are turned by a crank when in
use) are often sold to physicians. They are of little value. They cost
as much as a good faradaic instrument, and are not to be compared with
the latter. The current generated in both is practically the same, but it
is irregular in point of strength in the magneto-current machine, and
uniform in the faradaic instrument.

THE GALVANIC CELL—ITS VARIETIES AND THE GENERAL PRINCIPLES.
/ OF ITS CONSTRUCTION.

All substances -have an electrical condition which is inherent or
capable of being developed. This condition is known as the ‘“ porEN-
maL” of a body. The electrical condition of the earth (which may he
regarded as fixed and as a reservoir without limit) is used as a standard
of comparison of the “ potential” of any given substance.

Those bodies from which electricity tends to flow toward the earth
are known as “ positive bodies” or. bodies of “ high potential.” , They are
designated by the plus sign (|). Those which tend to draw electricity
614 LECTURES ON NERVOUS DISEASES.

from the earth are called “negative bodies” or bodies of “ low potential,”
and are designated with the negative sign (—). Almost every known
substance may, therefore, be classified either as positive or negative
under certain circumstances. Subsequent explanations will make this
more apparent.

When we speak of the “RELATIVE POTENTIAL” of two bodies, we
mean the difference in degree of the potential of each.

The bodies thus compared must both be positive or negative. One
metal, for example, may have a potential seventy times that of the
earth, and another one hundred times that of the earth. Both may he
positive, yet one is negative as compared with the other. Two such
metals have been happily compared to reservoirs at different levels
(De Watteville). The tendency between two bodies of different

 

 

 

 

Fic. 137.--A Simpce Gatvanic ELement. (After Erb.) Z7, zinc element; Cz, carbon or copper
element. ‘I'he fluid is composed of diluted sulphuric acid or a solution of some of the salts.
In 4 the circuit is open, in # it is closed by a wire connecting the elements. The arrow
shows the direction of the current outside of and within the cell,

relative potentials is for the current to flow from the body having the
highest potential to that possessing the lowest potential, thus tending to
establish an equilibrium between them. In a galvanic cell, the element
most corroded by the fluid of the cell has the highest potential (positive
element).

The difference in equilibrium between the “ potentials” of two
bodies regulates the intensity of what is known as the ‘ ELECTRO-MOTIVE
rorce” of the bodies selected; because the want of equilibrium is the
force which starts the flow of an electric current in all eases. The size
of the elements has nothing to do with it.

The simplest form of 1 GALVANIC CELL consists of two bodies uiose
potentials differ widely) immersed in a fluid which tends to excite
chemical decomposition of one of the elements. Zine and carbon are
VARIETIES AND CONSTRUCTION OF GALVANIC CELL. 615

commonly selected for the elements and dilute sulphuric acid for the
exciting agent. The zinc is strongly acted upon by the fluid, while the
carbon is not; hence, the zinc becomes the positive element and the
carbon the negative. In most batteries of this type the zinc is covered
with mercury (amalgamated), to render the action of the ecll more
uniform and to prevent local action upon the zine. It also tends to
preserve the zinc.

An apparently discordant fact should be remembered, 7.e., that the
wire connected with the carbon of such a cell (the negative element of
the cell) is the positive pole of the battery. This is because the electric
current passes through the liquid from the zine to the carbon, and back
through the external circuit from the carbon to the zine. (Fig. 137, B.)

When the elements of a cell are connected externally by a wire, a
current of electricity flows continuously from the cell-elements through
both the wire and fluid. This is known as a “complete” or “closed
circuit.”

The RESISTANCE offered to the passage of the current from the carbon
to the zine is the “external resistance”; that between the zine and the
carbon is known as the “internal resistance ” of the cell.

The INTERNAL RESISTANCE of:a galvanic cell may be modified as
follows: (1) by the distance between the elements; (2) by the size of
the elements; (3) by the tnlervention of some foreign body (such as a
porous cup) between the elements; and (4) by the character of the fluid
in which the elements are immersed. The nearer the elements are
placed, the larger their size, the more direct the passage of the current,
and the better the conducting power of the fluid used, the less the
internal resistance of the cell, and vice versé. The internal resistance
of a cell may vary between a fraction of an ohm and one hundred ohms,
according to its construction and its excitants.

The EXTERNAL RESISTANCE is modified by the length, the diameter,
and the character of the conductor employed. When any substance
(such as the human body, for example) is placed between the electrodes,
the resistance offered to the passage of a current by the interpolated.
substance must be added to that afforded by the conductors themselves.
The resistance of the human body varies from 600 to 18,000 ohms. It is
extremely low in subjects afflicted with general anasarca—probably
because an excess of fluid renders the body a good conductor. The
average resistance of the human body is not much above 2500 to 3500
ohms. The resistance afforded by the body is modified (1) by the
Saturation of the electrodes; (2) by the moisture of the surface of the
body; (8) by the tissues through which the current is directed; (4) by
pressure made upon the electrode; and (5) by many other factors which
will be mentioned hereafter. among which the addition of salt to the
616 LECTURES ON NERVOUS DISEASES.
water in which the electrodes are moistened is a very important one.*
In cautery batteries the external resistance is increased about y4, for
every degree centigrade when the temperature of the platinum wire is
raised (De Watteville). Thus heat may be a factor in modifying the
external resistance to be overcome.

The relative resistance of living tissues is represented by the following
figures (100 being taken as the maximum): The eye, 4; muscle, 6; nerve,
10; cartilage, 20; tendon, 20; fat, 75; bone, 100; skin, 100. Thus, the
eye offers only 4 the resistance afforded by skin and bone; muscle, ;;
nerves, 75; cartilage and tendon,}; and fat, # The epidermis, when
dry, is practically a non-conductor of electrical currents.

‘Respecting this point, De Watteville happily remarks that “the
human body may be compared to a vessel bound with a poorly-conducting
material (the skin), unequally packed with non-conducting solid particles,
the interstices being filled up with a saline fluid of fair conductive power.
The parts most densely packed with solid particles are represented by
the bones; those where liquid predominates, by the muscles. Between
the two are found the nerves, viscera, ete.”

Before we leave the discussion of the various forms of electric cur-
rents employed in medicine, it may be well to impress upon your minds
some of the more important facts relating to faradaism and galvanism
by means of a table in which the two are contrasted with each other.
Such.a table is not, to my knowledge, to be found in any work upon
electricity. It may prove of service in many ways :—

THE FARADAIC CURRENT

Isan “induced current.” Is produced
by the magnetizing and demagnetizing of
a core of soft iron.

Its polarity changes with each ‘“ make ”
and “break” of the circuit.

The current is an interrupted one.

It produces muscular contractions of
an apparently continuous character, pro-
vided the interruptions are very rapid.

The polarity is inconstant, because the
currents constantly alternate in direction.

THE GALVANIC CURRENT

Is due to chemical decomposition of one
or more of the elements of a galvanic cell.

Its polarity is constant. The negative
element of the cell becomes the positive
pole of the battery.

The current is a continuous one.

It does not produce muscular contrac-
tions, except when the intensity is increased
or when the circuit is made or broken.

Each pole has a special therapeutical
action peculiar to it under all circumstances.

*In testing this point lately by means of a Brenner’s rheostat, I found the resistance

from right palm to left palm, in a boy of thirteen years of age, to be 17,500 ohms, when
pure water was uscd and the electrodes pressed tirmly against the skin of both palms.
Adding a teaspoonful of salt to the water and again soaking the sponges reduced the resist-
ance to 7500 ohms. This illustrates well the necessity for so simple a precaution when
employing electric currents upon animal tissucs, When very high currents are being
used, especially in gynecological practice, salt should not be employed because it is apt to
be decomposed by the current,
VARIETIES AND CONSTRUCTION OF GALVANIC CELI.

Tae Farapatc CURRENT (continued)

Is seldom administered by the so-called
“polar method.”

Wide separation of the poles intensifies
the pain.

The “secondary current” has greater
penetrating power than the “ primary cur-
rent.” Neither equals the galvanic current
in this respect.

It has no chemical properties. It may
be modified by an automatic commutator,
so as to throw its currents constantly in the
same direction, as in a dynamo machine.
In this case it possesses chemical attributes.

A galvanometer will show only one
deflection, i.¢., the difference in strength of
the “make” and “break” currents. This
deflection is the same under all circum-
stances when the machine is in use. It
does not, therefore, indicate the strength of
the current conveyed to the patient.

There is no difference in the action of
the poles.

The faradaic instrument makes a
“buzzing noise” when in action.

617
Tur Gatyanie Current (continued)

Is administered chiefly by the “polar
method,”

Separation of the poles does not ma-
terially intensify the pain.

Has a remarkable power of penetrating
animal tissues placed “ in circuit.”

Possesses inherent chemical properties ;
hence its power of producing electrolysis,
and its use

in electro-plating, electric
lighting, etc.
Produces galvanometer deflections

which are proportionate to the strength of
the current employed.

The anode is the sedative pole; the
cathode is the stimulating pole.

A galvanic instrument gives no ex-
ternal manifestation of activity, because it
has no interrupter.

EvectricAL Unirs.—Before the construction of an electric battery

and the modifications in such an apparatus necessary to produce special
effects are considered, it is important that you familiarize yourselves
with the various units of measurement employed in electricity, and their
symbols. These are as follow :—

 

 

THING MEASURED. SYMBOL. NAME EMPLOYED FOR UNIT.
Quantity. Q. Coulumb.
Current. C. Ampere or Weber.
Electro-motive Force. E. M. F. or E. Volt. (contraction of Volta).
Resistance. R. Ohm.
vapacity. ” K. Farad. (contraction of Faraday).
Work or Energy. W. Joule.
Power. P,

Wate.

 

A counumn is the quantity that passes in one second of time against
one ohm of resistance under an electro-motive force of one volt. We use
this term as we do “pints” or “quarts” in spenking of fluids. One
coulumb will decompose 92 microgrammes of water, and thus evolve
10,4 microgrammes of hydrogen.
618 LECTURES ON NERVOUS DISEASES.

An AMPERE is the current produced by one volt against one ohm of
resistance. In medical practice, the milliampere is generally accepted
as the unit of current-strength. An ampere will decompose .00142 of a
grain of water.

A voit is the electro-motive force necessary to produce a current
of one ampere against an ohm of resistance. It practically equals the
electro-motive force of one Daniell’s cell. We speak of a battery as of
so many volts just as we designate an engine as of so many horse-power.

An ouM is the resistance necessary to allow of one ampere of current
under an electro-motive force of one volt. It is equivalent to a piece of
telegraph-wire one hundred metres in length and of a certain definite
sectional area, or a column of mercury one square millimeter in diameter
and 1.05 metre in height.

A FARAD is the capacity of a condenser which would contain a charge
of one coulumb under an electro-motive force of one volt.

A JOULE is the amount of electric energy absorbed when a coulumb
falls one volt. It is equivalent to about + of the heat required to raise
one gramme of water at 0.° C. one degree, or .7373 foot-pounds.

A watt is the power developed by one ampere falling one volt. It
is equivalent to 74g of a horse-power.

The prefixes “meg” and “micro” denote million and millionth.
For example, a megohm is one million ohms; and a microhm is a
millionth of one ohm.

The names selected for the various units of measurement are taken
from those of prominent electro-scientists (Ohm, Volta, Faraday,
Ampere, and others). .

Oum’s Law.—We are now prepared to consider the law of electric
currents discovered by Ohm, by which the intensity of a current that
will result from any combination of cells may be mathematically com-
puted, and many other electrical problems solved. It may be thus
stated :—

”

ELECTRO-MOTIVE Force ‘ F
INTENSITY OF CURRENT = —-—-~— ~~—--—— ; or, if expressed in
REsIsTANCE

(Internal+ Eaternal)
E

bols, © or I = ———
pineunieb eae em Tk ae

Now, in constructing a battery, the object to be attained must be first
considered, A battery designed to produce heat (the cautery battery),
for example, is not built upon the same plan as one designed for ordi-
nary medical purposes.

Again, different cells (such as those devised by Daniell, Grove,
Leclanché, Grenet, Bunsen, Smee, Hill, and others) possess special
VARIETIES AND CONSTRUCTION OF GALVANIC CELL. 619

advantages and disadvaniages which have to be considered carefully
before a decision is made respecting the one which should be employed.

Finally, the number of cells, the arrangement of the elements, and
the size of the elements are problems to be determined with special
reference to the purpose for which the battery is designed. These
points will be touched upon hereafter.

It is important that a few facts be stated in the beginning respect-
ing the more common methods of connecting and grouping galvanic
cells. Subsequently, the different forms of cells employed by well-
known manufacturers of electrical apparatus may be tersely described
with adyantage. Finally, the various attachments to an electric battery
designed for medical purposes should be mentioned, and the uses of each
briefly outlined.

=

 

 

 

 

 

 

Fre. 138—A Comrounp Cuain. (After Evb.) Three sets of elements are here connected
“behind one another,” or ‘‘in series."’ ‘Ihe direction of the current is shown by the arrows.
_ The circuit of closure is effected by a wire, as in Fig. 137, 2.

Let us suppose, for the purpose of illustration, that we have decided
to use a certain number of cells (one of the numerous forms subse-
quently mentioned) in preparing a battery for medical use. How shail
we connect them so as to best accomplish our purpose?

If we join the carbon and zinc elements together (using that form
of cell for example), and continue to do so throughout the entire series of
cells (Fig. 188), we have formed what is known as a “compound circutt mu
or an arrangement “in series.” If we join all the negative or carbon
elements together, and then the positive or zinc elements in a similar way,
we have what is known as a “simple circuit” (Fig. 141). Finally, we may
divide the cells into groups; then join those of each group in simple
circuit; and afterward unite these groups as if they were single cells.

Now, what will the effect of each of these methods of combination
have on the intensity of the current? Ohm’s law comes into play in
deciding such a problem.
620 LECTURES ON NERVOUS DISEASES.

We must first ascertain the internal resistance of the form of cell
which we have selected for our battery.* We must know also the
external resistance which we shall have to overcome in our proposed
use of it. Finally, we must ascertain the electro-motive force of the
elements of each cell.

 

 

 

Fic. 139.—A ScHEMATIC REPRESENTATION OF THE INTRODUCTION OF A HuMAN Bopy (2)
INTO THE CikCUIT oF CLosuRE oF a Gatvanic CHain. (After Erb.) + =the anode;
— = the cathode. es

Suppose, for example, that E—1, Ir = 20, Er=10. The current
of each cell would then be expressed as follows :—
. 1 1

C= =— = 0334,
20410 30

 

* To compute the internal resistance of a cell or battery requires apparatus not gener-
ally owned by medical practitioners, i.e., a coil rheostat, which may be confidently
regarded as accurate, and a carefully calibrated galvanometer, by a standard maker. The
rule given by De Watteville, and copied from him, apparently, by Amidon, would be simple
if it were true. Ihave tested it again and again, and have personally discarded it as
unworthy of credence. I have also had a professional electrician test it. He arrived at
the same unsatisfactory results. The rule of De Watteville, to which I refer, is as follows :
First note the needle-deflection of the cell or battery to be tested under a given resistance,
then introduce sufficient additional resistance to reduce the recorded needle-deflection
exactly one-half. The added resistance will equal the internal resistance of the cell or
battery tested. The internal resistance of any cell can be computed with accuracy ; but
by a more complicated method, described in most of the standard:works upon electricity.
Most manufacturers can give the requisite information respecting the internal resistance
of any cell used by them, and that resistance, multiplied by the number of cells employed,
will equal the total resistauce of a battery (the cells being united ‘in series,” as shown in
Fig. 188).
 

i

VARIETIES AND CONSTRUCTION OF GALVANIG CELL. 621

Now, if twenty cells of this kind be joined in “simple circuit,” the
elements have each been practically increased twenty times, and the
internal resistance has therefore been decreased twenty times.. The
external resistance remains the same. We therefore have

1 1
it = PGs,
20410

If these cells be now arranged in “compound circuit,” the electro-

a

 

 

Frc. 140.—S1x CELLS CONNECTED FOR INTENSITY. (After De Watteville.) 2, zinc elements ;c,
carbon or platinum elements. ‘This arrangement is known as “‘in series’’ or ‘‘ compound
circuit.”’ It increases the ‘‘electro-motive force’’ of the battery.

motive force and the internal resistance will be increased twenty times.
We should thus have the following formula :—

1x20 2
C=———— = — = 048+.
2020410 41
Finally, if the cells were arranged in four groups of five each in
simple circuit, we should have practically four cells with elements five
times as large; hence, the internal resistance would be only one-fifth that

 

Fic. 141.—Six CeLts ConNECTRD FOR Quantity, 7.¢., “in surface,” or in ‘simple circuit.’
(After De Watteville.) z, zinc elements: ¢, carbon or platinum elements. This arrange-
ment does not affect the “electro-motive force”’ of the battery.

ofasingle cell and the electro-motive force four times as great. We
should then have the following formula :—

M4 4D
—=- = .285+4.
29110 14 7
Remember that the electro-motive force means the difference in
potential of the cell elements. It is therefore unchanged by their size.
A cup of water elevated one hundred feet will produce as much press-
ure through a pipe connected with it (provided that the cup be kept

 
622 LECTURES ON NERVOUS DISEASES. .

constantly filled) as would a lake ten miles in circumference, at the same
elevation and similarly connected with the pipe. So it is with electro-
motive force. The size of the elements will alter the quantity of elec-
tricity generated ; but the electro-motive force of a cell or battery will
remain undisturbed by increasing or diminishing the size of the elements,
I frequently hear this remark made: ‘‘ The cells are too small for medical
purposes, are they not?” ‘To this question I would reply that intensity
of current and moderate quantity are to be aimed at in constructing a
a medical battery.

The few illustrations which have been given show that the current-
strength has been modified in each instance by the changes made in the
arrangement of the cell-elements.

If, however, we took a higher external resistance (as would be re-
quired in a medical battery—say about 2500 ohms), we should find that
the simple circuit arrangement made but little difference in the power of
the current, while the compound circuit materially increased the current-
strength. It is important to remember, therefore, that the external
resistance is an important factor in modifying the strength of the current,
and that all combinations of cells are not equally ettlicient.

The most useful battery for medical purposes is one which is planned
with a view of making the internal and external resistances as nearly equal
as possible.

When we wish to construct a battery for ordinary galvanic treat-
ment, it is best to overcome the high resistances encountered by using a
large number of small cells, with a high electro-motive force, coupled in
compound circutt,——t.e., “in series.” The aggregate internal resistances
of the cells never will exceed the external resistance furnished by the
living tissues.

In devising a battery for electrolysis, the arrangement should be
such as will secure simple intensity. The résistance to be overcome by
the current in passing through small portions of the body seldom exceeds
100 to 500 ohms. A small number of cells of medium size (16 to 24 of
Grenet’s cells), coupled in compound circuit, will give us the desired ends
and accomplish the best results.

A cautery batlery requires very large plates, placed closely together.
Tn the “ Piflard battery ” the zine plates are perforated, and the elements
are so arranged as to be mechanically shaken in the fluid while the
battery is in action. J regard this as the best instrument of its kind.
Its action is continuous, and the heat generated may be maintained at
any desired temperature by one familiar with its management.

Tue Various Forms or Cetrs—Human ingenuity has been strained
to its utmost for nearly a century to devise an absolutely perfect
galvanic cell. Space will only allow here of a brief statement of the
SPECIAL FORMS OF THE GALVANIC CELL. 623

varieties now in common use. The construction of each and the peculiar
advantages and disadvantages of each will be also tersely mentioned.

SPECIAL FORMS OF THE GALVANIC CELL.

All forms of galvanic cells may be classed under oné of three groups,
as follows: (1) one-fluid cells, with no depolarizer; (2) one-fluid cells,
with a solid or liquid depolarizer; (3) two-fluid cells.

Each of these three varieties has many modifications, which are
commonly named after the inventor. A few of each only need to be
mentioned.

I. OnE-FLUID CELLS, WITH NO DEpoLARIZzER.—The elements of this
group are all immersed in a fluid to which nothing has been added to
prevent polarization (7.¢., the formation of bubbles of hydrogen on the
negative and of oxygen on the positive element of the cell during its
period of activity).

Smee’s Cell (1840).—Perhaps the best of
this group is that devised by Smee. It consists
of two zine plates with one of platinized silver,
suspended between the zincs, immersed in di-
luted sulphuric acid. The electro-motive force
is about .47 volt.

Walker’s Cell (1859).—Platinized carbon
is used in place of platinized silver. It is
cheaper than Smee’s cell. HE. M. F. = .66 volt.

Il. One-FLuip CELLS, witn Sori Depoiar-

 

is a favorite with some manu-

1zERS.—The best of this group is the cell devised
by Leclanché.

Leclanché’s Cell (1868).—The carbon ele-
ment is packed ina porous cup, with the needle
form of the black oxide of manganese surround-
ing it. This cup is then placed ina glass vessel,

‘containing a rod of zine and a solution of sal. ammoniac.

facturers for a portable faradaic
machine. In the author’s opin-
ion, it is far less satisfactory
than Fuller's cell if the battery
isa permanent oneé,ora Grenet
cell if the battery is designed
for transportation. It is active
at first, but weakens rapidly
from polarization,

The cup is

carefully sealed to prevent evaporation and escape of its contents,
E. M. F. = 1.48 volt, when the battery is not polarized.

Marié-Davy Cell—Amalgamated zinc, acidulated water, carbon,
and a paste of sulphate of mercury. E. M. F. = 1.52 volt.

Agglomerate Leclanché Cell.—The carlon is surrounded by plates
of a special composition, which are bound around it by India-rubber

bands.
desired. E. M. F. = 1.48 volt.

The internal resistance can be intensified by adding plates as
The internal resistance with three

plates = 1.8 ohm; with two = 1.4 ohm; with one = .9 ohm.
. ID. One-rnuiw Cetis, with Liquip Deponarizers.—Of this group
the Grenet cell is the most used for medical purposes.
624 LECTURES ON NERVOUS DISEASES.

 

Grenet’s Cell. he elements are two plates of carbon and one zinc
plate (amalgamated). The zinc element can be lowered into the fluid or
raised at will. It lies between the carbons. The depolarizer is bichro-
mate of potassium. The active constituent of the fluid is dilute sulphuric
acid. These two ingredients form what is known as the “ red-acid fluid.”
These cells are of different sizes.

Trouvé’s Cells (1875).—Similar to Grenet’s, but of large size. E.
M. F. = 2 volts. The internal resistance varies from .0016, when first

 

 

 

 

Fic. 144.—Grenet’s Cett.—The
flasks come of all patterns,
according to the taste of the
various makers. Inthe form
here depicted the zinc is
lowered into the fluid by a
straight handle, This is the
cell most used in portable
electrical apparatus. It is
cheap, efficient, and easily
repaired. Removing the

 

Fic. 143.—Lecrancuer’s Cert.—The zine rod (the one with elements and replacing them
its rheophore attached) is shown as immersed in a solution overcomes ‘ polarization”’ in
of ammonic chloride. ‘Che carbon element is seen to.project case the current grows weak
slightly above the porous cup, in which, when the cell is from that cause. Some
properly prepared for action, it is packed with peroxide of makers place the zinc in adrip-
manganese and afterward covered with pitch. cup when the cell is not in use.

set in action, to .07 after the “spurt.” The plates are raised and lowered
by a windlass. The extent of immersion can thus be graduated. This
form of element is known as a “ plunge battery.”

Fuller’s Cell.—A porous cup containing zinc, mercury, and water is
placed in a large glass jar containing red-acid fluid, in which a large
carbon plate is immersed. ‘The mercury keeps the zinc amalgamated.
The elements are not removed when the cell is not in action. This
form-of cell is perhaps the best one yet devised to run the faradaic part
of a cabinet battery. ‘
SPECIAL FORMS OF THE GALVANIC CELL. 625

IV. Two-r.uip Cetis.—In this group, the Daniell, Grove, and Bunsen
cells are the most used. The two latter are not well adapted for medical
purposes. The fumes which arise from some of them are unpleasant.
Dynamos are now generally substituted for them in the mechanical arts.

Daniell’s Cell (1836).—The so-called “sulphate of copper” cells
(of various types) are modifications of that devised by Daniell. The
elements are zine and copper, separated in the original form by a porce-
lain or baked-clay diaphragm. ‘The zinc is immersed in dilute sulphuric
acid, and the copper in a saturated solution of sulphate of copper. E.
M. F. = 1.079 volt. ‘The solution for the zine element may also be pure
water, salt and water, or a solution of sulphate of zine.

      

eee ee mal

 

 

Fic, 145.—Fuiver’s Cerr.—tThis is the Vic. 146.—Stemens anp Hauske’s Cette —This

best cell (in the opinion of the author) cell is very efficient, but it is expensive to repair
to use in connection with a permanent when the ‘battery becomes exhausted. It is
faradaic machine. It is not well highly recommended by some European au-
adapted for transportation. thorities for use in a cabinet or permanent

office battery. In this country the Leclanché
cell is more favorably regarded.

Siemens and Halske’s Cell.—This is a favorite cell for medical bat-
teries in Europe. It is a modification of the Daniell’s cell and is
expensive. A copper rosette is placed in a saturated solution of sulphate
of copper at the bottom of the jar; this is covered with a porous
diaphragm packed with papier-maché, on which the zine rests surrounded
by water. Water is added to the battery from time to time, and also
crystals of the sulphate of copper. This form of cell is very constant ;
but it is extremely difficult to repair when out of order. Asa permanent
battery, such cells may last a long time with proper care; but they often
do not, as the cells may become impaired from a multitude of causes
{poor construction, improper use, etc.).

Hill’s Gravity Cell.—This is another modification of the Daniell cell.
It is used in medicine by many neurologists. A copper plate rests on

40
626 LECTURES ON NERVOUS DISEASES.

the bottom of the glass jar, covered with a saturated solution of sulphate
of copper. The zinc element is a disk perforated by a large central
opening, through which crystals of sulphate of copper may be dropped
when the battery is inactive. A solution of sulphate of zine floats, with-

9 =

   

Fic. 147.—H1Lv’s Graviry CeLt.—This cell is employed very extensively in telegraphy, and is
recommended by some authors for permanent medical batteries. When the jars are well
paraffined at the top the cells do not “‘salt’’ badly. They require but little care when prop-
erly set up. Personally, I prefer a modification of this cell (in which the zinc is placed
within a suspended porous eup to the one shown inthe curt. It requires less care, and is not
affected by agitation. It also a higher internal resistance.

out an intervening diaphragm, on top of the copper solution, and
immerses the zine disk. This battery must not be agitated, as the two
solutions would then become mixed. KE. M. F. = 1.068.

Grove’s Cell (1839).—This consists of amalgamated zinc immersed
in dilute sulphuric acid within a porous pot. Outside of this pot plati-

 

Fic. 148 —Grovr’s Creti.—This cell (shown here in the form of a battery) is not used in medi-
cal practice, chiefly on account of the fumes which arise from it If used in the mecha anical
arts, 1t is a very expensive cell to employ. Dynamo machines have now taken the place of
Grove batteries to a very great extent.

i
num is immersed in nitric acid placed ina glass jar. E. M. F. = 1.96
volt. The platinum is bent into an S-shape to increase its surface.
Many modifications of this cell have been made for use in mechanical
arts. The fumes arising from it are very objectionable,
" ATTACHMENTS TO A COMPLETE BATTERY. 627

Bunsen’s Cell (1840).—This is a modification of the Grove cell.
The platinum is replaced by artificial carbon in the form of a hollow
cylinder, and a cylinder of zine
is bathed in dilute sulphuric acid.
FE. M, F. = 1.9 volt.

ATTACHMENTS TO A COMPLETE
BATTERY.

Although it is not necessary
for a general medical practitioner
to have all of the attachments to a
battery such as are employed by
neurological specialists, still it is
important that they be mentioned =
here, and their uses interpreted. Fic. 149.—Bunsen’s Cert.—Parts are represented

as bitten away to show its arrangement: the
The most important attachments to Soc gin toe

carbon (c) withinit. ‘Uhis cell is not employed
a cabinet or fixed battery for office ean ane oe
use only are a galvanometer, a
rheostat, a thermo-electric differential calorimeter, a polarity changer or
“commutator,” and a variety of rheophores and electrodes. Portable
batteries do not require, as a part of their construction, the first three of
these attachments, but they should possess the others.

THE GALVANOMETER.— When a galvanic current circulates in a coil
of wire about a magnetic needle, it causes deviations of that needle, which
are modified by both the strength and direction of the current deflected
into the coil. This fact has led to the construction of an instrument,
called “the galvanometer,” for the purpose of measuring the strength and
direction of a current deflected into a coil beneath such a needle. When
‘this instrument (properly made and calibrated) is connected with a bat-
tery, the strength of current generated by any number of cells can be
determined in milliampéres.* It is vitally important that the dial of a
horizontal galvanometer should not be divided into degrees of equal dis-
tances. Such a galvanometer is absolutely worthless. The graduation
of the dial should be by tangents, as shown on Fig. 150.

The deflection of the needle grows less and less for every milliampere
of current; hence a dial, to be accurate, should be carefully graduated
so as to correspond with the needle-deflections for different current-
streneths. The first divisions on either side of the zero point on such
a dial will be coarse, but they should gradually grow finer and finer till
the maximum point is reached. Such adial will not be graduated around
its entire circumference, as the maximum point will be reached before the

 

*Every galvanometer should measure at least quarters of the first milliampére to be
considered worthy of indorsement.
628 LECTURES ON NERVOUS DISEASES.

90° of the circle on either side are required. One of my own galvanom-
eters is eraded into equal degrees on one half of the dial, and on the
other half it is calibrated to milliamperes.

Within the past few years the efforts of Erb, Kulenburg, and Bern.
hard in Germany, Gaiffe in France, and De Watteville in England have
awakened the profession to the necessity of accurately measuring the
current-strength employed upon a patient by means of a reliable galva-
nometer, To their views I lend my most hearty support. As well can I
conceive of a boiler without a steam-gauge, or of a drug-store without a
seale,as a galvanic battery without a galvanometer, provided its possessor

 

Fic. 150 —A GAtvAnomerer Diac. (After De Watteville.) The lower half of the circle is grad-
uated to milliampéres ; the upper half to degrees of equal distance. One serious criticism can
be made of this dial, viz., that it does not indicate fractions of the first milliampére of cur-
rent. ‘l’o my mind, a galvanometer-needle deflection for the first milliampére of current
should be sufficient to show at least a quarter or an eighth of a milliampére. This fault is
common to all vertical milliampére-meters with which I am acquainted. Even Hirschmann’s
instrument does not entirely overcome it. 1am at work at present upon a new form of mil-
liampére-meter, which I hope will remedy this serious objection and at the same time allow
the needle deflections to be read easily when the eye is on the same level as the needle.
aims at scientific precision in his treatment-of patients by galvanism.
Much of the neurological literature we now possess is materially lessened
in value by the fact that the observations recorded lack scientific precision.
If we expect to arrive at positive conclusions regarding methods of em-
ploying electricity for therapeutic or diagnostic purposes, we must have
i more accurate and scientific basis for recording the strength of the
current employed than the simple statement of an observer “that a
certain number of cells were used” in each particular instance. Cells
vary in their capacity and electromotive force; they change in both
respects from day to day, from use and polarization; the external resist-
ATTACHMENTS TO A COMPLETE BATTERY. 629

ance ailorded by different individuals is not uniform, although the poles
may be similarly placed and all precautions taken against poor condue-
tion; snd many other sources of error may creep into observations

 

 
 

 

eI

 

 

4S

|
|]
Pe

EQUAL PARTS

Fic. 151.—A DiaGram prSIGNED to ILLUSTRATE THE METHOD OF TANGENT CALIBRATION,
—The distances marked upon the straight line are uniform. When they are joined by im-
aginary lines with the centre of the circular dia}, these lines intersect its circumference at
points which steadily tend to approach each other; hence the first milliampére will produce
a needle deflection which may exceed that produced by ten or more milliampéres in some
other part of the dial., The more sensitive the needle, the greater will be the distances
marked upon the straight line, and the dial also, on either side of the zero point; hencea very
sensilive needle, balanced so as to avoid unnecessary friction, will record eighths and quar-
ters of one milliampére of current, if the coil be long enough.

practically made by “guesswork” only. The scientific world has now
quite generally accepted the “ milliampére” as the recognized standard
of a unit of current-strength.

 

Fic. 152.—A Horizontat MILLIAMPERE-METER. (After the Thistleton pattern.) The screw-
feet allow of adjustment so as to insure a perfect leveling of the instrument. Tt is then
revolved so that the needle (which will point north) rests at the zero point of the dial. Re-
versal of the current diverts the needle to the opposite side One of the rheophores shown
goes to a binding-post of the battery, and the other to one of the electrodes employed upon
the patient. ‘I'his instrument is very delicate, but the eye has to look down upon the dial in
order to observe the deflection of the needle. If the instrument is placed lower than the eye,
this objection is not serious. Withit it is easy to detect small fractions of a milliampére of
current, and it is much less expensive than a good vertical galvanometer and more accurate
than most of those offered to the profession. 1 do not recommend them for measuring very
high currents,

A milliampére-meter ts therefore the instrument which medical
practitioners should own, and all observations should be recorded from
the deflections of its needle.
630 LECTURES ON NERVOUS DISEASES.

We shall probably be able soon to state with some positiveness the
number of milliamperes which are required to excite each of the more
important nerves of the human body in health, and the exact limits
between which contractions of certain muscles may thus be excited,
Eulenburg and Weiss have already made a step in this direction.

One reason why the vertical form of galvanometer is commonly pre-
ferred to the horizontal is the fact that terrestrial magnetism does not

 

Fic. 153.— Deap-BEAT’’ MILLIAMPERE-METER.

exert an appreciable influence upon it; hence observations made with
such an instrument wouid be alike in all parts of the globe. The vertical
galvanometer is, however, more expensive, provided it is accurately cali-
brated, than the horizontal, and the bearings upon which of necessity
the needle rests are liable to cause more or less friction. At my request,
Messrs. Waite & Bartlett, of New York City, have lately graduated
some horizontal milliampére-meters with great accuracy (Fig. 152). I
ATTACHMENTS TO A COMPLETE BATTERY. 631

can recommend them as reliable and comparatively inexpensive. They
will not, however, accurately measure currents of over lilty milliamperes.
Before you purchase this important attachment to a battery, test it, if
possible, by one whose accuracy cxn be relied upon. I would far rather
have none than a poor one. At present I am using the so-called “dead-
beat” milliampére-meter, made after a late design.* Hirschmann’s
vertical galvanometer with astatie needles, called the “absolute galva-
nometer,” has been highly recommended of late. I have not yet pur-
chased one, as I find my own to be perfectly reliable.

The instrument represented on opposite page measures from one-
tenth of one milliamptre to five hun-
dred milliamperes. It is contained in
an all-metal case and carefully cali-
brated. It contains the Siemens’ bell-
magnet, and is dampened in its yibra-
tions by the induced currents set up
during the deflections of the needle,
whereas in most instruments of the
better class the oscillations of the
needle average at least twenty-five
before it comes to rest. In this in-
strument the vibrations seldom ex-
ceed from five to six. Shunts are pro-
vided in order to measure very high
currents. I regard this instrument
as’ fully equal, if not superior, to
Hirschmann’s expensive instrument.

Tue Raueostat.— This is an

 

Fic. 154.—A:Fium Ruegostat.-—This instrument

i reo r is used co throw additional external resistance
appliance to 1 egulate the extel nal into circuit. Coil rheostats er tne reliable,
resi ny Sy ring because fluid is decomposed and causes polari-
resistance of a battery under \ aby INS zation ofthe metal points when strong currents
circumstances. Several devices are are used. Some of the graphite rheostats are
7 ? preferable ¢o many containing fluid, and are

made for this purpose, but the fluid cheaply made.

rheostat (containing water, solutions
of salt, solutions of zine sulphate, ete.) is often all that is required
for medical uses. It is cheap, easily managed, and modifies the current-
strength. It is liable to polarize + when used too long, and does not act
80 well with strong currents as with weak ones. It consists of a glass
tube filled with water or some prepared solution (preferably a forty per.
cent. solution of sulphate of zinc), through which a brass rod or an

* This is shown in a cut of my own cabinet. battery, on a succeeding page, and in.
Fig. 153.

+ We speak of an element as ‘‘ polarized”? when bubbles of hydrogen or oxygen accu-
mulate upon it, and thus diminish its efficiency.
632 LECTURES ON NERVOUS DISEASES.

amalgamated zinc electrode is made to slide up and down, thus separating
its lower end from « button at the bottom of the tube. When the cur.
rent is sent through this rod, it is forced to. pass through the depth of
fluid that lies below it in order to reach the button at the bottom of the
tube. By moving this rod, the amount of fluid which is thus interposed
in the circuit of the battery cau be graduated to any desired point. In
this way a greater or less resistance can be made at will. A fluid rheostat
is absolutely useless for measuring the
strength ofa current, but is an excellent
appliance for modifying it.

A new fluid rheostat has lately been
devised by H. L. Bailey, which has been
highly recommended by Rosebrugh, of
Canada, and others. I have had no per-
sonal experience with this instrument.
It certainly does not measure resistance
(as a well-constructed coil rheostat may
be made to do), but it may prove a
valuable adjunct to an electrical outfit
for practical purposes, Fig. 155 shows
the instrument referred to.

The carbon plates of this device
are made of a wedge shape, and have
pyramidal pieces of sponge placed
between them. As the plates are with-
drawn from the fluid in the jar these
sponges hold sufticient water to afford
an extremely high resistance to the pas-
sage of the current. When the plates are
fully immersed the resistance afforded
is extremely small. It is claimed that
from ten to-one million ohms of resist-
ance can be thrown into the circuit
with this instrument. It is further
claimed that by raising or lowering the

 

Fig 15,—RoseuruGH’s FLrum RHEostatT. ‘ ,
(Canada Pract.) plates of this rheostat the necessity of a

commutator is dispensed with. even for the purpose of preventing a
shock to the patient when the poles are applied or removed.

Tre Thermo-Enecrri Direerentrat, CALORIMETER.—This apparatus
is used in medicine to measure differences in temperature in homologous
parts of the body, or of any two selected points. It is much more deli-
cate than any form of surface thermometer, and is often very valuable as
an aid in making a scientific diagnosis. Like many of the instruments
ATTACHMENTS TO A COMPLETE BATTERY. 633

-of precision, it requires experience to use it and it is somewhat expensiye.

The study of surface thermometry has not assumed the importance
which, in the opinion of the
‘author, it is destined yet to
‘take. Waite & Bartlett, of
New York, have constructed
for me one of the most perfect
instruments of this kind that I
have ever seen.

The study of cerebral ther-
mometry has already led to the
discovery that the left hemi-
sphere is normally hotter than
the right (Hammond); that
willed muscular action raises
the temperature of the scalp
over the motor centres called
into action (Amidon, Gray,
and others); that mental ac-
tivity, emotional excitement,
and merely arousing the atten-

 

 

tion cause a rise in temperature Fig. 156.—Turrmo-Erecrric DirrrrentiaL Catort-
METER.—UConnect the two thermostats as shown in figure,

(Lombard) ; and that tumors viz. : connect by means of one of the metal-tipped cords
wh aiken . one binding-post of each of the thermo-piles to the two
of the brain or its envelopes binding-posts on base of the galvanometer. ‘hen con-
. . . nect the two remaining posts, one on each of the thermo-

are indicated by 4 localized piles with cach other. After so doing, piace the thumb
2 is on the face of one of the thermo-piles and observe the
Tise in temperature over the direction of the deflection of the galvanometer-needle,
‘ then place thumb on face of the other thermo.pile, leaving
site of the neoplasm. I have the first uncovered, and, if the deflection is in the oppo-
site direction to that first obtained, the instruments are

lately made some novel and properly connected. If, however, the second deflection
: a . i é is in same direction as obtained by pressing thumb on
interesting experiments in this first thermo-pile, disconnect the two cords from either
fiel * thermo-pile and interchange them, viz. : take cord from
field which I propose shortly right-hand post and place in left, and cord from left post
t : +. si . and place in right-hand post; the deflections will then
0 publish. In detecting 1n- be as first alluded to, one pile turning necdle in one direc-

snes tion and the other in the opposite direction.
flammatory conditions of the mee oes

abdominal viscera. this instrument has lately been employed with
satisfactory results. I have lately made an improvement * upon this

*The improvement to which I refer consists in the addition of a polarity changer of
my own construction, which enables me to reverse the deflection of the ncedle without
removing the thermo-piles from the surface of the patient. If the needle, for example,
shows a deflection of 15° when one thermo-pile is on the right side and 12° on the left
side, the difference of 39 shows double the imperfection which exists in the thermo-pile
thus tested, and the proper registration should therefore be 1310. Such imperfections
in thermo-clectric piles are practically unavoidable and can be detected in no other
way. As far as J know, this defect has never before been remedied. This has here-
tofore been the only serious drawback to the differential calorimeter, and the addition
of this improvement renders the instrument far more valuable for accurate scientific
purposes.
634 LECTURES ON NERVOUS DISEASKS.

‘instrument which enables the physician to detect differences in the
electro-motive force of the thermo-electric piles employed. This corrects
ali errors in observations made with this instrument.

Tue CuRRENT-SELECTOR.—This device is now added to all of the
modern galvanic batteries, whether designed for office use or for trans-
portation. By it, the number of cells desired can be thrown into circutt.
Ifa circular dial studded with buttons (which represent the cell-connec-
tions) is used, the bar which revolves and impinges upon the buttons
acts as a connection between the button on which it rests and the metallic
pivot on which it revolves.

 

Fic. 157A New Form or Current Serector.—This allows of a selection of any desired

ps toate from any part of the battery, thus insuring equal wear and many other

It is important that this bar he broad enough to touch each button
before it leaves the one behind it, otherwise the current is apt to be
broken when the intensity of the current is changed. I have known of
serious results from such an accident when a large number of elements
were being used upon the head of a patient. At my suggestion, a modi-
fication of the dial current-selector has been made by Waite & Bartlett,
of New York City (Fig. 157).

Another form of current-sclector is that employed by the same firm
for some of their instruments. I greatly prefer it to any other kind for
a portable battery, as it enables the operator to select the desired number
of cells from any part of the battery, thus insuring an equal amount
ATTACHMENTS TO A COMPLETE BATTERY. 635

of wear upon ul of its parts. It consists of pins projecting from the °
dial-plate, each of which represents one cell, These may be brought
into circuit by means of two metal caps, which are placed upon any of
the pins desired; the number of pins between the caps will immediately
tell the operator how many cells are being used. An objection to its

 

|

 

Fic. 158,—A Sxeteton DrawinG OF THE Pin Variety or Portapie Gatvanic Barrery,
#, handles by which the tray of cells is raised and lowered, Z, zinc elements. C, carbon
elements, A, 2, binding-posts. D, attachment of the stopper which fits over the pins. 4,
arubber-covered diaphragm which separates the cells from the elements when the battery is
not in use; this is removed when the cells are lifted so as to immerse the clements.

use is that it dispenses with a polarity changer,—in case the cells
employed are capable of being thus selected.

Fig. 158 shows a portable galvanic battery of this make with the
current-selector attachment described. In this form one stopper only is
employed, however, and the cells in use are indicated by the numerals
placed at the base of each pin. With this arrangement a polarity changer
636 LECTURES ON NERVOUS DISEASES.

is admissible, and is generally affixed to all so constructed. This is
particularly to be desired.

One claim that is made in favor of this device is that this form of
key-board prevents oxidation, as the wires which are usually employed
to join the cell-elements with the current-selector in other apparatuses
are entirely dispensed with. This advantage is an important one to
those who live away from the large cities and are not sufficiently familiar
with electrical apparatus to make their own repairs. Furthermore, the
employment of the metal cap keeps the metal pins free from rust, and
gives a perfect metallic contact because the pins are being constantly
kept bright and clean.

In batteries which are formed of a large number of cells, it is best
to have two dial current-selectors, so that a gradual increase or decrease
of the current can be made without breaking the circuit. In one dial
each button should represent one cell, while in the other each should
represent from two to five cells. It is easier to make any desired com-
bination of cells with rapidity by means of such an arrangement than if
the dials were alike.

THe PouaRity Cuancer or CommutTatTor.—Most galvanic batteries
have a switch upon the key-board that is intended for the purpose of
changing the poles at will without disturbing the rheophores or elec-
trodes. The details of the many mechanical contrivances employed for
that purpose need not be given here.

This attachment is almost indispensable to a battery designed for
office or experimental work, since the reactions of the poles can thus be
more readily studied. It is desirable, moreover, to have it attached to a
portable galvanic battery.

It should be so arranged as to permit of opening and closure of the
ctrewit, as well as the reversal of the current.

Tue Ruxopnores.—These are flexible wires which are necessary to
conduct the electric current from the battery when in action to the
patient. Insulated copper wire forms the best rheophore, as it is an
admirable conductor. Tinsel threads insulated with cotton wrapping are
more generally used, because they do not kink and are more flexible
(although they are not such good conductors). They are connected at
one end to the “ binding-posts ” of the battery, and at the other to the
electrode. They should vary between four and six feet-in length. I
have some that are ten feet in length, which I employ when I examine
the naked body of a patient lying upon a sofa or bed.

Tus Enecrrope.—In order to apply a current of electricity generated
in a battery to the human body, various forms of electrodes are employed
as termini to the rheophores. It is best to havea pair of handles to
which different forms of tips may be screwed, according to the require-
ATTACHMENTS TO A COMPLETE BATTERY. 637

ments of each case. The tips may be made of plain metal, or of carbon
or metal covered with sponge, chamois-skin, or canton-flannel. The
canton-flannel covering is the cheapest and cleanest, and may be renewed
at pleasure. Each patient can thus have a clean covering for the elec-
trode at every application. Flat electrodes of large size are useful,
especially when a neutral point for the current is desired. Small tips
(motor-point electrodes) are generally employed to direct the current to
some special muscle or group of muscles.

 

Fic. 159,—Various Forms of Evectropes (NATURAL SIZE). ADAPTED TO A SCREW Hanpv_Le,
NOT SHOWN IN THE cuT. (After Erb.) a, the “fine’’ electrode, or smallest size; 4, the
so-called “small” electrode; c, the “medium” electrode. All electrodes are covered with
“sponge (asin @ and 6) or flannel or chamois-skin (as in ¢).
The wire brush is employed chiefly in cases where anesthesia exists.
It is the only electrode that is used dry.
Most manufacturers advertise a case of electrodes designed especi-
ally for the application of electricity to different organs. Selections may
be made from these as desired, I have personally devised several modi-
fications of electrodes.
638 LECTURES ON NERVOUS DISEASES.

A practical point may be mentioned here, viz., that the negative
electrode (cathode) is the most painful to the patient, and produces the
greatest chemical action. It is a well-recognized fact that a bullet does
the most damage at its point of escape from any dense substance which
it hag penetrated. In the same way an electric current produces the

 

   

Double-current Roller.

Fic. 160.—Various Forms oF SpecrAL ELECTRODES.

most profound effects at its point of escape from the body, «e., the
negative pole. It is not uncommon to see a reddening of the skin, and
even vesication, produced by a strong current at the negative electrode,
if kept too long in contact with it. The cathode is the “ stimulating”
or “irritating ” pole (if such an expression is admissible) of a galvanic
battery. The anode is, by contrast, the “ sedative ” pole.
CHOICE OF A BATTERY AND ELECTRICAL APPARATUS. 639

For the treatment of special forms of diséase by electricity, different
types of electrodes have been designed by various neurologists, A de-
vice of my own, which simplifies electro-diagnosis and enables a medical
observer to watch and compare the etfects of electrical currents of deli-
nite strengths upon muscle- and nerve-reactions of opposed limbs simul-
taneously, has been described in Section II. By means of this device,
the physician may sit at a key-board and excite ditferent sets of muscles
separately or simultaneously (without moving from his chair) by
touching certain keys, as if playing the piano or working a type-writer.
Ihave found it, moreover, of great assistance in demonstrating before
large audiences the action of nerves and muscles upon a living subject.

Space will not allow of a detailed description of the electrodes shown,
most of them being simple devices, which really require but a limited
experience to use them in a proper way.

When you purchase a battery, two sponge-covered electrodes will
probably be sent with the instrument. It is advisable, for the following
reasons, to remove the sponges: (1) Cases have been reported where
disease has been transmitted by sponge-covered electrodes. (2) In case
the metal electrodes become oxidized, they can be readily cleaned. (38)
When employed upon a patient’s body, absorbent cotton, wet in salt
water, can be placed upon the clean metal, and a piece of moistened
canton-flannel may then be wrapped over both and fastened to the handle
with a rubber band, thus insuring absolute cleanliness and perfect conduc-
tion of the electric current.

Patients of delicate sensibilities rebel against the use of sponges
which for months or even years have been employed in case after case
requiring electricity. Who would patronize a barber-shop where one
towel constituted the entire outfit of linen? Is it right to ask of
patients what you would yourself condemn? Furthermore, how can
electrodes covered with dirt and other deposits under a sponge be perfect
conductors of electricity? Absorbent cotton and canton-flannel are far
cheaper than sponges, and can be thrown away after being used.

THE CHOICE OF A BATTERY AND ELECTRICAL APPARATUS.

In selecting a battery for purely medical purposes, the chief objects
to be attained are, to my mind: (1) cheapness; (2) constancy of the
elements and their accessibility for repairs, cleaning, etc.; (3) durability
of the elements ; (4) a sufficient number of elements; (5) ease of renewal
of the elements; (6) ease of introduction of any number of elements into
the circuit; and (7) an ability to select such as may be required from
any part of the battery.

For the general practitioner it is necessary, as a rule, that a galvanic
or faradaic battery shall be arranged for transportation; hence the cups
640 LECTURES ON NERVOUS DISEASES.

which hold the fluid should have a rubber cover, or some other device
which will preclude the possibility of spilling the fluid. Again, some of
the batteries manufactured are liable to hecome rapidly oxidized by the
fumes of the battery-fluid. This tends to destroy their durability, and
to cause difficulty in keeping them in good working-order. Finally, it is

 

Fic. 161.—THe Puysitcran’s Hanpy Cabinet Battery. (Author's model.) Theaccompany-
* ing cut represents a light and compact form of cabinet battery, designed by the author. It
is on castors, ancl can be wheeled about the consultation-room. This admits of the useof the
instrument when the patient isin the gynecolugical chair or upon the offcelounge; or when
any form of fixe apparatus, such as the laryngoscope, the inhaler or spray, etc., is bein’
simultaneously employed. In some of my later models an immovable tray is place
beneath the battery for electrodes, and a movable shelf is also provided upon which a mil-
liampére-meter, the solution of table salt, and the electrodes in actual use can beset. A glass
cover protects the battery from dirt when not inuse. £, faradaic coils; A, plunger; G,
faradaic binding-posts: , interrupter: D,drip-cup; A, current-selector of single cells;
S, the same of four cells to each button; AZ, coilto work the interrupter for the galvanic
current; £, switch to work or disconnect the interrupter (I’); , galvanic binding-posts;
8-5 and 4-6, connecting ruds to allow of the action of AZ, The commutator lies above P.

very desirable that portable batteries should be as light as possible, and
not too large to be handled easily.

The attachments upon the key-board of every portable galvanic bat-
tery should comprise a current-selector and a commutator. There should
be at least four rheophores, in order to make allowance for breakage,
CHOICE OF A BATTERY AND ELECTRICAL APPARATUS. 641

additional connections, etc. Several electrodes of different sizes and
shapes should also be selected,—preferably a large, a medium, and a small
one,—a wire brush, and an interrupting electrode. These can be added
to as circumstances demand.

For office purposes, a CABINET BATTERY has some decided advantages
over & permanent one placed in an adjoining closet or cellar and con-
nected, by means of wires, with 2 key-board in the consulting-room. A
cabinet battery can be casily wheeled about, and is readily repaired.
The cabinet should be so arranged as to allow the back and front of the
compartment for the cells to be removed, in case the battery needs
repairs or a renewal of the fluid. The connections of the battery with
the key-board should also be made as easy of access as possible; this
decreases the expense of alterations or repairs when such becomes
necessary. They should be protected, moreover, as far as possible,
against oxidation and dirt.

The cabinet battery which I use in my own office was made, under
my special direction, by Waite & Bartlett, of New York City, and is as
nearly perfect, as one could desire. It contains forty cells of the Le-
clanché pattern, which are equivalent to sixty of the gravity cell. The
connections and the cells can be exposed and ‘easily reached by removing
the front and back of the case. The cut on the following page represents
its special features better than a long description. Considerable expense
in constructing such a battery may be saved in the case, and hy dis-
pensing with some of the accessory apparatus shown.

The perfected office cabinet battery (Fig. 162) was made after
my own designs. Jt consists of a handsome cabinet, arranged for
storing the cells in the under part as shown. The upper part consists
of a shallow closet suitable for affixing the upright switch-board as
shown. The closet contains forty cells of the kind generally known as
the “ Gonda-Leclanché,” for use as the galvanic part of the apparatus,
and four extra cells to be used in running the faradaic part of the
apparatus. The switch-board is provided with a universal current-selector
for the galvanic part of the apparatus, by means of which any cell or
series of cells can be brought into the circuit; thus doing away with the
necessity of using cells from the same part of the group, in order that
the cells can be worked and used up evenly. It is also provided (1) with
an attachment for interrupting the galvanic current ; (2) a wire rheostat,
for interposing resistance into the circuit ; (8) a pole-changing attach-
ment; and (4) a milliampére-meter for measuring the current-flow during
treatment. By means of a milliampére-meter and the wire rheostat, the
resistance afforded by the patient at the time of the sitting may be readily
measured. The apparatus also has a complete faradaic attachment ; this
latter being provided with fast and slow contact-breakers, as well as a

41
 

 
CHOICE OF A BATTERY AND ELECTRICAL APPARATUS. 648

contact-key to be worked by pressure of the finger at the will of the
operator. This latter attachment is of special use in electro- diagnosis.
The cabinet is mounted on rubber-tired castors of lar ge diameter,and can
readily be moved on finished and polished floors without marring the
sume. Itis also provided with a large drawer and closets for the elec-
trodes. The milliampere-meter attached to this cabinet is separately
shown in Fig. 153.

I believe this cabinet to be the most complete for practical work in
electro-diagnosis and general electro-therapeutics that has ever been
offered to the profession. [I am having a new cabinet so arranged for
my own use as to contain a storage battery, so that I can employ the
electric lamp or cautery at will. This is charged as circumstances
require. It can be removed from the cabinet and transported for
examinations or treatment at the paticnt’s residence. |

A PERMANENT BATTERY is somewhat cheaper to construct and takes
up less room in the oflice than a cabinet, because no ease is required ;
but, in my opinion, these two advantages are not sufficient to render it
preferable to the other for office or experimental work. I have known
several of my medical friends to discard it (after a thorough trial) for
acabinet battery. Ifa permanent battery is deemed preferable by any
of you (for reasons of your own) rather than a cabinet battery, be sure
and place your cells on shelves in your office or waiting-room, and not
inacellar. The wires will not be so liable to corrode from dampness,
and the cells will be constantly under your eye, so that you can see when
they require attention. a

The gravity cell makes a very serviceable and durable permanent
battery for office work. It has one advantage over some other cells, viz.,
that it has great constancy of action and that its activity can be renewed
by the addition of crystals of sulphate of copper to the fluid when
necessary without disturbing the cells. For this reason the sulphate-
of-copper cell, in some one of its various forms, is employed exclusively
in telegraphic lines. Unfortunately, it tends to “salt” excessively, and
the jars and elements become incrusted unless they are carefully watched
and taken care of. Again, it cannot be transported about the room to
suit the convenience of the patient or the physician during his examina-
tion so well as some other cells adapted for a cabinet battery. It is also
difficult in many cases to repair the wire connections of a fixed battery
(running, as they often do, through partitions and plastered walls to
reach the key-board) when they become inefficient from any cause. I
personally. prefer the Leclanché cell to any other yet devised for a cabinet
battery.

The engraving on page 644 represents the perfected cabinet so
arranged as to be detached from the cells and screwed to the wall. The
644 LECTURES ON NERVOUS DISEASES.

A i

nt) A

a ‘a "| WA

 
THE CARE OF A BATTERY. 645

cells may be placed in any convenient place, as closet or cellar. It is
the same in all of its attachments as the perfected cabinet just described,

Respecting the selection of the cheaper forms of batteries for gen-
eral medical use, it is important that accuracy of workmanship shall not
have been sacrificed in order to lessen the cost. The construction of
the primary and secondary coils of a faradai¢ machine and the adapta-
bility of the interrupter to slow and rapid breaks in the circuit should
be looked into before a decision is reached. Poor coils and a bad inter-
rupter render a faradaic machine almost worthless. A ‘ drip-cup”’ con-
taining mercury, in which the zine element is-placed when the battery is
not in use, is a desirable feature in a faradaic machine.

Do not buy « magneto-electrie machine whose motor power is
furnished by a crank to be turned by the hand. It is practically useless
for medical purposes when compared with a good faradaic instrument.

The Grenet cell is now used by most of the manufacturers of
electrical apparatus fora portable galvanic or faradaic battery. It is
the best cell for this purpose, in my opinion, for many reasons that I
have already expressed in print.* A thirty-cell galvanic battery of this
type gives all the current that is required by the general practitioner.

Every galvanic battery should have a commutator on the key-board.
Without this appliance electro-diagnosis becomes diflicult.

THE CARE OF A BATTERY.

The best battery is liable to get out of order. It is an easy matter,
asa rule, to correct the trouble if the construction of the apparatus is
thoroughly understood. The following hints may aid the reader in
obtaining a satisfactory current with a minimum expense :—

1. Keep your battery clean and bright in all ts parts. Close the
case when the battery is not in use, and thus keep out dust, grease, and
moisture. Emery-paper is useful to keep the metal connections free
from rust. Remember that a small amount of dirt, grease, or rust will
often arrest the action of any battery.

2. When the battery fails to act properly, examine the cells first and
see if the fluid requires renewal. The “red-acid fluic ” is easily made
by adding one part of commercial sulphuric acid to ten parts of cold
water; when cooled, one part of finely pulverized bichromate of potas-
sium should be added and mixed well. This is the fluid commonly
employed in portable batteries with cells of the Grenet pattern.

8 Ifthe fluid is found to be fresh, and if the zine and carbon
elements are in good order and the zine well amaloamated, eramine care-
fully all the screws and other connections attached to the elements and see
if they have become oxidized. Sometimes they become rusted or so

*N. Y. Med. Journal, 1885.
646 LECTURES ON NERVOUS DISEASES.

covered with accumulated dirt as to render the passage of the current
impossible. Occasionally the carbons may be disconnected and baked in
an oven to render a Grenet cell more active. Soaking the elements (in
situ) in hot water which does not reach the connections will generally
suffice to cleanse them.

4, If the cell has become polarized when in action (by bubbles of
hydrogen which accumulate upon the carbon and of oxygen upon the zine
clement), lifting the zine out of the fluid and replacing it immediately
will suflice to overcome this trouble, whenever the cells are of the Grenet
patteru. These bubbles of hydrogen and oxygen set up a counter-
current in the cell, which will weaken and may even neutralize the
original current.

5. Examine the interrupter, the buttons of the current-selector, and
the commutator for rust or dirt, and clean each thoroughly when the
trouble appears not to be due to the elements or their immediate con-
nections.

6. If a drip-cup is furnished with a faradaic or galvanic battery, be
careful to place the zine element in it when the battery is not in use.

7. In portable galvanic batteries, be sure to place the rubber-covered
diaphragm over the cells before closing the case and to screw it down
tightly. This prevents the fumes rising and oxidizing the connections
of the elements when not in use.

8. Be sure that the rheuphores are perfect before they are used upon
a patient. The wire used in their manufacture is Hable to become broken
or oxidized hy use. This is especially true of the flexible, cotton-covered
cords generally furnished with batteries. The electrodes may be tested
by employing a galvanometer, if an imperfection is suspected and cannot
be found. }

9, The wires that run from the cells to the buttons of the current-
selector or the commutator may be seen on the bottom side of the key-
board of a battery. They can be examined for imperfections when the
other parts of the apparatus appear to be perfect.

10. Do not short-circuit a battery. By this we mean, do not allow a
battery to run down, or, more technically, © polarize,” hy the poles being
brought into contact without an interposed body (such as animal tissue)
for any length of time. For example, galvanic cells which have a low
internal resistance (as a Grenet cell) become polarized in a few hours
when the poles are connected by a short wire which affords little if any
resistance to the current. :

ll. Keep your electrodes clean. As I have stated before, it is well
to cover them with fresh canton-flannel for every patient. This is an
act of preenution which will impress people with your regard for their
feelings and for their safety from contact with infectious matter. Sponges
STATIC ELECTRICITY. 647

are too expensive to be renewed so often. Absorbent cotton may often
be placed between the electrode and its covering with advantage.

STATIC ELECTRICITY.*

An exposition of the different forms of generators which may be
employed, and the various methods of application of this therapeutic
agent, together with hints respecting the care and management of induc-
tion machines and the selection of apparatus, seems to be advisable in a
work of this character. Most works on medical electricity are singularly
deficient in this field. :

We owe to the ingenuity of Otto V. Guericke, the inventor of the
air-pump, the first electrical machine where friction was employed as the

 

Fic. 164,—HAWKSBEE’S ORIGINAL ELECTRICAL Macuine. (From Lecons de Physigue ot the
Abbé Nollet, published in 1767.) The globe is of glass, and positive electricity is collected
upon a conductor suspended by silken cords from the ceiling.
exciting agent. It consisted of a ball of sulphur which was turned upon
its axis by hand-power. An assistant grasped the ball with his hands,
and, by so doing, served as a conductor for the escape of the positive
electricity to the earth. This primitive affair gave feeble sparks, which
could only be seen in total darkness.
Hawksbee substituted later a globe of glass for the ball of sulphur.
He obtained more satisfactory sparks with the positive electricity thus
generated.
Later still glass tubes were ‘nei: with hand rubbing; and they
entirely superseded the globe as generators until the middle of the
eighteenth century.

*A portion of this discussion of static electricity originally appeared as a contribution
to The Physician and Surgeon, Ann Arbor, Michigan, 1886.
648 LECTURES ON NERVOUS DISEASES.

In 1767, Hawksbee’s original machine was revived in a modified
form by Professor Boze, of Wittemberg; and for a time it came into
general use. The cut of this machine (Fig. 164) is taken from the
Lecons de Physique of Abbé Nollet.

The collector was hung from the ceiling by silken cords; and the
hands of an assistant were used as rubbers upon the globe of glass.

In 1768, Ramsden, of London, invented the so-called “plate
machine.” The glass plate was supported by wooden uprights, and the

——

ATMO

CERES
3

 

Fic. 165 —RAmSDEN’s ELECTRICAL Macuine. (Invented in 1768.) It has sector-shaped pieces
of oiled silk to prevent a loss of electricity from the glass plate while passing from cushion to
cushion,

friction was made by means of two ecushion-rubbers. The collectors
were of metal; and two combs of metal were employed to draw off the
electricity from the glass plate. The cushions were “grounded” by
means of metal supports, so that the negative electricity which accumu-
lated upon them could escape to the earth. In 1776, Von Marum modi-
fied Ramsden’s apparatus so as to obviate this loss,

Nairne next modified the machine of Ramsden by substituting a
cylinder of glass for a single glass plate, and by adding an attachment
for collecting the negative electricity by means of an insulated conductor
STATIC ELECTRICITY. 649

placed in communication with the rubbers. This was the first. machine
that satisfactorily furnished both positive and negative static electricity.

Probably the first electrical apparatus which can properly be said
to have been a true ‘ induction machine” was described as early as 1788,
by W. Nicholson, before the Royal Society of London. He called it the
“electric doubler.” It was built somewhat upon the plan of the machine
now known as the Toepler model. It had three disks, attached to a
common hub, These touched upon pins of metal at two points during
each revolution, and passed between two pairs of insulated metal plates
without touching them. They deposited their electricity upon a metal
ball, which they also passed during each revolution. This ingenious

Ce

  
 

 

Fic. 166,—Narenr’s Evectrricat Macnine.—The cylinder of glass revolves between two
separately insulated conductors, one attached to the rubber and the other to a metal comb,

little instrument could to-day be made quite effective by slight modifica-
tions; For some unexplainable reason, it was apparently thought to be
of little value, and even its existence is not mentioned by any standard
author on electrical subjects with which I am familiar. A cut of the
machine was published, however, together with the inventor’s description
of the machine, in an old work entitled the “ New Royal Encyclopedia
of Arts and Sciences.” (See Figs. 167 and 168.)

Lane and Adams both perfected frictional machines during the
eighteenth century, in connection with which the Leyden jar was used
for medical purposes. Some of the cures reported by these crude
machines are fully as startling as those now obtained by improved
apparatus,
650

LECTURES ON NERVOUS DISEASES.

In 1840, Sir W. sa devised a machine by which the friction

(is

te

Fic. 167.—Nicuotson’s “Exvecrric Douner.’

first induction machine invented ) ne from

the original cuts made in the cighteenth century.
._ lighter portions of the cuts are made of glass,

 

of cooled steam against the
sides of minute orifices,
through which it escaped
‘under a high pressure, be-
came the generator of static
electricity. The boiler was
insulated by glass legs, and
hecame negatively electrified.
The jets of steam conveyed
the positive electricity and
deposited it upon a metal
plate studded with points,
upon which the jets were
directed. This machine
proved very powerful, but dif-
ficult to manage, and totally
unfit for general use. I¢ made
a deafening noise, and satu-
rated everything near it. One
of these machines gave a.
spark of twenty-two inches.
To Holtz, of Berlin, we
do: not owe the discovery of
the first induetion-machine, as
many suppose. His apparatus
was not perfected until 1865.

(The
The

Although the original model seems crude in comparison with our present

 

Fic, 168.—Tue same Macuine, Viewed
FROM Abovg,

have usually a central opening.

instruments, still it cannot be denied
that it contained the principle which
formed the starting-point of all the
later improvements; and many of
the mechanical details of the original
instrument are to-day generally used.

There is a modified form of an
induction machine which is now sold
quite extensively to the medical pro-
fession. It is known as the Toepler
machine, or the Voss machine. It
ean be made with one or more re-
volving plates. The fixed plates are
larger than the revolving ones, and

They may, however, be divided or per-
STATIC ELECTRICITY. 651

forated centrally.* They are furnished with paper collectors and disks of
tin-foil. The revolving plates have metal buttons attached to one of their
faces. These buttons impinge upon
metal brushes as the plate is revolved.
The buttons rest on tin-foil cemented
to the glass. The fixed plates are
placed as close as possible to the re-
volving plates.

It is claimed that this machine
will work in all weathers. I have not
found this to be strictly fact; al-
though it is not as much affected by
dampness as an ordinary plate
machine.t This machine is usually
not encased,—a defect which I have
remedied with satisfactory results.
It is lighter and less expensive than
the improved patterns of the Holtz
model; but it is far less satisfactory
in medicine, because it generates a

. see Fic. 169.—ANn Apparatus FOR GENERATING
much smaller quantity of electricity Frictionac Evecrricity py Stream. (De-

 

 

and has less intensity. The spark ice te Wot eee a ae
elicited may be a moderately long Coe oe ee
one (when compared with the radius Gt cen ee a
of the revolving plates); but it is LO a eee

rather a thin spark at best,—thus confirming the view expressed by me
respecting the quantity generated. F

  

ica

Vic. 170,—One or THE Otpest Movers oF a CyLinprican Sratic Macuine.—The rubbers are
grounded, and a Leyden Jar is connected with the positive electricity stored in the receiver.

 

THE Principues or Static Inpuction.—The application of the prin-
ciples of static induction, as demonstrated in the machine devised by

*T have lately had one so divided, which works admirably.
1 This opinion is supported, morcover, by the fact that some manufacturers of these
Machines give to their purchasers explicit directions respecting the drying of the plates,
652 LECTURES ON NERVOUS DISEASES.

Holtz, is difficult to fully explain without devoting more time to the
general subject of electrical induction than is deemed wise. It may be
roughly summarized, however, as follows :—

Any body when electrified has the power, to a greater or less
extent, of exerting (even through an intervening substance, which in
this instance consists of a plate of glass) a peculiar effect upon the
electrical state of another body closely adjacent to it in position. It
tends to draw from the opposed body that variety of electricity which
it does not itself possess. Now, if an intervening substance happens

 

Vic 171 —Tue Orictnat Mover or Hortz’s Inpuction MACHINE WITH VERTICAL PLATES.
‘he same inventor also perfected a machine without win iows or armatures, in which two
horizontal plates revolved in opposite directions. ‘This machine is shown in a subsequent cut.

to exist between the two bodies, the electricity drawn toward it by induc-
tion may be deposited upon the corresponding side of that substance,
and a proportionate amount of electricity of the opposite variety is
abstracted from the intervening body. Hence, the intervening body
becomes either positively or negatively electrified on one side, as the
case may be.

In the induction machine, the intervening substance happens to be
the revolving glass plate; and the opposed bodies are the two paper
collectors and the two metal combs of the machine, which are separated
by the revolving plate of glass.
STATIC ELECTRICITY. 653

Tn all induction machines, the charge is practically constant when
once established, provided the mechanism be perfect and the plates kept
absolutely dry. Under such conditions, it ought never to fail to produce
its full effects when the wheels are set in revolution. This is a great
desideratum in medicine.

In the original Holtz model only one stationary and one revolving
plate were used. Both were circular inshape. The stationary plate had
openings or “ windows” cut in it. Paper collectors were glued to the
stationary plate, so made as to project from it and to come in close cou-
tact with and to face the openings in the stationary glass plate. The
revolving plate was insulated by legs of glass, while the stationary plate
was not. Metal combs were used as terminal attacInnents to the inner end
of the two poles of the machine.
They faced the revolving plate
and almost touched it.

You will find all of these
mechanical features practically
preserved in the improved
models of to-day. The revolving -
and stationary plates have been
increased in number, simply to
augment the quantity of elec-
tricity generated. The — sta-
tionary plates are no longer
circular; they are made in two
pieces, to allow of ‘ windows.”
Two paper collectors are glued
to each stationary plate. These

 

i . * ‘ Fic. 172.—THE Stationary Prare or THE OrIGI-
terminate in points, which pro- NAL HoLyz, SHOWING ITS AKMATURES AND
‘ ; ihe ” WINDOWS, WITH THE PROJECTIONS UPON THE
ject into the ‘“ windows” made ARMATURES.

by dividing the plates. The

poles of the machine have metal combs on one end and a brass ball at the
other. Extra combs have been added to draw off residual electricity,
which accumulates in excess; but these are “ grounded.”

Furthermore, the machine has been encased, simply to protect it
from atmospheric changes. Cat-skin rubbers have been added. They
are of use only as a means of exciting the plates when, from any cause,
induction shall have ceased. We call them the “chargers” of the
machine.

There have been many mechanical modifications made from time to
time of the original model, which have not been here specified by me ;
but as they do not in any way affect the principle of electrical induction,
they are not of importance in this connection.
654 LECTURES ON NERVOUS DISEASES.

In the original Holtz machine, a charge was primarily effected by
rubbing a piece of ebonite briskly with cat-skin until it became highly
charged with negative electricity, and then applying it closely to one of
the paper collectors on the stationary plate of the machine. By the
“law of induction ” the comb opposed to this paper collector becomes
electrically excited immediately. It at once deposits positive electricity
on the side of the revolving plate nearest to the comb, and takes nega-
tive electricity away from the revolving plate. Thus the revolving plate
becomes positively electrified to a very high degree at this point.

=}

Fig. 173.—Hortz's Static Inpuction Machine, witH Horizontat Pratrs.—The plates’
have neither winduws nor armatures, and they revolve in opposite directions.

 

Now, when the wheel is made to revolve to that point where it meets
the other paper collector upon the stationary plate, induction again
takes place. Negative electricity is deposited (1) by the collector on
the opposite side of the revolving plate (the side nearest to the paper
collector), and (2) by the metal comb; at the same time positive elec-
tricity is taken from the adjacent side of the revolving plate by the
collector, and also hy the metal comb, from the opposite side of the
revolving plate. This interchange of electricities charges ‘the “4 positive
pole” of the machine.

The revolving plate (now excessively charged with negative elec-
tricity) goes on to the next paper collector. Here a similar exchange
STATIC ELECTRICITY. 655

of electrical conditions occurs. The negative electricity is taken from
the revolving plate by both the paper collector and the metal comb, and
positive electricity is given to the plate in exchange from both of these
sources. Hence the “ negative pole” becomes highly charged.

As long as the revolving wheels are kept in revolution, this inter-
change of electricities continues at each of the poles; hence, the accumn-
lation at each pole soon becomes sufficiently great to allow of an escape
from pole to pole in the form of a spark, or into the atmosphere as a
“luminous brush ” easily seen in the dark.

STATIC ELECTRICITY AS COMPARED WITH GALYANISM.

It has been computed that the electro-motive force of a Holtz
induction machine is 52,000 times as great as that of a Daniell cell (or
52,000 volts). It is not affected by the velocity of rotation.

The quantity generated is proportionate to the velocity of rotation
and the number of wheels employed.* It is modified also by the
moisture present in the atmosphere.

The internal resistance of the machine diminishes rapidly with
increased velocity of rotation, It is not influenced by atmospheric
conditions.

STATIC ELECTRICITY IN MEDICINE.

The revival of static electricity (or franklinism) as 4 therapeutical
agent from the oblivion into which, for nearly half a century, it had
unaccountably sunk, has been occasioned by several factors. Among
these factors the following may be prominently mentioned :—

(1) The awakening of the profession at large to the fact that
electricai currents of different kinds have distinct therapeutical actions.

These are not to be attributed to or confounded with the strength
of the current employed, or its methods of application. The effects of
faradization, galvanization, and franklinization upon animal structures
differ widely in many respects. The time has come when an intelligent
physician cannot justly condemn all forms of electrical treatment of any
individual case, because he has failed to obtain satisfactory results with
one of the above-mentioned currents alone; even if he has employed
that particular form of current with the highest possible skill and
judgment.

This is an error into which many are unwittingly led. T could report
(if space would permit me to do so) the details of several cases where a
failure to employ the proper current proved most disastrous to patients.
One instance of this character (which was happily aborted) impressed
me so forcibly at the time that it is possibly worth narrating :—

* On this account I have lately increased the size of the driving-wheel, so as to insure
rapid revolution of the plates of the machine.
656 LECTURES ON NERVOUS DISEASES.

A patient, who had accidentally severed the musculo-spiral nerve by
x pistol-bullet, was sent to me some years since for diagnosis, and to
confirm or reject an opinion which had been expressed by a physician
of prominence, namely, that the only hope of cure lay in a surgical oper-
ation for the uniting of the severed ends of the nerve by sutures. This
opinion, as I found, was based upon the fact that the faradatie current
had failed to produce any movement in the paralyzed muscles, and that
several months had already elapsed since the accident, during which
time the hand was steadily becoming more and more deformed by con-
tracture of the flexor muscles of the hand and forearm.

My examination of the patient showed, however, that a galvanic
current produced violent contractions of the paralyzed muscles when
passed through the injured nerve (one pole being placed upon the ster-
num as a neutral point, and the other upon the musculo-spiral nerve) ;
and the galvanic reactions of the nerve and its muscles furthermore indi-
cated marked * degeneration ” as having developed in the nerve below
the point where it had been divided. Thus, the question of the advisa-
bility of an operation was decided positively in the negative. The nerve
had already united.

In about eight months the injured nerve was completely restored by
the use of the “static spark,” the contracture had disappeared, and
to-day the patient can see no difference in the usefulness of his hands.

(2) The improvements which have been made in machines for the
generation of static currents for medical purposes have had much to do
with the revival of this method of treatment. /

Some of the cases reported in the earlier encyclopedias and anti-
quated works on electricity are fully as startling as those now encoun-
tered when treated with the improved machines ; but, on the other
hand, many failures to obtain good results must of necessity have
occurred in olden times from the imperfect apparatus depicted in the
scientific works referred to. Later, I will discuss the various improve-
ments which have been made from time to time since Holtz first devised
the present model of an induction machine (1865).

(3) Improved methods of administration of static currents have
added materially to the effectiveness of this agent as a cure of disease.
Some of these methods were unknown in earlier times (as far as my
research goes to show).

(4) It is now known that a considerable quantity, as well as length
of spark, is essential to the successful use of a static machine in medi-
cine. Many of the static machines sold to-day are practically worthless,
save as a toy, hecause they do not produce a suflicient quantity of elec-
tricity. The requisites of a static machine for medical purposes will be
touched upon Tater,
STATIC ELECTRICITY. 657

(5) Experimentation with this agent seems to have confirmed the
views of its enthusiastic advocates of the present day, and to support the
accuracy of many of the observations reported in old scientific works,
The incredulity of the past is rapidly being overthrown in respect to this
method of treatment; and the special fields in which it proves of the
greatest service are being definitely mapped out. by those who are
scientifically recording the results of its administration.

For the past few years I have devoted considerable attention to the

 

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tit }

   

 

   
 

INT Aa
HL
1

 

 

 

 

Fic. 174. —Hortz Inpuction Macuine, as IMpRoveD BY THE AUTHOR.

improvement of the Holtz Induction Machine. Some of the results of
my experimentation have already been published. The machine now
described (Fig. 174) is in some respects an improvement upon the one
which I originally introduced to the profession through the Medical
Record of October 17, 1885. I have modified the charger originally used
by me, so that it now bears upon the outer revolving plates above the
metal combs, instead of passing between the central revolving plates. I
have found that the application of cat-skin at this point on the outer
42
658 LECTURES ON NERVOUS DISEASES.

plates awakens the machine into action (when not charged) with greater
rapidity and certainty than at any other part of the machine. Further-
more, there is no longer any difficulty in making the contact between the
charger and the glass when the wheels are revolving rapidly ;* while,
with the old charger, the springing of the rubbers often rendered their
insertion between the revolving plates (which are in extremely close
approximation) a matter of some little annoyance at times. This modi-
fication in the charger has entailed a slight change in the mechanism by
which the rubbers are brought into play when needed.t

*A slight touch of the charger of short duration upon revolving wheels, repeated at
intervals of a second or two, is more effective than a long-continued application to the
wheels of an induction machine. ,

¢ In some models of the present day, the charger cannot be raised from between the
revolving plates. This is a serious defect.

Notr.—The following description of this machine is quoted from the author's article in the
Medical Record, October 17, 1885 :—

“I would call the attention of the profession to an improved static machine which has been
lately devised by me.

“It is the result of many months of experimentation, and is the outgrowth of the dissatisfac-
tion which all other devices for generating electricity by friction have afforded myself, as well as
others who have employedthem. By those who have hal experience with static machines, it is gen-
erally conceded that they are frequently charged with difficulty and lve but a feeble spark during
damp weather; and that they are particularly unsatisfactory and of little service during the
summer months, when such conditions are liable to prevail. Jt is also conceded that some form
of motor is generally required to run a machine of large size, because the hand is soon fatigued
in overcoming the friction of the plates upon the rubbers, in addition to that produced by the
bearings of the axle and the belt which connects the driving-wheel with the axle. . Furthermore,
it is now well recognized that plates of large size (16 to 24 inches in diameter), and several of
them, are absolutely essential to a machine which is intended for medical use. Small single-plate
machines do not give sufficient quantity or length of spark to be of any practical benefit as a
curative agent. Again, it has been found by experience that building a glass case over a static
machine does not thoroughly protect the plates of the instrument from dampness. No cabinet-
maker can make joints of wood which will not admit of much moisture when the outside air is
impregnated with it; and chloride of calcium, if placed within the case, will not absorb all the
dampness that enters and collects upon the plates and metal of the machine.

“I found by experience that all the electrodes of a static machine (being insulated by glass
were liable to be easily broken; and that the poles of the instrument, when by accident expose
to outside violence or a blow, were also liable to cause a breakage of the glass windows in the
ease of the machine (which they perforate in most of the later models).

‘In some machines, the case is, moreover, too small for the plates and allows of an escape of
more or less of the electricity generated. The first machine which I made upon the present plan
had this objection, It would give the operator an occasional shock in consequence of this defect
when the hand was used as a motor, and it lost a large percentage of the volume of electricity
generated by “grounding” that proportion which jumped to the metal parts of the case.

‘Without entering further into numerous difficulties which | have had to encounter and
overcome, [may summarize the more important improvements made in the machine shown in
the accompanying cut, as follows :—

“(1) The case is so constructed that all of its joints are packed with soft rubber before its
Screws are tightened. This prevents the entrance of moisture from without, and makes the
machine a useful one at all seasons of the year. Soft rubber now constitutes the best packing
for stcuin apparatus, and is also used in hermetically sealing fruit-jars in preferance to any
known uivterial, All imperfections in the joints Of the case are perfectly sealed in this
instrument.

2) The doors of the case are so arranged as to be drawn tightly in contact with a frame
covered witb soft rubber by means of milled screws.

(3) ‘The glass in the case is put into the frames with putty, which is impervious to air.

_ (4) The poles of the machine perforate the wooden portion of the ease, instead of the glass
windows. They are insulated with hard rubber, and the apertures are protected by soft-rubber
packing placed between hird-rubber buttons and the wood. Thus the danger of bréakage of the
case by avcident is decreased without impairing its impermeability to dampness or allowing of
leakage of the electrivity generated when the machine is in use, while the strength of the case is
materially increased by this modification.

(5) The axle is so built as to reduce the friction to a minimum and to allow of its being
oiled without opening the case. :

“(6) The driving-wheel is very large, and rests upon a cast-iron support. This insures both
ease of motion and durability. :

“(7) The oe plates of the machine are nine in number. Six of these revolve, and three are
stationary. The stationary plates are of peculiar shape. The revolving wheels are made of
Sree y selected glass, so as to be as true as possible and bear evenly upon the rubbers as they
revolve.

 
STATIC ELECTRICITY. 659

Again, although chloride of calcium is not required during the
cool months in this particular machine for the purpose of drying the
air contained within the case (on account of the rubber packing between
all the joints of the case, which almost hermetically seals it), I have
found it desirable to use this or some other means of artificially drying
the plates during the summer months; because the air is then excessively
laden with moisture. To allow of the introduction of a tray contain-
ing chloride of calcium without opening the doors of the case I have
been forced to modify the wood-work of the machine somewhat, and I
have also raised the lower level of the stationary glass plates about two
inches. By this means I can now slide a tray nearly the whole width of
the case underneath the plates, and thus expose the air within the
case to a large absorbing surface, which deprives it of moisture very
rapidly.

I hope in time to so perfect my system of packing the joints and the
openings in the case (entailed by the parts of the machine which must
of necessity perforate it), as to make it absolutely air-tight at all seasons
of the year, When this feat is accomplished, the necessity of chloride
of calcium* or any artificial dryer within the case will have been entirely
dispensed with ; but until cabinet-makers can be found who never make
mistakes, or a better material than highly finished and shellacked woodt
can be obtainad from which to construct the framework of the machine,
I fear this scheme will never be perfectly accomplished. Practically,
however, this necessity is not so great as it might at first seem; because
during the summer months the diffusion of static electricity into the
atmosphere is so great as to seriously interfere with a satisfactory appli-
cation of this agent to a patient by the methods known as “ insulation,”

(8) The excitants consist of cat-skin rubbers so arranged as to touch the outer plates when
the machine loses its charge. This charger is a great improvement over all others previously
cuployed byme. Metal buttons are also placed upon the outer plates, which as materially assist
in charging.

(9) The collectors have tinsel attachments which aid in ans the electricity generated.

(10) The electrodes are made with handles composed of hard rubber instead of glass.
They are therefore less lialle to be broken, and are as perfectly insulated, __ . .
"(11) Each machine is provided with three pairs of Leyden jars of different sizes. It is
arranged also with hooks upon which the electrodes may be hung when not in use. | .

“Tn conclusion I would say that Ihave produced with the machine here described (24-inch
plates), and now in mv office, 2 spark of eleven inches in length during a muggy day in August,
when most static machines would fail to charge. It runs, after a few turns by the hand, for
nearly a minute without any power, and generates without interruption. Any boy of seven
years of age can run it without fatigue for half an hour, — : :

“The machine here described is manufactured by Waite & Bartlett, of New York City, who
have been industriously occupied for several months in perfecting it under my guidance,

“The cost of this machine has been materially reduced from the schedule prices of other
makers for similar instruments, rather than increased by the improvements made.” :

* In several instances I have known the chloride of lime sold in commerce to be placed
within the case of a static machine. The result has been to almost ruin the metal parts of
the machine. It took a mechanic nearly a week in one instance to restore the effective-
ness of the instrument.

} It has been computed that fifty coats of shellac-varnish are requisite to prevent the
penetration of gases through stone.
660 LECTURES ON NERVOUS DISEASES.

the “indirect spark,” and the “static wind,” in spite of a perfect gen-
erator. These methods, as well as other forms of application of static
electricity, will be described later.

In other respects than those enumerated, the modified Holtz induc-
tion machine introduced to the profession by myself some time since
remains practically unaltered. Its effectiveness seems to have been pre-
éminently satisfactory to those who have used it, and the quantity and
leneth of spark which can be elicited is as nearly an approach to the
maximum of its theoretical quantity and power as could be hoped for.

No statie machine can give off a spark greater than the radius of the
revolving plates. I have frequently demonstrated a spark of eleven and
a half inches from a wheel of twelve-inch radius. Furthermore, I think
I can justly claim to have so improved all previous models built on the
original Holtz plan as to insure a continuance of the charge throughout
nine months of the year without recourse to artificial means for drying
the plates. When properly cared for and handled, there is little necessity
even for a charger during these months.

Before I pass to the consideration of static electricity as a thera-
peutical agent, it may be well for me to state that the cost of a static
induction machine with plates of twenty inches diameter or over must
of necessity be large; although the cost has been materially reduced of
late by competition and improved methods of manufacture.

Again, it is impossible to transport a static induction machine from
house to house without danger of breakage and the employment of a
cartman; hence it becomes a part of a physician’s office outfit only, and
cannot be used in medical practice except by bringing the patient to the
machine or going to some expense and risk in transporting it.

Finally, a static machine of the induction model requires a certain
amount of care; otherwise the etfectiveness of the instrument is liable
to deteriorate, and its component parts to become more or less injured.

There is another form of static machine (already described as the
Toepler model), which has been sold extensively to the profession. It
has no case to protect it from the atmosphere. It can therefore be
more readily transported, and it costs much less to manufacture than
the induction model; but, on the other hand, it is far less effective, and
cannot be favorably compared with the more expensive machine as a
part of a physician’s oflice outfit. The quantity generated by such a
machine is necessarily small; and it is more or less seriously affected by
atmospheric changes. In spite of the fact that some of the later authori-
ties on electricity speak in its praise, I cannot give it an unqualified
indorsement. It may serve the requirements of scientific institutions
admirably ; but it is, at best, but a make-shift for the neurologist. I
think that Iam sustained in this opinion by those who have had experi-
STATIC ELECTRICITY. 661

ence with the two models, when provided with all their latest improve-
ments. I have been experimenting for some months to devise a cheap
static machine which patients can use at their homes, and I think T have
succeeded in producing a tolerably effective instrument; but T should
never advise a physician to purchase one for his own use, if he could
afford to buy an improved IToltz induction machine.

A Srarre Ovutrit.—The cost of an improved induction machine of
the latest pattern varies from $250 to $350, according to the size and
number of the plates; hence, this is a matter to be carefully considered
before purchasing one. It is advisable, in my opinion, to have not less
than six revolving and three stationary plates. The revolving plates
should not be below twenty inches in diameter. I prefer one with
twenty-four-inch plates, for medical purposes, over those of less power.

The attachments which should be purchased with such an instrument
comprise :—

(1) An insulated platform. These may be made to seat one, two,
or more persons at a time. I use for legs the heavy glass insulators
employed by telegraph companies upon their poles. They are very
strong and cheap, and have another advantage, namely, that they can be
screwed up and down upon a wooden pin which perforates their central
orifice. This admits of leveling the platform, in case the floor of the
room has settled.

(2) A set of electrodes. This item comprises a large and small brass
ball, a metal point, a wooden point, a roller of metal and of wood, an
umbrella-electrode, some sponge-covered electrodes, a pistol-electrode,
and a ring to hold the chain away from the patient during the applica-
tions. The handles should be long, and made of hard rubber or of glass.

(8) A set of brass chains of varying lengths.

(4) A set of hooks for attachment to the ends of the chains.

(5) A set of heavy insulated rheophores of varying lengths.

(6) Three pairs of Leyden jars of different sizes. I use those of
3-inch, 14-inch, and l-inch diameter, respectively.

(7) A wooden chair or stool which fits the insulated platform.

(8) A connecting brass rod, for use when the Leyden jars are
employed.

(9) Some pieces of cat-skin.

(10) Several bottles of well-selected chloride of calcium.

Tue Care or an Induction Macuine.—A few suggestions of prac-
tical value may be made upon this subject.

It is advisable, in the first place, that an induction machine should
be placed in a perfectly dry room, well lighted by the direct rays of the
sun; and, when possible, in close proximity to a window which shall
allow the sun’s rays to fall directly upon the glass plates of the instru-
662 LECTURES ON NERVOUS DISEASES.

 

Carbon Electrode, round end.

 

One and a quarter inch Brass Ball,

   

Rubifacient,

  

Two and a quarter inch Brass Ball.

    
 

 

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Spinal Roller for Massage.

 

Brass Point and Chain-Holder. Morton’s Pistol-Electrode.

Fic, 175,—Exxcrroprs Emptoyrep witv An Inpuction MACHINE.
STATIC ELECTRICITY. 663

ment. By this step we obviate dampness, and thus insure the greatest
effectiveness of the machine.*

In the second place, the metal parts of the machine and the metal
electrodes should be rubbed briskly every morning with dry chamois-skin
or silk. Accumulated moisture on the poles or electrodes is a serious
drawback to successful static applications.

In the third place, although the metal parts of the machine are
shellacked when made, they are apt after a lapse of time to require
repolishing with emery-paper, powdered emery, or rotten stone. A light
coat of shellac-varnish should be given these parts after their brightness
has been restored, and all grease or moisture thoroughly removed from
them.

Again, it becomes necessary, at intervals, to oil the bearings of the
wheel-axle and the plate’s axle; also to occasionally tighten the leather
belt,f and to re-shellac the case if it becomes blistered by the sun. The
latter step tends to exclude the entrance of moisture within the case
through the pores of the wood.

During the summer months /resh chloride of calcium should be
constantly kept within the case. It should be renewed whenever sufticient
fluid appears in the tray to become evident to the eye. Unless the case
is packed with rubber, this method of artificially drying the air must be
employed at all seasons of the year. A few drops of petroleum on the
floor of the case help to prevent the accumulation of atmospheric
moisture upon the plates.

Occasionally, the best machine will lose its charge. Should it do
80, you will probably find that one of the following causes has led to
this result :—

(1) The servant, or some inquisitive person, may have turned the
revolving plates in the wrong direction; this causes the accumulators to
lose their electrical state and thus to arrest “induction” through the
glass’ plates.

(2) Atmospheric moisture may have entered the case and been depos-
ited upon the plates. In all models that I know of, but my own, this
occurrence must of necessity be very frequent, as no safeguards exist to
prevent it.

(3) The instrument may have been left, after an application to a
patient, with both the poles “ grounded ” by means of the chains dangling |
from'them and resting upon the floor. This oversight may not prove
serious in dry, cold weather; but, it is never advisable to leave the
chains attached to the poles when the instrument is not in use.

*T have my own in a bay-window, where the afternoon’s sun has free access to it.

t Thumb-screws beneath the driving-wheel post are provided for this purpose in my
model, :
664 LECTURES ON NERVOUS DISEASES.

(4) The plates may have loosened from the axle; and, in conse-
quenee, some may fail to revolve properly. To obviate this occurrence,
double nuts should be used on the plate-axle.

(5) The combs may have become displaced, so as to touch the glass
or to ‘bear an improper relation to the paper collectors.

(6) The case may be too small for the plates; and thus allow of
escape of the electricity to the ground. This will be very apparent to
the eye when tested in darkness,

THe CHarcinc or A MAcHINE.—It is well to know what steps are
necessary to start a static induction machine, in case it loses its charge.
I have seen a few instances where the owner of such an instrument has
worked himself into a heat of passion as well as of body by fruitless
attempts to obtain a spark, while a patient calmly waited with expec-
tancy for the successful termination of his feat. Some of my readers may
have had such an experience. I suggest, therefore, that they follow the
directions given, with some regard to their details :—

(1) See that the plates and charger are dry. If not, you can easily
render them so by exposing the machine to strong sunlight, and by
putting an abundance of chloride of calcium in trays at the bottom of
the case. This may require some hours of delay. Always open the
door of the case if the sun’s heat be used; and close them tightly (by
means of the milled screws which perforate the door) as soon as the
machine regains its charge.*

(2) After you have got the plates thoroughly dry, start them in
rapid revolution by turning the driving-wheel from left to right as you
stand facing it. Now apply the chargers lightly near to the edge of the
revolving wheels for a second or two, and then sweep them across their
face at intervals of a few seconds, until the machine starts. The poles
should be approximated to within one-half inch, and the chains should
not be connected with the poles.

(8) If the machine fails to start, in spite of these directions, you
can then take a piece of cat-skin and warm it thoroughly over a gas-jet.
Then set the wheels in rapid revolution and apply the warmed cat-skin
as a rubber (to the plate with the buttons on it) as close above the metal

*If you cannot spare the time for these procedures, « large alcohol-lamp may be
lighted within the case. The air may thus be heated sufticiently to temporarily render the
machine useful. Iam aware that J have been criticised (in a carping spirit) for offering

‘this suggestion in print ; but, as a temporary expedient, it oftentimes proves a valuable aid
in rapidly regaining a lost charge, and rendering an induction machine efficient.

Ihave frequently known the nozzle of a hot-air furnace (such as is used in giving a
hot-air bath to a patient beneath the bed-clothes) to be directed into the case of an induc-
tion machine for the purpose of drying the plates when very damp. Atone time I tried to
build a machine with a tube passing through the case, by means of which the air in the

case might be heated indirectly without opening the door; but I found it impracticable,
for many reasons,
STATIC ELECTRICITY. 665

comb as it is possible to hold it. This seldom if ever fails; but it
requires the opening of the door of the ease.

(4). Be sure that the poles are well dried with chamois-skin before
the machine is put in action; also, that the poles are closely approxi-
mated, but not in contact.

METHODS OF APPLICATION OF STATIC ELECTRICITY.

Static electricity can be applied in several ways to a patient, Each
of these methods has some therapeutic effects which are peculiarly its
owh. Moreover, the sensations experienced by the patient during the
application are greatly modified by the method employed. For these
reasons, it is necessary to go into greater detail respecting the manage-
ment of a static machine than that of any other electrical apparatus in
medicine with which I am familiar.

We can apply the static current to a patient in the following ways :—

(1) By the “ indirect spark.”

(2) By the “ derect spark.”

(3) By the “ Leydenjar spark” or “ static shock.”

(4) By “ static insulation,”

(5) By the “ statte breeze.”

(6) By the “ static induced current.”

Tue Inpinect Spark.—To administer static electricity by this
method, the patient is first placed upon the insulated platform, and
sufficiently removed from all surrounding objects to prevent the escape
of the charge from the patient ‘to them. The machine is then connected
with the patient by a chain, which is either held or simply attached to
the stool on which the patient sits. The chain must be sufficiently
elevated from the floor to prevent “ grounding” of the current. It may
be attached to either the positive or negative pole of the machine,
according as the operator may desire positive or negative insulation.
A chain is then attached to the other pole of the machine, and is
“‘orounded.”? This can best be effected by attaching it to the gas-fixture
or a faucet attached to a constant water supply. If this is not conveni-
ent, the chain may be thrown upon the floor, when not carpeted, in case
the generating power of the machine is ample.

The poles of the machine are now widely separated and the wheels
put in rapid motion. You will notice that the hair of the patient imme-
diately rises; and, in a dim light or total darkness, you should perceive
a peculiar purplish light escaping from the tips of the finger-nails, the
hair, and other parts of the body which are more or less pointed. The
rapidity of this escape is influenced (1) by the extent of the charge;
(2) by the proximity of a part to some surrounding object; and (3) by
the condition of the atmosphere, as regards its moisture. As the patient
666 LECTURES ON NERVOUS DISEASES.

moves his finger-tips near the door-casing or some article of furniture
not insulated, you may be able to perceive this escape of electricity, even
in a strong light.

Now we have a condition which is known as “static insulation,”
If the machine is a powerful one, it may be carried to a high point. The
patient happens to be charged, in Fig. 176, with positive electricity,
because he is connected with the positive pole of the machine.

The final step consists in presenting to the part which you wish to
influence a brass ball on the end of an insulated handle. This electrode
is connected, as you see, with a gas-pipe by means of a brass chain. A
water-pipe makes an equally good connection. When this ball reaches
a certain degree of proximity to the patient,* you notice that a discharge

Te

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Fic 176.—TuHe Inpirect SPARK,

of the accumulated electricity occurs in the form of a “spark.” This is
known as the “indirect spark,” because the electricity takes an indirect
course (through the earth) to form a circuit. It leaps from the patient
and escapes to the earth down the gas-pipe or whatever grounding the
electrode may chance to have.

The length of the “indirect” spark is directly proportionate to the
generating power of the machine—supposing, of course, that all other
factors in the application are equal (such as the humidity of the atmos-
phere, the completeness of insulation, ete.).

*The length of the spark elicited depends on the power of the machine, the dryness

of the atmosphere, and the perfection of the insulation of the patient. I freqnently have
drawn a spark of eight inches by this method.
STATIC ELECTRICITY. 667

The volume of the spark is modified by the size of the brass ball on
the end of the electrode. A large ball will produce a heavier spark than
a small one.

The therapeutical effects of this method of application will be dis-
cussed later. I would call attention, however, to the violent muscular
contractions which occur with each spark,

This method is somewhat painful. The withdrawal of a spark leaves
a‘“weal” or lump, which somewhat resembles a recent mosquito-bite.
They almost entirely disappear when friction is employed after the
application; hence, it is my custom to rub the part with my handker-
chief, if exposed (the face or hands, for example), after the application.

I would caution you here, in passing, against giving static sparks
(by any of the three specified methods) to a patient on his first visit.
You are apt to frighten a patient, unless he is well prepared for it.
Again, patients grow tolerant of this method of treatment after a while ;
hence, you can gradually increase the volume and length of spark at
successive sittings without endangering the patient’s confidence in you
or creating alarm. You can regulate the length of the spark by the
speed of revolution of the plates of the machine.

For some hours after such an application the patient feels a sense
of heat at the spot where the spark occurred. This is not at all unpleasant
tomany. Some patients even speak of it as agreeable.

By using a wooden ball in place of a brass one, a number of very fine
sparks are simultaneously elicited—giving to the patient a feeling aptly
compared to a ‘shower of sand.” This electrode is admirably adapted
for use about the eye or the face, although this is not the limit of its
usefulness.

Finally, it is not essential to this form of application the that
clothing be removed ; as the finest silk or woolen fabric is not injured by
it. This isa great point in favor of static application, especially in the
treatment of females.

It is customary to use a second electrode with a ring of brass
attached to the insulated handle, through which the chain is passed
before it is attached to the ball-electrode. This is to keep the chain
away from the patient, so that sparks will not be caused at points where
you do not desire them to occur. A little practice will enable you to
handle both with one hand, while you turn the wheels of the machine
with the other. Sometimes it may be necessary to have the patient
stand rather than sit upon the insulated platform while these applications
are being made.

Let us pass now to the second method enunciated.

un Direct Spark.—By this method, the circuit between the poles
of the machine included the patient only. He sits on the insulated
668 LECTURES ON NERVOUS DISEASES.

platform, which is connected with one pole of the machine; or one pole
may be directly attached to some particular extremity of the patient,
when the effects of the current are to be concentrated as much as pos-
sible upon that member. The electrode is attached to a chain, which is
fastened to the other pole of the machine. The length of spark to be
administered is regulated by the extent of separation of the poles of the
machine and the speed of revolution of the plates. The farther apart
the poles, the longer and more severe is the spark.

The ring electrode is employed (as in the former method) to protect
the patient from an accidental contact with the chain attached to the
electrode.

In neither this nor the method previously described are Leyden jars
employed.

 

Fic. 177.—TuHe Direct Spark.

I question, personally, whether the selection of the poles for the
attachment of the electrode has much, if any, influence over the thera-
peutical action of the “direct.” spark. Tf it has, I have not as yet
clearly formulated in my own mind any deduction respecting this point.

Static Suock, on tHe Leypen-Jarn Spark.—This method of appli-
cation is accomplished hy first altaching a pair of Leyden jars to the
poles of the machine, and connecting their outer covering of tin-foil by a
brass rod.

The poles of the machine are then brought into close approxima-
tion; because the strength of the shock is modified (1) by the size of the
jars, and (2) by the separation of the poles.
STATIC ELECTRICITY: 669

As this method is, at best, a very severe form of application, it is
well to begin with very small jars, and to place the poles as nearly in

as

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Fic. 178,—Suock witu Leypen-Jar Discuarce.

contact as possible (without actually touching each other). They can
then be separated at will, as the exigencies of the case seem to demand.

The chains are arranged ina similar manner to that described in
the preceding method (direct-spark application).

 

Fic. 179.—AN ApeLicaTION oF THE LeypEN-Jar SHock DurinG THE EIGHTEENTH CENTURY.
(Copied from an old English work.)

This method is best applied to the bare skin. The polarity of the
electrode is not, to my mind, a matter of much consequence.
I advise you to handle this form of treatment with extreme caution.
670 LECTURES ON NERVOUS DISEASES.

I have several times accidentally received a moderate static shock, and
I can'assure you it is not associated with pleasurable sensations.

Sratio InsuLATIoN.—This method has already been described in
connection with the administration of the *‘ indirect spark.” It is, per-
haps, the most agreeable of all methods of static treatment. The patient
is simply charged for a variable space of time (three to twenty minutes)
with either positive or negative electricity. The pole of the machine is
attached to the insulated platform on which the patient sits or stands.
The other pole is ‘“ grounded” by a brass chain running to the floor, a
water-pipe, or a gas-fixture.

The poles of the machine are as widely separated as possible before
the wheels are set in revolution.

 

Fic, 180.—Static INsuLATION,

No pain is experienced. The hair becomes erect, unless very much
oiled. The patient experiences a peculiar “tingling sensation,” with a
tendency toward perspiration if the administration is long continued.
If you approach the patient too closely, a spark is elicited at the nearest
point. This should be avoided, if possible.

Its therapeutical effects will be discussed later.

Tue Sratic Breeze.—This method of administration of static elec-
tricity consists in the withdrawal of the static charge from a patient by
means of an electrode of metal or wood, which is pointed.

If the breeze be indirectly induced, this electrode is grounded by
chain attached to a gas-pipe, a water-faucet, or placed in contact with a
wood floor when the other connections are not easily accessible. The
STATIC ELECTRICITY. . 671

patient is first insulated (in order to retain a charge), and is then con-
nected with one of the poles of the machine by means of a chain, which

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Fic. 181.—Tue Invirect Svatic Breeze,

he either holds or fastens to the platform upon which he sits. The
electrode is then employed.

 

Fic. 182, —Tue Direcr Sratic Breeze.

When the breeze is directly induced, the insulated stool is connected
with one pole of the machine, and the electrode with the other pole
672; LECTURES ON NERVOUS DISEASES.

If the electrode be a metal one, the electricity is drawn rapidly from
the patient at the point which is nearest to the electrode, and a sensation
resembling that of a breeze is experienced at the spot where the
electricity escapes. Single or multiple points may be employed on the
electrode.

In either of these methods, when the electrode is composed of wood,
the sensation is modified, to a certain extent, by the poor conductivity
of the wooden point. Most patients compare the effect of such an appli-
cation to a “ shower of sand ” concentrated upon the point of withdrawal
of the charge.

When this method is employed about the eye, the wooden ball or
wooden point is usually preferable to one of metal.

 

Fic, 183,—Tue Evectricar Heap-Batu, A VARIETY OF ADMINISTRATION OF THE Static Breeze.

When application to the head and scalp are deemed requisite, a
metal cap studded with points is hung over the head of the patient by a
chain, which is grounded. This cap is known as the “ umbrella elee-
trode.” Tt should not touch the patient’s head or hair, when he is placed
beneath it upon the insulated platform. The numerous points of the
electrode draw off the electricity through the hair and scalp, which passes
from the machine to the patient, and produce a sensation which is par-
ticularly pleasant. A “strong wind” is felt permeating the hair and
encircling the head.

Sraric INpucep Current.—To convert a static machine into what,
to all practical purposes, may be considered a “ Faradaic” instrument,
some slight moditications only are required.
STATIC ELECTRICITY. 673

The discovery of this method may justly be attributed to the inves-
tigations of Professor W. J. Morton, of New York; although Matteucci
first devised an instrument which gave shocks by induction simulta-
neously with the discharge of a Leyden jar. (See Fig. 795 of Ganot’s
work on “ Physies,” by Atkinson.)

To produce this form of current, it is necessary to first hang a pair
of Leyden jars upon the arms of the machine. The size of the jars
employed modifies the strength of the current; hence it is necessary to
have jars of different sizes as a part of the static outfit. You now attach
the chains or, by preference, insulated wires, which serve to connect the
machine with the patient, upon the hooks that rest upon the outer coating
of the jars. Finally, you attach to the other end of each rheophore an
electrode for use upon the body of the patient. The electrodes may be

 

of metal without any covering, or ordinary sponge-covered electrodes
may be employed (care being taken that the insulating handles are
somewhat longer than usual).

Before the machine is set in motion, its poles should be approximated
closely. This step is important, because the separation of the poles inten-
sifies the current, as long as a spark will pass between them. There are
two factors, therefore, in determining the strength of the static-induced
current :—

(1) The size of the jars.

(2) The extent of separation of the poles.

Dr. Morton has devised an ingenious electrode which allows of an
application of this form of current to a patient without disturbing the
poles of the machine; but it is not an essential part of a static outfit,
because an interruption of the current can be accomplished without it.

43
674 LECTURES ON NERVOUS DISEASES.

This electrode represents 2 simple mechanical means of putting into
practice the method discovered by him in 1880, of converting the static
electric charge into dynamic electricity or current. Electric nerve-and-
muscle reactions had previously been obtained by means of the inter-
rupted galvanic and the faradaic currents. It has also been noticeable
that the “spark” discharged on a nerve motor-point, or over a muscle,
produced the characteristic reactions. But the spark was painful, and
diflicult to direct accurately, particularly about the face and head. To
avoid these objections, Dr. Morton arranged this electrode, by means of
which the disruptive discharge or spark of static electricity takes place
between two brass balls, one of which is in relation with the “ ground,”
while the other is connected to an ordinary moist-sponge electrode.
This in turn is applied at the point desired of the patient charged on the
insulated platform.

As a result, for every static discharge occurring between the two
brass balls there is a dynamic discharge or current at the point where

 

Fic. 185.—Morron’s Pisto.r-ELectropeg,

the sponge is applied, and the nerves and muscles may be stimulated, or
rather “irritated,” exactly as by the ordinary interruptions of battery
- currents, direct or induced.

This electrode is another means of converting static into dynamic
electricity, based upon the principle described under the name of “ static
induced current” by Dr. Morton,

This “static induced current,” as has been already stated, was
obtained by attaching ordinary sponge electrodes by their connecting
rods to the outer layer of tin-foil on the Leyden jars. The patient, in
other words, replaced the usual connecting rod between these coatings.
On putting the raachine in motion and causing a spark between the
poles,.a “current” was felt by the patient, no insulation of course being
required. The advantage of this method is that the ordinary Holtz
machine may when required be called upon to perform the work of an
ordinary faradaic or induction machine.

The greatest event after its discovery, in the history of medical
ELECTRO-THERAPEUTICS. 675

statical electrization, or franklinism, was the invention of the Holtz or
induction machine in 1865. Next in importance, perhaps, is the method
discovered and put into practice by Dr. Morton, in 1880, of converting
the static discharge into a dynamic discharge or current, and the electrode
represented on opposite page is the only novel electrode of any importance
not bequeathed to us by the medical electricians previous to 1880.

The difference between the “static induced current” and the
faradaic current is this: The former has a fixed polarity and direction,
and greater electro-motive force. It is far less painful, also, than is the
faradaic current when the electrodes are widely separated.

My attention has lately been drawn by Dr. Morton to another device
of his for the prevention of the escape of sparks from a sponge-covered
electrode while employing the static induced current. It consists in
applying a coil of copper wire closely upon the fiat surface of the metal
end of the electrode which is covered by the sponge. This is done in
order to prevent the concentration of the current at any one point on the
‘surface of the electrode while in use.

He has also been experimenting of late upon the effects of deriving
currents for medical purposes from a helix of insulated wire wound upon
each of the Leyden jars of a Holtz induction machine.

I have not yet tested the working of either of these later appliances
but I shall do so soon, when I am provided with the necessary apparatus.

PART II.

ELECTRO-THERAPEUTICS.

Gatvanic MEASUREMENT AND DosaGE.—Quite an active discussion
of this important subject has been indulged in through the columns of
various journals during the past year. Prominent among the partici-
pants in this discussion may be mentioned, Drs. Rockwell, Martin,
Engelmann, Massey, and Bailey.

The fact must be apparent to any one who has watched the progress
of electro-therapeutics with interest that the professional mind is at last
becoming keenly alive to the necessity of knowing exactly how much
electricity is being administered to a patient at each sitting, The method
commonly employed in the past of noting the number of cells used (even
this precaution not being always taken by some writers) is only an
approach to a scientific record of a case. It offers no opportunity for
advancement in our efforts to bring electro-therapeutics to a tangible
basis of scientific precision.

A few hints previously offered respecting the important subject of
galvanic dosage may therefore be repeated here with possible benefit to
the reader.
676 LECTURES ON NERVOUS DISEASES.

Galvanic cells differ in their electro-motive force according to their
mechanical construction, viz., the character of the elements employed,
the internal resistance, ete. On the other hand, the quantity generated
depends upon the size of the elements or the extent of their immersion,
and the character of the excitant, when all other conditions are practi-
eally similar.

For example, two galvanic cells of identical make and size will not
generate the same quantity when one has been exhausted and the other
has been freshly filled ; or when one is polarized and the other is not
polarized.

The electro-motive force has no relationship with the size of the
elements, but the quantity generated has. A stream may flow five miles
an hour, be it a brook or a river; but the quantity of water that passes
a given point in the same interval of time is not the same in each case,
as the merest child can easily understand. On the other hand, a lake at
a height of one hundred feet will exert no-greater pressure through a
pipe leading from it to the ground than would a tea-cup at the same
elevation, if kept constantly filled. The quantity is determined in the
first instance; the pressure (or electro-motive force) is illustrated in the
latter. The bursting of water-pipes in our dwellings is not induced by
the size of the distributing pipe nor by the size of the reservoir, but by
the height of the original source of supply.

Again, a bullet, when propelled from a weapon with a given charge
of powder, will penetrate a board more deeply than a piece of iron. So it
is with electric currents. A current of a definite electro-motive force
will travel faster through some tissues than others; will penetrate the
skin of a thick palm with greater difficulty than the thin skin on the
back of the hand; will be facilitated in its passage by large elec-
trodes and retarded in proportion as their size is reduced; will be
aided in many instances by the saturation of the electrode (especially
with a saline solution), and will be retarded by the absence of such
conditions ; will be aided by a close approximation of the electrode to
the surface of the body, and retarded by an imperfect approximation of
the electrode.

Currents derived from a galvanic battery invariably enter at the
positive pole (the anode) and escape at the negative pole (the cathode).
Now, a bullet, when shot through a board, tears most at its point of exit.
We may consider the negative pole as that which tends chiefly to stimulate
-the parts with which it comes in contact or upon which its effects are
indirectly exerted, while the positive pole is to be clinically regarded
rather as the sedative pole, in contradistinction from the negative. The
positive pole is acid in its reaction, while the negative is alkaline.

When we bear the essential facts of electro-physics in mind, many
ELECTRO-THERAPEUTICS. 677

of the difficulties of electric measurement are more clearly appreciated, as.
well as some clinical facts that are indirectly related to this subject.

To accurately determine the dose of electricity which the patient is
taking, several factors have to be considered :—

In the first place, the number of milliampéres (the unit of current-
strength in medicine) may be measured by a reliable milliampére-meter.

This instrument must be thrown into the circuit,—, é., between the
positive pole of the battery and its negative pole,—the patient being
similarly. interposed and constituting the main resistance offered to the
current which is supposed to be passing. The resistance of the rheo-
phores and of the galvanometer itself must be added to that of the
patient in determining the total of external resistance offered to the
electric current,—provided the electrodes admit of a circuit.

The importance of having a reliable milliampére-meter (if any is
employed) must be apparent to the merest tyro in electricity. Unfor-
tunately for science, the market is flooded to-day with cheap instruments
that are absolutely worthless for scientific purposes. Many of them are

never tested individually before being sold, even if made upon scientific

principles. Others fail to record more than thirty or forty milliamperes
of current, and on that account are not adapted for use when very high
currents are employed, even if deemed reliable as far as they go. Con-
siderable ingenuity has been shown of late in the attempts of profes-
sional electricians to perfect this instrument, the utility of which is
becoming more generally recognized each day, and which will soon con-
stitute a very important part of each electrician’s outfit. Perhaps one
of the best instruments yet introduced to the profession is known as the
“dead-beat ” milliampére-meter, and is manufactured by Messrs. Waite
and Bartlett, of New York.

This instrument (Fig. 153) is so called because the oscillations of its
needle (which in most galvanometers amount to from fifteen to sixty
before the needle comes to rest) .are dampened by the suspension of the
needle in a cylindrical block of copper by means of a fibre. This block
becomes electrified by an induction and creates an opposing current, which
reduces the oscillations to three or four after the current has been shut off
orreversed. By means of two shunt-coils this instrument can be made to
accurately record as high as five hundred milliamperes, or as low as one-
tenth of one milliampere. The mirror allows the operator to read the
needle-deflections with as much ease as he would those of a vertical
galvanometer. Rockwell, in a late publication, joins with me in the
view that this instrument is a great improvement upon any other hitherto
at our command for the measuring of current-strength.

The “absolute galvanometer” of Hirschmann is another desirable
instrument, but it is too expensive for general use in the profession. |
678 LECTURES ON NERVOUS DISEASES.

The needle, however, rests upon two points which are liable to get bent
or to oxidize.

Respecting the employment of the galvanometer in the measure-
ment of galvanic dosage, M. Vigouroux has lately contributed a paper to
the Biological Society of Paris, in which he raises a point not generally
considered, viz., whether the electro-motive force which propels the cur-
rent through the external resistance afforded by the galvanometer, the
rheophores, and the tissues of the patient should not be taken into
account along with the reading of the galvanometer. He cites, as an
example, that to give two patients a current of five milliampéres, thirty-
six Daniell elements were required in one and only twelve in: the
other. Both received the same quantity; but one received it under
three times the pressure of the other. In any given case, as he states,
the galvanometer fails to show this point. He believes that currents are
modified in tueir physioiogical attributes by the electro-motive force as
well as by the quantity and density. He therefore suggests that the
quantity as shown by the galvanometer and the eletro-motive force,
which is easily ascertainable, after noting the number and the character
of the cells employed, be alike recorded in each observation. By multi-
plying the electro-motive force by the quantity, we obtain the energy of
the current in “ volt-ampéres ” or “ watts.”

Respecting this point, this observer suggests that with an equal
number of “watts” a current of great intensity and feeble electro-
motive force would have a totally ditferent therapeutic action from a
current inversely constituted.

He employs the Deprez-d’Arsonval galvanometer with a vertical
needle. ‘This instrument is perfectly astatic. He also employs a special
commutator, which is so arranged as to place at will the galvanometer
in the circuit of the clectrode or in derivation. It is graduated for fifty
volts.

The only criticism that I would make to the views of this observer
is that possibly the resistance in the rheophores. the electrodes, etc.,
have not been uniform in all his experiments. Much of the electro-
motive force may have been expended in trying to overcome an imper-
fect conduction outside of the tissues of the patient. In that case the
patient wouid not receive the current under as high a pressure as the
electro-motive force of the battery would indicate.

In the second place, mere measurement of current-strength. by the
milliampeére-meter ts not sufficient for exact and scientific electrical
treatment of morbid physical conditions,

If an experiment be made with a fixed number of cells of the same
pattern and freshly filled, by passing the current through animal tissues
with electrodes of ditlerent sizes placed upon identical spots of the same
ELECTRO-THERAPEUTICS. 679

individual, it will be found that the milliampére-meter will record a
larger number of milliamperes when the electrodes are large than when
small, and that the smaller the electrodes the greater will be the dis-
comfort to the patient, in spite of the fact that the amount of current ig
less than when the electrodes are increased in size.

Now, the density of the current is a very important factor in electro-
therapeutics, especially so after the current has reached the diseased
portion of the body which we wish to influence by it. All electrical
currents tend to diffuse themselves to a greater or less extent after they
enter animal tissues: hence, if the diseased part is deeply situated there
is of necessity more diffusion and less relative density than if the part
be superficial, and therefore nearer to the electrode. Zenner puts this
point in a late lecture very clearly, when he says, “The density is in
inverse proportion to the size of the conductor through which it flows:
therefore, with the same current-strength it is greater when we apply
small, less when we apply large, electrodes. When the area of disease is
near the surface we often apply small electrodes in order that as dense a
current as possible should enter it; but if we wish to affect a deep-seated
part, the spinal cord for example, as the current becomes very much
diffused before reaching it, it is necessary that a large quantity of elec-
tricity should enter the body, and for this reason we apply large
electrodes.”

We have already noted the important fact that the density of the
current affects the current-strength. A patient wili feel a very dense
current of five milliamperes (administered of necessity through a some-
what small electrode) more perhaps than one of twenty milliampéres
entering the same region of the body through a large electrode.

In the third place, some basis of measurement of electrodes must
be generally accepted by the profession before electrical dosage can be
considered as placed upon a positively scientific basis.

Erb has suggested that an electrode of 10 sq. cm. be regarded as the
normal size. Remak has proposed that a series of graduated electrodes
of 10, 15, 20, ete., sq. cm. be employed, and the size recorded as each
application is made. It has been suggested also to express the relation
between the current-strength and the electrode by making the milliam-
peres the numerator and the size of the electrode in square centimetres
the denominator of a fraction.

By such a system of record the results of treatment in the hands of
different observers could be critically analyzed. Some satisfactory
deductions relative to electro-therapeutics might possibly be then estab-
lished beyond contradiction, provided that due care be taken relative to
the saturation of the electrodes, the pressure employed upon them, the
conduction of the rheophores, the skin of the patient, etc.
680 LECTURES ON NERVOUS DISEASES.

In the fourth place, it is very important that the placing of elec:
trodes upon the cutaneous or mucous surfaces should be based upon’
scientific principles. e 4

Erb has shown, in some diagrammatic cuts incorporated in his book,
the different areas of diffusion that ensue whenever the electrodes are
placed near together or wide apart. When near together the greatest
density lies almost in a direct line between the electrodes, especially
when applied to a similar surface of the body. When we wish to obtain
the greatest possible density in deeply situated parts, or when the special
effects of either pole of a galvanic battery are to be attained, the elec-
trodes are to be widely separated.

The sternum is probably the best point upon the cutaneous surface
of the body, in the vast majority of cases, for the application of the so-
called “neutral electrode,”—7. e., the pole whose effects upon the diseased
part are the least to be desired. Another point commonly used for this
purpose is the nape of the neck. This point is most easily reached on
account of the clothing, but it is too abundantly supplied with muscles
to be as desirable as the sternum.

A wide separation of the electrodes during a galvanic application is
a very important point to insure in case the effects of either pole upon
some special part are particularly to be desired. Thus, for example,
when the electrical formule of individual muscles or special nerve-trunks
are being tested to determine if the “ reaction of degeneration ” exists
or is absent, the experiment should never be made when the neutral pole
is sufficiently near to the active pole whose effects are being studied to
influence the reactions obtained. Again, in the treatment of disease we
sometimes wish to influence the diseased part exclusively by means of the
anode or cathode. In such a case, the poles of the battery should be
as widely separated as possible.

In the fifth place, the conductivity of the skin to electrieal currents
as modified by several factors which must be carefully considered in every
case.

Among these the saturation of the electrodes, the employment of:
salt in the saturating solution, and the amount of pressure exerted upon
the electrodes when applied to the skin are worthy of special mention.
Patients afflicted with dropsical conditions offer a less resistance than
those in whom the tissues are normal.

These minor details are not to be ignored by those who endeavor to
do scientific electrical work in the treatment of disease by galvanism.

If you wish to test the value of these suggestions, put a patient and
also a reliable milliampére-meter into the circuit of a galvanic battery.
First, use dry or metallic electrodes and note the current-strength of a
definite number, of cells when they are applied lightly and also firmly to
ELECTRO-THERAPEUTICS. E81

the skin. Then cover the electrodes with absorbent cotton and wet them
thoroughly in plain water, noting, after so doing, the results shown by
the galvanometer of light and firm pressure. Finally, add a teaspoonful
of table-salt to the water and again thoroughly wet the electrodes and
the skin of the patient with this saline solution, noting for the third time
the current-strength obtained by a light and firm application of the elec-
trodes. In each experiment be sure that the battery has the same number
of cells in action and that polarization has not been allowed to occur.
This can be insured in most batteries by raising the elements from the
fluid while the cells are not in use.

The effect of firm pressure upon the electrodes and the use of salt
is to lessen the resistance; hence, the current-strength is often height-
ened by so doing. It has been wisely suggested that the handle of elec-
trodes be furnished with a spring gauge which will enable the observer
to know positively that the pressure exerted upon the electrodes in any
given case is uniform at each sitting.

In the sixth place, the employment of a good rheostat in galvanie
applications is very advantageous and oftentimes almost indispensable,

The conductivity of the skin varies in the same individual with the
condition of the surface. When wet, as for example with perspiration,
or somewhat dampened by a humid atmosphere, it is better than when
dry or parched. This tends to explain in many cases why patients feel
a galvanic application of a definite number of cells more at some times
than at others. The milliampére-meter will, when employed, always show
the reason of this.

Again, it is often necessary for scientific record to determine the
exact resistarice which any part offers to the passage of a galvanic cur- .
rent. This can be accurately measured by a coil rheostat. For example,
the tissues of a patient may cause a deflection of the needle of a galva-
nometer, placed in the same circuit as the patient, of twenty milliamperes
with thirty freshly filled Grenet’s cells. Now drop the patient from the
circuit and place a coil rheostat in his stead, adding sufficient resistance
by means of shunts in the rheostat to bring the needle-deflection to
exactly twenty milliamptres. The resistance indicated in the rheostat
marks the resistance of the tissues of the patient, the rheophores, and the
electrodes, which were traversed by the galvanic circuit when the needle-
deflection was first noted.

In the cabinet battery which I have devised for the use of physicians
(Fig. 162) I have lately incorporated a reliable coil rheostat, which may be
connected or disconnected at the will of the operator by means of a switch,
This I regard as a most valuable improvement upon the original model.

The rheostat enables us, furthermore, to gradually increase or
decrease the current-strength without a danger of breaking the current.
682 LECTURES ON NERVOUS DISEASES.

(an accident not without danger when very high currents are being
employed). We do not have to touch the battery when this instrument
is employed, but simply turn on its full capacity and graduate its
strength by the rheostat alone. Many modifications of the fluid rheostat
have been made with the view of removing the many objectionable
features of this instrument. I have for some years personally discarded
fluid rheostats in my practice because of the repeated annoyances they
have caused and the uncertainties which attend their use.

I must confess that on reading the description of various instruments
I fail to see any practical advantage to be gained by their use over a well-
constructed coil rheostat. Yet, on the other hand, there is without
doubt a field for a perfect fluid rheostat. They are cheaper to construct;
they are somewhat easier for a novice to manage; they can be trans-
ported with little additional weight or inconvenience; and they mate-
rially aid an operator in graduating the current without danger of sud-
denly breaking it while the application is being made.

A physician in general practice wants an apparatus that is light, not
too bulky to transport easily, and one that is reliable under all conditions.
This is the great desideratum, and, unfortunately, less easily furnished
than desired. A reliable milliampére-meter, a serviceable fluid rheostat,
and a good galvanic battery are perhaps the three most important parts
of an electrician’s outfit for general use at the homes of his patients.

The general practitioner is apt to become easily confused by a super-
abundance of switches, plugs, and other electrical devices. He wants his
electrical outfit as simple and inexpensive as it can be made without
sacrificing delicacy, reliability, and durability in any part of his apparatus.
If he strives for scientific attainments he will sooner or later be able to
judge himself of the defects of his outfit, and supply the wants with
greater discretion than when he originally purchased it.

At the present time, gynecologists are testing very extensively the
method first advocated by Apostoli for the treatment of uterine fibroids
in which currents of from one hundred milliampéres upward are being
frequently employed.

The question of galvanic dosage has been brought prominently for-
ward in a controversial conflict between some of the advocates of this
method and electricians during the past year; some of its adherents
being accused of serious errors in the computation of the actual currents
which have been employed in this therapeutic procedure.

The whole controversy, to my mind, seems to turn upon two factors
which do not appear to be fully decided. These are: (1) the internal
resistance of the batteries employed to generate the current; and (2) the
external resistance which the rheophores, the galvanometer, and the
animal tissues traversed by the circuit together help to constitute.
ELECTRO-THERAPEUTICS. 6£3

Now, the employment of a coil rheostat will enable any one to
determine the exact resistance oflered by the tissues in each individual
case with little loss of time or labor.

The external resistance to the passage of a galvanic circuit is a very
important factor in modifying the current-streneth which the milliam-
ptre-meter indicates. To repeat what has already been said, there are
only three factors in Ohm’s law, any one of which can be easily figured
when the other two are known. Ohm’s law is as follows: The electro-
motive force divided by the resistance equals the current-strength. The
electro-motive force (I) is estimated in volts; the resistance (It) in ohms;
and the current (C) inampéres. To put this in a mathematical form, the
following equations are applicable to the solution of any such problem :—

E E
C=—orE=CX RorR=—
R C

Finally, in the seventh place, the length of the sitting is a factor in
electrical dosage.

This factor must, unfortunately, remain—for some time at least—
a matter of pure empiricism. Asa general rule, the weaker the current
the longer may its application be prolonged. Still there are, without
question, certain individuals who are more tolerant of electrical currents
than others ; and the physical conditions of each patient have to be taken
into consideration before the duration of a séance can be decided upon.
Of necessity, the experience and judgment of the operator will always
prove of material service in deciding such questions as they arise; and
it is here that the success of some and the lack of success of others may
possibly lie.

The tendency of the age is toward the use of much stronger currents
than were formerly considered judicious by the German investigators.
Especially is this true in the treatment of some of the graver diseases,
and in many conditions where electrolysis and the galvano-cautery are
now successfully employed.

In concluding my remarks concerning galvanic dosage, I trust the
many aspects of the question may now be more clearly understood by
some of my readers; and that the necessity of a more complete electrical
outfit than many general practitioners now possess may be apparent to
them, These remarks apply only to galvanic currents, and not to
faradaic or static applications.

We have now discussed the essential points pertaining to electro-
physics and electro-diagnosis, and there remains now for us to consider
the uses of electricity in the treatment of diseased conditions of various
organs and tissues.

Before we pass to details of the practical part it may be well for us
684 LECTURES ON NERVOUS DISEASES.

to review in a general way some of the laws‘which should govern us in
applying electric currents to the different tissues, and the objects to be
attained by the employment of faradaism, galvanism, and static electricity.

GENERAL ELECTKO-THERAPEUTICS.

The rapidity and completeness of reported cures of nervous affec-
tions by the use of electric currents upon living tissues during the
last quarter of a century leave no room for doubt that this agent is
particularly valuable in the treatment of paralysis, neuralgia, spasmodic
diseases, disturbances in the sensibility of the skin, and many disordered
states of the brain, spinal cord, and peripheral nerves themselves. We
have undisputed facts which prove also that blood may be coagulated
with safety within some aneurismal sacs by the galvanic current, that
the life of the ovum may be destroyed in extra-uterine pregnancy, that
animal tissues may be disintegrated by chemical changes induced within
them by this agent, and that neoplasms may be removed without hemor-
rhage by the cautery loop.

Our present ignorance of the molecular and nutritive changes in
tissues (as the cause or result of disease) renders it impossible to do.
more than speculate upon the theory of the therapeutical action of elec-
tricity in many cases; but, on the other hand, our empirical knowledge
of these effects is none the less valuable because we are unable to explain
them. The same criticisms would otherwise hold good in reference to.
almost all of the drugs employed in medicine. None of us know exactly
how they produce their specific effects.

Concerning speculation upon electrical effects on living tissues,
Erb remarks as follows: “ What appears more natural than that neu-
ralgia and spasms could be relieved by the sedative action of the
anode, with production of anelectrotonus, and that angesthesia and
paralysis could be cured by the exciting action of the cathode, with
production of catelectrotonus? But, apart from the fact that we are
not certain that an increase of irritability really occurs in one group
of cases and a diminution in the other, it must be remembered that
electrotonic action disappears very rapidly aiter the cessation of the
current, while the curative eflects of the current are more or less
permanent.”

Now, we may summarize the general principles which regulate the
use of electric currents as follows :— ,

(1) They may exert, under certain circumstances, a stimulating or
trritating effect. This is, perhaps, the basis of the most varied applica-
tions of electricity to disease.

(2) They may exert, when properly applied, a sedative action on
nerves or nerve-centres,
GENERAL ELECTRO-THERAPEUTICS 685

(3) They may be made to exert a catalytic action upon neoplasms,
enlarged glands, ete.

(4) They are capable of causing electrolysis. This action is one
which has lately come into prominence.

(5) They create heat under certain conditions. The galvano-cautery
is to-day assuming a very prominent place in some of the departments
of surgery.

Let us now discuss each of these special actions separately, noting
the general points of interest pertaining to each which will aid us in
properly treating our patients. Electrolysis and the galvano-cautery
have been treated of in previous pages.

STIMULATING oR Irgivarina Errecr or Evecrriciry.—This is indi-
cated in many diseased conditions encountered by the neurologists as
well as by the general practitioner. Among these the following may be
prominently mentioned :—

Some of the various forms of cerebral and spinal diseases.

Depressed irritability of some special nerve-trunks.

Abnormal resistance to conduction of electric currents, exhibited by
the motor or sensory nerve-filaments of some part.

As a counter-irritant to some pathological conditions.

Trophic disturbances of special regions (skin, nails, hair, etc.).

Vaso-motor depression.

Atrophic changes in muscles.

As a means of indirectly affecting the nerve-centres through the
sensory nerves, thus influencing respiration, circulation, phonation,
vaso-motor paths, peripheral organs, the muscles, ete.

The methods of application which are best adapted to accomplish
irritating or stimulating effects are differently stated by authors. Per-
sonally, I do not confine myself exclusively te faradaism or galvanism.

The faradaic current is more commonly. employed for this purpose
than the galvanic. The electrodes should be selected, as to their size
and shape, in accordance with the parts to be acted upon; they should
be well moistened with salt water, and kept closely in contact with the
skin. The wire brush is the best electrode to stimulate the nerves or
other tissues of the skin. It should be used dry. I prefer the secondary
faradaic current to that of the primary coil for stimulating effects.

If galvanism is employed as a stimulant, Remak’s plan, of moving
the well-moistened cathode rapidly over the nerve-trunk or muscle to be
stimulated, with «a current sufficiently strong to cause strong wave-like
contractions, is a good one. Another method, termed by this author
“terminal labile stimulation,” consists in stroking the tendinous end
of a muscle with tie cathode so as to affect the entire length of the
muscle, In both of these methods, the anode is kept stationary upon
686 LECTURES ON NERVOUS DISEASES.

some indifferent or neutral point—the centre of the sternum by preference,
or the nape of the neck.

One of the most vigorous methods of stimulation consists in rapidly
changing the polarity by means of a commutator, when the galvanic
battery is employed.

The Combined Current.—Another method which I employ (not
generally mentioned in text-books) consists in connecting a galvanic
battery, by means of a rheophore, with a faradaic instrument, thus
bringing both a constant and induced current to bear upon the tissues at
once. The rhcophore which connects the batteries joins the positive
binding-post of the galvanic instrument with the secondary coil of the
faradaic; the two rheophores connected with ‘the electrodes run from the
negative binding-post of the galvanic and from the secondary coil of the
faradaic instrument. The two instruments (faradaic and galvanic) are
thrown into action simultaneously, and the strength of the current em-
ployed is graduated by the number of cells used in the galvanic battery
and by the extent of the overlap of the secondary coil of the faradaic
instrument. I have obtained some remarkable results by the stimulation
thus produced in various forms of trophic disturbances of the skin and
muscles. /

The stimulation of nerve-fibres (when obstacles exist to their con-
duction) should be performed peripherally from the site of the lesion in
sensory nerves, and as centrally as possible in motor nerves (Erb).
Degenerated and atrophied nerves and muscles require a direct effect of
the currents employed. For these reasons, the site of stimulating elec-
trical applications depends upon the situation and character of the lesion
and the object to be attained.

Moptryine Errects or ELectRic Currents.—The irritability of nerves
and muscles may be influenced by electric currents.

In certain diseased conditions, we may expect a favorable result from
such an action. Thus, for example, in some types of paralysis, in anes-
thesia, in certain vaso-motor disturbances, and in depressed states of
cerebral and spinal activity, the irritability of nerves or of muscular
fibres is diminished ; hence we resort to the so-called “ catelectrotonic
action ” of electricity as a means of stimulating and restoring the normal
irritability of the tissues affected.

Tt is now generally accepted as proved that feeble faradaic currents
will accomplish this end. Galvanie currents, when applied for this pur-
pose, give more positive results, however, than faradaic.

In order to increase irritability by galvanism, the negative electrode
should be applied in a stabile manner (7.e., without being moved) to the
part upon which this effect is to be produced; and the strength and
duration of the current should be steadily increased. When the muscles
GENERAL ELECTRO-THERAPEUTICS. 687

or motor nerves have been exhausted by over-exertion, excessive fatigue,
etc., this action (termed by Heidenhain the “ refreshing action” of
galvanism) is particularly indicated.

Those conditions in which the normal irritability of nerves or
muscles is. intensified demand the so-called “ anelectrotonic action” of
electricity. These conditions comprise all irritative states of the sensory,
motor, and vaso-motor tracts within or without the brain and spinal cord ;

hence, we employ this action in neuralgias, spasmodic affections, hy perss-
_ thesia of any of the cerebro-spinal nerves, headache, excitation of any
of the special senses, cerebral and spinal irritation, ete.

In order to decrease the irritability of nerves or muscles, we may
employ very powerful faradaic currents. We may also begin by em-
ploying a feeble faradaic current and gradually increasing its strength to
the highest point of endurance; then maintaining it at this point for
some time; and subsequently reducing it gradually to the feeblest cur-
rent perceptible to the patient. This method is known as the “ increasing
induction method.” Electrodes, well moistened and of large size, should
be employed and kept immovable upon the same points during the appli-
cation. It is often advisable to repeat this procedure several times at
one sitting (Erb).

When the galvanic current is employed for the purpose of decreasing
irritability, the positive pole is made fast at the point to be influenced.
The current is increased in strength and maintained at its maximum for
some time, after which it should be decreased gradually until it cannot be
perceived by the patient. The gradual decrease of the current-strength
prevents the marked temporary increase of irritability which is liable to
follow this method when this step is omitted.

Static electricity exerts in many cases an immediate beneficial effect
upon neuralgic pains (especially upon sciatica) and upon the various
spasmodic affections, as, for example, chorea, paralysis agitans, tremor,
contracture, etc. These effects are obtained, in some cases, when gal-
vanism and faradaism have proved of no benefit. IT should never regard a
case as incapable of benefit by electric treatment until static electricity,
in the form of insulation, the electric wind, or the spark, had been
thoroughly tested. I have had better results with this form of current
in tremor than with galvanism or faradaism.

Some forms of pain (as, for example, the pains of ataxia, sciatica,
trigeminal neuralgia, muscular rheumatism, etc.) are oftentimes relieved
by a few applications of static electricity. My experience with this
agent has convinced me that its effects are often satisfactory in
cases where pain is a prominent symptom, when galvanism has been
tried without benefit. I have found that insulation and the ab-
straction of heavy sparks from the seat of pain give the best results.
688 LECTURES ON NERVOUS DISEASES.

This therapeutical agent will be discussed separately, later in this
volume.

Caratytic Action oF ExvecrricaL Currents.—Under this heading
we include (1) an increase of absorption produced by dilatation of the
capillary blood-vessels and lymphatics; (2) an increased capability of
tissues for imbibition of fluids, through an increase of osmotic processes ;
(3) changes in the disassimilation and nutrition of nerves, on account of

their stimulation or refreshing effects; (4) changes in the molecular _

arrangement of tissues, caused by electrolytic processes; and (5) the
results of the transportation of fluids from one pole to the other (Remak
and Erb).

Remak has shown that muscles become congested and greatly
swollen when subjected to galvanism. They are rendered tense, and
(according to this observer) absorb water more freely than muscle which
has not been galvanized.

Changes of a marked character may be induced in the skin by gal- :
vanism. These have been studied by Erb, Remak, Bollinger, and others.

The vaso-motor nerves may be influenced by electrical currents.
This is shown by many of the later investigations,—prominently those -
of Lowenfeld, which apparently demonstrate that contraction and
dilatation of the vessels of the brain result, respectively, from antero-
posterior and transverse currents through the head from a galvanic
battery.

Although we are, as yet, unable to speak with positiveness regarding
the certainty of the catalytic effects of electrical currents, or to map out
the furms of disease which are to be regarded as specially indicating
these catalytic effects, still it may be said that the following states have
been successfully treated by electrical currents, and that the cures are
probably to be attributed to a catalytic action. (1) inflammatory affec-
tions of the nervous system, including sclerosis, myelitis, neuritis, ete. ;
(2) arthritis and chronic exudations into joints; (3) glandular enlarge-
ments; (4) hard cicatrices, periosteal swellings, and fibrous adhesions ;
(5) contusions, sprains, extravasations of blood, and other results of
traumatisms.

The galvanic current is the one that is generally employed when
catalytic effects are desired. In diseased conditions of the brain, spinal
cord, or any of the deeply seated organs, the faradaic currents are not
usually productive of benefit.

The “stabile method” of application of the galvanic current is
preferable, to my mind, when catalytic action is to be attained. The
streneth of the current should be sufficient to easily overcome the
resistance offered, and the duration should be sufficiently prolonged to
accomplish changes in the tissues subjected to its influence. One pole
GENERAL ELECTRO-THERAPEUTICS. 689

is placed, as a rule, at an indifferent point (the sternum by preference),
and the other over the tissue diseased. Sometimes, as in the case of the
brain, for example, the poles are placed upon either side of the diseased
part. Although there are exceptions to the rule, it is well to use the
anode or positive pole over the diseased part when pain is present, when
symptoms of active irritation exist, or when the morbid processes are
very active. The cathode or negative pole is best adapted to influence
chronic morbid processes, such as sclerosis, indurations, ete. Erb recom-
mends that the polarity of the current be changed several times in cither
case ; he doubts the infallibility of the rule given, although it is theoreti-
cally sound. Chvostek urges the use of short and moderate currents
for a few minutes (three to ten) when catalytic action is desired. In
this way, he believes, the vaso-motor and trophic nerves are more
impressed than by any other method.

Respecting the catalytic action of faradate currents, a difference
-of opinion exists between authors of note. One thing is certain, viz.,
that strong currents are required, and that the currents must be passed
directly through the diseased part to accomplish marked results.

Glandular tumors have been resolved by this method with great rapidity:
in some recorded instances.

GALVANIZATION OF THE CERVICAL SYMPATHETIC.—This method has
afforded relief, according to published cases, in vaso-motor.and trophic
disturbances of the nerve-centres, the eye, viscera, muscles, joints, and:
skin. Thus, for example, cases of cure of epilepsy, atrophy of the optic
nerve, Basedow’s disease, progressive muscular atrophy, lead-palsy,
scleroderma, chroni¢ rheumatic arthritis, bulbar paralysis, neuralgias of
various types, and many other conditions have been reported by means
of this method. Respecting this step, Erb wisely remarks as follows:
“There can probably be no doubt of the correctness of a part of these
observations, but this does not by any means imply that the cervical
sympathetic is responsible for such results.”

When we review the structures which compose the neck and recall
the numerous connections which exist between the sympathetic cords,
the pneumogastric nerve, the brain and cervical segments of the cord,
the medulla oblongata, the brachial and cervical plexuses of nerves, etc.,
it becomes clear why De Watteville applies the term “ sub-aural galvan-
ization ” and Erb the term “ galvanization of the neck” to this special
procedure.

The steps required to influence these parts by Meyer’s method con-

sist in the application of a small electrode (cathode) under the angle of

the jaw and adjacent to the hyoid bone, and then crowding it backward

and upward against the vertebral column, the positive electrode (of

larger size) being placed over the seventh cervical spine. The current
: 44
690 LECTURES ON NERVOUS DISEASES.

may be stabile, labile, or interrupted; or the polarity may be changed
from time to time during the sitting of from one to three minutes. Six
te ten galvanic cells ofthe Grenet variety are sufficient. The application
may be unilateral or bilateral, according to the demands of the case.

Corning bas devised an instrument which insures carotid compres-
sion with galvanization of the neck for the treatment of cerebral
hyperemia and some other morbid conditions.

Benedict places the positive pole in the jugular fossa, and the
negative pole upon the superior cervical ganglion.

GENERAL FarApizaTiIon.—-This method of administering electricity
was first employed by Beard and Rockwell. By this procedure the
‘entire body is subjected to secondary faradaic currents of varying inten-
sity. It is applicable chiefly to those forms of nervous disturbance which
are associated with general debility, poverty of the blood, special
diatheses and cachexiz, hysterical affections, skin diseases, persistent
chronic inflammations, and other results of low vitality or functional
derangements of the organs.

To apply this method, the patient must be undressed or very loosely
clothed. The feet are immersed in a bowl of tepid water with a little
salt added, in which the cathode is also placed after being connected by
means of a rheophore to the binding-post of the secondary coil of a fara-
daic machine. The anode is held in one hand of the physician, and his
other hand (well moistened in salt water) is applied to all parts of the
surface of the patient’s body. If the subject can bear it, a large electrode
covered with absorbent cotton and flannel, or with a soft sponge, is
employed in place of the hand. The application should begin at the
head and terminate at the feet, the strength of the current being modi-
fied from time to time as the feelings of the patient may demand. The
extremities and back should have vigorous stimulation, the nerves of the
neck should be influenced by a much weaker current, and the cceliac
plexus should be influenced by a stabile application of a few minutes over
the epigastrium. The entire duration of the application occupies from
ten to twenty-five minutes. It may be applied as often as three times a
week if necessary.

Personally, I can attest the efficacy of this treatment as a general
tonic. I have witnessed immediate effects from it in some of my cases,
and I employ it constantly in a modified form.

In case the hand of the attendant is to be employed as an electrode,
I would advise the use of an instrument which I have devised as an
improvement over the way originally described by the inventors of this
method, It is called the electric bracelet. It is placed upon the right
wrist of the attendant over a pad of wet absorbent cotton, and the rheo-
phore is screwed into the binding-post upon it. The right hand is then
GENERAL ELECTRO-THERAPEUTICS. 691

wet in salt-water and used as previously described. By this instrument
the hand of the attendant is alone subjected to the current, and the
fingers can detect muscular contraction in ‘the pitient even when too
feeble to be seen easily. As an adjunct to massage, I employ this useful
instrument with decided benefit.

GENERAL GALVANIZATION._The steps required by this method are
similar to those previously described, except that the constant-current -
battery is employed in place of a faradaic machine.

CENTRAL GALVANIZATION.—The cathode is placed over the epigas-
trium. This electrode should be of large size. The anode is stroked
over the forehead, with a current of about two milliampéres, for two
minutes; then made stabile over the cranium for about two minutes;
then moved up and down the neck on each side for the same duration ;
finally it should be moved along the length of the spine for about five
minutes. This method was a favorite one with the late Dr. Beard, who
reported cures of gastralgia, hysteria, hypochondriasis, nervous dys-
pepsia, and many of the symptoms of cerebral and spinal neurasthenia
by its continued use. In two cases of gastralgia in which I personally
employed it for some time I obtained an absolute recovery,

THE EtectricaL Bata.—This method of administration of electricity
toa patient. may be accomplished by using a metal tub, or one which is
composed of a non-conductor. If a metal tub is employed, the patient
must be protected from actual contact with it. This is usually accom-
plished by means of wooden slats or some other medium of support for
the patient when immersed. If the bath-tul is of metal, one rheophore
of the battery employed is attached to the tub, while the other is
attached to an electrode held by the patient or placed in contact with
his body. If the tub is of a non-conducting material, both electrodes
may be placed in the water. The electrodes employed should be very
large (often running the entire length of the tub), in order to allow
of as great a diffusion of the electricity as possible. The fluid in the
tub may be simple water, or, preferable, a solution of salt, soda, or
an acid.

The battery employed for a bath should have very large plates, so
as to generate an abundant quantity of electricity without a very high
electro-motive force. .

Personally, I am not a strong advocate of this method of treatment.
It violates one of the fundamental principles of electrical treatment of
localized affections in that it does not confine the polar action to the part
or parts diseased. In the second place, I have not found its tonic action
to equal that of general faradization or general galvanization.

Strong claims have been made in its favor as a remedy for tremor
(especially of the alcoholic and mercurial varieties) and for chronic
692 LECTURES ON NERVOUS DISEASES.

articular rheumatism, but Iam not yet convineed that they are to be.
regarded as well established.

If the reader desires to try this method of treatment in any case, it is
well to know that the temperature of the bath, as well as the strength of
the current employed, should be modified by the condition of the patient.
The duration of the bath should never exceed thirty minutes, and ten
minutes will generally suffice. The current should be strong enough to
be perceived by the patient in all cases. The elements of the cells
employed to generate the current should be large, in order to insure
quantity as well as electro-motive force.

Tur Reiee or Painrut Pornrs.—One of the most generally useful
effects of electricity is the relief which it affords in many cases to pain.
Of all the methods of treatment of neuralgia now employed, I consider
electricity, in some of its various forms of application, by far the most
efficacious. Personally, I have almost discarded internal medication for
the relief of this class of sufferers.

In the majority of subjects afflicted with neuralgia, painful points
may be detected along the course of the affected nerve or its branches.
These are situated, as a rule, where the nerve gives off a branch or
bifurcates, and also where it passes through a foramen. Sometimes
it is necessary to make pressure along the course of the nerve to detect
the existence and seat of these points.

Now, it should be remembered that the successful electrical treatment
of neuralgia depends largely in some cases upon the direct treatment of
these painful points. They seem in some way to have a relationship
with both the production and relief of some types of neuralgia, as well as
spasm of the muscles, ataxic symptoms, and other forms of nervous
diseases. These points may be the seat of a localized periostitis, a
circumscribed inflammatory exudation, a neuritis, an enlarged gland,
and many other conditions which create nervous phenomena. In a few
instances the symptoms even of ataxia have been relieved, ly the elec-
trical treatment of painful points in the region of the spinous and trans-
verse processes of the vertebrie, by men of note, among whom may be
mentioned Brenner. Remak, Meyer, Legros, and others.

The steps which you should employ in the treatment of painful
points are as follow: 1. Use the galvanic current, employing from three

to eight Grenet cells. 2. Apply the anode to the painful spot, and keep
it stationary at that point. 8. Place the cathode at some indifferent
point, preferably the sternum. 4. Do not use a current which will be
excessively painful to the patient, nor exceed five minutes in the appli-
cation. I frequently do not allow the duration of the current to exceed
two minutes at a sitting. It is advisable, in persistent cases, to make
the applications daily.
GENERAL ELECTRO-THERAPEUTICS. 693

Of late some experiments have been made, with apparent benefit, by
having patients of this class wear over the painful points a piece of
metal, connected with another piece of metal (which is also in contact
with the skin) by an insulated wire. The best metals are zine and cop-
per. They should be brightly polished before the application, and
should have a piece of dampened linen between them and the skin.
They may be worn continuously for weeks, or changed each day on
retiring and rising.

Some authors recommend the employment of very feeble galvanic
currents for an hour or two at each. sitting, the anode being placed over
the painful point. Le Fort goes so far as to suggest the propriety of
applying such currents continuously for weeks, by means of ordinary
rheophores and electrodes, when fatty changes, contractures, or reflex
. paralyses are to be combate,

ELEcrRoLysis.—When a galvanic current is concentrated within
animal tissue by a close approximation of the electrodes, or when, by
means of the ‘‘ polar method ” and insulated needles, a galvanic current
of high intensity is made to traverse some selected spot upon the human
body, there is apt to be a chemical decomposition of the water and salts,
and a coagulation of the albuminous elements of the tissue thus acted upon.
The salts are then separated into their bases and acids, while the water
is simultaneously decomposed into hydrogen.and oxygen. The positive
- pole attracts to it the acids and the oxygen; the negative pole attracts
to it the alkalies and the hydrogen. For this reason the insulated needles
tend to become oxidized when they are connected with the positive
rheophore. They do not become so when attached to the negative rheo-
‘phore, The free alkalies deposited at the negative electrode are apt, on
the other hand, to cause destructive effects upon adjacent tissues. These
are greatly in excess of that produced by the oxidation of the metal
points of the insulated needles when joined to the positive rheophore.

When we wish to test the strength of the current which we propose
to employ for electrolysis, it may be easily done by sending the current
through the white of an egg for twenty or thirty minutes. In that time
it should coagulate the albumen.

In order to reach the parts upon which we most desire to pects
electrolysis, it is often necessary to perforate the skin and the muscles.
To do this, needles are employed. They should be insulated with hard
rubber, collodion, or shellac, except at their point for one-half inch, and
tle uncovered part should be gilded, as a rule, in order to prevent its
oxidation. They should be from two to five inches long; should be
strong enough to penetrate tissues without a liability of breaking ; should
be as small as is consistent with the current-strength to be employed ; ;
and should be so arranged as to enable the operator to adjust them in a
694 LECTURES ON NERVOUS DISEASES.

handle to which one of the rheophores of the battery may be attached.
Ordinary sewing-needles strung on a wire may be employed in treating
superficial nevi, tumors, ete., if you lack the instruments specially
designed for the purpose. You may shellac them for insulation if
deemed best. ’

It is very important, in some cases, that the insulation of the needles
employed be as perfect as possible; and that the tips of the needles be
triangular or lancet-shaped, in order that they may penetrate the skin
with ease. The needles and handle required can be bought of any
manufacturer of electrical appliances.

The battery employed for electrolysis need not be unlike that for
ordinary thedical purposes. Twenty-four of Grenet’s cells will produce
a sufficient intensity of current, provided they are freshly filled. Robin’s
statement that a current of forty-five milliampéres is requisite must be
based upon a very limited external resistance. It is well to use 2 battery
of greater power than is actually required, so that fresh cells can be
added without breaking the current during the operation, when deemed

 

The needles are fine and numerous, and are

arranged as shown at a. This is an excel- °

Fic. 186.—ELgctrop& FoR ELECTROLYSIS lent device for affecting the cureof diffused
(with three insulated needles), nzvi, small glandular tumors, etc.

 

necessary. Personally, I use insulated copper wire for rheophores when
performing electrolysis, in preference to the tinsel cords commonly em-
ployed for electric applications, They are less flexible than the tinsel
cords, but they are vastly superior to them as conductors.
Electrolysis has been employed for the following purposes, with
more or less success :—
The coagulation of blood in aneurismal sacs.
The relief of nevi and erectile tumors.
The cure of cystic tumors.
The cure of goitre.
The cure of ecchinococci.
The cure of ovarian cysts, and those of the broad ligament.
The cure of urethral stricture.
The cure of malignant and fibroid growths.
The cure of hydrocele,
The destruction of the foetus in extra-uterine pregnancy.
. The removal of cicatrices, polypi, and other new formations.
The destruction of superfluous hairs and their follicles.

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PES 9
GENERAL ELECTRO-THERAPEUTICS. 695

Since many of these conditions come under the observation of the
neurologist, either as a factor in the causation of nervous symptoms or
as co-existing troubles which demand relief, it may not be inappropriate
to hastily dwell upon the electrical treatment of such conditions in a
volume of this character.

Respecting the treatment of large aneurismal sacs by this method,
statistics show that the operation merits more general recognition, as a
means of possible cure of intra-thoracie and abdominal aneurisms which
cannot be safely treated by ligation, than it has received. Nine cures
out of thirty-seven cases have been collected by Duncan from various
sources; and Bartholow has since collected others which have been
benefited by it, although not positively cured. In none of these cases,
so far as I can ascertain, was the current-strength measured by a gal-
vanometer. There is reason to hope that the operation may become

more generally employed when the steps of the procedure necessary to
its success are determined with greater exactness. There seems to be a
doubt, as yet, regarding the best method both of generating and direct-
ing the current, so as to prevent suppuration and secondary hemorrhage.
In two cases of blood-sacs upon the face, intrusted to my care, I have
succeeded in consolidating the tumor and effecting its radical cure by
this means without suppuration or other complications, I employed the
positive rheophore for the needles and placed the cathode at the nape
of the neck in both cases. The duration of the two sittings in each case
was about ten minutes, and twenty-four Grenet cells were employed. I
believe that the anode produces the firmest clot; hence the danger of hem-
orrhage on the withdrawal of the needles is less than when the cathode
isemployed. The risk of embolism, as a result of disintegration of the
clot, does not seem to be so great as one might at first imagine.

The employment of electrolysis in cystic tumors of the neck, the
ovaries, and the thyroid gland, has been resorted to by many experi-
menters of note. Among these may be mentioned Althaus, Amussat,
Ultzmann, Clemens, Semeleder, and others. ‘Some of the cases reported
seem to point toward this method of treatment of these diseased con-
ditions as potent and comparatively devoid of danger if properly carried
out.

The treatment of urethral stricture by electrolysis I have always
heretofore combated, chiefly because I think it less safe and far less
certain than gradual dilatation. I must confess, however, my prejudices
may be more or less without foundation. My perusal of the reported
cures by this method has not, as yet, carried to my mind a thorough
conviction of the permanency of the eure. The method still seems to

wine to lack absolute precision, which should, to my mind, form the basis
of all surgical procedures within that canal. I am having made some
696 LECTURES ON NERVOUS DISEASES.

modifications of urethral electrodes which I believe will insure greater
precision than any yet devised.

Ordinary cases of goitre, and the enlargement of the thyroid gland
which accompanies Basedow’s disease, have been cured by electrolysis.
Rockwell and Butler have reported some astonishing results in the
treatment of exophthalmic goitre by galvanism of the thyroid gland.
Rockwell places the cathode over that body and the anode over the
solar plexus, combined with the employment of the anode in the auriculo-
maxiilary fossa and the cathode over the cilio-spinal centre (cervical
segments of the spinal cord) at each sitting. His cases of reported cure
required from fifty to sixty-nine sittings. Needles were occasionally
employed upon the goitre. This treatment was supplemented by the
use of iron, zinc, digitalis, and ergot; and a restricted diet, with in-
structions regarding the necessity of the repression of the emotions and
passions, was enforced.

The arrest of extra-uterine pregnancy by electrolysis, and also by
shocks transmitted through the sac from Leyden jars charged with static
electricity, from a galvanic battery, and also from a faradaic machine,
constitutes, perhaps, one of the most successful and remarkable contri-
butions to medicine.

The treatment of cancer by electrolysis has been followed by satis-
factory results in some cases, according to the observations of Beard,
Butler, Mussey, and Neftel. The question of accurate diagnosis of the
cases reported as cured must still be considered as unsettled. The
results apparently obtained should certainly awaken the profession to a
trial of this method of treatment of a malady which internal medication,
caustics, and the knife seem powerless to combat.

Bartholow reports a cure of four out of six cases of fibroid tumors of
the breast by electrolysis. The remaining two patients failed to continue
treatment for a sufficient length of time. He did not employ needles in
any of these cases.

The relief of hydrocele by the introduction of two needles connected
with the rheophores of a galvanic battery and brought within a half-inch
of each other at their points has been reported by Rodolfi, Frank, Bar-
tholow, and others. Some of the cases reported as cured required only
one application.

In dismissing this subject it may be well to summarize the effects
of electrolysis, as follows :—

1. A feeble current tends to cause dilatation of the capillaries and
the lymphatic vessels, and thus to aid in absorption.

2. A stronger current decomposes the salts and the water of tissues,
and coagulates the albuminoid elements.

3. A disintegration of the tissues immediately adjacent to the pole
GENERAL ELECTRO-THERAPEUTICS. 697

which produces the effects previously described takes place, with an
escape of bubbles of gas, when the decomposition of tissues is active.

4. As an eschar may be formed by a current of great intensity, it
is maintained by some authors that the cicatrix which results from such
a slough is soft and pliable if the eschar has been made by the anode,
and dense, with a tendency to contract, when due to cathodal action. I
am usabte to confirm or deny this nictoment

5. The danger in electrolysis is that of “doing too much” rather
than too little. The former error cannot be repaired; the latter can by
repeated sittings.

§. When an escharotic effect is desired, it is well to have the needles
made of zinc. The decomposition of the ailoride salts forms indirectly
the chloride of zinc, because the liberated chlorine attacks the needle.
This is absorbed by the tissues adjacent to the needle, and an escharotic
effect is thus produced. In the treatment of salient growths such
needles, with currents of weak intensity, and long sittings, seem particu-
larly well adapted. This method is almost painless, and has produced
excellent results in some cases reported.

7. The introduction of needles into the tissues is not an absolute
necessity when treatment by electrolysis is indicated. The same effects
to a lesser degree may be obtained by placing the electrodes in contact
with cutaneous or mucous surfaces.

8. The employment of iron needles has been suggested for the rapid
coagulation of blood, on account of the styptic effect of the chloride of
iron which tends to form by the liberation of chlorine from the chlorides
of sodium, potassium, and calcium.

THE GaLvANno-CauTERY.—When a large quantity of electricity is
forced through the resistance offered to its passage by a platinum wire
ora strip of platinum (usually bent into the form of a knife), the heat
produced causes the platinum to rapidly approach redness or whiteness.
Such an arrangement is known as a “cautery loop” or a “cautery
knife.” The battery which is employed to generate electricity in suflicient
quantity to accomplish such a result is known as a “ cautery battery.”
In cautery batteries the plates are large and near together; hence unusual
precautions have to be taken to prevent “ polarization,” which takes
place -very rapidly on account of decomposition of the fluid in which the
elements are immersed.

Of all the devices which have been suggested to overcome this
difficulty, I prefer that of Dr. Piffard. In the battery devised by him
the zine plates are perforated, so that the fluid can be forced through
them upon the platinum plates by means of 2 rocking motion when the
battery is in action. The assistant who operates the battery can produce
any degree of heat required by making the plates move slowly or rapidly
698° LECTURES ON NERVOUS DISEASES.

through the fluid. The key-board of the battery is so connected by
means of large thumb-screws that the elements can be connected for
either quantity or intensity,as the operator may desire. The rheophores
are composed of large copper wire, heavily insulated with rubber.

I have made several improvements upon the original Piffard battery
of late, which, in my opinion, will increase the ease of working the
instrument. They are not, as yet, fully perfected.

It may be advisable to again impress upon you the fact that batteries
designed for ordinary medical purposes are totally unfit for heating a
cautery loop or producing an electric light. A battery designed for
cautery purposes is also totally unfit for other purposes in medicine.

 

 

 

 

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Fic. 188S—Prrrarp’s Cautery Battery,—(a) The battery as suspended when not in action,

(4) Arrangement of the top of this battery, showing the screws which regulate the connec-

tions between the different cells. The battery is rocked during its action to prevent extreme

Lig ne ap rene the movement slow or rapid, the heat of the loop or knife may
In operations upon the tongue, nose, pharynx, uterus, vagina, rectum,
and in some other regions, the galvano-cautery seems destined to super-
sede the scalpel and écraseur. No blood need be lost in amputations of
considerable magnitude, provided the operation is skilfully performed.
If the loop is employed, it is slipped when cold over the part to be
removed. It can be adjusted, therefore, with every precaution against
accident. After the current is turned on, the heat of the wire even can be
regulated with great precision. Care should be exercised against draw-
ing the wire too closely to the handle, and in selecting a wire which will
not burn off or prove too large for the battery employed. As in all sur-
gical procedures, this instrument should be handled by an expert. It
is well for a novice to practice upon pieces of meat or bone until he
‘GENERAL RULES GOVERNING ELECTRO-THERAPEUTICS. 699

familiarizes himself with the details of its use, in case he meditates per-
forming an operation upon a human subject. When operations are to be
performed within the mucous cavities of the body, the patient has
frequently to be trained to tolerate the necessary manipulation. A
dull-red heat is preferable to a white heat in dividing vascular tissues,
and it is very important that the division be slowly performed. When
the skin is to be embraced within the loop, it is well to divide it first
with a cautery knife, and subsequently to adjust the wire.

The cautery knife has been successfully used in removing cancerous
growths within mucous cavities, in tubal pregnancy, in tracheotomy,
in extirpation of the breast, and many other similar procedures.

An attachment to the cautery battery, known as the “ dome cautery,”
consists of a coil of platinum wire over a cone of porcelain, These may
be of any size, and the porcelain cone may be omitted if deemed neces-
sary. It may be employed in destroying hypertrophied tonsils, haemor-
rhoids, polypi, neevi, epithelioma, etc.

The great advantage which the galvano-cautery has over the use of
the knife is the absence of hemorrhage and of great pain, The platinum
 knife.can be made of any form desired. There is no limit to special
forms of attachments which may be devised to simplify its use in different
regions of the body.

In operating upon the tongue, needles may be passed through the
organ in front of the site selected for the loop, so as to prevent slipping
of the wire. Bryant, who has had an extensive experience in this oper-
ation, recommends a twisted wire rather than a large one. There is some
reason to believe that the heat tends, moreover, to destroy (in the case
of cancerous growths) the germs of the disease which miglt elude the
knife.

GENERAL RULES GOVERNING ELECTRO-THERAPEUTICS,

Before we pass to the consideration of special methods of employing
electricity in the treatmeat of disease, it seems to me advisable to sug-
gest a few rules which may possibly aid you in deciding where and how
to direct your treatment in any special case. There are, of course, some
exceptions to each of these rules; but they are, nevertheless, sufliciently
accurate to be used as guides in your practice :—

1. Soak your electrodes in a weak solution of table-salt, not in
simple water. This diminishes the resistance afforded by the skin at
least fifty per cent.

2, Always press your electrode firmly and evenly against the part
which it touches. This renders the current employed an even one to the
patient and assists in its conduction.

3. Put a milliampere-meter or a galvanometer, as well as the body
of your patient, into circuit, and record all your observations, respecting
700 LECTURES ON NERVOUS DISEASES.

the current-strength employed, from its scale. It is neither scientific
nor accurate to simply record the number of cells employed. Cells grow
weak by long-continued use, by polarization, and other causes. In case
a faradaic instrument is employed, a galvanometer is useless ; hence you
should record the number either of centimetres or inches of the primary
or secondary coil employed.

4, Always endeavor to apply one of the poles to the part which is
diseased. The plates of Ziemssen which I incorporate in this volume
indicate the situation of the ‘‘motor points” of the head, trunk, and
extremities, Such plates will enable you to direct your eaenenent to
any special nerve or muscle. :

5. Acquire, by frequent experimentation upon yourself,a knowledge
of the effects of different current-strengths, the situation of most of the
more important nerve-trunks, the formula of contraction of healthy nerve
and muscle, and all other information necessary to the use of electricity
in medicine.

6. Never use too strong a current upon a patient at the first sitting.
It may frighten him, and he may never return. It is always best to
begin with weak currents; in the majority of cases weak currents are
indicated rather than strong ones.

7. If you have no galvanometer, the intensity of a galvanic current
can be approximately determined by the burning sensation produced in
the skin by the electrodes when they are applied to it.

8. The “ polar method” is more painful when the faradaic current
is employed than when the galvanic current is used. It is not well to
separate the poles of a faradaic machine too widely ; pain is intensified,
and no special benefit is gained by so doing. Remember that the fara-
daic current has no fixed polarity. A galvanomcter will record the
difference between the current produced by the “make ” and “ break ”
of the circuit only ; hence it is of no value in determining the intensity
of - faradaic current actually administered to a patient.

. The “polar method ” is absolutely requisite to electro-diagnosis
sani the galvanic reactions of nerve or muscle are being tested. It con-
stitutes the best method also of administering the galvanic current for
therapeutical purposes, because it is usually important that the anode or
cathode exert its special influence upon the part diseased. The farther
apart you place the poles, the less is the effect.of the indifferent or neutral
pole upon the part which you wish chiefly to influence. :

Although clinical experience seems to prove that we obtain different
results in the majority of cases by employing the anode or cathode upon
the part to be influenced, T am inclined to question the correctness of the
view that those effects are in any way dependent upon the direction of
the transmitted current. We know that it is not possible to confine an
GENERAL RULES GOVERNING ELECTRO-THERAPEUTICS. 701

electric current to any one channel by means of animal tissues. Every
current becomes diffused to a greater or less extent, as is illustrated in
diagrams prepared by Erb and other authors upon electro-therapeutics.
It is probably more correct to view the special effects obtained hy
employing the positive and negative poles of a galvanic battery as the
etfects of the poles themselves, rather than the result of the direction of
the current.

10. Remember that the anode or positive pole of a galvanic battery
is the sedative pole, and the cathode or negative pole is the stimulating
or irritating pole. When the cathode is made the indifferent pole, it is
well to use a very large electrode.

1], Do not change the polarity of a current during its application to
a patient any oftener than circumstances demand. As a rule, it is
unnecessary to do so at all. It causes unnecessary irritation, which
should always be avoided. In the treatment of neuralgia, diseased con-
ditions of the brain or spinal cord, and painful points, it should never be
done without some special reason. It is positively contra-indicated when
catalytic effects are desired. :

12. When galvanic currents to the head are indicated (especially if
the current is to be sent through the brain), employ only those of mod-
erate intensity (save in exceptional cases), and do not reverse the current
unless there is good reason for so doing. When you read about thirty-
cell currents being sent through the brain, it is safe to suppose that the
battery was not of the most active kind, or that the ability of the patient
to endure such a current was very exceptional. It is rare to meet with
® patient who can tolerate a current of more than from three to six
milliamperes through the brain, and it is not safe to break currents of
high intensity when employed about the head.

13. Static electricity will sometimes produce muscular contractions
when faradaic currents will not. In hysterical conditions, some of the
spasmodic diseases, sciatica, and organic spinal affections, it is well to try
this form of electricity when galvanism fails to afford relief.

14. Respecting the duration of individual applications of electricity
in its various forms, my experience teaches me that short sittings accom-
plish as much, and often more, than long ones. I seldom exceed five or
six minutes, unless I am endeavoring to induce catalytic action, to benefit
chronic articular rheumatism, etc.; or when I am employing general
faradization, general galvanization, central galvanization, electrolysis, the
valvano-cautery, or other procedures which require a longer sitting.
Frequently, thirty seconds to two minutes is all that is required when
some particular part of the body is alone to be galvanized or faradized.

15. It is impossible to Jay down any rule which will guide you in
determining the frequency of the applications required by any individual
702 LECTURES ON NERVOUS DISEASES.

case. It is seldom necessary to employ this agent oftener than every
day, and three sittings a week will suffice in the majority of cases. If
the disease is of a chronic type, it is often advisable to occasionally dis-
continue treatment for a few weeks, and then to renew it with vigor.
Experience has taught me that the effects of electricity are more vigor-
ous after such intermissions. It is often well to change from galvanic
to faradaic, and again to static currents, from time to time, in the treat-
ment of obstinate diseases which fail to progress satisfactorily.

15. I would advise you to be persistent in employing this agent
when your judgment tells you that it is advisable to begin it. Many
of the chronic forms of cerebral and spinal diseases are materially bene-
fited and often completely cured by a proper course of electrical treat-
ment which has been followed, with occasional intermissions, for some
months during each year for several years.

17. As adjuncts to a course of electrical treatment, you will find
massage, baths of various kinds, a change of climate, enforced rest in
bed, and judicious internal medication, indicated in special cases. Deli-
cate subjects, who suffer from neurasthenia, hysteria, persistent
neuralgias, mental depression, sleeplessness, morbid fears, excessive
“nervousness,” rapid or extreme emaciation, profuse and _ persistent
sweating of the palms or feet, dyspeptic symptoms, and the thousand
other manifestations of debility, are especially benefited by these adjuncts
to a judicious use of electricity.

18. When simple excitation of motor or sensory nerves is demanded,
the faradaic or static current is the best one to employ.

19. As a counter-irritant, and in the treatment of anesthesia, dry
faradization with a wire brush excels all other electrical applications,
unless it be the use of static electricity.

20. In spasmodic diseases, in neuralgia, and other like conditions,
galvanism and static clectricity are alone of material service.

21. Interrupted galvanic currents are of service when muscular
contractions of a forcible character are desired, When degeneration of
a nerve exists, these cannot be produced by the faradaic current.

22, The size of the electrodes modifies the density of the current
directly. When large, the current is less dense because it is more dif-
fused. The cathode should. as a rule, be larger than the anode when
electrical applications are being made.

STATICAL ELECTRO-THERAPEUTICS.

We have now discussed at some length in this section (1) the
physics of this form of electricity ; (2) the improvements made from
time to time in machines designed :to generate it; and (8) the various
methods of application of this agent,
STATICAL ELECTRO-THERAPEUTICS. 703

We are now prepared to consider more intelligently the various
diseased conditions of the human body which static electricity has been
shown either to ameliorate or arrest. In this connection I take the
liberty of first quoting from an admirable paper of my friend, Dr. W. J.
Morton, published some years ago upon this subject, certain paragraphs
which relate to the rise and fall of static electricity as a therapeutical
agent. He says :—

“In 1730 Mr. Stephen Gray, of London, first insulated and electri-
fied a human subject, and in 1784 the Abbé Nollet received the first spark
drawn from a body thus insulated. From ‘this incident undoubtedly
sprung the modern idea of electro-therapeutical science, for Nollet pur-
sued electrical investigations to great lengths, and as early as 1746 was
treating paralytics by insulation, sparks, and shocks. About this time,
also, Professor Kruger, of Helmstadt, and Kratzenstin, his pupil, cured
paralysis by electricity, and Klyn cured by means of sparks a paralyzed
arm, These cases were the first strivings of modern electro-therapeutics,
but they produced little effect on medical practice.

“Tt was a publication in 1748 by Jallabert, professor at Geneva, that
first drew the earnest attention of the medical world to the real curative
power of electricity. Jallabert restored to perfect motion and sensation
in two months a locksmith’s arm which had been paralyzed during fifteen
years. In the meanwhile the invention and perfecting of the electric
machine and Leyden jar paved the immediate way to the practical use
of electricity as a remedial agent, and soon, following the success of
Jallabert, the whole medical world was awake on the subject of medical
electricity. At Montpelier, under the auspices of Sauvages, president
of the Academy of Medicine, the people flocked in multitudes to have
their ailments relieved, and so great was the number of successful treat-
nents that the physicians were obliged to appeal to the priests to protect
them from the charge of witchcraft. Deshais, in 1749, wrote a disserta-
tion upon the Montpelier experiences. Quelmalz, Linnwus, and Zetzel
followed him, and from this period onward, up to the year 1800, works*
on the subject multiplied in all countries.

‘“It is interesting to recall that Franklin, in 1752, treated paralytics
at Philadelphia by statical electricity.

‘Tt is evident, then, that statical electro-therapeutics was already, at
the end of the last century, entering upon a marked career of service to
medicine when galvanism and the voltaic pile, in 1800, extinguished it at
the very height of its progress. It is not improbable that its abandon-
ment was a loss to medical science.

* Besides those mentioned, the most important are by De Haen, Watson, Franklin,

Priestley, Gardane, Sigaud de la Fond, Bertholon, Cavallo, Wilkinson, and Manduyt; the
latter is particularly valuable to the student of medico-statical electricity. ;
704 LECTURES ON NERVOUS DISEASES.

“ Up to comparatively recent times frictional electricity for medical
purposes was produced from a single glass wheel. Its tension was low
and its quantity small. But the invention of Holtz, in 1865, marked out
for modern statical electricity the possibilities of a new career. In the
Holtz machine we have an apparatus simple and durable in construction
and capable of furnishing electricity of high tension and in great quan-
tity. And by means of the Leyden-jar condensers, and of the possibility
of increasing the number of wheels, both tension and quantity are within
the control of the operator. At a given length of spark or tension,
every additional wheel adds only to the quantity, and Holtz machines
with as many as twenty revolving wheels have been constructed, in
which the quantity, of course, was very great. This very fact of a
greatly increased working quantity of statical electricity justifies the
expectation that modern electro-statical therapeutics will take a step
greatly in advance of its past.

“ Statical electricity, as we have already seen, has never had fair play
in modern medicine. The older practitioners (1740 to 1800) have left us
glowing records of its value—records embodied in a period of literature
still full of fruitful suggestion in other branches of medicine, though in
none more advanced than in the treatment by electricity. The physicist
of to-day cannot neglect the work of Franklin, of Symmer, of Du Faye,
of Cavendish, and the long line of the men of their time who unrolled to
view the mysteries of a new science. No more can the physician neglect,
from a medical point of view, De Haen, Boze, Bertholon, Nollet, Wilkin-
son, Cavallo, Manduyt, and a dozen others. True, the mantle of their
labors decked in a degree the new galvanism and the newer faradaism,
while in the act statical electricity dropped from sight. It found con-
scientious revivers in Sir William Gull, Golding Bird, and Wilks in 1850,
and thereabouts, and it is gratifying to note in their writings the highest
appreciation of its merits. When at last it fell from their hands again
abandoned, it was only and simply because of the inconvenience of
administering it. The machine of their day refused to work in the damp
of London fogs, and it was necessary in the electrical room of Guy’s
Hospital to keep a large fire constantly burning to dry the air; and even
to-day, in Paris, one may visit the rooms of a practitioner heated summer
and winter.

“But these disadvantages have now been removed. Statical elec-
tricity was again revived, and with great success, by Professors Clemens
in Germany and Sewanda in Austria. In France, its revival has already
received a notable impetus emanating from the famous clinic at Salpe-
triére, where the presiding care of Professor Charcot and the efficient
labors of Dr. Vigouroux have each contributed to place statical electro-
therapeutics on a scientific modern basis.”
STATICAL ELECTRO-THERAPEUTICS. 705

The remarks of Dr. Morton which I have quoted are peculiarly
significant in this connection. During the years in which I have per-
sonally been engaged in experimenting with various modifications and
improvements upon the original model of Holtz’s induction machine
which have suggested themselves from time to time to my mind, I have
had ample opportunities to observe, in the daily routine of my practical
oflice work, the effects of static electricity upon many patients afilicted
with diversified diseases. In preparing this article I have carefully
searched through the records of quite a large number of cases where it
has been most successfully employed by me. I have been struck in many
instances with the rapidity with which it etfected an apparent cure; in
other cases, with the permanency of its beneficial results; and in all,
with the simplicity and ease of its application. To a lady, for example,
it isa matter of no small moment that she is freed from the necessity
of divesting herself of any garments worn, and that almost any part of
the body can be treated without exposure or annoyance. To the busy
practitioner, also, to whom time is valuable, it is not unimportant that
several patients can be treated simultaneously; and that no delays are
caused by waiting for each one to remove and replace their clothing.

Again, the application of “static insulation” is far more agreeable
than “ general faradization” or “general galvanization;” and, in my
experience, it is fully as efficient in many cases in its remedial action as
either of the methods referred to. The inconvenience to the patient of
having to disrobe almost completely, and the distaste which many
naturally exhibit to having a wet electrode or the operator's wet hand
rubbed over the skin for from ten to twenty minutes is entirely obviated.
With a sufficiently large insulated platform several patients can, if
desired, be given’ a static bath in the physician’s consulting-room in the
same period of time as would be consumed in administering general
faradization to one patient, and be spared the annoyances mentioned.

Ido not mean to infer that some cases do not require the use of
faradaic or galvanie treatment; nor would I be construed as casting any
reflection upon the therapeutical value of the methods which were first
suggested and employed by Drs. Beard and Rockwell, of New York.
The question at issue is simply one of convenience to the patient and the
physician ; provided that the indications of the case justify the trial
of the static bath as a substitute for “ general faradization ” or “ general
galvanization.”

In the second place, I think it has been justly claimed for static elec-
tricity that some of its therapeutical effects are more certainly and rapidly
obtained than by means of any other form of electrical application.

As examples of such effects, I prominently mention (1) the re-
lief of contractured muscles; (2) the relief of certain forms of pain;

45
706 LECTURES ON NERVOUS DISEASES.

(3) the production of muscular contraction and the restoration of mus-
cular power after the “reaction of degeneration” has shown itself; (4).
the improvement of muscular power and general sensibility in certain
organic spinal diseases; and (5) the stimulation of the skin in certain
trophic neuroses.

Respecting this statement, I take the liberty of again quoting certain
paragraphs from the writings of my friend, Dr. Morton. He says :—

“We may now ask the special question, Why, above and beyond other
forms of electricity, does static electricity cure? I will offer two explana-
tions, and these are, first, simple mechanical disturbances, followed by a
local alteration of nutrition; and, secondly, reflex action from irritation
of the peripheral distribution of nerves.

“ With regard to the first, when the electric discharge in the form
of a spark takes place in a resisting medium like the various parts of
the human body which are submitted to it, a very great mechanical
disturbance in the tissue at the point of discharge must inevitably result.
A piece of paper, for instance, held between the electrode and the skin
is perforated by the spark. A parallel to the mechanical action referred
to, though in a less localized and less powerful degree, is to be found in
ordinary physical exercise or in massage. From this point of view,
static electricity by the method of sparks has, in a special degree, owing
to its high tension, great advantages. The spark strikes a sharp, in-
cisive, and penetrating, though scarcely painful blow, and, often repeated
in a given region, creates, by simple disturbance, a great alteration in the
nutrition of the part. This, at least, is the only way in which I can account
for the almost instantaneous relief and cure, after a few applications, of a
large class of pains seated in deep and superficial fascize, and due to sub-
-acute and chronic rheumatism. Neither blisters, other violent counter-
irritation, nor medicine will dissipate these pains, while, on the other
hand, static electricity will subdue them at once.

“The contraction of muscles is also often due to the same me-
chanical effect of the spark, just as muscles of the thigh may be made
to contract by a snap of the finger or sharp blow from a percussion-
hammer.

“With regard to the second explanation,—that by reflex action
following a peripheral irritation of the terminal sensory filaments and
endings,—a very intricate question is opened, which we can no more
than glance at here.

“ How can simple electrification by insulation and the drawing of
sparks, it is asked, produce the decided effects that are claimed for it?
Static electricity, it is said, owing to its high tension accumulates
mercly on the surface of the body, and does not penetrate into the
deeper organs, while the spark is merely the briefest kind of current.
STATICAL ELECTRO-THERAPEUTICS. 707

“ Recent investigations on the irritative action of applications to the
skin have thrown a new light upon this question, and show that, though
previously unexplained, the etlects of the great accumulation of elec-
tricity on the surface and the sharp blow of the spark were, in truth,
effects based upon a true physiological principle,—the principle named by
Brown-Séquard, its recent expounder, “the phenomena of inhibition.”
A few drops of chloroform applied to the neck of a guinea-pig produced, -
on some occasions, an epileptic attack ; on others, the nerves and muscles
became highly excitable to stimulation.

“But the most notable effect of irritating applications of chloroform,
as well as other substances, was a general anesthesia; reflex symptoms
were inhibited and muscular excitability lost.

“An interesting element has entered into our physiological and ther-
apeutical studies,—that of the reflex phenomena of peripheral irritation.
And we may at once place under this single heading a large number of
facts long familiar.

‘External irritant applications, in one form or another, have always
formed an important clement in medical treatment. And most of these
applications have been used to relieve pain, or in some way modify the
general sensibility, either in contiguous or remote parts.

“Familiar examples are blisters, sinapisms, cupping, the actual
cantery, ammonia, the moxa, aqua and acupuncture, and in later days the
magnet, the tuning-fork, and hypodermic injections of water into the
thoracic walls for the purpose of allaying the cough of phthisis. ‘The
latest novelty in this direction is the electric percutor of Baudet, con-
sisting of a tuning-fork kept in vibration by electricity, and communi-
cating to any desired nerve or part, by means of a slender rod, the
mechanical vibrations originated in the fork.

“Charcot, after cautious experimentation, has given his adherence
to the statement that metals (metallotherapy) do produce effects con-
tiguous and remote when applied to the skin,—that the magnet also
produces similar effects, both upon general sensibility and muscular
power. Vigouroux has pointed out that the vibrations of a tuning-fork,
either alone or communicated to a sounding-board, provoke similar
phenomena.

“ Here, then, in this collection of well-known facts, and.in the broad
generalization of Brown-Séquard, drawn from his recent experiments,
we have at last, it seems to me, found the law which governs the results
ptoduced and to be expected from statical electrification, as well as from
some other. uses of electricity. This law is the effect produced upon
remote parts by affecting the peripheral distribution of the sensory
herves, and the effect, produced is most commonly relief of pain or spasm
in a remote part; and in this principle of inhibition from peripheral
708 LECTURES ON NERVOUS DISEASES.

application may doubtless be found the explanation of many of the
definite and hitherto inexplicable effects of static electricity.

“The ‘insulation’ alone holds the entire sensory peripheral dis-
tribution of the skin in its grasp. Every nerve-filament is vibrating, is
polarized, or affected, whatever term we choose to use, by the tense layer
of electricity or electrical influence collected on the surface, there bound
. by the natural laws of physics, and only waiting to be drawn off by a
spark or diffuse itself gradually into the atmosphere, while in the spark
itself is found a still more potent and localized stimuiating agent.”

I have quoted the preceding paragraphs from the pen of Dr. Morton,
because they coincide in the main with my own views; the possible
exceptions being a few technical points in which I might not fully agree
with that author.

From conversations held with him I am led to infer that his ex-
periences and my own have been generally in accord respecting the
therapeutical effects of each of the several methods of statical applica-
tions already described by me in preceding pages.

It is extremely difficult to formulate general deductions respecting
any therapeutical agent. Such attempts necessarily tend to evoke
criticism, because exceptions to every general statement may be
brought forward as evidences of their unreliability. I am, however,
inclined to offer the following general deductions respecting static elee-
trical applications for the benefit of the reader, with the proviso that
they may not apply to every case, and that they be not construed too
literally :—

First.—My experience has not confirmed the view (heretofore ad-
vanced by some authors) that the positive pole of a static machine has a
“tonic” and the negative pole a “ depressant” action.

I have found, after repeated experimentation, that either pole seems
to answer equally well upon most patients. I commonly employ in my
office the positive pole, however, because it happens to be the most con-
yeniently connected with the patient.

Second.—As a curative agent, I regard static electricity as of great
value.

While galvanism must always hold a preéminent place in electrical
therapeutics, because of the chemical effects so obtained, there are
certain diseased conditions in which static electricity is unquestionably
superior to faradaism and galvanism,

Third—It has been shown in preceding pages that the static in-
duced current fulfills all the known indications of faradaism.

It has, moreover, two great advantages over the faradaic instrument,
namely, that a constant polarity is obtained and a much greater electro-
motive force. It is also less painful than the faradaic current.
STATICAL ELECTRO-THERAPEUTICS. 709

Fourth.—Static, electricity possesses a decided advantage in some
cases where faradization or galvanization have either given negative re-
sults or have apparently lost their remedial power after their use has been
too long continued.

It is a common expedient with medical electricians to shift from one
form of current to another from time to time whenever the progress of the
case seems unsatisfactory. Under such circumstances franklinigm forms
another link to the chain, and greatly aids us when faradaism and gal-
vanism have both proven inefticient.

Fifth —I have found heavy static sparks to surpass any other 0h
of electrical application for the relief of contractured muscles.

The sparks are withdrawn from the part so affected in rapid suc-
cession for about five minutes.

Post-paralytic contracture, old deformities from preternaturally
shortened muscles, and the various forms of obstinated and protracted
tonic muscular spasm often yield like magic to the influence of heavy
sparks.

Sixth.—It is well known that certain forms of pain often disappear
at once after static applications.

The most marked type of pain so relieved is the so-called “ rheu-
matic muscular pain,” or that observed in genuine muscular rheumatism.
I have seen many such cases where one application of heavy sparks to
the seat of pain for a few minutes has caused permanent relief.

Again, neuralgias of a distressing kind are often dissipated after a
few applications of heavy indirect static sparks for from five to ten
minutes at a sitting.

Finally, I know of no other agent which exerts so marked an effect
of a happy kind upon the ‘lightning pains” observed in locomotor
ataxia as does the heavy static sparks.

Seventh.—The application of the spark, hoth by the direct and indi-
rect, methods (Figs. 176 and 177) excites powerful muscular contractions.

This etfect is often desired in the treatment of hemiplegia and olher
forms of motor paralysis.

Some authors recommend the employment of “static shock” (Fig.
178) for cases of paralysis of long standing; but, personally, I am in-
clined to regard this form of application as too severe for most patients.

I have often obtained a complete restoration of muscular power in
special nerve-trunks by static sparks alone after the “reaction of degen-
eration ” was fully developed and all faradaic excitability had ceased.

Eighth.—Cases which exhibit a marked impairment of sensation
(whether of touch, pain, or temperature) are generally improved, in ny
experience, by the use of static sparks over the anesthetic area more
rapidly than by the faradaic or galvanic currents.
710 LECTURES ON NERVOUS DISEASES.

I have encountered several very striking cases which illustrate this
point admirably, but a lack of space precludes the insertion of their
histories.

Ninth_Remarkable effects of static sparks upon that form of bald-
ness known as the so-called “tvory spots,” or alopecia arieta, have been
observed by myself through the courtesy of my friend Dr. F. B.
Carpenter, of New York. I have seen several of his cases where he has
wrought a wonderful change in the appearance of the scalp after several
months of treatment of the bald spots by the “direct”? spark. The
growth of the hair, which had apparently been totally destroyed over
the affected regions, is attributable probably to the rekindling of the
circulatory and nutritive conditions of the affected area upon the scalp.

Tenth—As a general tonic and also as a stimulant to depressed
nervous functions, “ static insulation” (Fig. 180) seems to be particu-
larly of service.

I employ static electricity constantly by this method in neurasthenia,
with marked benefit.

I have observed also remarkable improvement in disturbed visceral
functions (such, for example, as dyspepsia, habitual constipation,
diabetes, vertigo, asthma, etc.) after the use of static insulation for from
ten to twenty minutes at a sitting.

Many such cases have expressed to me the greatest delight at the
beneficial effects which such an application invariably produced. For
the past three years, I have used my static machine almost exclusively
as a means of improving the “general nervous tone” of patients, in
preference to my faradaic or galvanic apparatus. It is much more
satisfactory to patients because of its ease of application; and,as far as
I have observed, equally effective as a tonic.

Eleventh.—I am inclined to think that those authors who have
written upon static electricity as a therapeutical agent in a lukewarm
spirit have probably been supplied with an apparatus which has been
ineffective because it generated too slowly or imperfectly.

The size and number of the revolving plates and their thorough
protection from atmospheric changes are factors of the greatest import-
ance.

As I have already said, many of the static machines sold to the
profession are hardly more than mere toys. Any machine which gives a
thin spark (even if a long one) lacks one essential factor to success as a
therapeutical agent, namely, QUANTITY.

Twelfth.—I! have used static insulation and sparks with satisfaction
in the treatment of chronic inflammatory and spasmodic diseases ; such,
for example, as influenza, phthisis, bronchitis, ashthma, laryngitis, neu-
ritis, synovitis, ete.
STATICAL ELECTRO-THERAPEUTICS. 711

Three cases of chronic synovitis of the knee-joint of an intractable
form recovered completely under my care within a month, under the
daily administration of statie sparks to the affected joint.

Many cases of bronchitis and asthma have been greatly benefited by
insulation and sparks to the chest.

T have used static insulation (followed by the withdrawal of sparks
from the spine and abdomen) upon subjects afilicted with dyspepsia,
flatulency, and constipation. In many instarices this form of electrical
treatment gave very marked relief.

The influence of this agent upon visceral derangement is, however,
a field for future investigation. It gives promise of happy results. As
yet, my personal experience is too limited to justify me in formulating
any positive conclusions respecting the method which is best employed
in individual cases.

Thirteenth._Static electricity is of value in the treatment of hys-
terical states and other allied conditions.

Charcot has long been an advocate of this therapeutical agent in
such cases. My own experience teaches me that it is of great service as
an aid to recovery; although I believe that in a very large proportion
of these subjects reflex irritation from ‘ eye-strain”’ has to be combated
by the relief of anomalies in the eye or its muscles before a perfect
restoration of health can be attained. I have discussed this field else-
where, (See New York Medical Journal, February, 1886, and April,
1887.)

In closing, I would state that the length of this article (already too
prolonged, perhaps) precludes the insertion of the histories of many
typical cases which would be of great interest in this connection. To
fairly illustrate the subject in its many ramifications a very large number
of lengthy records would, however, be required.

Medical literature within the past ten years, and antiquated works,
also, fairly teem with cases reported by leading men in the profession
here and abroad, which illustrate their concurrence and firm belief in the
views expressed in preceding pages.

Static electricity is to-day, for the second time, generally recognized
by the profession as a valuable therapeutical agent. Most of the leading
neurologists have now a Holtz induction machine as a part of their oflice
equipment.

The later editions of recognized works upon electricity as applied
to medicine show almost without exception that this variety of elec-
tricity is deemed worthy of more attention than it received in the earlier
editions. It has passed through its stage of neglect and distrust safely.
It is steadily regaining the popularity it sq justly achieved in the
eighteenth century.
712 LECTURES ON NERVOUS DISEASES.

SPECIAL ELECTRO-THERAPEUTICS.

We have thus far discussed the various methods of employing elec-
tricity in a general way, and there remains for us to consider how we
shall proceed in employing this avent when special organs are diseased.
I would preface my remarks upon this field with the statement that the
curative properties of electricity must, of necessity, be modified by the
pathological conditions which exist in each individual case. The prog-
nosis is naturally more grave in some conditions than in others.

For example, a patient who has motor paralysis which is due to
degenerative changes in the cells of the anterior horns of the spinal gray
matter will not usually recover the power of motion completely, while he
may do so if the paralysis be due to a cerebral or spinal lesion which is
not accompanied by degenerative nerve-changes. Again, all forms of
functional nervous derangements are more amenable to electrical treat-
ment (if judiciously employed) than are the graver results of organic
disease of the nerve-centres. A muscle which has atrophied from disuse
can usually be restored, while one which has wasted from imperfect
nutrition (resulting from a degenerated nerve) may possibly withstand
all efforts to improve it. The therapeutical use of electricity is subject
to the same influences as that of any other remedial agent, and the
prognostic conditions are not always the same even among cases of the
same nature.

In previous pages I have given many hints relating to the differential
diagnosis which you will be called upon to make in nervous diseases, and
enough has been said in reference to the anatomy and physiology of the
nervous system to assist you in properly interpreting abnormal nervous
phenomena. I shall therefore give, in closing, directions only as to how
‘to employ electric currents upon different parts of the body without
entering to any extent into the causation of the symptoms which you
will be called upon to treat. Remember, however, that accuracy of
diagnosis is the basis of cure in a large proportion of cases.

ELECTRICITY IN CEREBRAL AFFECTIONS.

Experiment has shown beyond dispute that galvanic currents can
be made to pass through the substance of the brain when inclosed within
the skull. It is much less certain whether the same may be said of fara-
daic or static currents. The beneficial results which are obtained by the
two latter (and possibly many of the effects of galvanism as well) upon
cerebral diseases are to be attributed, in my opinion, chiefly to the
alterations produced in the blood-supply of the brain. Some of the most
remarkable results obtained by neurologists from the employment of
electricity upon the head itself or the cervical ganglia of the sympathetic
ELECTRICITY IN CEREBRAL AFFECTIONS. 713

are unquestionably due to an alteration produced in the calibre of the
cerebral vessels. JI have never been convinced that organic lesions of
the brain can be cured by the direct use of this agent on that organ.
On the other hand, I am fully satisfied that the symptoms of cerebral
hyperemia and anemia are directly influenced by galvanism and static
electricity. I believe that any unprejudiced mind can be readily con-
vinced of the scientific accuracy of this conclusion. I have treated
many patients (who gave undisputable evidences of basilar hyperamia
by the deflections of the needle of a calorimeter), and have brought
them to a state of perfect health within the space of a few weeks by
galvanism of the head. The calorimeter confirmed the cure in these
cases by the absence of deflection, which existed before treatment was com-
menced. In some instances of this condition, static electricity proves a
very valuable adjunct to galvanism. I will give in detail a few of the
methods which, in my experience, may be employed in cerebral diseases
with a prospect of great benefit to the patient.

CEREBRAL HyPer2uia.—First ascertain by means of a calorimeter
the situation and extent of the congestion. Test all parts of the head.
When necessary, do so by separating the hair and bringing the poles as
closely as possible in contact with the scalp. It is not necessary, as a
rule, to shave the head. In case very accurate observations are demanded,
this step may have to be taken,—as, for example, when a cerebral tumor
is suspected to exist.

At the nape of the neck, over the mastoid processes, upon the
temples, and over the forehead, no hair exists to interfere with the deter-
mination of the relative temperament of the two sides, or of different
regions of the corresponding side. The calorimeter will aid you in diag-
nosis and treatment ; if properly used, it is sometimes invaluable.

The following are the steps in treatment most generally useful :—

(1) Apply the cathode to the nape of the neck, close to the skull,
and the anode over the forehead. Make stabile applications for one or
two minutes to each side of the forehead, the cathode remaining stabile.
(2) Make labile anodal applications to the forehead transversely for one
minute. (3) Move the cathode to the mastoid region of each side, place
the anode centrally on the forehead, and continue each stabile applica-
tion for from thirty seconds to one minute. This may make the patient
dizzy. (4) Do not use a current which produces pain to the patient, but
have as great intensity as he can comfortably bear. (5) Never reverse
the current when the poles are on the head.

These applications may daily be alternated with “insulation” and
the “electric head-bath,” if you possess a static machine. The sittings
should oceur daily until the symptoms are cured and the calorimeter
ceases to show its previous deflection.
714 LECTURES ON NERVOUS DISEASES.

It is sometimes well to stimulate the superior cervical ganglion by
placing a small anode in the fossa behind the angle of the jaw, and the
cathode on the seventh cervical spine, and to slowly interrupt the current.
Caution must be exercised against employing too strong currents.

Finally, active faradization of the limbs is sometimes necessary, in
order to draw the blood to the limbs. It is not well to employ this step
if it Gauses an elevation of temperature.

The effects of this treatment should be to relieve the pain or sense of
fullness in the head, the vertigo on rising, the mental confusion or distress,
the insomnia, and the many other symptoms peculiar to this condition;
and to steadily reduce the calorimeter deflections when the poles are in
contact with homologous parts,

  

’

Fie. 189.—A ScHematic REPRESENTATION OP THE Fic. 190.—A ScHEMATIC REPRESENTATION OF THE

DistrmuTION OF AN ELECTRIC CURRENT AP- Course OF ELecTRIC CURRENTS SENT TRANS-
PLIED UNILATERALLY THROUGH THE Heap. VERSELY THROUGH THE Heap. (After Erb.)
(After Erb.) The anode (+) rests above the The cathode (—) is represented as placed on
ear of the left side. The cathode (—) is sup- the same side as the lesion,

posed to be at the nape of theneck, and to exert
its influence as farasthe line drawn horizontally
across the neck.

CEREBRAL ANZMIA.—I should advise you to begin the use of very
weak galvanic currents after an attack of embolism. I believe that cur-
rents of this kind sent transversely through the head from the temples,
and occasionally in the antero-median plane, assist in absorbing the col-
lateral cedema and cause a diminution of the collateral hyperemia. I
prefer to use the cathode on the side of the embolic obstruction when
transverse currents are employed. In my opinion, it tends to promote
absorption and to contract the vessels far more than the anode. The
paralyzed muscles should be treated separately, by methods given in
detail later.

Some four years ago Liwenfeld published some deductions relative to
the action of galvanic currents upon the brain, based upon experimental
researches, Although their accuracy has been justly called in question
by authors of note, my own experience leads me to confirm them in part
ELECTRICITY IN CEREBRAL AFFECTIONS. 715

and to attach some importance to them. These conclusions were as fol-
low: (1) anode at forehead and cathode at neck cause contractions of
the vessels of the pia; (2) anode at neck and cathode at forehead cause
dilatation of the vessels of the pia; (3) when transverse currents are
employed, the cathode causes contraction of adjacent vessels, and the
anode dilatation.

When cerebral anemia of a general character exists (as a manifesta-
tion of poverty of the blood, defective heart-power, etc.), general fara-
dization, central galvanization, and static electricity by insulation are
often of material benefit. The removal of the cause by judicious medi-
cation, etc., is, of course, vital to successful electrical treatment.

HEMIPLEGIA OF CEREBRAL Oricin.—A very large proportion of pa-
tients with hemiplegia from cerebral causes owe the paralysis of their
limbs to hemorrhage, softening, or embolism. The electrical treatment
should be directed to both the brain and the muscles. It should not be
commenced (save in the case of embolism or thrombosis) until a month
has elapsed since the attack. Each patient’s susceptibility to the agent
should be carefully studied, and the strength of current employed
should be modified accordingly. The muscles may be treated by faradi-
zation or galvanization, or by the static current (indirect sparks being
drawn from the paralyzed limbs). The brain should be subjected to
galvanization only, or to static insulation. :

If the patient fails to show improvement within a month after the
treatment has been daily applied, or if the improvement of the first few
days is rapidly lost in spite of continued treatment, the prognosis, as
regards marked amelioration of the paralysis by electrical applications,
is grave.

HemMIan#stHEsta is best treated by the wire brush upon the dry skin
in connection with the secondary faradaic current. I have also obtained
some remarkable effects with the combined current (as before stated),
and also with the static current, in cases where the faradaic current was
ineffective.

Post-pARALYTIC Riarprty (occurring late) is the result, in most cases,
of secondary changes within the spinal cord. The supervention of pig-
mentation of the nails, edema, a shiny skin, disease of the joints, and
other evidences of trophic alterations, points to a serious and often per-
manent destruction of the nerve-centres.

Hints which have been given under the head of general electro-
therapeutics will guide you in modifying the treatment according to the
exigencies of each individual case. The remarkable improvement which
some hemiplegics obtain through the instrumentality of electrical treat-
ment should impress you with the necessity of employing it long enough
to ascertain whether its continued use is indicated.

.
716 LECTURES ON NERVOUS DISEASES.

Monopiecia on Monospasm.—These conditions are particularly in-
dicative of cortical disease. The muscles affected are a guide to the
convolution attacked. I have covered this field in a previous section.
The indication in such a case is to improve, if possible, the nutrition of
the diseased part directly by galvanism, and also to stimulate the
muscles functionally associated with it. I employ for this purpose a
“medium ” electrode over the diseased convolution, the indifferent elec-
trode being placed over the centre of the sternum. It is my custom to
employ both poles separately to the head for an interval of two minutes
each ata sitting. The monoplegic limb may be treated by labile galvanic
applications, the wire brush and faradization, or the indirect spark by
means of a static machine.

Ducuenne’s Disease.—The morbid changes in the nuclei of the

pe wwe

 

Fic 191—A Scuemaric REPRESENTATION oF THE DISTRIBUTION AND DENSITY OF THE
THREADS OF CURRENT WITH REGARD TO THEIR ENTRANCE INTO THE SPINAL Corb,
(After Erb.) In @ the poles are placed near each other. In 4 the poles are more widely
separated. The size of the electrodes shown in the cut is the same for both the anode and
cathode.
medulla which accompany bulbar paralysis may, in some cases, be held
in check for a while and the symptoms markedly improved by placing
the positive electrode (of large size) at the nape of the neck and as
close as possible to the foramen magnum, and applying the negative
electrode (covered with absorbent cotton and attached to a long handle)
successively to the pharynx, fauces, tongue, cheeks, and lips. As strong
a current as the patient can easily endure should be used. The duration
of the sitting should not exceed five minutes. It is well to complete the
sitting by passing transverse currents through the neck, so as to excite
the muscles concerned in deglutition. Some authors recommend the
employment of currents through the head, both longitudinally and trans-

versely.
ELECTRIZATION OF THE SPINAL CORD.

ELECTRICITY IN SPINAL AFFECTIONS.

_ There are various ways of bringing the spinal cord under the
influence of electrical currents. The method of application selected in
any individual case will depend somewhat upon the symptoms which the
patient presents, and also upon the character and seat of the lesion.
The diagrammatic cuts of Erb, which illustrate the diffusion of electrical
currents, show in a graphic way the effects of close approximation and
wide separation of the poles, We may also modify some of the morbid
conditions of the spinal cord by electrization of the extremities when the
indifferent pole is placed over spinous processes. It is well to increase
the size of the electrodes proportionately to
the strength of the current employed.

Fig. 191 illustrates the eflect of separation
of the poles when applications of electricity
are made to the spinal column. Some of the
threads of current depicted are rendered in-
effective on account of their diffusion. This
is made more apparent in Fig. 192.

ELECTRIZATION OF THE SPINAL CORD.
Yo treat properly of the various methods
which may be used when the application of
electrical currents as a therapeutical measure
for the relief of spinal diseases seems indicated,
it would be necessary for me to enter into -

f
f
!
t
f
'
'
1
1
1
1
1
t
\
4
‘

-

 

Fic. 192—A ScuHematTic ReEpRE-

greater detail regarding spinal discases than
the space allotted to these lectures will permit
of. I am reluctantly forced, therefore, to
summarize somewhat hastily the main points
which my experience with this agent leads me

SENTATION OF THE DENSITY OF
THE CURRENT UPON APPLICATION
OF THE ELECTRODES TO THE SAME
SURFACE AND IN CLOSE RELATION
TO EACH OTHER. (After Erb.)
The dotted lines indicate the in-
effective threads of current. The
shaded portion represents the zone
of greatest intensity.

to indorse. Most of my readers are probably

already familiar with the pathological changes which exist in connection
with the more common diseases of the cord; but, if any are not so, these
changes should first be studied and thoroughly mastered before they can
hope to successfully combat them.

Galvanie currents are of greater service in the treatment of spinal
diseases than fiuradaic or, perhaps, the static,—chiefly on account of the
depth of the tissues affected and the chemical and molecular changes
which galvanic currents tend to induce.

Spinal electrodes should be of large size.

The applications may be either stabile or labile, the former being of
the greatest benefit when the spinal lesion is circumscribed in extent,
718 LECTURES ON NERVOUS DISEASES.

and the latter when a larger part of the spinal cord is affected. If labile
applications are indicated, the movements of the electrodes should be
made somewhat slowly.

In directing galvanic currents to the cervical and upper dorsal seg-
ments of the cord, it is well to place one electrode of medium size
behind and below the ear alternately on the two sides of the neck, while
the other is applied to the spine.

Points of tenderness to pressure along the spine should be subjected
to stabile applications of the anode. They should be sought for in each
individual case with care and separately galvanized. :

The strength of the currents employed should be modified in indi-
viduals by the condition which is presented for treatment. Weak cur-
rents of from two to five milliampéres act best, as a rule, when excessive
irritability of the organ exists; chronic pathological conditions respond
better to currents of greater intensity. I often use eight to twelve
milliampéres of current in chronic cases.. :

It is advantageous, in some subjects, to make electrical applications
to the limbs when the cord is affected. Stimulation of the peripheral
nerves and the muscles connected with the segments of the cord involved
should be particularly aimed at, although the electrization of the skeletal
muscles and the skin should not be exclusively confined to the limits thus
indicated. It is my custom to employ the “ combined current” (previ-
ously described) when applications to the limbs are thus made. This
form of current is particularly indicated when the muscles exhibit a ten-
dency toward atrophy. ‘The electrode which rests upon cervical or lum-
bar enlargements of the spine should be of large size, while that used |
upon the limbs should be of medium size, so as to direct the combined
currents to the nerves or muscles affected.

If galvanism alone is used upon the limbs in spinal disease, it is
often beneficial to the patient to break the current by an interrupting
electrode, or to reverse its direction by means of the commutator.

Some authorities advocate faradization of the vertebral region and
of the limbs in conjunction with galvanic applications. I have seen, in
a few instances, some remarkable effects follow the employment of the
wire brush slone in poliomyelitis of children, and I can see no reason
to doubt its occasional efficacy in other forms of spinal disease.

In some unexplained way the excitation of muscular action and
stimulation of the cutaneous nerves exert in many instances a remedial
effect upon lesions of the spinal cord.

It is not always possible (as, for example, in poliomyelitis) to excite
muscular action by faradaism alone. In these cases interrupted galvanic
currents, or the “combined current” (galvano-faradaic), will accomplish
the desired end, I have repeatedly observed beneficial effects of this
ELECTRICITY IN PARALYSIS OR PARESIS. 719

treatment in locomotor ataxia, and Rumpf has published some cases
which sustain this view in which the wire brush was used upon the arms
and legs daily for about five minutes.

In all acute inflammatory disorders of the cord I deprecate the use
of electrical applications. When the acute stage has passed, or when
the disease has assumed a chronic type, many of the etfects of the dis-
ease (as, for example, muscular paralysis, rectal or vesical complications,
incipient. caries, anesthesia, etc.) may often be greatly relieved by its
judicious use. The current-strength employed in such cases usually
varies from five to eight milliamperes. The applications should be made
daily. When possible, it is important that the reader localizes early the
seat of the structural lesion and concentrates the treatment, for a while
at least, upon the segments of the cord involved. The muscles, skin,
bladder, rectum, etc., should be separately subjected to the influence of
electricity in case they exhibit a loss of f unction.

ELECTRICITY IN PARALYSIS OR PARESIS.

Hypokinesis may be due to many different conditions; hence, its
electrical treatment and prognosis must vary in accordance with the
cause which excites it. You should remember that paralysis of a muscle
is only symptomatic of other conditions,—such, for example, as lead-
poisoning, diphtheria, hysteria, mechanical pressure upon a motor nerve,
severance of a motor nerve, destructive processes or inflammation
within the motor cells of the brain or spinal cord, and changes in the
vessels. All of these tend to impair either the generating power of a
motor centre, or the conducting power of a motor fibre.

Respecting the application of electricity to the seat of central
lesions (i.e., lesions of the brain or spinal cord) in cases of motor
paralysis, De Watteville pertinently remarks as follows :—

“Tt is true that we have too often but a very imperfect idea of those

processes in the nerve-centres upon which the symptom depends, and
that we have no right to assume that the current has any specific cura-
tive influence upon any one of them ; still, as a justification for central
treatment in such cases, we may plead our very ignorance, we muy urge
the poverty of our therapeutical arsenal in arms wherewith to combat
our enemy, and may also invoke the possibility of at least staying its
progress by promoting nutrition of the surrounding portions of the
nervous structures threatened by its invasion.”
_ When the lesion directly affects the conductivity of a nerve, we
have reason to believe that the direct influence of electrical currents upon
the lesion tends to overcome the resistance offered to conduction by the
disease-process, and facilitates the subsequent transmission of voluntary
stimuli.
720 LECTURES ON NERVOUS DISEASES.

There are certain general rules that are applicable to the electrical
treatment of paralysis of motility. These may be stated as follows :—

1. The treatment should not be alone confined to the region of the
paralyzed muscles.

2. The seat of the exciting lesion should be ascertained early, if
possible, and subjected to the influence of this therapeutical agent in an
intelligent way.

3. If the motor paralysis is accompanied by anzesthesia, hyperes-
thesia, or other sensory disturbances, or if the vaso-motor system of
nerves be apparently implicated, the wire brush may often be used with
advantage upon the skin in the vicinity of the lesion, and also over the
muscles paralyzed.

4, Faradaic currents (provided they excite muscular action), or the
cathode-pole of a galvanic battery (with interruptions of the current), are
of use in exciting the conductivity of the nerve-tracts affected. Static
electricity is also of great utility in inducing muscular contractions, and
-is generally less painful than strong faradaism or galvanic shocks.

5. The “combined current ” (galvano-faradaic) is chiefly of service
in overcoming trophic disturbances, which often manifest themselves in
connection with motor paralysis.

6. I prefer labile applications to stabile in applying either faradaism
or galvanism to the muscles. Stabile applications are preferable to
labile when the brain, spinal cord, or peripheral nerve-trunks are to be
influenced. :

7. Never begin the use of electricity immediately after the onset of
paralysis (when due to a central lesion). It is always best to wait until
all danger of exciting a recurrence of the attack by stimulation of the
nerve-centres has passed.

ELECTRICITY IN SPASMODIC AFFECTIONS.

Hyperkinesis is frequently encountered as one of the varied forms
of external manifestation of irritative and destructive lesions of the
central nervous system. For example, it is by no means uncommon to
observe convulsions (of the clonic or tonic type), tremor, muscular
rigidity and contracture, etc., in connection with morbid changes in the
brain and spinal cord. By these symptoms we are often assisted in deter-
mining the seat of the lesion, although, as De Watteville remarks, ‘“ the
pathogeny of spasm is one of the most obscure problems in neurology.”
On the other hand—as, for example, in many instances of chorea,
epilepsy, hysteria, ete.--spasm may exist without any apparent structural
changes in the nervous system; being excited by some source of reflex
irritation, such as visual defect, phimosis, uterine displacement, insuf-
ficiency of the ovular muscles, etc. In tetanus the exciting cause is
ELECTRICITY IN SPASMODIC .AFFECTIONS. 721

generally found in one or more of the peripheral nerves. Sclerosis of
the motor fibres of the lateral columns of the spinal cord is known to
produce muscular contracture as a prominent symptom, probably because
the inhibitory influence of the brain upon the reflex excitability of the
spinal cord is arrested, or because the sclerosis directly excites the motor
apparatus of the cord. The peculiar deformities produced by post-
paralytic contracture, and the eccentricities of gait and posture exhibited
by patients suffering from tetanoid paraplegia (lateral spinal sclerosis),
are illustrative of the diagnostic value of tonie muscular spasm in the
course of some spinal affections.

Respecting the effects of electrical treatment of spasm, I am con-
vinced that in some cases many methods must be tried without benefit
before the right one is discovered. I have occasionally had_ brilliant
results follow some particular method, and subsequently I have been
utterly disappointed when it was tried upon some other patient with
identical symptoms.

I think that in this class of subjects more depends upon success
in ascertaining and removing the cause than upon any electrical applica-
tions (valuable as they may be as adjuncts). The correction of an optical
detect by elasses, the relief of ocular insufficiency by tenotomy or prisms,
the operation of circumcision, the mechanical relief of a displaced womb,
the removal of bad teeth, and many other such procedures, form the basis
of an absolute cure in many cases which have been otherwise treated
unsuccessfully. This fact is too often disregarded.

Electrical currents may be made to act upon these cases (1) as a
sedative (chiefly the action of the anode and static insulation); (2) as a
stimulant (the action of the cathode, the static spark, or faradaism); (8)
as a counter-irritant; (4) as a check to the progress of some peripheral
or central morbid state (catalytic action); and (5) as an agent for the
destruction of some neoplasm, induration, etc. (electrolytic action), or as
a cautery.

I have lately come to regard static electricity (franklinism) as more
generally applicable to spasmodic conditions (hysteria, torticollis,
blepharospasm, tremor, contracture, etc.) than either faradaism or galyan-
ism. It seems, in my experience, to act more promptly, and to produce
more lasting results than the methods more commonly recommended by
authors. I would advise those who decide to purchase a static machine
to try the effects of insulation, the “electric wind,” and the indirect
spark (as the circumstances may indicate) faithfully before they resort
to galvanization or faradization. If good results are not obtained, they
can easily substitute for it the other forms of treatment at a later
date. I should never regard any case as hopeless until it had been thor-
oughly tried (after all reflex causes had been removed). J have cured

46
(22) LECTURES ON NERVOUS DISEASES.

several severe cases of tonic spasm of the muscles of the neck in a few
sittings by means of the indirect spark, and relieved many cases of suf-
fering from other forms of spasm in a short time.

In EPILEPSY, the employment of galvanism alone has never, to my
knowledge, resulted in a complete cure, although some decided benefits
have been reported from its continued use. There is, to my mind, a close
relationship in many cases between epilepsy and ocular defect, to which
I have already called attention. This element in the causation of
epilepsy certainly merits attention. When all defects in the visual
apparatus have been corrected (in case such exist), or when other reflex
causes (such as phimosis, for example) have been relieved, galvanism and
static electricity may become valuable aids in controlling the subsequent
convulsive attacks. Latent hyperopia, astigmatism, and insufliciency of
any of the muscles of the eyeball may (and, in my opinion, often do) excite
epileptic seizures. It is absurd to expect of electricity, or any other
therapeutical agent, curative results when so important a source of irrita-
tion of the central nervous system is allowed to remain uncorrected.

Rockwell’s method of employing “ central galvanization ” in epilepsy
does not, to my mind, equal in beneficial etfects the use of static insula-
tion and the drawing of indirect sparks from the neck and back of the
patient. It is my custom, however, in some cases to employ both of
these procedures, each being used alone during alternate weeks for a
period of two or three months with daily sittings,

In cuorza I have obtained the best results with static insulation
and sparks.

My previous remarks respecting the relationship between defects in
the organ of sight and epilepsy apply with equal force to this disease
and all other types of functional nervous derangements. I have
discussed this subject more in detail when functional nervous diseases
were being considered.

If galvanism is employed, it is best to subject the muscles affected
with spasm to the action of the anode. The prognosis will depend
somewhat upon the duration of the disease. The earlier you begin
electrical treatment, the greater is the prospect of cure (provided all
sources of reflex irritation have been successfully removed).

My experience with faradaism in the treatment of chorea has been
somewhat limited; but the results obtained by me have not been so
satisfactory as with static electricity.

In FACIAL sPAsM (histrionic spasm) gooll results are occasionally
obtained by following the plan of treatment suggested in connection
with chorea; but treatment of the facial nerve alone is seldom satisfac-
tory. Ihave one case at present under treatment, however, in which I
have thus far had little, if any, success in my attempts to control the
ELECTRICITY IN SPASMODIC AFFECTIONS. 723

spasm. It is a case of long standing, and is therefore more rebellious to
treatment than if it were not chronic. The patient has an ocular defect
which it is difficult to correct perfectly.

In these cases I have obtained the best results by subjecting both
the cortical centres for facial movements and the nerve itself to stabile
applications of the anode (the cathode being placed on the breast-bone),
and by treating the nerve at intervals with static sparks drawn from the
affected portions of the face. The electrode for the head should be large.
The duration of each daily sitting should not, exceed five minutes.

NysraGMus and BLEPHAROSPASM belong to the choreic type of dis-
eases, and are best treated by electrical currents, provided they are seen
before the condition has become chronic. ‘Lhe prospect of a radical
cure steadily becomes less as time clapses. If static currents are em-
ployed, wooden tips to the electrodes should be used. I usually treat
these cases as if the seventh nerve were involved in all of its branches.
Sometimes it is well to place the anode upon the mastoid process and
the cathode upon the closed eyelid. The current should be very weak at
first; should be gradually increased until faint flashes of light are per-
ceived ; finally, it should be again decreased to the faintest perceptible
point. ,

TORTICOLLIS, Or WRY-NECK, when subjected early to static sparks or
strong faradization, may often be cured very rapidly. Interrupted
galvanic currents are also of material benefit in some cases.

The spinal accessory nerve is usually the one which is at fault. A
rheumatic origin may often be detected. If so, judicious medication
will tend to hasten the cure.

Some cases of wry-neck are associated with symptoms of paresis.
These have, as you might suspect, a more serious prognosis, Electrical
treatment will prove, as a rule, only palliative. Too often organic
changes have already occurred in the spinal accessory nerve, the spinal
cord, or the vertebrae. The duration of treatment should extend over
a period of months.

Spasmoprc astuma may often be benefited by galvanism of the neck.
T have previously described the steps of this procedure. Its beneficial
effects are probably due to changes induced ‘in the vagi. Drawing of
indirect sparks (by means of the static machine) from the anterior and
posterior surface of the chest has proved, in my experience, an admirable
preventative against such attacks.

Some patients have assured me that they experienced a sense of
great comfort after each sitting, and that the frequency of the paroxysms
of asthma has been perceptibly modified by them. My experience in
the electrical treatment of these cases is as yet somewhat limited ; but I
am inclined to believe that greater benefit can be derived from it than
724 LECTURES ON NERVOUS DISEASES.

from internal medication. Certainly it is worthy of a more extended
trial as an adjunct, if deemed wise, to other:remedial measures, or as a
substitute for them. ;

In TerANus (both of the traumatic and idiopathic varieties) two cases
of cure have been reported by Mendel, of Berlin. He employed galvani-
zation and subjected the muscles affected with spasm to the stabile influ-
ence of the anode, the cathode resting over the spinous processes of the
vertebre. The applications were continued for fifteen minutes, and the
currents employed were mild ones. Bartholow suggests, when speaking
of these cases, that the effect of these applications was probably due “ to
the influence of the currents upon the sensory nerves, thus lessening the
intensity of the reflexes.” The cures were complete in about ten days.

Personally, I have not as yet been able to test the effects of the
different forms of electrical currents upon a case of tetanus. To my
mind it would be very interesting, however, to observe the effect of static
insulation and static sparks upon the spasms which occur paroxysmally
in this disease. It is well known that this agent exerts a remarkable
effect upon contracture of muscles. Thus far, to my knowledge, it has
never been tried in tetanus.

SNEEZING, HICCOUGH, and COUGHING are spasmodic efforts of a reflex
character. Occasionally they become distressing from their persistency.
They may, in some instances, be relieved by faradization of the epigas-
trium, galvanization of the neck, and static electricity. De Watteville
reports some curative effects of galvanization of the nasal mucous
membrane in chronic cases of persistent sneezing.

ELECTRICITY IN DISORDERS AFFECTING SENSORY NERVE-TRACTS.

The discovery that different bundles of fibres which help to compose
the substance of the spinal cord serve to convey sensory impulses only,
and the later researches which have also been made respecting the paths
of conduction specially prepared for sensations of pain, touch, tempera-
ture, pressure, the muscular sense, visceral sensations, etc., have a
practical bearing upon both diagnosis and treatment.

Clinical observations go to show that, of the separate and distinct
types of sensation enumerated, some may be partially or completely
destroyed by diseased conditions without impairing the others. Thus,
for example, a patient under certain conditions may be able to exercise
his sense of touch with normal acuteness and yet be rendered absolutely
insensible to pain; again, he may be unable to discriminate between
degrees of heat or cold (provided the tests do not produce pain),
although he retains unimpaired sensory faculties in all other respects.
We are therefore forced to recognize a variety of types of anesthesia
as presenting themselves for diagnosis and treatment.
ELECTRICITY IN DISORDERS OF SENSORY NERVE-TRACTS. 725

The sensory functions may be either increased (hyperexsthesia) or
diminished (anasthesta).

Hither of these states may be of organic origin (by which we mean
that structural changes in the nervous tissues accompany them), or of
purely functional origin, in which case no structural changes can be
shown to exist. Examples of the former are found in connection with
central lesions (those of the brain or spinal cord), and with peripheral
lesions of the sensory nerves or the organs of special sense, while exam-
ples of the latter are frequently encountered in connection with hyster-
ical conditions, neurasthenia, cold, injury, imperfect capillary circulation,
rheumatism, neuralgia, and many other morbid conditions.

In all forms of sensory disturbance the removal of the cause consti-
tutes in many cases the basis of a cure, and the treatment will necessarily
be modified by the causal indications.

Many suggestions which have previously been offered respecting
electrical applications to the brain, spinal cord, and peripheral nerves
are applicable alike to sensory as well as motor disorders when due
to organic changes; hence, when this fact is borne in mind, it will be
unnecessary to repeat what has already been given.

AN4STHESIA.—In the treatment of this morbid condition nothing
can surpass in its results the daily use of the wire brush for about ten
minutes over the regions affected. This form of electrode should be
applied dry and with the secondary coil of a faradaic machine, The
stabile electrode should be well moistened and pressed closely in contact
with some distant point.

If trophic disturbances coexist with anesthesia, I have found the
“combined current” (galvano-faradaic) to be more efficacious than
faradaism alone.

Statice sparks and static insulation often act wonderfully in func-
tional nervous <liseases.

Static insulation has been previously described. It should be
administered daily for from ten to thirty minutes.

If the “indirect spark” is employed (see Fig. 176), the length of the
spark should be sufficient to be perceptible to the patient, and the dura-
tion of the application should seldom exceed five minutes. It is well to
administer a fusillade of sparks to the region of the spine after each
insulation, in case the sensory disturbances are dependent upon hysteria
or neurasthenia.

I seldom employ the “direct spark” (Fig. 177) except in the treat-
ment of organic disturbances of sensation or motion. This form of
administration should be uscd with extreme caution if the generating
machine is a powerful one.

The “umbrella” electrode furnishes an agreeable and effective
726 LECTURES ON NERVOUS DISEASES.

method of concentrating static electricity to the head of the patient.
he sensation is one which resembles that of a strong breeze circulating
through the hair.

Hemranzstugsta (whether of cerebral or spinal origin) is often
benefited by cutaneous faradization of limited portions of the area
attected,—a point first observed by Vulpian, who employed this method
with marked success.

TROPHIC DISORDERS may occasionally manifest themselves, often in
the skin, nails, hair, and muscles, when sensation is markedly affected.
One such case (suffering from locomotor ataxia) was lately placed under
my care. The fingers of both sides were almost destitute of sensibility
to pain, and tactile sensation was impaired. The nails were thickened,
loosened for half of their length, and deeply pigmented (as if stained
with iodine). The terminal phalanges were “ clubbed,” the nails being
bent almost in a semicircle. The skin was thickened and very hard
under the loosened nails. The “combined current ” (galvano-faradaic)
with a wire-brush electrode caused decided improvement within a few
weeks.

NeEvurauata (when of idiopathic origin) is more successfully treated
to-day by electricity than by any medicinal agent. Jn many instances it
is cured in a few sittings.

It is well to bear in mind, however, the fact that neuralgic pains are
very often symptomatic of causes more or less remote from the affected
nerve, and that a permanent cure is impossible in many instances as long
as that cause actively exists. Defective teeth, morbid processes in the
bones, pressure upon a nerve, organic changes in the nerve itself, toxic
diatheses, rheumatism, gout, reflex irritation from the eye, uterus, digest-
ive tract, ovaries, etc., cardiac and pulmonary disorders, and many other
morbid eonditions, hay be enumerated as among the exciting causes of
neuralgia,

Respecting the electrical treatment of neuralgic pains (per se) the
following deductions may prove of some advantage to you :—

1. If points of tenderness to pressure ( puncta dolorosa) exist along
the course of the affected nerve or its branches, it is well to subject them
to stabile galvanic applications of the anode, the cathode being placed at
a neutral point.

2. The anode should be made to cover as large an area as possible.

3. The duration of the sitting should not exceed five minutes, save
in exceptional cases. The sittings may be repeated several times a day
if necessary.

4. Asarule, it is unwise to break the current. In obstinate cases
the current may occasionally be reversed, without changing the poles, by
means of the commutator.
ELECTRICILY IN DISORDERS OF SENSORY NERVE-TRACTS. 727

5. Faradization of the nerve and the use of the wire brush upon the
skin have been recommended when galvanism proves unsuccessful in
arresting the pain. It should not be used (in my opinion) until galvan-
ism has been thoroughly applied.

6. It is well in obstinate cases to direct the applications of galvanism
to the central origin of the affected nerve, as well as to its peripheral
distribution.

1. Static electricity often produces marvelous results in neuralgia,
T have more faith in it as a cure for sciatica than in any other remedial
agent. It should be applied (by the “ spark ” method) over the affected
nerve. One sitting has, in my experience, frequently arrested severe
pain. It gives immediate relief, in most cases, to muscular rheumatism
aso, and to lumbago. Sutferers from muscular and neuralgic pains are
perhaps as frequently encountered by the physician as any class, and
static electricity should highly recommend itself to his confidence for
such cases. The expenses of the outfit, and the fact that the machine is
too large for transportation, will probably prevent its general use by the
profession ; but, until its effects upon a patient have been tried, I would
caution against expressing an unfavorable opinion, even if galvanism,
faradaism, and medicinal treatment have proved powerless to relieve the
suffering.

8. The operation of electro-puncture of a nerve for the relief of neu-
ralgia has proved of benefit in the hands of some neurologists; but it is
an operation which, if injudiciously employed, will produce electrolysis,
and serious results may follow its use.

9. The electrical treatment of various other forms of pain is similar to
that of neuralgia. The judgment of the physician should be exercised
regarding the position and size of the electrodes, the variety, strength,
and duration of the current employed, and various other minor points
suggested by the condition of the subject.

10. Visceral neuralgias (as, for example, the conditions known as
hemicrania, migraine, gastralgia, enteralgia, hepatalgia, etc.) are often
relieved by electricity, irrespective of the reflex or constitutional con-
dition which induces the morbid state. The removal of the exciting
cause, however, will greatly assist in making the cure a radical one. I
have long taught in my lectures ‘that I had yet to encounter a patient
who had suffered for years from migraine who had not some defect in
the eye or its muscles as an exciting cause. Experience leads me still
to strongly assert this as my conviction, The same cause is very
frequently manifested by paroxysms of spinal pain,—peculiarly so at two
points, viz., between the scapule, and at the junction of the last lumbar
vertebrae with the sacrum.

The currents which act best upon these cases are the galvanic and
728 LECTURES ON NERVOUS DISEASES.

static. JI have in two instances employed faradaism in gastralgia with
good results, but I regard it as inferior to galvanism or franklinism.

In treating the abdominal viscera by galvanic currents, one rheo-
phore may often be attached with advantage to a rectal electrode, and
the other to a large electrode placed over the organ to be influenced. I
do not believe that polar effects are to be particularly aimed at. In some
cases, an occasional substitution of the “combined current” (galvano-
faradaic) for galvanism makes the improvement of the patient more rapid.

Static applications to the abdomen are best made by employing
indirect sparks of about two inches in length. Long sparks are not
borne well by sensitive subjects. If patients are subjected to static
insulation only for twenty minutes daily, or to the electric spray over
the abdomen, relief is often afforded and the application is painless.
The clothing need not be removed in making ‘applications of franklinism
by either of these methods,—a point which renders the treatment par-
ticularly agreeable to ladies.

ELECTRICITY IN DISEASES OF THE CERVICAL SYMPATHETIC, THE
VASO-MOTOR SYSTEM, AND ALLIED NEUROSES.

The CERVICAL SYMPATHETIC is undoubtedly, in rare cases, the seat
of isolated morbid changes; but, as Erb-remarks, these eases “ consti-
tute pathological curiosities.” The morbid conditions which have been
detected embrace inflammation, compression, traumatism, rheumatic
conditions, ete. Such conditions may create either irritation of the
sympathetic system or paralysis of its functions, or both simultaneously.
in different parts of the body.

Irritation of the cervical sympathetic produces pallor of the face
and neck upon the affected side, with a sense of coldness in the parts.
The pupils are dilated, the temporal arteries exhibit increased tension,
the power of accommodation and the reaction of the pupil to light are
both impaired, the eyeballs protrude slightly, and the secretion of sweat
is diminished.

Paralysis of the cervical sympathetic induces the opposite con-
ditions. The skin is red and hot, the patient suffers from a sense of heat
in the skin, the pupils are contracted and exhibit normal reactions to
light and accommodation of vision; the eyeball does not protrude,
there are often headache and vertigo, the secretion of tears and sweat
is increased, and the pulsation of the carotids is excessive.

In the electrical treatment of these opposed conditions Erb recom-
mends stabile applications of the anode (with a strong current) until a
change in the pupil is observed, if the condition of irritation exists. The
same author suggests the use of the cathode with a feeble current,
frequent interruptions, and occasional reversal of the poles, if the par
ELECTRICITY IN DISEASES OF CERVICAL ‘SYMPATHETIC, ETC. 729

alytie state is present. He places the “indifferent” electrode upon
the spine. He also suggests applications of the wire brush, or labile
galvanie currents, to the skin of the face and neck.

To the views of this author I would urge the advantage of trying
the effects of static insulation. and sparks directed to the neck and face.

ANGIONEUROSES OF THE SKIN may assume one of two forms, viz.,
spasm or paralysis. They are most frequently observed in connection
with neurasthenia and in hysterical patients. The abnormal contraction
or relaxation of the vessels may cause (1) modifications in the color and
the general “ feel” and sensibility of the skin; (2) subjective sensations
of heat, tingling, formication, etc.; (3) disturbances of perspiration ;
(4) awkwardness of movement of the part (especially in the hands); and
(5) many reflex symptoms referable to the viscera.

Unnatural conditions of the vessels of the skin (spasm or paralysis)
are most frequently observed in the upper limb, less frequently in the
lower limb, and least often in the face and neck. They may be excited
by a variety of causes,—such as fatigue, excitement, menstrual disturb-
ances, malaria, exposure to cold, the effects of poisons, and direct
irritation of the skin itself.

I have seen the skin (especially of the fingers) made as white as
chalk in some cases, and in others rendered cyanotic, by spasm of the
vessels. The muscles of the papillae of the skin may participate in the
spasm and produce the so-called “ goose-flesh” appearance. Pain,
tingling, formication, partial ansesthesia, and other disturbances of the
sensory apparatus may occur as sequels to the vascular spasm.

Paralysis of the cutaneous vessels leads to directly opposite con-
ditions. The skin may be made intermittently or permanently red, and
feel unnaturally hot and extremely sensitive. Subjects so afflicted fre-
quently suffer from insomnia, headache, disturbed heart-action, excessive
perspiration, vertigo, and other visceral manifestations of irritability.

Respecting the electrical treatment of angiospasm and angioparaly-
sis, the general rule may be given that weak or moderate applications of
faradaism or galvanism to the affected part act best upon dilated vessels,
and stronger currents upon those affected with spasm.

Applications of static electricity are oftén very beneficial to nenras-
thenie and hysterical subjects. Personally, I believe this method of
treatment surpasses any other in its effects upon this class, although it
is well to alternate with galvanism and faradaism when a case proves
obstinate to treatment.

When any of the methods suggested are employed, it is well to
subject. both the vaso-motor centres and the nerve-trunks which supply
the affected regions (as well as the parts directly) to the influence of

electrical currents.
PLATE 1,

 

i )

=

 

A DIAGRAM OF THE Moror POINTS OF THE FACE, SHOWING THE POSITION OF
‘THE ELECTRODES DURING ELECTRIZATION OF SPECIAL MUSCLES AND NERVES,
‘THE ANODE IS SUPPOSED TO BE PLACED IN THE MASTOID FOSSA, AND THE
CATHODE UPON THK PART INDICATED IN THE DIAGRAM.

1, m, orbicularis palpebrarum ; 2, m. pyramidalis nasi; 3,.m. lev. lab. sup. et nasi; 4, m.
ley. lab. sup. propr.; 5, 6, m. dilator naris; 7, m. zygomatic major; 8 m. orbicularis
oris ; 9, n. branch for levator menti; 10, m. levator menti; 11, m. quadratus menti;
12, m. triangularis menti; 13, nerves, subcutaneous, of neck; 14, m. sterno-hyoid ; 14,
m. omo-hyoid ; 16, m. sterno-thyroid ; 17, n. branch for platysma: 18, m. sterno-hyoid ;
19, m. omo-hyoid ; 20, 21, nerves to pectoral muscles ; 22. m. oecipito-frontalis (ant.
belly) ; 23, m. occipito-frontalis (post. belly) ; 24, m. retrahens and attollens aurem ;
25, nerye—facial; 26, m. stylo-hyoid; 27, m. digastric; 28, m. splenius capitis; 29,
nerve—external branch of spinal accessory; 30, m. sterno-mastoid ; 31, m. sterno-
mastoid; 32, m. levator anguli scapulw; 33, nerve—phrenic ; 34, nerve—posterior
thoracic; 35, m. serratus magnus; 36, nerves of the axillary space. In this text
m. = inuscle; n. = nerve.

(731)
PLATE I.

M. external head of triceps *--

    
 

Musculo-apiral nervo *~
M. brachialis anticus

M. supivator longus
M. oxtensor carpi rad. longio:

M. extensor carpi rad. brevior-

Tnx Motor Points on THE OuTER AsPgor or sau ARM,

(732)
PLATE Ik

 

THE MOTOR POINTS ON THE INNER SIDE OF THE ARM.

1, m. internal head of triceps; 2, musculo-cutaneous nerve; 8, median nerve; 4, m.
-coraco-brachialis ; 5, ulnar nerve; 6, branch of median nerve for pronator radii
teres ; 7, musculo-cutaneous nerve ; 8, m. biceps flexor cubiti.

(733)
PLATE IY.

 

THE MoToR PoINTs ON THE EXTENSOR (POSTERIOR) ASPECT OF THE FOREARM.

1,m, supinator longus; 2, m. extensor carpi rad. longior; 3, m, extensor carpi rad.
brevior; 4, 5, m. extensor communis digitorum ; 6, m. extensor ossis. met. pol. :

 

'
m, extensor primi, internod. pol. ; 8, m. first dorsal interosseous: 9 1m. second dor-
sal interosseous ; 10, m. third dorsal interosseous; 11, m. extensor carpi ulnaris;

12, m. extensor min, digiti; 13, m. extensor secund. internod. pol. ; 14, m abduet.
min, digiti; 15, m. fourth dorsal interosseons.

(734)
PLATE. Ve

 

THE MoTor POINTS ON THE FLEXOR (ANTERIOR) ASPECT OF TITE FOREARM.

1, median nerve and branch to m. pronator radii teres; 2, m. palmaris longus ; 3, m.
flexor carpi wharis; 4, m1. flexor sublim. digit. 5.4, uInar nerve; 6, m. flex. sublim.
‘dig.; 7, volar branch of the ulnar nerve ; 8, in. palmaris brevis ; 9% m. abductor min.
‘digit. ; 10, m. flexor min. digit. ; 11, m. opponens min. digit. 5 12, 18, 1m. Inmbricales ;
‘14, m. flexor carpi radialis 5-15, in. flexor profund. digitorum ; 16, m. flexor sublim.
digitorum ; 17, m. flex. longus pollicis ; 15, median nerve; 19, m. opponens pollicis 5
20, m. abductor pollicis ; 21, m, flexor brevis pollicis; 22, m. adductor pollicis ; 23,
m. first lumbricalis.

 

(735)
PLATE VI.

aan

 

THE MoToR POINTS ON THE POSTERIOR ASPECT OF THE THIGH.

1, branch of the inferior gluteal nerve to the gluteus maximus muscle; 2, sciatic

“nerve ; 3, long head of biceps muscle; 4, short head of biceps muscle; 5, adductor
magnus muscle; 6, semi-tendinosus muscle ; 7, semi-membranosus muscle ; 8, tibial
nerve ; 9, peroneal nerve; 10, external head of gastrocnemius muscle; 11, soleus
muscle ; 12, internal head of gastrocnemius muscle.
PLATE VII.

 

THE MoTor POINTS ON THE ANTERIOR ASPECT OF THE THIGH.
1, crural nerve; 2, obturator nerve ; 3, sartorius muscle, 4, adductor longus muscle 3
5, branch of the anterior crural nerve for the quadriceps extensor muscle; 6, the
oe. muscle; 7, branch of anterior crural nerve to the vastus internus
muscle; 8, tensor vagins: femoris muscle (supplied by the supsrior gluteal nerve) ;
9, external cutaneous branch of anterior crural nerve; 10, rectus femoris muscle ;
1], 12, vastus externus muscle. *

47 (731)
PLATE VIIL

 

THE MOTOR POINTS ON THE INNER ASPECT OF THE LEG.

1, internal head of gastrocnemins muscle: 2, soleus muscle ; 3, flexor communis digi-
torum muscle ; 4, posterior tibial nerve; 5, abductor pollicis muscle.

(738)
PLATE IX,

 

THE MoTor POINTS ON THE OUTER ASPECT OF THE LEG.

1, peroneal nerve ; 2, external head of gastrocnemius muscle; 3, soleus muscle; 4, ex-
tensor communis digitorum muscle ; 6, peroneus brevis muscle ; 6, soleus muscle ;
7, tlexor longus pollicis ; 8, peroneus longus muscle ; 9, tibialis anticus muscle ; 10,
extensor longus pollicis muscle; 11, extensor brevis digitorum muscle ; 12, ab-
ductor minimi digiti muscle ; 13, deep branch of the peroneal nerve to the extensor
brevis digitorum muscle; 14, 14, 14, dorsal interossei muscles.

(739)
PLATE %

   
  
    

- et

THE NEnvous DISTRIBUTION OF TITE SKIN OF TILE Tk AD. (After Flower, but

slightly moditied., ?

J, region supplied by the svpra-orbital branch of the fifth nerve; 2. region supplier!
by the supra-trochlear branch of the fifth nerve: 4, region supplied by the infra-
frochlear branch of the fifth nerve: 4, region supplied by the mfra-orbilad branch
of the fifth nerve ; 4, region supplied by the byvecal branch of the fifth nerve: 6,
region pub ed by the mental branch of the fifth nerve; 7, region supplied by the
superficial cervical from the cervieal plexus: &, region supplied by the great
auricular from the cervical plexus; 9, region supplied by the fem poro-aater
branch of the fifth nerve: I), region supplied by the fechryaet branch of the
fifth nerve; lJ, region supplied by the «uriculofemporal branch of the fifth
nerve; 12, region supplied by the great occipital (a spinal nerve) * 1a. region: supe
plied by the small occipital from the cervical plexus; 4, region supplicd by the

supra-claviculur from the cervical] plexus.

 

 

THE CUTANEOUS NERVE SUPPLY OF TITLE POSTERIOR PORTION OF HEAD AND
NECK. (Modified from Flower.)
1, region supplied hy the great occipital nerve ; 2, region supplied by the auriculo-
temporal nerve : 5, region supplied by the small occipival nerve ; 4, region supplied
by the great auricular nerve; 5, region supplied by the third cervical nerve,

 

(740)
PLATE, XI.

 

 

A DIAGkKAM OF TIE REGIONS OF CUTANEOUS NERV DISTRIBUTION IN THT
ANTERIOR SURFACE OF THE UPPER EXTREMITY AND TRUNK. (Modified

from Flower.)

J, region supplied by the supra-clavicular nerve (branch of the cervical plexus) : 2.
region supplied by the circumflex nerve; 8, region supplied by the intercosto-
humeral nerve; 4, region supplicd by the intercostal nerve (lateral braneh); 3,
region supplied by the lesser internal cutaneous nerve (nerve of Wrisberg) ; 6,
region supplied by the musculo-spiral nerve (external cutaneous branch) ;7, region
supplied by the internal cutaneous nerve; 8, region supplied by the museulo-
cutaneous nerve ; 9, region supplied by the median nerve; 10. region supplied by
the ulnar nerve: UH, region supplied by the intercostal nerye (anterior branch).

 

(741)
PLATE #11

  

IS,

 

 

Moor CTHE REGIONS OF CUBAN KE ODS Nia DISTE te pras ON CPITIG
POSTERIOR SURV OF CTH UPR POOPIE AEPEY VND PRE NIK. CModitied
from Itower.)

 

region supplied by the second dorsa? verve sy U vegion stpplied dy the segrres
SeCupHa Merve: YO, region supplied by the efreduaiee nerve: 2h region supplied
Hy the fatercoste- hiameral nerve region supplied by the catered eulaneous
NEVE; revion supplied by the in ernul eutane ous braneh of Ue musento spirdl
herve; 2h region supplied bY the serve of Waisberg oo 25, region supplied by the
lateral branches ol the Giflercostad neryes; 26, vewion supplied by Che datcraad
eitcoreous nerves 27, region supplied by the nirese rile eltaneous WETVE LD 2B royion
supplied bw the ice brane Aol the eo Treuinal nerve {U0 reeion stepplied: ly the
radéad nerve 5 80, region sipplied by the dna ne TVes

 

 

 

   
   

  
 

 

(742)
PLATE XIlfi.

  

Wereree.,
saaervners;

    
  

m
eeweweee sg rerens

  

seer tceneygy

   

a
~

   

  

A DIAGRAM OF THE CUTANEOUS SUPPLY OF THE ANTERIOR ASPECT OF THE
LOWER EXTREMITY. (Modified from Flower.)
1, region supplied by the lateral branches of the intercostal nerves: 2. region supplied
hy the anterior branches of the intercostal nerves: 3, region supplied by the ilio-
_hypogastrie nerve: 4, region supplied by the ilio-inguinal nerve ; 5, region supplied
_by the genito-crural nerve; 6, region supplied by the middle cutaneous branch of
the anterior crural nerve; 7, region supplied by the internal cutaneous branch of
the anterior crural nerve and partly by the obturator nerve; & region supplied by
‘the external cutaneous nerve: 9, region supplied by the long saphenous branch of
the anterior crural nerve; 10, region supplied by the branches of the external
popliteal nerve ; 1], region supplied by the mnusculo-cutaneous nerve : lL region sup
plied by the terminal filaments of the musculo-cutaneous nerve ; 13. region supplied
y the external saphenous nerve ; 14, region supplied by the anterior tibial nerve.

(743)
PLATE XIV.

 

 

 

prensa emnasncrren

  

A DIAGRAM oF TITE CUTANEOUS SUPPLY OF THE POSTERIOR ASPECT OF TILE
LOWER EXTREMITIES. (Modified from Flower.) ‘
45, region supplied by the lateral branches of the intercostal nerves ; 16, region sup-
nlicd by the posterior branches of the lumbar nerves; 17, regien supplied by the
line branch of the ilio-hypogastric nerve ; 18, region supplied by the pudic nerve ;
19, region arehepied by the inferior gluteal branch of the small sciatic nerve ; 20,
region supplied by the external cutaneous nerve: 21, region supplied by the
internal cutaneous braneh of the anterior crural nerve: 22. region supplied by the
sthall and great sciatic nerves: 28, region supphed by branches from the external
popliteal nerve: 24 region supplied by the external saphenous nerve; 25, region

supplied by the posterior tibial nerve.

(144)
GLOSSARY.

AccommopaTion or Viston. The adjustment of the crystalline lens of the eye for the
clear perception of objects within a radius of twenty feet from the eye. It
(F ayy estimated, however, at about fourteen inches from the eye

ig. 39). ,

/ESTHESIOMETER. An instrument to estimate the acuteness of the tactile sense in any
given part. .

MstuEsopic. Pertaining to the appreciation and conduction of sensations of various
kinds. Centripetal.

Acrusta. A loss of taste. ;

Aarapuia. A loss of the ability to write or copy familiar characters correctly.

Axiyesia. <A loss of voluntary motion.

Aurxra. A loss of the power of reading.

AmpiyoriA. Indistinct vision from structural changes accompanying disease of the eye
or optic nerve.

Amira. A loss of the power of making appropriate gestures.

Amnesta. <A loss of memory. .

Amyepata. It literally signifies the “almond.” The term is applied to a mass of gray
matter seen aller a section made through the tail oF the caudate nucleus of
the cerebrum (N C/ in Fig. 9).

Amyorropuic. <A term which signifies defective nutrition of muscles.

Anaucesta. The abolition of sensibility to pain in any part.

Ayarturia. <A peculiar form of imperfect speech due to interference with the speech-
tract (Fig. 24). ‘

Anopk. The positive pole of a galvanic battery. ,

Axosmta, The abolition of the sense of smell in one or both nostrils.

Avuasia. <A morbid condition where speech, reading, or writing become impaired, either
from an inability to properly codrdinate the muscles, or from a defective
interpretation of Baan or visual impressions.

Apraxta. A loss of the power to recognize common objects and often to appreciate their.
ordinary uses.

Asemia. See Asymbolia.

Assocratinc TRacts. Fibres which serve to unite the various physiological centres of
each side of the brain, and also of the cord, with each other, so as to allow
of a harmony of action and the proper performance of complicated mental
and physical processes (I*ig. 6). :

AsrHenopra. An inability to use the eyes without great discomfort. It is usually
dependent upon a disturbance of equilibrium in the eye-muscles, with or
without some coexisting error of refraction.

Astiamatism. An abnormal condition of vision caused .by irregularity in the curvature
of the cornea or crystalline lens of the eye. .

Asympotra. Loss of power by a patient of signing or ‘duplicating his or her customary

: signature.

Ataxia. A morbid condition, characterized by a loss of the normal power of performing
coérdinated movements.

Aruertosis. Constant and uncontrollable movements of the fingers or toes (Fig. 47).

Basay Ganeura. Collections of nerve-cells buried within the substance of each cerebral
hemisphere near to its base. See Corpus Striatum and Optie Thalamus

(Fig. 1). ;
Basis CRURIS. Fe Crusta Cruris (Fig. 11).
Brtt's Pararysis. Unilateral facial palsy,
Berz’s Cetts. The motor cells of the cerebral cortex. They are arranged in groups of
five or six, called “ Betz's nests.’ They are found only in the so-called
“motor area.” ;
Burnp. Spot. The point in the retina where the optic nerve enters,—about two lines to
the nasal side of the macula lutea.
(745)
746 GLOSSARY.

Bounrmia. Insatiable hunger.

Bracu-Bomperc Symprom. An inability to stand without swaying or staggering when
the eyes are closed. It indicates anesthesia of the soles of the feet, and is
frequently observed in locomotor ataxia,

Buisar Symproms. <A train of symptoms referable to the tongue, lips, palate, pharynx,
and larynx, caused by a degeneration of those nuclei in the medulla (Fig.
16) which preside over movements of the respective parts. (Duchenne’s

so disease, : :

Burpacu’s CoLumy. ) The postero-external column of the La cord (Tig. 29).

CALORIMETER, An instrument for the actual estimation of heat, or the comparison of the
relative temperature of differing parts.

CarsuLar Fisres. Two distinct masses of fibres which embrace and act as a capsule to
the lenticular nucleus of the corpus striatum. They are designated, from
their relationship to this body, as the “ internal capsule” and ‘external cap-
sule” (Fig. 9). They are prolonged dorsad into fie crus and pass cephalad
into the corona radiata. :

CarpraLata. Neuralgic paroxysms in the region of the heart.

Caratersy. A morbid condition, characterized by coma and the so-called “ waxy flexi-
bility ” of the muscles.

CatuopE. The negative pole of a galvanic battery.

CreytRAL Convourions. The ascending frontal and ascending parietal gyri of the cere-
brum (Figs. 4 and 5). og es

Centre. A term commonly employed to designate some special subdivision of any collec-
tion of nerve-cells which has diversified physiological functions. It is often
used synonymously with the term “ nucleus.”

Cuerrospasm. Writer's cramp.

Curyve-Stokes Respiration. An abnormal form of respiration in which the rhythm
undergoes frequent and regular modifications.

CuoKEp oat The condition of the retina observed in connection with neuro-retinitis °

Fig. 87).

thins, i synonym for the so-called “ girdle-pain.” A sense of painful con-
striction of some part. :

Cuarke’'s Cotumn. “A column of cells in thespinal gray matter, probably associated with
the transmission of visceral sensations to the cerebellum by means of the

; direct cerebellar column (Fig. 32).

Cravate Nucrevs. A collection of cells which are structurally related to the fibres of the
column of Goll, and in which they probably end. See also Triangular
Nucleus.

ComMissuRAL Tracts. Fibres which tend to unite the cells of homologous parts of the
cerebral hemispheres, chiefly of the cerebral cortex (Vig. 6).

Contracture. A pee rigidity and shortening of a muscle. It is commonly ob-
served in connection with lesions involving the crossed pyramidal tracts
of the spinal cord.

Corowa Raprara. This term embraces all the fibres which pass from the cerebral cortex
toward the region of the crus (peduncular group). Some are structurally

- associated with the basal ganglia, while others constitute the so-called ‘ cap-
sular fibres” of the lenticular nucleus. See Capsular Fibres.

Corpus Stratum, ‘This term literally signifies the ‘striped body.” A ganglion of the
cerebrum, consisting of two nuclei (the caudate and the lenticular). It is

‘ one of the so-called “basal ganglia” of the cerebrum (Figs 1 and 9).

Correx. A term that literally signifies “rind” or “external covering.” It is applied.
therefore, to the gray matter of the convolutions of the cerebrum and
cerebellum :

Crossed Pararysis. A condition where right or left hemiplegia coexists with a paralysis
of some cranial nerve of the opposed side, Te varies in type, according to

: the cranial nerve impaired.

Crusta Croris. The anterior or motor part of the crus cerebri (Fig. 11).

Cunzarge Nuctrus. See Triangular Nuclens,

Cungus. <A part of the cortex of the occipital lobe of the cerebrum, lesions of which tend

. to cause homonymous hemianopsia. ; .

Detayep Seysarion. A peculiar retardation of the transmission of tactile pain or
temperature sensations to the seal of consciousness of such sensations within
the cerebral cortex.
GLOSSARY. 747

_Dretorra. Double vision. This may be habitual, as exists with strabismus; or transient,
as observed in many cases of heterophoria. This distinction is of great
clinical importance.

Ducnennr’s Patsy. See Bulbar Symptoms.

DyNaMOMETER. An instrument to determine the relative muscular power in the hand or
foot of the two sides.

Dyspuacia. Difficulty in swallowing. A frequent symptom of Duchenne’s disease.

Dyspya@a. Difficult respiration.

Ecrampsta. Acute attacks of epileptiform spasms.

Exscrropes. The terminal attachments to an electrical instrument, by means of which
electrical currents are applicd to a patient.

Emsouism. Plugging of a blood-vessel by a clot or foreign body which has been trans-
ported to the seat of its lodgment by means of the blood-current.

Exmerropra. The power of vision with an eye whose axes are normal (Fig. 38).

EncerHatorraacia. Cerebral hemorrhage. Cerebral apoplexy.

EprenpyMa, The gray lining of the ventricular cavitics of the brain.

Ksopporta. <A tendency on the part of the visual lines to deviate inward.

Exopuoria. A tendency of the visual lines to deviate outward.

FarapaisM. The employment of the interrupted current generated by the magnetizing
and demagnetizing of a soft-iron core within a helix.

Fascrcutis TEretes. See Round Bundle.

Fipripiary Twitcuines. Slight muscular contractions of a fibrillary character. These
may be cieeeyal after tapping or faradizing the skin, blowing on the
skin, or exposure of the skin after disrobing. They are most frequently
met with as a symptom of progressive muscular atrophy.

Fiutuet. See Lemniscus Tract.

Fissure. A prominent and distinct demarcation between component parts of the brain,
the spinal cord, etc. See Sulcus.

Foor-cronus. A morbid reflex phenomenon observed at the ankle, in connection with
spinal diseases.

Formication. <A feeling ‘as if ants were creeping over a part.” One of the many sub-
jective phenomena caused by organic and functional disease of the nerve-
centres.

FRraygnism. The employment of clectricity generated from glass plates by means of
friction. The so-called “induction machines” are now generally employed
for medical purposes.

Frieprercn’s Disease. The so-called “hereditary ataxia” or “ generic ataxia.”

Gatvanism. The employment of a current generated by means of a chemical action.

GaLvaxometer. An instrument for measuring the current-strength of a galvanic battery.

GANGLIoN. Any isolated collection of nerve-cells; usually possessing considerable mag-
nitude and distinctly marked boundaries.

Generic ATAxra. Sce Friedreich's Disease.

GIRDLE-PAIN. See Cincture-feeling.

Gureper’s Memusers. Subdivisions of the lenticular nucleus. Sce Figs. 6 and 9.

Guossorrecta. Paralysis of the hypoglossal nerve, causing a loss of control of the tongue.

Gotu's Conumy. The postero-median column of the spinal cord (Fig. 29).

GrapHospasm. Writer's cramp. ; Le

Gupier’s Linz. An imaginary line connecting the points of apparent origin of the

\ trigeminal nerve-roots (Fig. 26).

Gyrus. A synonym for “convolution.”

H#MATOMYELIA. Spinal apoplexy.

Hamatorruacuis. Meningeal spinal apoplexy. .

HeMrANastuEsta. Impairment of tactile sensibility in one lateral half of the body.

HemrayorsrA. Blindness of one lateral half of the retina. Three varieties are to be
clinically recognized,—the homonymous, the bi-nasal, and the bi-temporal.

Hemrcnorea. Convulsive twitchings of the right or lett half of the body. |

Hemioric Purrpnary Rertex. A response of one lateral half of the pupil only to a
concentrated pencil of light. It is advisable to throw the beam upon the
iris at an obtuse angle. :

HEMIpaRaPLEGtA. Paralysis of one lower limb. ;

Hemipiecra. Paralysis of the lateral half of the body,—right or left arm and leg.

Herreropuorta. A disturbance of the normal state of equilibrium in the muscles which
move the eyes. :
748° GLOSSARY.

HypromyettaA. Cavities within the substance of the spinal cord.

Hypruria. An abnormal secretion of sugar by the kidneys.

Uyprrasrigesis. An abnormal acuteness of sensibility in a part. .

HyvercrusiA. Abnormal sensitiveness of the taste-apparatus. Often accompanied by
parageusia.

Hyrerxinesis, Spasimodic disease.

Hyvermerroria. <A defect in vision caused by an-abnormal shallowness of the eye
(Fig. 38). Its existence is commonly masked by abnormal ciliary action.

t is revealed after the full effects of atropine.

Hyprrosmia. Abnormal acuteness of smell,—often associated with parosmia.

Hyrrerrnonia. A tendency of the visual lines to assume different vertical planes.

HypocnossaL Tracr. A bundle of fibres which serves to connect the cortical centre for
the tongue with the hypoglossal nucleus of the medulla oblongata.

InrerNsL CarsuLe. One of the paths of those peduncular fibres that are probably
unassociated structurally with the valle of the basal ganglia of the cerebrum.
See Capsular Fibres. These fibres constitute an internal capsule, as it were,
to the lenticular nucleus (Fig. 9).

Inrer-ontvAry Tracr. <A part of the lemniscus tract, lying between the olivary bodies
of the medulla oblongata (Fig. 27). It probably constitutes a part of the
so-called ‘ fillet.”

Kringsopic. Pertaining to the power of motility. Centrifugal.

KussmMauL-Lanpry’s Paratysis. The so-called ‘acute ascending spinal paralysis.”

Lemyiscus Tracr. A term used synonymously with the so-called “ fillet.” “A bundle
of fibres in the pons and medulla, which is probably associated with codér-
dination of movement, and possibly also with our dependence upon the
visual sense as an aid to qoehlinanen (Figs. 12, 36, 37).

Macrorsta. An apparent magnifying of visual images by the eye,—due to paresis of the

external rectus oe Objects appear abnormally large to the patient.

Macura Lutra, The retinal area for distinct visual perceptions.

Maxum Corunniut. Neuralgia of the sciatic nerve. Sciatica.

Masropynia. Neuralgia of the breast.

Mrcatopsta. An apparent exaggeration of the size of objects when viewed by the
ayes to paresis of the external rectus.

Mrcrorsia. An apparent diminution of the size of familiar objects when viewed by the
eye,—due to paresis of the internal rectus. ;

Mreraine. Hemicrania. Sick-hcadache.

Minuiampkre. The unit of current-strength employed in medical treatment of disease
by galvanism.

MILLIAMPERE-METER. A medical galvanometer for estimating the current-strength
during galvanic applications.

Moaterarata, Writer's cramp.

Monoanestuesta. Impairment of tactile sensibility in some distinctly localized part.

Monorarastunsr®. Subjective sensory phenomena confined to some special part,—such
as tingling, numbness, formication, etc.

Monopircia. Paralysis of some special group of muscles not, as a rule, supplied by one
nerve. It differs from paralysis of a spinal nerve-trank in the latter respect.

Monospasm. Uncontrollable siento movements of some special group of muscles not,
as a rule, supplied by one nerve.

Motor Tracts. Those fibres which are functionally associated with voluntary motion.
They arise from the cells of the “motor area” of the cortex of each hemi-
sphere of the cerebrum, The “pyramidal tracts” are the paths for these
fibres within the spinal cord. The motor. fibres traverse, in order to reach
the spinal cord, the following parts successively: The corona radiata, the
internal capsule, the crusta cruris, the pons, and the anterior pyramids of
the medulla oblongata (Fig. 12).

Muscunar Sense. The power of analyzing any muscular effort being exerted by the
patient. The relative position of the limbs is also thus estimated, the aid of
the visual sense being excluded.

Myortiasis. Preternatural dilatation of the pupil.

Myovia. A defect in vision due to an increase of the antero-posterior axis of the eye over
the normal standard (Fig. 38).

Myosts. Preternatural contraction of the pupil.

Myoronta Concenita. See Thomsen's Disease.
GLOSSARY. 749

Myxe@pema. A morbid state, characterized by a swelling and distortion of the outlines
; of the features, from a deposit of mucin beneath the skim.

Necrotic Sorreninc. Death of a part from a sudden arrest of its blood-supply.

Nevrran Pore. The pole whose effects are not being observed during a galvanic applica-
tion by the polar method.

Nucter or Sriniinc. The so-called “red nuclei” situated in the tegmentum cruris.
See Red Nucles (Fig. 11).

Nucteus. Any collection of nerve-cells, possessing some special physiological function ;
but often without distinct limits of demarcation from neighboring cells.

Nystacuus. Oscillatory movements of the eyeballs. :

(EpemaA. Transudation of the sero-albuminous elements of the blood, without a rupture
of the vessels.

OPHTHALMOPLEGIA. Paralysis of the muscles which move the eyeball, causing strabismus
of varying types.

Optic Toatamus. ‘This term literally signifies the “ bed” of the optic fibres. It is one
of the “basal ganglia” of each hemisphere of the cerebrum (Fig. 1).

OxruorHorta. The normal state of the equilibrium in muscles which move the eyes. .

ParaGeusia. Abnormal subjective symptoms referable to taste. This condition is usually
observed in hysterical and insane subjects. These sensations are apt to be
nauseous and perverse.

PaRapHasia. The substitution of wrong words in conversation; an incorrect use of
numerals, etc.

ParapLecia. Paralysis of the lower half of the body,—both legs and possibly the pelvic
organs.

PaRgsis. Tneamiplete or partial paralysis.

Parkinson's Disease. Shaking palsy. Paralysis agitans.

Parosmia. Unpleasant subjective sensations of smell, or a perversion of the apprecia-
tion of the odors commonly encountered. This condition is usually ob-
served in hysteria and insanity; and also during an epileptic aura, or from
organic lesions of the olfactory nerve or brain.

PepuncLe. A term commonly applied by neurologists to bundles of fibres which con-
nect the hemispheres of the cerebrum and cerebellum with adjacent parts,—
as, for example, the cerebral peduncles (crura), and the three pair of cere-
bellar peduncles.

Perimeter. An instrument for the determination and registration of the visual ficld
of a patient. ;

PizsMETER. An instrument for the estimation of the “ pressure-sense” in any given

art. :

PoLar ied, The form of application of galvanism made with special reference to
the determination of the individual effects of the postitive or negative
vole.

PoLaR euenan. The effect of the closure or opening of the galyanic current when

: either pole is applied to a nerve or muscle. In health, the reactions so ob-
tained follow a recognized sequence, according as different degrees of current-
strength are employed.

PoLioMvELItIs ANTERIOR. Inflammation of the cells of the anterior horns of the spinal
gray matter. The so-called “infantile paralysis.”

Potyprpsta. Insatiable thirst. ;

Potyneuritis. Disseminated neuritis. Multiple neuritis.

PotypHacia. Voracity. Excessive hunger. . |

Posterior Lowarrupinat Buwypie. A bundle of fibres supposed by Spitzka to assist in
bringing into harmony the corpora quadrigemina, the nuclei of: the fourth
and sixth nerves, and those which govern muscles of the neck (Fig. 11).

PosTBRO-EXTERNAL Conumn. See Goll's Column,

Postrro-MEpIAN Conumn. A term applied by Gowers to the column of Burdach, See
Burdach’'s Column. :
Post-paraLytic Rierprry. A state of contracture which often develops in muscles after

an attack of paralysis. ‘

Prespyorra. Failure of the power of accommodation due to age. .

Prosection Systems. A classification of the various bundles of fibres which serve to
unite component parts of the nervous system.

Prosopanera. Facial neuralgia. :

Prosopopysmorpaia, Progressive facial hemiatrophy.
750 GLOSSARY.

PsyenicaL Brinpness. An inability to properly interpret visual perceptions, due to a
lesion of the cortex of the occipital lobes of the cerebrum.

Prosts. Inability to prevent a falling of the upper lid over the eyeball. Paralysis of the
levator palpebree superioris muscle.

Punvinar. The posterior tubercle of the optic thalamus. It is believed to be functionally
associated with the optic fibres.

Punera Dotorosa, Points of tenderness clinically observed along the course of nerve-
trunks affected with neuralgia, They were first described by Valleix.

Purinnary Reriex. The contraction of the pupil caused by an excess of light entering
theeye. It is to be idnguibial from the contraction of the pupil observed
when near objects are forused upon the retina.

Porkinun'’s Cents. A form of cell peculiar to the cerebellar cortex.

PyramipaL Tracts. Fibres which are so called because they pass through and compose
the anterior pyramids of the medulla oblongata. They are probably func-
tionally associated exclusively with motor impulses (Hig. 29).

Quintus Tracr. The ascending root of the trigerinus nerve (Fig. 11).

Ratway Paratysis. Spinal concussion. Erichsen’s ‘railway spinal affection.”

Rapuania. Ergot poisoning.

Reacrion or Decunuration. Abnormal electrical formule of the so-called “ muscular
reactions to galvanic currents.” This is also associated with an impairment

/ or a total loss of faradaic excitability of nerve and muscle.

Rep Nucrer. ‘I'wo collections of cells in the “ tegmentum cruris,” which are structurally
associated with the superior cerebellar peduncles (Fig. 11).

AEFLEX Action. A sensory impression transforined into a motor impulse.

Resprrarory Bunpue. See Round Bundle.

Resrirorm Bopy. The inferior peduncle of the cerebellum. The so-called “ processus e
cerebello ad medullam.”

Rertoutar Ganeuion. A term applied by Spitzka to the gray matter of the “ formatio
reticularis” of the pons and medulla oblongata (Fig. 27).

RurorHores. The cords of an electrical battery which are employed to connect the poles
with the electrodes during an electrical application. / .

Ropertson’s Purr. A failure of the pupil to react to light without any perce tible im-
pairment of its normal reaction during the accommodation of vision for

, _ near objects. ;

Rotanpo's Tissure. The fissure which separates the frontal lobe from the parietal lobe
of the cerebrum (Fig. 4).

Round Bunpur. The so-called “respiratory bundle” of Krause and the “trineural
bundle” of Spitzka. A bundle of fibres within the medulla probably asso-
ciated with ninth, tenth, and eleventh nerves. / :

Sommerine’s YeELLow Spor. The point where most distinct vision is afforded by the
retina, situated about two lines to the outer side of the entrance of the optic
nerve.

Saurarory Spasms. A dancing or hopping of the body, caused by uncontrollable spasms
of the muscles of the lower limbs, back, neck, or upper limbs.

Scierosis. A morbid condition dependent upon an increase in the connective-tissue
elements of an organ or other structures. /

Sprecco Tract. A bundle of fibres which serves to join the cortical coordinating centre
of speech (Broca’s centre) with those nuclei of the medulla oblongata that

reside over the various movements associated with articulate speech (Fig.
4).

SPIDER-CELLS . Derrers. A form of cell which belong to the connective-tissue forma-
tion. (Neuroglia.)

SpinaL Seament. A disk of the cord, with a pair of the spinal nerves attached to it,—
one on either side (ig. 30).

Status Erizzrricus, A state characterized by continued epileptic convulsions with
scarcely perceptible intermissions,

Srrazismus. A condition of abnormal deviation of the visual axes, resulting in habitual
diplopia, of which the patient may often be unconscious.

Supsectivs Symproms. Any stipe nervous phenomenon of which the patient is him-
self conscious.

SuBEPENDYMAL., Situated beneath the ependyma,—the lining of the ventricles.

Suucus, <A line of demarcation between convolutions of the cerebral cortex.. Less deep
and more subject to variations than the so-called cerebral “ fissures.”
GLOSSARY. 751

Syivian Fissunn. The fissure containing the middle cerebral artery and separating the
parietal from the temporal lobes of the cerebrum (Fig. 4).

SYRINGOMYELIA, Cavities within the substance of the spinal cord.

Tases Dorsatis. Locomotor ataxia. Posterior spinal sclerosis.

TrementuM Cruris. The posterior or sensory part of the crus cerebri (Fig. 11).

TeraNorD PARAPLEGIA. A type of paraplegia associated with a peculiar rigidity of the
muscles and exaggeration of the spinal reflexes.

Trranus Nronatorum. Infantile tetanus, following umbilical irritation, fecal stasis, puer-
peral infection, etc.

Trrany. Paroxysmal tonic muscular spasms. They may be artificially induced by
pressure on a nerve-trunk or a main artery. (Trousseau’s test.)

Tuomsen’s Disease. Primary spinal muscular spasm. Attempts at voluntary move-
ments are suddenly hindered or interrupted. A hereditary affection.

THromposis. Occlusion of a blood-vessel by a coagulum formed at the seat of occlusion.

Trce-convutsir. Diffuse clonic facial spasm.

Trc-pouLouREUX. Neuralgia of the facial nerve.

TrranguLar Nucieus. .A collection of cells which are structurally related to the fibres
of Burdach’s columns, and in which they prabaltly end. This nucleus

together with the clavate nucleus) probably gives origin to some of the
bres of the fillet tract (Fig. 12).

TRINEURAL BunpLE. <A term applied to the round bundle of the medulla by Spitzka,
See Round Bundle.

Trocunear. Relating to a pulley. The superior oblique muscle of the eye is so called
because it works through a sullen:

Turck’s Conumn. The so-called “direct pyramidal column” of the spinal cord (Fig. 29).

Wii-tracr. A term employed by Spiel as synonymous with the pyramidal tracts.
See Pyramidal Tracts, and Fig. 12.

Worp-BLiInDyEss. A loss of ability to properly interpret ordinary sight-perceptions,—
chiefly the meaning of printed and written characters. It must not be con-
founded with actual blindness.

Worp-pearvess. A loss of ability to properly interpret ordinary sound-perceptions, such
as the meaning of spoken language, etc. It must not be confounded with
deafness, where sounds are not perceived on account of some defect in the
apparatus of audition.
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INDEX.

Abdominal reflex, 96
Abolition of reflexes, 352
Acute ascending spinal paralysis, 442-444
diagnosis of, 443
etiology of, 442
morbid anatomy of, 442
prognosis of, 444
symptoms of, 442, 443
treatment of, d44
Adams’ frictional machine, 649
-Esthesiometers, 200, 201
4Esthesodic system of spinal cord, 91
Age of patients, its clinical relations, 111
Ages, relative, nervous diseases common
to, 111
Ageusia, 210
Agglomerate Leclanché cell, 623
Agraphia, 64, 234, 236
Albuminuria, from medullary lesion, 78
Alcoholic poisoning, 572-578
Alcoholism, acute, 372, 573
chronic, 574-576
prognosis of, 576, 577
symptoms of, 573, 576
treatment of, 577, 578
Alexia, 234
Amaurosis, 208
Amblyopia, 208
Amimia, 234
Ampére, 618
Amyotrophic lateral sclerosis, 376-379
diagnosis of, 378
deformity of, 377
etiology of, 376
morbid anatomy of, 376
prognosis of, 379
stages of, 377, 378
symptoms of, 377, 378
table of, 422
treatment of, 379
Anemia, cerebral, electricity in, 714, 715
Anesthesia, 202, 203
alcoholic, 575
diagnostic importance of, 203
electricity in, 725
from lead, 569
Anarthria, 76 ‘
Anelectrotonic action of electricity, 687
Angioneuroses of the skin, 729
Ane later, tests for, 173
Anode, 608
effect of, 638
Anosmia, 79, 208

 

Anterior spinal sclerosis, 357
Ape-hand, 381
Aphasia, 233-239
amnesic, 60, 63
ataxic, 16, 60, 61
clinical deductions respecting, 66-68
coexisting with hemianopsia, 82
diagram of, 67
differential diagnosis of, 66, 238, 23
etiology of, 66, 233, 23
from lesions of internal capsule, 30
its clinical significance, 60-67
morbid anatomy of, 66, 233, 234
motor, 63, 233, 234
prognosis of, 239
symptoms of, 66, 234-236
treatment of, 239
Apoplectic coma, 262, 263
foci, 260
stroke, 262
Apoplexy (see cerebral hemorrhage)
Application of static electricity, methods
of, 665-675
Apraxia, 234
Aqueduct of Sylvius, 31
Arachnitis, 293
Architecture of brain and spinal cord, dia-
grammatic summary of, 97-103
Arcus senilis, 121
Argyll Robertson’s pupil, 93, 400, 401
Armstrong’s frictional machine, 650
Arsenical paralysis, 571, 572
Arteritis obliterans, 77
Asthenopia, 130, 131, 528
Asthma, spasmodic, electricity in, 723
Astigmatism, 129, 130
Asymbolia, 234 ~
Ataxia, cerebellar, 404
cerebral, 81, 332, 404
from brain-lesions, 276
eneric, 591
ereditary, 591
hysterical, 404
of spinal origin, 93
spinal, 40+
Atheroma, 221, 222, 223
etiology of, 222
morbid anatomy of, 221
. ~ symptoms of, 222
Athetosis, 161
symptoms of, table of, 498
Atrophic spinal paralysis, 365
Atrophy of brain, 335
( 763 )
764

isease, 352
of optic nerve in locomotor ataxia, 401
Atropia in eye-examinations, necessity of,
146

soeen hy of muscles, a symptom of spinal

Attachments to a complete battery, 627-639
Attitude, a guide in diagnosis, 162-167
caused by cerebellar disease, 76
Auditory tracts, 42
of brain, 30
Aure of Pusey: 476
of petit mal, 478

Bailey's fluid rheostat, 632
Basedow's disease, 598
Battery, care of, 645, 646
choice of, 639, 640
complete attachments to, 627, 639
desirable points in, 639, 640
fluid, renewal of, 645
permanent, 643, 645
Battery current (see galvanic current)
Beard and Rockwell’s method, 690
Bed-sores, after cerebral hemorrhage, 277
Bell's palsy, 123
paralysis, 85, 152
Benedict's method, 690
Bladder and rectum, affections of, in loco-
motor ataxia, 400, 401
Bladder, paresis of, 403
Blepharospasm, electricity in, 723
Boat-shaped abdomen, 307
Boulimia, 509
Boze's frictional machine, 648
Brachialgia, 508
Brach-Romberg symptom, 403
Brain, abscess of (see cerebral abscess)
a composite organ, 2
architecture of, diagram of, 34
atrophy of (see cerebral atrophy)
base of, diagram of, 74
cells of, 6-8
congenital defects of, 217-219
diagram of transverse antero-posterior
section of, 24
embolism of, 229-233
fatty tumors of, 340
fibrous tumors of, 340
fluxionary, hyperemia of, 241
general physiology of, 2-10
hydatids of, 340
hyperemia of, 239-249
hypertrophy of (see cerebral hyper-
trophy)
induration of, 329, 330
inflammatory diseases of, 218
injuries of, effects of, 2, 3
lesions of, effects of, diagram of, 255
oe of, general symptomatology of,
motor tracts of, diagram of, 258
osseous tumors of, 340

 

INDEX

Brain, parasitic tumors of, 340, 341
pearl-tumors of, 340
sand-tumors of, 340
sclerosis of (see cerebral sclerosis)
sensory tracts of, diagram of, 259
softening of (see cerebral softening)
structural diseases of, 218
thrombosis of vessels of, 223-225
tumors of, 218 (see also cerebral tumors)
etiology of, 341
vascular tumors of, 340.
vessels of, diseased conditions of, 217
Breeze, static, 670-672
Broca’s centre, 60
of speech, 15, 16
Bromism, 579-581
symptoms of, 580, 581.
treatment of, 581
Bulbar paralysis, 378
from lesions of the internal capsule, 30
Bulbar symptoms, with cerebellar disease,
87,

Bunsen’s cell, 627

Cabinet battery, advantages of, 641
description of, 641
Cachexia, 120, 121
from lead, 568
Cachexic pachydermique, 601
Calorimeter, differential, thermo-electric,
632, 633
Cancer of brain, 339
Capsule, external, fibres of, 28
lesions of, 72, .73
of cerebrum, 31
internal, 67 (see also internal capsule)
caudo-lenticular portion of, 29
effects of brain lesions of, 30
fibres of, 28
knee of, 29
lesions of, 73
of brain, subdivisions of, 29, 30
of cerebrum, course of, 30
‘ thalamo-lenticular portion of, 29
Carcinomata of brain, 339
Cardialgia, 508
Care of a battery, 645, 646
of an induction machine, 661-665
Case-book, sample page of, 116
Case, crowbar, 2
Catalepsy, 514, 515
facial expression of, 155, 156
Catalytic action of electrical currents, 688,
689.
Catelectrotonic action of electricity, 686
Cathode, 608
effect of, 638
Cautery battery, 608, 698
Cell of cerebral cortex, diagram of, 7
Cells of brain, 6-8
Central galvanization, 691
Central myelitis, 407-409
INDEX.

Central myelitis, diagnosis of, 408
etiology of, 407
morbid anatomy of, 407
prognosis of, 408
symptoms of, 407, 408
treatment of, 408
Centres of optic thalamus, 24-26
Centres of speech, 66-68
Cephalgia, 508
Cerebellar cortex, 39
disease, gait of, 165
‘hemorrhage, 76
nuclei, 39
Cerebellum, architecture of, 37
architecture of, diagram of, 38
diagrammatic summary of, 99
effects of lesions of, 39-41, 76, 77
fibres of, 99
functions of, 16, 39-41
inferior peduncle of, 37
its control over equilibrium, 35
middle crura of, symptoms due to, 77
middle peduncles of, 34, 37
nerves connected with, 39
peduncles of, 37
superior peduncle of, 31, 32, 38
Cerebral abscess, diagnostic symptoms of,
table of, 328, 329
differential diagnosis of, 326-329
eels of, 327
morbid anatomy of, 326, 327
prognosis of, 329
symptoms of, 327, 345
treatment of, 329
varieties of, 326
affections, electricity in, 712-716
anemia, differential diagnosis of, 252,
258
electricity in, 714, 715
etiology of, 250, 251
iar anatomy of, 249, 250
prognosis of, 253
symptoms of, 251, 252, 345
treatment of, 253, 254
apoplexy (see cerebral hemorrhage)
~ “symptoms of, 345
table of, 480
architecture, diagram of, 5
methods of study of, 11, 12
ataxia, 276, 404
atrophy, 335
differential diagnosis of, 336
etiology of, 335, 336
ra aoe. of, 335
prognosis of, 336
symptoms of, 336
treatment of, 336
varieties of, 335, 336
automatism, as shown. in the frog,

4,5
congestion, 241
symptoms of, table of, 480

 

765

Cerebral — destructive lesions of, effects
of, 49
functions of, 8, 9
irritative lesions of, effects of, 49
depression, 243, 244
diseases, advent of, 345
convulsions in, 345
coma in, 345
cranial pain in, 345
defects in speech in, 345
disturbance of special senses in, 345
electro-contractility in, 345
impairment of intellect in, 345
motor paralysis in, 345
muscular contracture in, 345
sensory paralysis in, 345
summary of, symptoms of, 345
vee of, diagnostic value of,
table of, 345
tremor in, 345
embolism, 227, 229-233
differential diagnosis of, 232, 233
etiology of, 230, 231
arent anatomy of, 229, 230
prognosis of, 233
symptoms of, 231, 232, 345
treatment of, 233
fluxion, 241
lioma, illustration of, 339
ematoma, (see pachymeningitis)
hemiplegia, 285, 286
hemispheres, 97, 98, 183-185
hemorrhage, 254
differential diagnosis of, 278, 279
etiology of, 260, 261
morbid anatomy of, 254-260
symptoms of, 261-279
treatment of, 279-281
hyperemia, 239-249
differential diagnosis of, 246
electricity in, 713, 714
etiology of, 240-243
morbid anatomy of, 240
symptoms of, 243-245, 345
treatment of, 246-249, 713
varieties of, 239-241
irritation, 243, 244, 306, 307
localization, views respecting it, 2
meningeal hemorrhage, 282
Meningitis, acute, 29:
differential diagnosis of, 296
diffuse variety of, 293
etiology of, 294
morbid anatomy of, 293
prognosis of, 297
symptoms of, 204, 345
synonyms for, 293
treatment of, 297, 298
sclerosis, 329
differential diagnosis of, 333, 334
etiology of, 330
illustration of, 332
766

Cerebral sclerosis, morbid anatomy of, 329,
330
prognosis of, 334
symptoms of, 330, 331, 345
treatment of, 334, 335
varieties of, 329, 330
softening, 317
diagnostic symptoms of, table of,
328, 329
differential diagnosis of, 322-324
etiology of, 318
morbid anatomy of, 317
prognosis of, 325
symptoms of, 319, 345
treatment of, 324-326
varieties of, 317, 318
thermometry, 211, 212
study of, 633
a 223-225 j ee
capillary variety, etiology of, 22
agra cent of 228
symptoms of, 228, 229
differential diagnosis of, 226, 227
table of, 227
etiology of, 223
morbid anatomy of, 223
prognosis of, 228
symptoms of, 223-225, 345
treatment of, 228
tumors, 218, 337
diagnostic symptoms of, table of,
328, 329
differential diagnosis of, 343
from cerebral softening, 323,
3 324
etiology of, 341 ‘
morbid anatomy of, 338, 339
prognosis of, 343
symptoms of, 341, 342, 345
treatment of, 343, 344
varieties of, 218, 337-339
Cerebro-spinal axis, fibres of, diagram of, 34
Cerebro-spinal sclerosis, symptoms of, table
. of, 498
Cerebrum, capsular fibres of, 28, 98
* caudate nucleus of, 20
circulation of, diagram of, 242
convolutions of, diagram of, 12
corpus striatum of, 16, 20
cortex of, 13, 14 :
destructive lesions of, 285
irritative lesions of, 285
cortical areas of, diagram of, 14
corlical centres of, 11
diagram of, 10
cortical lesions of, 69-71
symptoms of, 266, 267
diagram of transverse antero-posterior
section of, 24
effects of cortical lesions of, 49, 50
effects of removal of, 4,5
fibres of, 17-19

 

INDEX.

Cerebrum, fissures of, 13
ganglia at base of, 20
geniculate bodies of, 20 he
inflammation of (see’ encephalitis)
internal capsule of, diagram of, 265, 268
lenticular nucleus of, 20
lesions at base’ of, 82
lobes of, 13
motor centres of, diagram of, 54
motor centres of (Horsley), 49-51
muscular area of, 14
non-cortical lesions of, 72
symptoms of, 267, 268
obscure lesions of, tests used in diag-
nosis of, 183-185
optic thalamus of, 16, 20
sight area of, in occipital lobe, 15
speech area of, 15, 16
temporal cortex of, its relation to
hearing, 15 "
Cervical paraplegia, 177
sympathetic, diseases of, electricity in,
728, 729
irritation of, 728
paralysis of, 728
Charcot’s disease, 401, 402
illustrations of, 399, 402
Charging of a static machine, 664
Cheirospasm, 436
Childhood, nervous diseases common to, 111
Choice of a battery and electrical appa-
ratus, 639-645 ~
Choked disk, 81, 208
diagram of, 322
in cerebral tumors, 342
Cholesteatomata, 340
Chorea, 494-506
complications of, 497
diagnosis of, 497
~ from cerebral sclerosis, 333
etiology of, 494, 495
facial expression of, 155
alvanism in 722
its dependence upon anomalies of the
visual apparatus, 501-505
morbid anatomy of, 495
pe eels symptoms of, table of,
8

prognosis of, 497-500

static electricity in, 722

symptoms of, 495, 496

table of, 498

treatment of, 500-506
Chronic cerebral meningitis, 299

myelitis, diagnosis of, 405
Cilio-spinal centre, 415
Cincture-feeling, 91, 93, 408
Claustrum, 28
Claw-hand, 381
Clinical history of patients, 108-116
Column, direct cerebellar, 92

of spinal cord, 37, 41
INDEX.

Columns of Burdach, 88, 91
of Goll, 88, 91
of Turck, 88
vesicular, of Clarke, 94
Coma, alcoholic, 278, 279
apoplectic, 278 :
causes of, differential diagnosis of, table
of, 480
differential diagnosis of, 278, 279
from cerebral embolism, 278
from chloral, 279
from opium, 279
in cerebral lesions, 72
. uremic, 278
Combined current, 686
Commutator, 636 ,
Complete battery, attachments to, 627-639
Conducting tracts of spinal cord, 87, 92
Congenital muscular spasm, 440-442
Conjugate deviation of eyes and head from
cerebral hemorrhage, 274, 275
Consciousness, in connection with cortical
lesions, 6Y
Constant current (see galvanic current)
Contracture, asymptom of spinal disease, 96
of muscles, 276, 277, 345, 352
from spinal disease, 94, 96
post-paralytic, 166, 167
Convulsions, alcoholic, 575
of cortical origin, 70
Convulsive tremor, symptoms of, table of,
498
Coérdination, tests for derangements of,
179-181
Corning’s method, 690
Corpora quadrigemina, effects of lesions of,
33

their relations to the tegmentum cruris,
33

Corpus striatum, 16, 20
fibres of, diagram of, 21
functions of, 22
two nuclei of, 20
Cortex of cerebrum, diagram of areas of, 14
functions of, 8, 9
Cortical area, of hearing, 15, 16
of speech, 15, 16
areas, functions of, 13-16
centres of cerebrum, 11
paralysis, 49
spasm, 49 :
Coughing, electricity in, 724
Coulumb, 617
Cranial pain, 69
in cerebral lesions, 72
' Cremasteric reflex, 96
Cretinism, 156
Crossed facial paralysis, 74, 75
olfactory paralysis, 80
paralysis, of facial nerve, 85
of motor oculi nerve, 82
of trigeminus nerve, 84

 

767

Crossed paralysis, with involvement of optic
nerve, 80, 81
pyramidal fibres, distribution of, dia-
gram of, 358
trigeminal paralysis, 75
Cross-eye, its clinical importance contrasted
with insufliciency, 467, 468
its relation to refractive errors, 453
Crowbar case, 2
Crus cerebri, 31
diagram of a cross-section of, 32
its relation to third cranial nerve, 31
lesions of, 73, 74
speech tract in, 67
Crusta cruris, 31
Cuneus, effects of lesions of, 70, 71
lesions of, 81
Current-selector, 634, 636
Cutaneous vessels, paralysis of, 729
Cyclocephalous deformity, 219
Cysts of brain, 339

Daniell’s cell, 625
Deflection of head and eyes in cerebellar
disease, 77
Delayed sensation, 91, 206, 398
Delirium tremens, 572
Dementia, paralytic, 152
Dental irritation in epilepsy, 464
Detection of buried metal, 196
Diabetes, from medullary lesion, 78
Diagnostic key-board, 12
Diatheses, 112, 113, 119, 120
gouty, 119
lymphatic, 120
nervous, 119
strumous, 119
Differential, calorimeter,
632, 633 ,
Diplopia,.a clinical evidence of strabismus,
461

thermo-electric,

Direct cerebellar tracts, 42
spark, 667, 668
Duchenne’s disease, 78, 85, 86, 151, 152, 378.
electricity in, 716
facial expression of, 384, 385
Dura mater, inflammation of (see pachy-
meningitis) ed —
Duration of symptoms, clinical significance
of, 110
Dynamograph, 178
Dysphagia, 86
Dysphysia, 78

Ear, a guide in diagnosis, 154, 155
Electric currents, varieties of, 608-613
Electrical apparatus, choice of, 639-645
Electrical bath, 691, 692

currents, therapeutical action of, 655,

656
reactions of muscles, 186-189
tests of the skin, 198, 199
768

Electrical tests, table of record of 191
units, table of, 617
Electricity, in anesthesia, 725
in cerebral affections, 712-716
in diseases of the cervical sympathetic,
the yaso-motor system, and allied
neuroses, 728, 729
in disorders affecting sensory nerve-
tracts, 724-728
in facial spasm, 722, 723
in hemianesthesia, 726
in inflammatory diseases of the cord,
719
in neuralgia, 726, 727
in nystagmus, 723
in paralysis, 719, 720
in paresis, 719, 720
in sneezing, coughing, and hiccough,
724

in spasmodic affections, 720

in spasmodic asthma, 723

in spinal affections, 717

in tetanus, 724

in torticollis, 723

in trophic disorders, 726

in wry-neck, 723
Electrization of the spinal cord, 717-719
Electrodes, 636-639 .

flat, 637

placing of, 680

pressure on, 681

saturation of, 680, 681

size of, measurement of, 679

small tip, 637

poner: reasons for removal of sponges,

wire brush, 637
Electro-diagnosis, of aural diseases, 196, 197
menacal principles of, 185-187
Electrolysis, 608, 693-€97
aes of positive and negative pole in,
general rules for, 696, 697
in aneurism, 695
in cancer, 696
in extra-uterine pregnancy, 696
in goitre and Basedow’s disease, 696
in hydrocele, 696
in urethral stricture, 695, 696
needles for, 693, 694
Electro: physics, 606-675
Electro-therapeutics, 675-729
general rules for, 699-703
statical, 702-711
Fimbolism, 227, 229-233
si ane 316
ifferential diagnosis of, 317
etiology of, 316
morbid anatomy of, 316
symptoms of, 317
itieepin lanes, 219
Encephaloid tumors of brain, 339

 

INDEX.

Endarteritis obliterans, 224
Epigastric reflex, 96
Epilepsy, 472-483
complications of, 479, 481
conditions of visual apparatus in, 474
diagnosis of, 476, 477, 479
electricity in, 722
etiology of, 472-474
eye-detects in, table of, 489
facial expression of, 155
irregular, 479
morbid anatomy of, 475
ocular defects in, 722
prognosis of, 481, 482
symptoms of, 475-478
table of, 480
treatment of, 482-494
varieties of, 472
Epileptic aure, 476
ery, 476
seizure, 477, 478
Epileptiform attacks, 86
Epithelial tumors of brain, 339

-Esophoria, 143

Exaggerated reflexes, 352
Examination of patients, necessity for care
in, 107, 108
Exophoria, 143
Exophthalmic goitre, 598-601
diagnosis of, 600
etiology of, 599
mode anatomy of, 598, 599
prognosis of, 600
symptoms of, 599, 600
treatment of, 600, 601
Experiments relating to artificial convulsive
seizures, 463
Extra-uterine pregnancy, electrical treat-
ment of, 696
Eye, abductive power of, test for, 139
adductive power of, test for, 139
a factor in the causation of nervous
symptoms, 124-130
a guide in diagnosis, 133-150
asthenopic, 130, 131
astigmatic, 129, 130
changes observed in, 121-123
clinical alterations in, 123-128
degenerative effects of extirpation of,
25

examination of, table of record for, 145

hypermetropic, 126-129

in cerebral tumors, 342

lids of, a guide in diagnosis, 151

movements of, 121

muscles of, insufficiency of, 130-132,
137, 138

muscles of, paresis of, 122

muscular anomalies of, new terms for
(Stevens), 140-144

muscular anomalies of, tests for, 137-
150
INDEX,

Eye, myopic, 129
neuro-retinitis of, diagram of, 322
normal fundus of, diagram of, 322
physiology of movements of, 121, 122
refractive errors of, tests for, 133-138
sursumduction of, tests for, 139

Eyes, conjugate deviation of, 75

Face, cortical area of, 50
_ hemianesthesia of, 83
Facial hemiatrophy, 386
deformities produced by, 386
Facial spasm, 153
electricity in, 722, 723
Farad, 618
Faradaic current, 608-612
catalytic action of, 689
in spinal diseases, 718
its stimulating effects, 685, 686
modifying effects of, 686, 687
table of, contrasted with galvanic cur-
rent, 616
Fauces, in facial paralysis, 85 :
Features, clinical study of, 117-119
Feigned disease, detection of, 195
Fibres, associating, of cerebrum, 17
commissural, of cerebrum, 17
of cerebro-spinal ‘axis, diagram of, 34
of cerebrum, classification of, 17-19 |
diagram of, 18
peduncular, of cerebrum, 17
pyramidal, of brain, 28-30, 36
Fibrillary twitchings, 383
Fillet (see lemniscus-tract)
Fissure of Rolando, external guides to, 50,
51
of Sylvius, external guides to, 50, 51
Fissures of cerebrum, 13
Flechsig’s method, 19
Fluid chewetat of H. L. Bailey, 632
Focal lesions, of cervical segments, 411,
412
of dorsal segments, 411, 412
of lateral half of spinal cord, 414
of lumbar segments, 412, 413
of spinal cord, 408-448
Foot-clonus, 96 - ;
its clinical significance, 174
tests. for, 173
Foot-reflex, 96
Forehead, clinical facts relating to, 120, 121
Formatio reticularis, 43, 45
its relation to sensory tracts, 84
Formication, 55, 56
Fornix, fibres of, 17
pillars of, 28
Frictional machine, of Adams, 649
of Armstrong, 650 ;
of Holtz, 650
of Lane, 649
of Nicholson, 649
of Otto v. Guericke, 647

49

 

769

Frictional machine, of Professor Boze, 648
of Toepler, 650
of Voss, 650
Friedreich's disease, 591
Front-tap contraction, 173
Fuller's cell, 624
Functional nervous diseases, as purely, re-
flex manifestations, 463-472
necessity for examination of reflex
causes of, 470, 471 ,
their relationship to anomalies of the
visual apparatus and other reflex
causes, 452-472
views-respecting medication in, 471
Functional paraplegia, 435, 436
etiology of, 435
symptoms of, 435, 436
treatment of, 436

Gait, a guide in diagnosis, 162-165
of cerebellar disease, 76
Galvanic batteries, methods of construct-
ing, 619, 623
Galvanic battery, key-board attachments,
10

method of connecting the cells, effect
on intensity, 619-621
Galvanic cell, 613-623 /
electro-motive force of, 676
external resistance of, 615, 616
internal resistance of, 615
one-fluid cells, with liquid depolarizers
623, 624
one-fluid cells, with no depolarizer, 624
with solid depolarizers, 623
resistance of, 615
simplest form of, 614, 615
special forms of, 623-627
varieties of, 618
Galvanic current, 608
catalytic action of, 688, 689
density of, 679
in spinal diseases, 717, 718
length of application of, 683
modifications of, 608
modifying effects of, 687
quantity of, 676
table of, contrasted with galvanic cur-
rent, 616
Galvanic dosage, 675-684
Galvanic formule of muscles, 186, 187
Galvanic measurement, 675-684
Galvanism, in chorea, 722
its effects on living tissues, 684
its sedative action, 684
its stimulating effects, 684, 685
its various properties, 684, 685 ,
Galvanization of the cervical sympathetic,
689, 690
Galvano-cautery, 697-699.
Galvanometer, 627, 628
Ganglia, basal, 98
770

Gastric crises, in cerebellar disease, 76
Gastro-enteritis, 310
General electro-therapeutics, 684-702
General faradization, 690 ;
General galvanization, 691
General paralysis, 336
Generic ataxia, 591
Girdle pain, 91, 93
Girdle sensation, 91, 93, 408
Gloma of brain, 339 ;
illustration of, 339
Globus hystericus, 508
Goitre, exophthalmic, 598
Grand mal, 476-480
Graphospasm, 436
Graves’ ees 598
Gravity-cell battery, advantages of, 641
Gray degeneration of spinal cord (see loco-
motor ataxia)
Grenet cell, 624, 645
Grove’s cell, 626
Gubler’s line, 36, 74, 85
Gudden's method, 19
Guericke, Otto v., frictional machine of, 647
Guides to focal spinal lesions, 410-415
Gummata of brain, 338
Gums, a guide in diagnosis, 153

Hematoma of the dura mater (see pachy-
meningitis)
Hematomyelia, 425-427
Haematorrhachis, 427, 428
Hair, changes in, after paralysis, 277
Hallucinations, from lesions of the thala-
mus, 25, 27
Hand, a guide in diagnosis, 156-162
atrophy of, 157 . ’
bird-claw, 169, 170
deformities of, encountered, 156
in erase muscular atrophy, 381,
of the idiot and imbeciles, 161
tremor of, 156
woolly, 161
Head, abnormal posture of, from eye-defect,
121-123
Hearing, disturbances of, with facial paral-
ysis, 85
tests of, 210
Hearing impressions, cortical area of, 15
Heart, symptoms referable to when medulla
_ is implicated, 77, 78
Hemianszsthesia, 55
cerebral, 81
electricity in, 715, 726
from lesion of internal capsule, 30
in connection with hemianopsia, 81
of cortical origin, 69
Hemianopsia, binasal, 58
bitemporal, 58
clinical significance of, 80, 81
coexisting with motor aphasia, 82

 

INDEX.

Hemianopsia, diagram of, 57
homonymous, 56, 185 ;
clinical — signifi-

uncomplicated,
cance of, 81
its clinical significance and varieties,
56-58

tests for detection of, 56
Hemiathetosis, 28
Hemiatrophy, of face, illustration of, 386
of tongue and palate, illustration of,
386
Hemichorea, 28
Hemiparaplegia, 353, 415
Hemiplegia, 72, 86, 176, 353
from lesions of corpus striatum, 22
gait of, 162
its clinical significance, 52, 53
of cerebral origin, 265, 266, 285, 286
electrical treatment in, 715
of spinal origin, 285, 286, 414
Hereditary ataxia, 591
Heredity, its clinical relation, 112
Hiccough, electricity im, 724
Hill’s gravity cell, 625, 626
Holtz machine, 650, 653
Ranney’s improvement on, 657-661
Hydrargysm, diagnosis of, 579
symptoms of, 578, 579
treatment of, 579
Hydrocephalic ery, 307
Hydrocephalus, acute, 303
attitude of patient, 166
differential diagnosis of, 309
etiology of, 305, 306
morbid anatomy of, 304
prognosis of, 310
symptoms of, 306-308
treatment of, 311, 312 .
acute and chronic, symptoms of, 345
ehronie, 312
deformity of, 314
differential diagnosis of, 315
etiology of, 313, 314
morbid anatomy of, 312
prognosis of, 315
symptoms of, 314
treatment of, 315
spurious, 310
Hydromyelia, 433, 434
Hydrophobia, 557-561
diagnosis of, 559
etiology of, 557
morbid anatomy of, 557
prognosis of, 560
symptoms of, 558, 559
treatment of, 560
Hydruria, 86
a cerebral, electricity in, 713,
1 ‘

Hyperesthesia, 56, 202, 203
diagnostic importance of, 204, 205
from lead, 569
INDEX,

Hyperesophoria, 143
Hyperexophoria, 143
Hyperkinesis, 720
Hy permetropia, 126-129
Hyperopia, latent, its effect on nervous
centres, 467
Hyperosmia, 208
Hyperphoria, 143
Hypertrophy of brain, 337
differential diagnosis of, 337
etiology of, 337
morbid anatomy of, 337
prognosis of, 337
symptoms of, 337
Hypoglossal tract of brain, 29, 30, 36
Hysteria, 506-519
diagnosis of, 510
etiology of, 507
morbid anatomy of, 508
symptoms of, 508, 509
table of, 480, 498
treatment of, 515-519
Hysterical paralysis, gait of, 165
Hystero-epilepsy, 511
symptoms of, 513
Incontinence, of urine, treatment _ of,
406
aralytic, 175
; Foal 175
TIncoérdination of movements, 93
Indirect spark, 665-667
length of, 666
volume of, 667
Induced current (see faradaic current)
static, 672-675
Induction machine, care of, 661-665
Infantile paralysis, 365
remittent fever, 310
spinal paralysis, 369, 375
Infarction, 229, 230
‘Inflammatory disorders of the cord, elec-
tricity in, 719
Injuries of brain, effects of, 2, 3
Insufficiencies of eye-muscles, general rules
for determination of, 454-456
Insufficiency, latent, of eye-muscles, 130-
132, 137, 138
of ocular’ muscles, clinical importance,
467, 468
of the eye-muscles, manifest and latent,
454
Insula, lesions of, 71
Insulation, static, 670
Intermittent cramp (see tetany)
tetanus, 437 (see tetany
Internal capsule, diagram of, 255, 268
of brain (see capsule, internal)
subdivisions of, 268-270
Interrupted current (see faradaic current)
Interrupter, of faradaic machine, 609
Intra-cerebral hemorrhage, 256, 257

 

771

Island of Reil, its relation to speech, 16
lesions of, 71

Jacksonion epilepsy, table of symptoms of,
285

Joints, changes in, after paralysis, 277

Joule, 618 ,

Jounod’s boot, 375

Key-board attachments, of galyanic battery,
640
Kinesodic system of spinal cord, 93, 94
Kuee-jerk, 96 }
abolition of, 403
tests for, 173
Kussmaul’s paralysis, 442

Landry’s paralysis, 442
Lane’s frictional machine, 649
Latent insufficiency of eye-muscles, 132,
137, 138
muscular anomalies in the orbit, 456,
457
Lateral spinal sclerosis, 357
diagnostic table of, 364
diagram of, 362
etiology of, 359
morbid anatomy of, 359
varieties of, 359
secondary variety, 361
diagnosis of, 363, 364
etiology of, 361, 362
mothe anatomy of, 361, 362
prognosis of, 365 ‘
symptoms of, 362-364
treatment of, 365
Law, of Ohm, 618
Lead-colic, 568
Lead-encephalopathy, 569
Tas pete, 160, 568
Lead-poisoning (see plumbism)
Leclanché’s aa 623
agglomerate, 623
Le Fort’s-method, 693
Lemniscus tract, 43, 46
its spinal origin, 33
its two bundles, 32, 33
lesions of, 77
Leptomeningitis, infantum, 303
spinalis, 415-423
Leyden-jar spark, 668, 669
Limbs, cortical areas of, 50
Line of Gubler, 36, 74, 85
Lips, a guide in diagnosis, 151-154
Living tissues, relative resistance of, 616
Lobe, occipital, its relation to sight, 15
Localization, cerebral, views respecting it, 2
Lock-jaw, 581
Locomotor ataxia, 390-405
diagnosis of, 404
diagram of, 397
etiology of, 395, 396
772

Locomotor ataxia, gait of, 164, 388, 389
astric crisis in, 402, 403
illustrations of changes in cord of, 392
joint changes in, 399-401
morbid anatomy of, 391-395
pains of, 397, 398
prognosis of, 405
pupils in, 396, 397
stages of, 396-398
symptoms of, 396-403
relative frequency of, 403
table of, 549, 565
treatment of, 405, 406
Léwenfeld’s deductions relative to the
action of galyanic currents on the
brain, 715
Lower limb, cortical area of, 50
Lungs; symptoms referable to, when me-
dulla is implicated, 78

Magneto-current, 613

Marié-Davy cell, 623

Median nerve, paralysis of, 158, 159

Medulla, injuries of, 2:
oblongata, 100

architecture of, diagram of, 78
component parts of, 41

effects of lesions of, 77, 78, 86
functions of, 16, 43-45

nerves of, lesions of, 85, 86
nuclei of, diagrams of, 42
symptoms of compression of, 86
tracts of, diagram of, 45
vaso-motor centres of, 86

Megalopsia, 123

Megrim (see migraine)

Memories, affected in cortical disease, 70-72
of muscular acts, cortical centre of, 16
storage of, in cerebral cortex, 61, 62

in cortical cells, 9

Meningeal hemorrhage, 282
differential diagnosis of, 284
etiology of, 282
morbid anatomy of, 282
prognosis of, 283
symptoms of, 283
treatment of, 283

Meningitis, basilar, 303
cerebral, chronic variety, 299

differential diagnosis of, 301

etiology of, 300

morbid anatomy of, 300

prognosis of, 302

symptoms of, 300, 301

treatment of, 302, 303
subacute variety, 298

differential diagnosis of, 299

etiology of, 290°

morbid anatomy of, 299

prognosis of, 24)

symptoms of, 299

treatment of, 299

 

INDEX.

Meningitis, cerebro-spinal, attitude of pa-
tient, 166
tubercular, 303 (see hydrocephalus)
Mental alcoholism, 576
faculties, physiology of, 3, 13
Mercurial poisoning, 578, 579
Mesencephalon, 99
Method of Flechsig, 19
of Gudden, 19
of Tiirck, 19
Meyer’s method, 689
Microcephalic brain, 219
Micropsia, 123
Migraine, 532-541
etiology of, 532, 533
heredity of, 532, 633
its dependence on eye-strain, 532, 533
symptoms of, 533-539
treatment of, 539-541
Miliary aneurism, 220-222
etiology of, 221
morbid anatomy of, 220
symptoms of, 221
Milliampére-meter, 629-631, 677, 678
Modifying effects of electrical currents,
68 ee
Mogigraphia, 436
aca. 70
Mono-paresthesia, 70
Monoplegia, 69, 70, 176, 264, 265
electricity in, 716
Monospasm, 70
electricity in, 716
Morbid fears, 529
Morton’s pistol-electrode, 674
Motor impulses, 4
paralysis, rules for electrical treatment
in, 720 (see paralysis)
Mouth, a guide in diagnosis, 151-153
Movements, rotary, in cerebellar disease, 77
Multiple neuritis, 374, 561-567
diagnosis of, 564, 565
etiology of, 562
morbid anatomy of, 561, 562
prognosis of, 566
symptoms of, 563, 564
table of, 565
treatment of, 566, 567
sclerosis, 331 ,
spinal sclerosis, diagram of, 363
tie. electrical reactions of, 186-188
Muscular area of cerebrum, 14
atrophy, its relation to spinal diseases,
93, 94
reactions to galvanism, normal, 190
sense, tests of, 181, 182
Myelitis, 428-433
acute, 428
diagnosis of, 430
etiology of, 428
morbid anatomy of, 428, 429
prognosis of, 430, 431
INDEX.

Myelitis, acute, symptoms of, 429, 430
treatment of, 430, 431
chronic, 431, 432
~ diagnosis of, 432
etio og of, 431
Tiere: anatomy of, 431
prognosis of, 432
symptoms of, 431, 432
treatment of, 432
diffuse, symptoms of, table of, 565
symptoms of, table of, 426
Myelomeningitis, 429
Myopia, 129
Myosis, 403
Myotonia congenita, 440-442
Myxeedema, 601-604
diagnosis of, 603
etiology of, 602
morbid anatomy of, 601, 602
prognosis of, 604
symptoms of, 602, 603
treatment of, 604

Nails, changes in, after paralysis, 277
Nairne’s modification of Ramsden’s ma-
‘chine, 648
Nerve, abducens, lesions of, 83
facial, course of fibres of, origin of, 43
decussation of its fibres within the
pons varolii, 36
effects of lesions of, 85
paralysis of, 85
motor ae lesions of, 82
paralysis of, 82
special nuclei of, 82, :
musculo-spiral, paralysis of, 159, 160
olfactory, lesions of, 79, 80
optic, diagram of, 57, 59
lesions of, 80-82
trigeminus, deep fibres of, 43, 44, 83
general clinical deductions relative
to lesions of, 84
paralysis of, 83, 84
trochlear, lesions of, 83
ulnar, paralysis of, 157, 158
Nerve-reactions, normal, 190
Nerve-roots, effects of lesions of, 91
spinal, anterior, 93-95
. posterior, 91, 93, 95
Nerve-stretching, 406
Nerves of medulla, lesions of, 85, 86
Nervous bankruptcy, 466
predisposition, rationale of, 468, 469
Neuralgia, 541-553
diagnosis of, 550
differential diagnosis between various
types of, 547
electricity in, 726, 727
etiology of, 542-544
modifying causes of, 542
morbid anatomy of, 544-546
predisposing causes of, 542

 

173

Neuralgia, prognosis of, 550, 551

symptoms of, 546-550

tables of 547, 549

treatment of, 551-554

trigeminal, 84

types of, percentage of, 545

visceral, electricity in, 727
Neurasthenia, 519-532

cerebral, 525, 526
diagnosis of, 525
elton: of, 520-524

morbid anatomy of, 525

prognosis of, 529, 530

spinal, 526, 527

symptoms of, 525-529

treatment of, 530-532
Nicholson’s “ induction machine,” 649
Nuclei, caudate and lenticular, functions of,

22
of the medulla oblongata, 42-45
Nucleus, caudate, of cerebrum, 20
lenticular, capsular fibres of, 28
lesions of, 73
of cerebrum, 20
of Stilling, 31
red, 31, 32, 38, 39
: effects of lesions of, 33
Numbness, 55
Nymphomania, 509
Nystagmus, 76
electricity in, 723

Ohm, 618
Ohm’s law, 618, 683
Omalgia, 508
Ophthalmoplegia, external, 82
Ophthalmoscopic examinations, 149, 150
Ophthalmoscopy, in determination of re-
fractive errors of the eye, 453
objections to, as a means of measuring
refraction, 453, 454
Optic atrophy, 403
nerve, diagram of, 57, 59
thalamus, 16, 20, 23-28
diagram of, 23
effects of lesions of, 25-28
pulvinar of, 25
subdivisions of, 23-25
transverse vertical section of, 27
tract, its relations to internal capsule, 30
Orthophoria, 142, 143

Pachydermique, cachexic, 601
Pachymeningitis, 287
differential diagnosis of, 289
etiology of, 288
neachid anatomy of, 287
prognosis of, 291
symptoms of, 288, 345
treatment of, 291, 292
varieties of, 287, 288, 290
spinalis, 415-423
774

Pachymeningitis spinalis, varieties of,
symptoms of, 416, 417, 419, 420
Pain, impressions, cortical area of, 15
its clinical significance, 109
its relation to spinal diseases, 91
spinal, its clinical significance, 93
Painful poe electrical treatment of, 692,
693

Palate, a guide in diagnosis, 154
in facial paralysis, 85
Palm, flattening of, 381
Paralysis agitans, 161, 586-591
diagnosis of, 589, 590
from cerebral sclerosis, 333
etiology of, 587
gait of, 163, 164, 588
morbid anatomy of, 586, 587
prognosis of, 590
symptoms of, 587, 588
table of, 498
treatment of, 590
Paralysis, alcoholic, 575, 576
bulbar, 85, 86, 378
facial expression of, 384, 385
complete, 53 :
crossed, 53
‘of olfactory type, 80
electricity in, 719, 720
facial, crossed, 74, 75
from arsenic, 571, 572
cortical cerebral lesions, 49, 284
lead, 568
non-cortical cerebral lesions, 284
‘phosphorus, 572
hysterical, facial expression in, 170
gait of, 165
Kussmaul-Landry’s, 442
labio-glosso-pharyngeal, 85
motor, degrees of, 177
rules of electrical treatment in, 720
tests for, 171, 176-179
of abducens nerve, 83
of Bell, 85
of face, from cerebral hemorrhage, 276
of motion, clinical significance of, 48, 49
of motor oculi nerve, 82
from cerebral hemorrhage, 275 276
of the insane, 336
of trigeminus nerve, 83, 84
of trochlear nerve, 83
pseudo-hypertrophic, characteristic at-
titude of, 167, 168
gait of, 164
sensory, from intra-cerebral hemor-
rhage, 272
its clinical significance, 53-60
spastic, 357
ait of, 163
spinal, 91, 93, 94
infantile, 369
of adults, acute, 369
trigeminal, crossed, 75

 

INDEX.

Paralytic dementia, 152
Paraphasia, 16, 63, 66, 234
Paraplegia, 86, 353
cervical, 17
gait of, 162, 163
tetanoid, gait of, 163
Paresis, electricity in, 719, 720
of eye-muscles, 122
Parkingon’s disease. 586
Patellar reflex, abolition of, 403
Patient, acquired diseases of, 113, 114
age of, value of in diagnosis, 110
features of, 117-119
habits of, 113
occupation of, 113 '
sex of, importance of noting, 112
Pearl tumors, 340
Perimyelitis, 429
Permanent battery, 643-645
Peroneal reflex, 96
test for, 173
Petit mal, 478
Phosphorus-paralysis, 572
Pia mater, inflammation of (see meningitis)
Piesmeter, 199
Pinniform.decussation of sensory tracts, 45
Pistol-electrode, Morton’s, 674
Plantar reflex, 96
Plate machine of Ramsden, 648
Plumbism, 567-571
diagnosis of, 569, 570
etiology of, 567
morbid anatomy of, 567
prognosis of, 570
symptoms of, 567-569
treatment of, 570, 571
Polarity changer, 636
Polarized cell, 646
Polar method, 186
Poliomyelitis anterior, 365
diagnosis of, 372
etiology of, 368, 369
morbid anatomy of, 366, 367
prognosis of, 374
symptoms of, 369-372
table of, 426
treatment of, 374, 375
varieties of, 368-372
infantile variety, 368
photographs of, 366-370
symptoms of, table of, 565
Polyuria, 509
Pons varolii, decussation of facial nerve ix,
36
effects of lesions of, 36, 74
fibres of, 33
gray substance of, 33
its construction and functions, 33-37
reticular formation of, 35
transverse section of, 36
Posterior longitudinal bundle, 35
Postero-lateral spinal sclerosis, 591-598
INDEX.

Postero-lateral spinal sclerosis, differential
diagnosis of, 595-597
morbid anatomy of, 591, 592
symptoms of, 592-594
treatment of, 598
Post-hemiplegic contracture, 270
Post-paralytic rigidity, electricity in, 715
tremor, 333
Potential, high and low, 613, 614
Primary current, 612
lateral sclerosis (see lateral spinal scle-
rosis).
Principles of static induction, 651-655
Prisms, their indications and uses, 458, 459
Progressive muscular atrophy, 372, 379-388
deformities of, 382-385
diagnosis of, 384
diagrams of, 380
etiology of, 380
gait of, 165
morbid anatomy of, 379, 380
prognosis of, 386, 387
symptoms of, 380-384
treatment of, 387, 388
Psammoma, 340
Pseudo-hypertrophic paralysis, 373, 388-
390

attitude of, 388, 389
diagnosis of, 390
etio By, of, 388
gait of, 389
morbid anatomy of, 388
prognosis of, 390
symptoms of, 388-390
treatment of, 390
Ptosis, 82.
Pulvinar of the optic thalamus, 25, 27
Pupil, Argyll Robertson’s, 93
~ contraction of, 120
_ dilatation of 120, 121
hemiopic reaction of, 83, 121
in. lesions of pons, 75
rigidity of, 403
Robertson’s, tests for, 120
Pyramidal tracts, 42
diagram of, 45, 58
in crus cerebri, 31
in pons varolti, 33
of brain, 28-30, 36

Rachialgia, 508
Ramsden’s plate machine, 648
Ranney’s improvement on | the
machine, 657-661
Reaction of degeneration, 189, 190
Reflex, abdominal, 96, 171
ankle, 96
cremasteric, 96, 171
epigastric, 96, 172
foot, 96
gluteal, 171
patellar, 96

Holtz

 

Reflex, peroneal, 96, 173
plantar, 96, 171
pupillary, 176
rectal, 174
scapular, 96, 172
sexual, 175, 176
vesical, 174
Reflexes, a guide to the spinal segments, 172
deep, 96
organic, 174-176
skin, 171, 172
diminution of, 174
spinal, 170-176
abolition of, 96, 174
clinical deductions respecting, 174
deep, 96
exaggeration of, 96
in connection with incodrdination,

96
tendon, 172, 173, 182
exaggeration of, 174

Relative resistance of living tissues, 616
Remak’s method, 685
Resistance of galvanic cell, 615
Respiration, Cheyne-Stokes, 86
Restiform body, 37
Retarded sensory impulses, 91 ~
Reticular formation of pons varolii, 35
Rheophores, 636
Rheostat, 631, 632

description of, 631, 632

employment of, in galvanic applica-

tions, 681, 682

fluid, of H. L. Bailey, 632

use of; 632
Robertson's pupil, 208

tests for, 120

Sand-tumors of brain, 340
Saturnine-poisoning (see plumbism)
Scapular reflex, 96
Scirrhus of brain, 339
Sclerosis, cerebro-spinal, facial expression
in, 170
cerebro-spinal, gait of, 165
spinal, 334
Secondary degeneration, 267
lateral aelecoais (see lateral spinal scle-
rosis)
Senile meningitis, 297
Sensation, delayed, 206
of pa and temperature, tests for, 206,
of touch, pain, and temperature, corti-
cal centres of, 15
Sensory area of cerebral cortex, 15
nerve-tracts, electricity in disorders
affecting, 724-728
phenomena, abnormal, 352-354
their clinical significance, 93
tracts, 42
of brain, 28, 30, 36
776

Sex, its clinical relations, 112
Shaking palsy, 586
Sick-headache from eye-defect, 126, 128,
129 (see migraine)
Siémen’s and Halske’s cell, 625
Sight. its relations to occipital cortex, 15
views of Ferrier, Munk, and others, 15
Sinuses of brain, diagram of, 225, 226
Skin, angioneuroses of, 729
electrical tests of, 199
reflexes, 95, 96, 171, 172
tests for tactile sensibility of, 199-201
Smee’s cell, 623
Smell, abolition of, 79
Sneezing, electricity in, 724
Spasm, a symptom of spinal disease, 96
effects of electrical treatment of, 721
of spinal origin, 96, 174
static electricity in, 721
Spasmodic affections, electricity in, 720-724
asthma, electricity in, 723
tabes, 357-359
Spastic paralysis, 357
Special electro-therapeutics, 712
senses, impairment of, from cerebral
hemorrhage, 273, 274
in cortical disease, 70
tests for, 207-209
Speech, Broca’s centre of, 15, 16
cortical area of motor impulses con-
cerned in, 15, 16
diagram of mechanism of, 67
disorders of, 60-68
from lesions of the pons, 75
Speech-tract, 67, 75
of brain, 28, 30, 36
Spinal affections, clectricity in, 717
anemia, 447
diagnosis of, 447
etiology of, 447
morbid anatomy of, 447
prognosis of, 447
symptoms of, 447
treatment of, 447, 448
apoplexy, diagnosis of, 426
etiology of, 425
morbid anatomy of, 425
prognosis of, 426, 427
symptoms of, 425, 426
table of, 426
treatment of, 427
automatism, 101
commissures, 89
conducting tracts, diagram of, 87, 92
congestion, 444-447
diagnosis of, 445, 446
etiology of, 444, 445
-morbid anatomy of, 444
prognosis of, 446
symptoms of, 415
treatment of, 446
contracture, 94, 96

 

INDEX.

Spinal cord, anterior columns of, sclerosis of,

anterior horns of, 89, 95 .
inflammation of . polic-
myelitis anterior
congenital abnormalities of, 350
construction of, diagram of, 350,
, 861
descending degeneration of, 88
diseases of, 349
table of, 350
effects of complete division of, 95
lesions of, 86-97
pressure upon, 95
focal lesions of, 349, 350, 408-448
functional diseases of, 350, 434-448
rray matter of, functions of, table
of, 355, 356
roups of fibres in, 349-352
Tacious of, guides in diagnosis of,
356, 357
gray matter of, 93
motor cells of, 88
columns of, 88
non-systematic lesions
408-448
posterior columns of sclerosis of
o locomotor ataxia)
refiex arcs of, diagram of, 95
sensory columns of, 88, 91
summary of, 100, 101
systematic lesions of, 349, 350
trophic cells of, 88, 91
tumors of, 423, 424
unilateral lesions of, 95
diagram of, 391
vascular lesions of, 350
visceral disturbances in diseases of,
94

of, 349,

white matter of, functions of, table
of, 355
sl secondary, diagram of,
54
diseases, faradization in, 718
galvanic current in, 717, 718
symptoms of, table of, 353
gray matter, diagram of, 94
hemiplegia, 285, 286, 414
hemorrhage, 425
irritation, 435
etiology of, 435,
symptoms of, 435
treatment of, 435
lateral ee (primary variety), 359-
61

diagnosis of, 361
symptoms of, 360, 361
Rae symptoms of, table of,
Avo

meningeal hemorrhage, 427, 428

etiology of, 427
morbid anatomy of, 427
INDEX.

Spinal meningeal hemorrhage, prognosis
A of, ‘to7, 428 eee
symptoms of, 427
. Table of, 426
treatment of, 428
meningitis, 415-423
diagnosis of, 404, 420-422
etiology of, 418
morbid anatomy of, 416-418
prognosis of, 421
symptoms of, 418-420
treatment of, 421, 423
varieties of, 416-418
nerve-roots, 350, 351
effects of lesion of, 91
nerve-tracts, diagrain of, 47, 58
neuralgias. symptoms of, table of, 549
pachymeningitis, symptoms of, table
of, 422
pain, 93
reflexes, 89, 94, 96. 170-176
abolition of, 3852
exaggeration of, 352, 353
superficial, 95
sclerosis, 354
of anterior columns, 357
postero-lateral, 591-598
segments, 88, 89
~ architecture and
tables of, 355, 356
diagrams of, 89, 90, 92
tumors, 423, 424
diagnosis of, 424
etiology of, 424
morbid anatomy of, 423
prognosis of, 424
symptoms of, 424
treatment of, 424
Sponge electrodes, reasons for removal of
sponge, 639
Spurious hydrocephalus, 310 .
Squint, its relation to refractive errors of
the eye, 453
Statical electro-therapeutics, 702-711
Static breeze, 670-672
electricity, 612, 613, 647-675
compared with galvanism, 655
electro-motive force of, 655°
general rules for use of, 708-711
in chorea, 722
in medicine, 655-661
in spasm, 721
indications for, 705, 706
internal resistance of, 655

functions of,

methods of application of, 665-675

modifying effects of, 687 ;
physiology of therapeutical action
of, 706-708
quantity of, 635
induced current, 672-675
induction, principles of, 651-655
insulation, 670

 

777

Static machino (see frictional machine)
care of, 661-665
charging of, 664
improvements in, 656
length of spark, 660
quantity of, 656
outfit, 661
shock, 668, 669
Stevens’ method for the detection and cor-
rection of anomalies of the visual
es axioms relating to, 452-
6

operation, 460
Strabismus, 121
its clinical importance contrasted with
insufficiency, 467, 468
Strumous diathesis, 119
Subacute cerebral meningitis, 299
Substantia nigra, 31
cells of, 32
Symptoms, general, duration of, clinical sig-
nificance of, 110 /
exciting causes of, 110, 111
revealed by clinical history of the
patient, 108-116
revealed by the sense of sight during
a clinttal exaaination, 116-170
revealed by various tests, 170-213
Syncope, symptoms of, table of, 480
Syringomyelia, 433, 434
diagnosis of, 434
etiology of, 433
morbid anatomy of, 483
prognosis of, 434
syinptoms of, 433, 434

Tabes dorsalis, gait of, 164 (see locomotor
ataxia :
Tahbes, spasmodic, 357-359
Tache cérébral, 307
Tactile sensibility, normal, table of, 201
Taste, disturbances of, with facial paralysis,
85
tests for, 209, 210
Tegmentum cruris, 31
effects of lesions of, 33
Teeth, a guide in diagnosis, 153, 154
defects of, as a cause of epilepsy, 464
Temperature impressions, cortical area of,
modifications of, in cerebral hemor-
rhage, 274, 275

| Tendon reflexes, 96

Terminal labile stimulation, 685
Tests, electric, 171, 185-187
electrical, 185-199
summary of, 194, 195
employed in diagnosis, 170-213
for associating tracts of cerebrum, 184
for commissural fibres of cerebrum, 184
os incodrdinatign of movement, 179-
81
778

Tests for irritability of the muscles, 171, 182,
183

for motor paralysis, 171, 176-182
for reflex excitability of the spinal
cord, 170-176
for sensory nerves, 171
for tactile sense, 199-202
for am and ocular movements, 133-
150
Tetanoid paraplegia, 357
Tetanus, diagnosis of, 584
electricity in, 724
etiology of, 581
facial expression of, 155, 583
prognosis of, 584, 585 -
symptoms of, 582, 583
table of, 422
treatment of, 585
varieties of, 582
Tetany, 437-440
diagnosis of, 439
etiology of, 438
morbid anatomy of, 438
prognosis of, 439, 440
symptoms of, 438, 439
treatment of, 440
Therapeutical action of electrical currents,
655, 656
Thermo-electric
632, 633
Thermometry, cerebral, study of, 633
Thomsen’s disease, 440-442
diagnosis of, 442
etiology of, 440
morbid anatomy of, 440, 111
symptoms of, 441, 442
treatment of, 442
Thrombosis of cerebral capillaries, 228, 229
of. cerebral sinuses, 223-226
Toepler machine, 650
Tongue, a guide in diagnosis, 153, 154
oss of power of protrusion of, 78
Torticollis, electricity in, 723 :
Touch-impressions, cortical area of, 15
Touch, its disturbances, clinical significance
of, 91
Tract, fronto-central, 184
hippocampo-temporo-central, 184
hippocampo-temporo-frontal, 184
occipito-central 184,
occipito-temporal, 184
temporo-central, 184
temporo-frontal, 184
Tremor, alcoholic, 574
etiology of, 586

differential calorimeter,

 

INDEX.

Tremor, in cerebral diseases, 72
of cerebral origin, 331
ost-paralytic, 333
taint, guides for, 49-51
Trismus, 581
neonatorum, 582
Trophic disorders, electricity in, 726
disturbances, 353
Trouvé's cells, 624
Troussean’s test, 438
Tubercular tumors of brain, 338, 339
Tumors of brain, 218
etiology of, 341
varieties of, 338-341
of the brain and its envelopes, 337
Ttrck’s method, 19 ;
Two-fluid cells of galvanism, 625-627

Ulnar paralysis, 157, 158

Units, electrical, table of, 617
Upper limb, cortical area. of, 50
Uremia, symptoms of, table of, 480

Vaginismus, 509
Vaso-motor, and trophic disturbances from
cerebral hemorrhage, 277, 278
centres of the medulla, 86
sa diseases of, electricity in, 728—
2!

Vermis, lesions of, symptoms of, 76

Vertebral caries, symptoms of, table of, 549

Visceral functions, their dependence upon
the nerve-centres, 466

Vision, tests for defects of, 133-135

Visual field, 145

Volt, 618

Voltaism (see: galvanic current)

Vomiting, 86

Von Marum’s modification of Ramsden’s
machine, 648

Voss machine, 650

Walker's cell, 623
Watt, 618
Will-tract of cerebrum, 28-30
Woolly hand, 161
Word-blindness, 65, 66, 234-236
Word-deafness, 64, 65, 234-236
Wrist-drop, 159, 160, 385
Writer's cramp, 436, 437
etiology of, 436
morbid anatomy of, 437
symptoms of, 436, 437
treatment of, 437
Wry-neck, electricity in, 723
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