UNIVERSITY OF CALIFORNIA, SAN OIEGO 3 1822.00182 0232 iiiii IP iiiliiis«sti ">'''/''" i'S iiiiii! BIOMEDICAL LIBRARY UNIVERSITY OF CALIFORNIA, SAN DIEGO UNIVERSITY OF CALIFORNIA SAN UbljU 3 1822 00182 0232 DATE DUE JNIVFRSITY 1B«AKV I-IW) f CALlfOPfi;/, :w*N DlcGo LA JOLLA, CA 92093 APR ^ 6 REC'D 1 DEMCO 38-: >97 xD THE DIAGJfOSIS OF DISEASES BRAIN, SPINAL COED, NERVES, AXD THEIB APPENDAGES. J. RUSSELL REYNOLDS, M.D., Lond., riflTBBSITV MEDICAL SCHOLAR, ASSISTANT PHTSICIAJf TO THE HOSPITAL FOE SICK CHILDHEIf. " Let it be reiterated, that truths must not be denied and distrusted, because we can only make approximative applications of them, and cannot easily eliminate their individual eft'ects ill complex cases." — IjYNch. LONDON: JOHN CHURCHILL, NEW BURLINGTON STREET. M. DCCC.lv. PEINTUD BT S. GEOGHEGAN, PALSGBAVE PLACE, TEMPLE BAK, LONDON. MARSHALL HALL, M.D., F.R.C.P., F.R.S.S., L. & E. ETC. ETC. ETC. ^l)is ©aiovfe is ISeliicattli, AS A TRIBUTE OF RESPECT TO THE RESEARCHES AND GENIUS WHICH HAVE CONTRIBUTED LARGELY TO THE ADVANCE OF PHYSIOLOGY AND PATHOLOGY : AND AS A TOKEN OF GRATITUDE FOE THE FRIENDLY COUNSELS AND KIND SUGGESTIONS WHICH LED THE AUTHOR, WHEN COMMENCING HIS STUDENT'S LIFE, TO A COURSE OF STUDY AND LINE OF THOUGHT FROM WHICH HE HAS DERIVED THE DEEPEST PLEASURE. P 11 E E A C E . The motives which have induced me to write tin? following work are those which, I imagine, must actuate every author in entering upon a similar em- ployment. They are, the importance of knowledge upon the subject ; the deficiency of such knowledge, and of the means for its attainment ; and the hope that some part at least of that deficiency may be supplied. It is quite unnecessary to make any lengthened comment upon the first of these motives. The value of diagnosis, in relation both to prognosis and treat- ment, is at once and universally admitted ; and tlic only difference of opinion which can or does exist is, with regard to the limits beyond which diagnosis may lose its practical utility. However, the majority of the medical profession feel that diagnosis should bo carried as far as possible ; for although the immediate results of certain differentiations may be imperceptible in their direct influence upon treatment, there is much satisfaction to be derived from the simple fact of know- ledge ; and we cannot but believe that its progressive increase must eventually alleviate the sufferings and lessen the soitows of humanity, even should it be found that the laws of life and death are but little VI PREFACE. affected (except with detriment to the individual) by interference with the laws of nature. By the application of a true system of pathology, hygiene, and therapeutics, practical medicine is so directed that it does not interrupt the processes of nature, but assists their development, by placing the individual in the best circumstances for the accomplishment of their destined results. Little more than this can be either expected, or desired : but for the application of such a system the essential pre-requisite is diagnosis ; imderstandiug by that word the recognition of an indi- vidual case as belonging to a certain category of disease, the general laws of which form part of the systematic science ; so that the particular case in ques- tion is thus known to have a certain probable issue, and to require a special kind of medicinal, general, and social treatment. That our power of diagnosticating cerebral and spinal diseases is far less than that which we possess with regard to the derangements of any other system of organs, which are equally frequent, is generally admitted. "We constantly hear it said that a patient has had an " apoplectic attack," a "convulsive seizure," or that he suffers from " some affection of the brain or spinal cord," and this without any attempt being made to discover whether the anatomical basis of these groups of symptoms is congestion, softening, haemorrhage, chronic meningitis, tumor, or any other definable disease. PREFACE. Vll This ignorance arises partly from the obscurity of the diseases themselves, and partly from deficient ac- quaintance with thosej facts which have already been employed by others to remove some portion of that obscurity. To supply the want created by the essen- tial difficulties of appreciating the true character of nervous diseases requires an elaborate examination of the subject — i. e., of the relation subsisting between structural changes or conditions and morbid functions, and the establishment of a true system of pathology by a detailed natural history of disease. This is not the object of the present work, and the reader is referred for such information to the works of Lallemand, Bouil- laud, Andral, Marshall Hall, Fardel, Eostan, Yalleix, Herpin, Foville, Louis, Martinet, Ollivier, and others. But this reference, wliich does much injustice, by its omissions, to many who have laboriously studied diseases of the nervous system, is sufficient to indicate one source of the other deficiency, which it is my object to endeavour to supply. Many have neither the leisure nor the inclination to wade through the voluminous writings of the authors whose names I have mentioned ; and the student of medicine finds his time occupied with the reading of such "systematic authors" as may bo prevalent in the school at which he studies, and it is quite out of his power to become acquainted with more than one or two of the monographs to which allusion has been made. In order, therefore, to supply the deficiency which I VI U PREFACE. felt when at college myself, and which others have often expressed to me since, I have undertaken the present work, in order to place within reach of the student's time, and the practitioner's leisure, those facts which have been elicited by others and by myself, so far as they bear upon the diagnosis of nervous diseases. Nothing can be further fi-om my thought than the presumption that this little book can supply the place of those greater works, many of which must remain as models of scientific investigation, and as replete with important information so long as disease is one object of human study ; and nothing can be further from my wish than that any, who have within their power the acquaintanceship of such authors, should rest satisfied with this or with any other book Avhich does but give them assistance in rising to the first step in practical medicine, the diagnosis of indi- vidual diseases. The manner in which I have endeavoured to accom- plish the object that was in view will be obvious from a glance at the table of contents. The differential diagnosis of individual diseases is preceded by some chapters on '' the objects" to be attained, and upon the terms employed. Eeasons are given for adopting a clinical classification of diseases — i. e.^ for forming large groups which may be readily recognised by their general and prominent characters : and after present- ing, in a separate chapter, the diagnosis of these groups, special diseases are considered, and the means PREFACE. IX for their differentiation are j^ointecl out. This has been done in a similar manner throughout ; the diag- nosis of allied affections is not given in a dii'ectly anti- thetic form, but the symptoms of each disease (so far as they are of diagnostic value) are grouped, and placed in distinctly lettered paragraphs, so that it is perfectly easy to compare and contrast tl.ose of one affection with those of another ; for example, the mental, moto- rial, and sensorial phenomena of htemorrhagic apoplexy are stated in lettered paragraphs, and so are those of softening, in order that by a comparison of the two series their differentiation may be at once accomplished. Several diseases, as, for instance, tubercular menin- gitis and ui-inaemia, occupy a position in two or more chapters, and this is necessitated by their clinical dif- ferences ; but should it be wished to obtain a connected view of the diagnosis of a particular anatomical con- dition in its several clinical forms, this can be accom- plished by means of the Index, which will at once refer to the several chapters imder which the disease is represented, as it is presented phenomenally under different phases during life. Knowing well the many difficulties which beset any endeavour to arrange diseases of the nervous system, and to point out their diagnosis, I cannot but be con- scious that imperfections and inaccuracies must creep into an attempt which embraces so wide a range of phenomena. It must further be distinctly understood that I do not for a moment think that the lines of b X PREFACE. differentiation which are pointed out in the following pages are either final or satisfactory in their applica- tion to all cases of disease; since, many individual instances are met with, of which it is impossible, in the present state of science, to frame an accurate diag- nosis. A consideration of the points suggested may, however, make this possible in the majority, and en- able the observer to carry the diagnosis so far as it has been carried hitherto ; it may enable him to distinguish clearly between those diseases which are diagnosticable, and others which are not ; and, even in the latter, more systematically to observe their phenomena. Gkosvenor-street, April ISth, 1855. CONTENTS. PART I.— GENERAL. CHAPTER I.— The Objects of Diagnosis and its Limits. First Object, Locality of Lesion .... Second „ Nature of Affection (functional change) , Third „ Anatomical Condition CHAPTER II. — The Elements for Diagnosis. I. Intrinsic Symptoms . Modifications of Volition „ „ Ideation „ „ Emotion „ „ Sensation „ Motility II. Extrinsic Symptoms (Local and General) CHAPTER III. — The Classification adopted. Reasons for not framing a Classification upon either Anatomical or Physiological basis ....... Clinical Classification ....... CHAPTER IV. — The Diagnosis op Locality, generally. Of Extrinsic from Intrinsic Diseases . . . • • Diseases of the Brain, Cord, and Nerves from each other Meningeal from Central Diseases ..... 2 6 10 14 16 22 25 27 32 45 48 51 52 57 61 PART II.— DISEASES OF THE BRAIN. CHAPTER V. — Diagnosis op Bkain Diseases, as to their General Nature. . Febrile, or Inflammatory Diseases . . . . • I Aiioplectic Diseases ....... 3 ) Diseases marked by Delirium ..... • Convulsive Diseases ....... 63 6t 65 66 xu CONTENTS. 2 / Diseases Marked by Exaltation of Function , „ Decrease of „ „ „ Excess and Defect in Combination CHAPTER VI. The Differential Diagnosis of Acute Febrile Diseases affecting the Brain. Simple Meningitis (of the Convexity and of the Base) Tuberculous „ (in the Adult, and in the Child) Rheumatic „ (or Meningeal Rheumatism) Inflammation of the Dura Mater Cerebritis (General and Partial) . Continued Fever, with Cerebral Complication Gastric Remittent Fever (of Children) . Simple Hypersemia ("Determination of Blood" Delirium Tremens (Febrile form) Mania (of Febrile type) . CHAPTER VII. — Differential Diagnosis of Apoplectic Diseases. Congestion, or " Coup de Sang " Haemorrhage (Hemispheres, Ventricles) Arachnoid Hsemorrhage Serous Effusion . Acute Red Softenuig Tumor of the Brain, or Meninges Tubercular Meningitis Urinpemia, and Diathetic Conditions Morbus Cordis, Ansemia, &c. CHAPTER VIII. — Differential Diagnosis of Diseases marked by Delirium. Hypercemia Cerebri ....... Acute Softening ........ Delu-ium Tremens ....... Diathetic Diseases ....... CHAPTER IX. — Differential Diagnosis of Convulsive Diseases. Eccentric, Toxsemiaj (Exanthemata, &c.) Eccentric Irritation Centric, Idiopathic (Dynamic) Congestion Softening Tubercular Meningitis . Tubercle and Tumor of the Brain HaDmorrhage Hypertrophy Acute Chorea CHAPTER X.— Differential Diagnosis of Acute Hyperesthesia. Cephalalgia, Extrinsic Origin ...... Intrinsic „....•• CHAPTER XI.— Chronic Diseases, generally. DifiBculty of Distinction, &c. . . . • • • 68 69 69 71 75 80 82 82 84 87 89 91 94 100 101 102 105 106 107 112 115 117 118 121 123 125 128 130 132 133 135 136 137 138 139 140 141 CONTEXTS. XIU CHAPTER XII. — Diseases characterised by Exalted Activity. Excessive Ideation — Hypochondi-iasis Tarantism, &c. Excessive Sensation — Hemicrania Hallucinations Illusions (Sensory Vertigo, &c.) Excessive Motility— Motor Vertigo Co-ordinated Sjiasm Chorea Tremors (iKiralj^sis agitans) CHAPTER XIII. — Diseases marked by Dijunution oi- Ansesthesia Muscularis . - . . . Functiok. CHAPTER XIV. — Diseases characterised by the Combination of Increased and Diminished Function. PART III.— DISEASES OF THE SPINAL CORD. 145 147 148 150 151 156 157 158 163 165 Hysteria ...... . 168 Epilepsy ...... . 173 Tumor ....... . 182 Chronic Meningitis ..... . 187 Chronic Softening ..... . 190 Chronic Induration ..... . 193 Chronic Hydi'ocephalus .... . 196 Urinsemia ...... . 197 CHAPTER XV. — The Diagnosis op Special Locality, affected. Region (Cervical, Dorsal, Lumbar) . . . . . Column (Anteiior, Posterior, Lateral) . . . . • Histological Elements (Grey and White Matter) CHAPTER XVI. — Diagnosis of Spinal Diseases — As to their General Nature. Modifications of Conductive Functions . • • „ „ Centric »••■•• CHAPTER XVIL— Acute Diseases of the Spinal Cord and its Meninges. Plethoi-a Spinalis Meningitis Myelitis . Meningo-myelitis Tetanus (idiopathic) Hydrophobia Hemorrhage Concussion 198 200 200 201 203 207 208 210 212 213 214 214 216 XIV CONTENTS. TAOS CHAPTER XVIII.— Chronic Diseasks ok the Si'ixal Cokd. Myelitis -....,.. . 217 Meningitis ....... . 219 Induration and Hypei-trophy . . . . . 220 Tumors, &c. ....... . 220 Paraplegia (Idiopathic) ...... . 221 PART IV.— DISEASES OF THE NERVES. CHAPTER XIX. — General Considerations. Excessive and Diminished Activity of Function . . . 224 CHAPTER XX. — The Diagnosis of Special Diseases of the Nerves. Organic — Neuritis ....... 225 Tumors . . . ... . 227 Inorganic — Neuralgise ....... 228 Hypercineses ....... 230 AntEsthesise ....... 232 Acineses ....... 232 APPENDICES. APPENDIX A. — On the Sensori-motor Ganglia. APPENDIX B. — On the Relation between Functional Disturb- ance AND Structural Changes. APPENDIX C. — On the Relation between Volition and Involun- tary Movements. THE DIAGNOSIS OF DISEASES BRAIN, SPINAL CORD, NERVES, AND THEIB APPENDAGES. PART I.-GENERAL. CHAPTER I. THE OBJECTS OF DIAGNOSIS, AND ITS LIMITS. The clear statement of a problem removes mucli difliculty from its solution; and, in order to elicit the truth from nature, we must ask questions which bear upon that truth. We must know what it is we wish to find out before wc commence the process of its discovery. We must, therefore, state at the outset what we are endeavourini^- to find, or, in other terms, what arc "the objects of diagnosis," before detailing the means bj which those objects may be attauied. The problems of which this treatise is intended to ofier some solution are threefold, and may be stated thus: — First, — Given, a certain class, or group of phenomena, to find the organ or organs affected; in other words, — given, the symptoms to discover the locality of lesion. Second, — Given, the symptoms and the organ affected, to find the nature of the affection.* Third, — Given, the symptoms, locality, and nature of tlie affection, to discover its anatomical conditions. * The result of this second inqiury (the nature of affection), may be stated in two classes of terms :— A. Dynamic — i. c. a general statement of the affection in pathological phrases ; such as depression or exaltation of this or tlie other function. B. Static — /. e. an account of the anatomical conditions which induce or underlie such pathological (dynamic) results. The order adopted in the text is preferred to this division of the second prolilem. j B A^ / 2 OBJECTS OF DIAGNOSIS. First. — Locality, or organ affected. The earliest and most important distinction we have to make, is that of the extrinsic from the intrinsic diseases of the nervous system. I. Extrinsic diseases. This term is employed to denote all those collocations of nervous symptoms which depend upon some general morbid condition, rather than upon the particular state of the nervous system itself. It is not intended that this treatise should contain a resume of all the various phenomena of disturbance in the nervous functions resulting from derange- ment, of the nutritive processes generally, or of some particular organ ; but that it should point out the means for distinguishing certain well-marked groups of "nervous symptoms," when the attendants upon such changes in the vegetative sphere, from those which are induced by primary alterations in the function or structure of the nervous centres themselves. Frequently the symptoms of these two classes are closely allied, and they may complicate each other. We cannot state positively, that in the case of nervous symptoms arising from extrinsic disease, there is any morbid condition of the nervous centres themselves ; for the symptoms in question may be nothing more than the appropriate reaction of those centres upon the special stimulus brought in contact with them. The really diseased element is the stimulus.* For example, — the coma or spasmodic movements which result from the presence of urea, some urinary constituent, or from opium in the blood, do not indicate disease of the brain or spinal cord. They may be as truly the physiologic or healthy result of those con- ditions as sleep is the result or sequence of exertion, and contraction of the pharyngeal muscles the consequence of an impression on the mucous membrane of the fauces. The importance of such distinctions, in respect of treatment, renders it imperative, in every case, to seek first for the pre- sence of any general organic conditions of disease, to which all the symptoms may be referred ; and in the event of their discovery, to examine carefully their nature, and appreciate * The word " stimulus" is here used in its widest meaning ; viz., the exciting cn.u«^, or occasion of nervous action. LOCALITY. S their value. But if such indications are undiscoverable, we tlien (and not until then) infer the existence of disease or de- rangement in the nervous system itself. II. Intrinsic diseases. This expression is intended to include all those groups of morbid phenomena which depend ujjon functional or structural changes in the nervous system itself, and its immediate appendages, the meninges, &c. There are three well-marked lines of distinction, which, from their evident relation to anatomical and physiological characters, will be adopted in the present work. They divide, of course, the encephalon, the spinal column, and the nerves. A. The Encephalon. This has to be considered separately, in respect of the nervous tissues themselves and their meninges. It often happens that this distinction cannot be established sa- tisfactorily, disease of the one being so frequently complicated with derangement of the other; but in many cases the separa- tion is quite possible, and in some there is little, if any, room for doubt. 1. The nervous structures of the encephalon are to be re- solved into the cerebrum, cerebellum, and sensory (or sensori- motor) ganglia. It is often quite impossible to affirm the locality of disease, even with such rough precision (if the term may be used) as to separate these well-marked anatomical elements; but in some cases — as of tumor, for example — this may be accomplished. a. The cerebrum. We may in the majority of structural diseases determine which lateral half is affected; and in parti- cular cases we may arrive at strong probability that the lesion is situated in certain portions of the cerebrum, such as — i. The substance of the hemispheres, with the occasional discrimination of cortical (vesicular, grey) from central (me- dullary, tubular, white) substance, especially in inflammatory affections. ii. The ventricles. The occurrence of ha2morrhage (for example) into these cavities may sometimes be distinguished from effusion into the substance of the hemisphere. iii. The base of the brain, and B 2 4 OBJECTS OF DIAGNOSIS. iv. Its superior surface. Inflammation of the brain-sub- stance and of the meninges presents different symptoms when occurring in the two latter situations. h. The cerebellum. Much obscurity yet hangs around our appreciation of the proper functions of this organ, and the modifications which its diseases may occasion in the processes of life ; but there are reasons for thinking not' only that some of its diseases may be recognised during life, but that we may separate, more or less accurately, those which affect — i. The centre, or processus vermiformis, from those seated in — ii. The lateral lobes. c. The sensorl-motor ganglia. It appears to me that we are compelled, upon physiological and patholico-clinical grounds, to consider these bodies as nervous elements, equally distinct from the cerebrum, cerebellum, and spinal cord, as either of the latter is from the others. (For some of the reasons for these opinions see Appendix A.) Certain diseases, such as softening, for instance, appear to have a special proclivity for affecting these organs ; and there are some dynamic changes which are more satisfactorily referred to a morbid condition of their func- tions than of any others. In the present state of our science we are unable to determine which ganglionic mass is affected ; but the progress of research may render it possible to dis- tinguish i. The corpora quadrigemina. ii. The thalami optici. iii. Tire corpora striata, iv. The pons VaroHi. 2. The meninges, and coverings of the brain. Under cer- tain circumstances, to be discovered by the history and com- memorative progress of a case, we may distinguish diseases of a. The pia mater and arachnoid, from those of h. The dura mater. The symptoms in the main arising from the influence which meningeal conditions exert upon the functions of the under- lying organs, it is possible sometimes to distinguish menin- LOCALITY. 5 gitis (for example) of the base from tliat of the convexity of the brain. The primary commencement of disease in the dura mater may often be inferred from its connexion with morbid conditions discoverable in the organs of special sense, or from the existence of disease in c. The bones of the cranium, and d. The integuments, and subintegumental tissue. B. The sjiinal column. We have here to observe a dis- tinction similar to that pointed out with regard to the encephalon : the separation of disease in — 1. The spinal cord itself from that of its meninges; and the same remarks apply with regard to the occasional ditliculty of such a discrimination. However, in many instances, tl^e diagnosis may be made, and we have further to mark out the locaHty of lesion in respect of — a. The region affected. Sometimes the precise limitation of disease may be established, and minute examination will com- monly dilFerentiate i. The cervical, ii. The dorsal, and iii. The lumbar regions. h. The column, or columns, implicated, c. The grey, or white matter. With respect to the two latter, there is much more doubt; but the discrimination of their diseases as separate elements should be borne in mind in relation to symptoms and post-mortem appearances, even when during life we cannot assign the point of contact of the two. 2. The coverings of the cord. In many cases it is quite easy to determine the anatomical elements in which disease has commenced, although at an advanced period all the tissues may be involved. Some morbid conditions of the spinal cord arc more frequently associated v/ith disease of the bones tlian arc any allied conditions in the brain. We have to distinguish diseases of — a. The meninges, and h. The bones. The latter allbrding frequently niost impor- tant aid. 6 OBJECTS OF DIAGNOSIS. C. The nervous trunks. The precise symptoms, and the ordinary course of disease in these prolongations of the nervous centres have yet to be systematised. There are occasionally met with cases in which some phenomena are to be referred to many of these trunks. The most important, because the most frequent, and those whose morbid conditions arc the best known, are: — 1. Cranial nerves (or having origin and exit from the cranium). a. Sensory. i. The trigeminal, or fifth nerve, ii. The pneumo-gastric. h. Motor. i. The third, or motor oculi. ii. The sixth, or abducens oculi. iii. The portio dura of the seventh. 2. Spinal nerves. Any one of these may be alibcted, and we have to distinguish diseases of — a. The anterior, or posterior roots (motor, or sensory divisions) and also h. The region, or portion of trunk implicated. Second Problem. — Nature of the Affection. — It will be immediately recognised that (as stated in note, p. 1.) there are two methods in which this object may be viewed, or rather that there are two " stand-points" from which it may be considered. The term " disease" may mean the morbid pheno- mena and processes which are present, or the modifications induced in the functions of life ; and in this sense it is merely a general expression of the group of symptoms. It may mean, on the other hand, the cause of these morbid phenomena; the organic conditions upon which they depend; or the physical (anatomical) lesion which underlies the symptoms. The general agreement between symptoms produced by dis- similar physical lesions of the nervous system, and their fre- quent disagreement when arising from apparently similar causes, show that we have not yet arrived at a correct appre- ciation of the point of contact between the two ; at the same NATURE OF AFFECTIOX. 7 time tliey lead us to believe that it is not so mucli the nature of these physical changes as their degree and mode of induc- tion which determines the result. If the future progress of pathological research should eflfect the harmonisation of these two categories of disease, it has failed to do so up to the present time; and it is more consistent with truth to maintain their separation, pointing out whenever and wherever we can the places in which one may impinge upon the other. Having discovered the probable locality of disease, it is our next object to know its general character ; i. e., the nature, quoad function, of the change induced. For example, the head is displaced from the erect position by some abnormal disposition of action in the muscles of the neck, and we have to discover whetlier paralysis on the one side or spasm on the other is the cause of such displacement. A man suddenly falls to the ground, senseless and helpless, with stertorous breathing, and we have to find out whether this is an acute apoplectic seizure, or whether it is one of many other phenomena of chronic epilepsy. These illustrations are quite sufficient to make apparent the object and scope of the following classification of diseases; or rather, of general pathological conditions, which shall represent " the nature " of nervous affections. I. Acute diseases. These are separated from chronic not merely by their relation to time, but by the severity of their symptoms, and by their simultaneous development. Some diseases, which, although they may persist for a long time (the only change in their phenomena being a gradual and very slight diminution of their intensity), are, nevertlieless, at their onset, so suddenly induced, and carried so rapidly to their highest point of deviation from health, that we are compelled to place them in the list of acute affections. Hemorrhagic apoplexy affords an illustration of this class; but, on the other hand, some diseases (as, for example, acute softening), though rapid in their passage to a fatal termination, may be developed so insidiously and gradually in certain instances, that, until 8 OBJECTS OF DIAGNOSIS. undeceived by death, we may have looked iipon them as chronic affections of rather trifling importance. However, as a general rule, no difficulty will be felt, and the acute diseases will be readily distinguished, and separated into two classes, the febrile and non-febrile. A. Febrile diseases, or those accompanied with the signs of general febrile disturbance, such as heat of skin, high pulse, thirst, general oppression, anorexia, &c. The most important diagnoses to be made are the distinction of — 1. The specific fevers, with nervous complication, from 2. Febrile excitement, the result of the nervous state. Although this is a part of the general question of locality (the differentiation of intrinsic and extrinsic diseases) it does not fall completely under that head; and it is only necessary to make reference to the difficulty of distinguishing meningitis with fever of typhoid type, from true typhoid fever with meningeal irritation, to indicate the importance of such a separation. With the exception of a very few diseases, the affections of the nervous centres, even though referrible to the organic con- ditions of inflammation and its results, arc not marked by high fever. The greater number fall into the second list — B. Non-febrile affections; marked by 1. Diminution, or loss of functional activity. This con- stitutes the large class of apoplectic and paralytic diseases. 2. Increase, or excess of action, recognisable under three prominent groups formed by the natural endowments of the several organs : — a. Sensibility : the most marked characteristic being pain. h. Motility : its main features being convulsion and spasm. c. Ideation : marked by the occurrence of delirium. These various modifications of nervous function are presented in every form of combination ; but their most frequent group- ings are the subject-matter of ulterior classification rather than the object of the present chapter. II. Chronic diseases. As may be gathered from the remarks upon acute affections, the term is used to express not only the time but the severity of disease, and its mode of gradual NATURE OF AFrECTIOX. 9 development. However, no one of these characteristics must be taken by itself, and made the basis of division; since, for example, the severity of pain in many neuralgia3, essentially chronic in their course, is excessively intense, and may be developed witli full force in the first attack. The " time " comes to be of great importance in the diagnosis of these cases; and we must, in all instances, take a general view rather than fix our attention upon particular characteristics. The diflerent nature of chronic diseases may be arranged thus: — A. Those marked by excessive functional activity — 1. Of sensation; e.g., neuralgise, hallucination, &c. ; 2. Of motion, instanced by chorea, &c.; 3. Of ideation, as observed in the hypochondriac, &c. B. Those characterised by diminution, or loss of functional activity. 1. Of sensibility, in anaesthesias, &c. ; 2. Of motility, in paralyses, &c. ; 3. Of mental activity, in dementia, epilepsy, &c. C. Those presenting different elements of A and B in com- bination. The following combinations are excessively common in many organic diseases; e.g. 1. Loss of motility, with increased sensibility. (Paralysis with pain.) 2. Loss of mental, with increased motor activity. (Coma with spasm.) 3. Loss of sensibility, with increased motility. (Anaesthesia with reflex spasm.) To enlarge upon this scheme would be to entrench upon the subject of the next chapter (the means for diagnosis). The two mutually illustrate each other, and we can arrive at know- ledge upon the diseases of the nervous system in only the same manner as upon every other subject ; i. e., not by the progressive addition of element after element in a linear series, but by the simultaneous consideration and apposition of each class of truth in its relation to the others. It i^; by careful examination of 10 OBJECTS OF DIAGNOSIS. the symptoms in their threefold relationships of locality, func- tion, and structure, that we can arrive at conclusions with regard to either ; and the correct interpretation of symptoms being a matter of great difficulty, a separate chapter is devoted to their consideration. The heads given in this section are those under which the morbid conditions of function in an organ may be ranged, when, by careful examination, the seat of disturbance has been discovered: and thus the second object of diagnosis is obtained. Third Problem. — The Anatomical Condition. Some of the conditions referred to in this section occur much more frequently in one portion of the nervous system than another; others are common to them all. I. The nervous organs may be healthy; (i. e., so far as our present means of investigation enable us to decide the point.) There are many diseases in which there is no reason to believe that the nervous centres undergo, necessarily, any static or physical change, although, during life, there may be most marked and important symptoms. Allusion is made to the class of diseases known under the names of epilepsy, chorea, hysteria, neuralgia, &c. &c. ; and it is not unphilosophical to believe in the existence of morbid functions without demon- strable physical lesion, since the material world presents us Avith similar relations between the static and dynamic properties of matter. This treatise is not the proper place for a discussion of the question at issue, but some remarks will be found upon it in the Appendix.* Although many of these affections will come imder notice, the most numerous may be ranged under the second group: — II. Diseases accompanied by some physical change in the organs. A. Without change in the tissues themselves. ' 1. Blood abnormal in quantity. a. Anaemia; or, in less degree, Hyposmia. It is not pro- posed to decide, either positively or negatively, the question as to whether more than a fixed proportion of blood can find its * Vide Appendix B. ANATOMICAL CONDITIONS. 11 way into the brain. It is certain that very difTercnt apparent vascularity is discoverable post raortera, and that there are two classes of nervous symptoms dependant upon the amount of blood in the brain, if we may form any estimate from the demonstrable varieties of its amount in the body generally. b. Hyperasmia; distinguishing the old-fashioned — i. Active; arterial; or " determination ;" from ii. Passive; venous; or "congestion." These distinctions, inasmuch as they cannot be recognised post mortem, have recently received less attention than they merit. Their symptoms are dillerent when occurring as simple elements of disease; and they are still more diverse when pre- sented as the complications, or secondary results of other and more serious lesions. 2. Blood abnormal in quality ; whether arising from — a. Specific fevers ; typlioid and exanthemata : h. Retained secretion-elements ; urina^raia, icterus, rheuma- tism : c. Introduced poisons; alcohol, opium. 3. Excess of serous etflision in ventricles, or arachnoid cavity. B. Diseases having textural changes in the organs. 1. Homologous, or normal products, &c. a. Inflammation, with exudation and suppuration. b. Fibrinous exudation, with induration or adhesion. c. Softening, and vascular changes. d. Haemorrhage, and transformed haemorrhagic clots. e. Fatty, or calcaieous degeneration of vessels. 2. Heterologous, or abnormal products. a. Deposits in tissues, not of independent growth — i. Tubercle (granulation and crude tubercle); ii. Carcinomatous intiltration ; iii. Cretaceous deposit. b. Growths, vascularised or increasing — i. Hydatids; ii. Fibrous and osteoid tumors, &c. It is nut intended that this sunnnary should be exhaustive. c 2 12 OBJECTS OF DIAGNOSIS. It is ratlier a simple classification of those forms of organic change which may, any one of them, under certain circum- stances, be inferred with much probability to exist in some portions of the nervous system. The object of this treatise is not descriptive pathological anatomy, but the relation during life of symptoms to static changes, and the means by which a diagnosis of the latter may be established by a due considera- tion and estimation of the former. The means for arriving at a solution of the three problems stated in the outset may be given thus, in general terms : — 1. The locality of lesion, or the organ affected, is deter- mined by — a. The special quality of the symptoms — i. e., the existence of morbid changes in a particidar function or group of func- tions; which are at once referrible to (because the functions are the proper action of) a certain organ, or part of an organ. Thus, mental changes are referred to one, emotional to another, and sensorial to a third portion of the nervous centres. b. The topographical distribution or limitation of the symp- toms. For example, the unilateral or bilateral distribution of paralysis (hemi- and para-plegia). 2. The nature of disturbance is a general statement quoad function of the organic condition. If a diagnosis has been formed with regard to the first object, there is less difficulty in arriving at the second : the two classes of consideration mutually assist each other. The second problem is solved by a carefid interpretation of the phenomena upon physiological and patho- logical orrounds. 3. The organic, or static condition is determined, not from the particular character or distribution of the symptoms so much as from — a. Their order of development; b. Their proportion to each other; c. From many extrinsic conditions; d. From certain objective, [)hysical signs; e. From the application of general pathologic laws. Pathological anatomy is a matter of inference onlv, during ORGAN — FUNCTION — .STRUCTURE. 13 the lifetime of the patient. In many instances the inference is attended with great doubt ; a doubt greater than tliat which attends the diagnosis of other classes of disease, owing to the larger number of subjective symptoms, or those for which we are dependant upon the statements of the patient. Still, in many cases we can arrive at approximative certainty ; and there can be no doubt that — as it has happened in the past so it will happen in the future — increased exertions and more careful methods will be rewarded with increased success. CHAPTER II. THE ELEMENTS FOR DIAGNOSIS. By the term " Elements for Diagnosis," is intended the symptoms of disease, which furnish the means by which diagnosis may be established. These symptoms are so varied in their character, and are susceptible of such different inter- pretations, that it would be impossible to render distinct the meaning of all passages in the several chapters devoted to the diagnosis of special groups of disease, unless some definition were given of the terms employed. To introduce these defi- nitions in the course of the chapters referred to would be both cumbersome and tedious; and it is, therefore, preferred to devote some little space to their consideration now. It will be at once apparent that such a course is necessary, if we call to mind a very few terms that are employed every day, and then consider what ideas are attaclied to them wlicn made use of by different individuals. For example, the phrases " loss of con- sciousness," "loss of memory," "sopor," and "convulsion," mean very different things, or may mean very little, when employed, as they often are, carelessly and without distinct limitation. The elements for diagnosis resolve themselves into two large 14 ELEMENTS FOE DIAGNOSIS. grou]3s, the iutrinsic and extrinsic; using these words with the meaning abeady appHed to them. I. The intrinsic, or proper nervous symptoms, are essentially modifications of the manner in which the organs of the nervous system perform their functions; or, in other words, they are altered functions. As these are dynamic in character, we must group them upon a physiological rather than anatomical basis. And it is the more desirable to do so, since, in the present state of our science, the particular functions of different portions of the encephalon and spinal cord are very variously interpreted. A. Mental phenomena. This group is composed of all those processes which make up the intellectual life of the individual ; those properties which pertain to the man subjectively con- sidered; the conditions of thought, volition, emotion, memory, judgment, &c., as distinct from simple motility and sensibility, which place him (objectively) in relation with the external world. As in the latter phase or sphere of life there is a ready distinction practicable into the two groups of property, by one of which the individual derives impressions from without, and by the other of which he is enabled to act upon and from him- self upon surrounding objects; so, in the higher operations of his own inner life, we may recognise two leading classes of mental function, the passive and the active : the former repre- senting that condition in which mental and emotional pro- cesses, open to all the influences of suggestion and impression from without, may " gently lead us on," without determinate direction or definite end ; the latter including those qualities of mind by which it earnestly engages itself, in the contemplation of its own internal operations, or of the modifications which they undergo from contact with the external world, and that spontaneous power by which all its actions may be directed to the attainment of a special object. We have to consider separately volition and emotion, as the two extremes of mental action, with ideation as their inter- mediating link, sometimes in subordination to the one, and sometimes to the other. INTRIXSIC SYMPTOMS. 15 1. Symptoms rcferrible to volition. Under this heading wo should range those modifications of the will (or the direction of consciousness) which appear to be primary elements of disease. They may be recognised in relation to ideation, emotion, sensation, and motility; and it may be premised that very frequently certain morbid processes are referred to one of the latter, when, in reality, the primary change is in the exer- cise of volition itself. Illustration of this will appear as we proceed. a. Volition in relation to ideas (or to ideation). We judge of this relationship by observing the kind and amount of influence exerted by the will in the acquiring of new ideas; in the recollection of old ones ; in the direction and the use which may be made of earlier knowledge in its bearing upon the events and actions of the day. The symptoms of this class resolve themselves into — i. Modifications in the power of attention (or the simple direction of consciousness), which may be those of excess or defect; and when the former usually indicate some perversion. Diminution may exist in any and every degree, until the faculty is completely lost. It may be estimated directly or indirectly, as pointed out under iii; being a most potent cause of the earlier so-called deficiencies of memorv. The exao't^erated attentiveness of the insane man, and the listless apathy of some epileptics, and of many hysterical subjects, present illustrations of this element of disease. ii. Modified power of apprehension. An unusual quickness of perception is sometimes observed ; but we have more fre- quently to encounter the inverse change of diminution. Its association with deficient attention is obvious, not only theo- retically but practically; there arc, however, cases presenting deficiency of apprehension, although the patient may be all eagerness and attention to what is going on. The distinction between the hysteric and the idiotic patient may well illustrate this point; in the former case, however, it is volition which is immarily at fault, in the latter, it is ideation. To this kind of case I ain not referring now, except in support of the state- 16 ELEMEiSl'S FOR DIAGNOSIS. ment that it is not solely a question of attention. Loss ol' apprehension appears to be the second step in the process of" volitional decay : the second external phenomenon of the internal deterioration. iii. Changes in the faculty of recollection. Memory and recollection are not the same ; we have a thousand things in our memory which we cannot vohmtarily recal, although some susfsrcstions, or " remlndino-s " from without mi2"ht in- stantly bring them back. It is questionable wliether an im- pression once being made upon our minds, and having become the subject matter of thought, woven, as it were, into the fabric of our intellectual life, is ever effaced; although it may be lost for a time, and hidden under the accumulation of suc- ceeding years, some new circumstances, some morbid condition, or some direct suggestion, may bring it to the light, and render it as clear and intelligible as on the day of its reception. Thus, the memory is the faculty of retaining, and the fact of retained impressions. Recollection, on the other hand, is the power of finding and bringing into use the facts or ideas which are retained. Loss of memory, or more truly of recollection, is exhihited well by the epileptic. In its earlier stages and slighter degrees, the individual remembers accurately events that have long since passed, but cannot retain in his mind from day to day the trivial things which he may be told. The real cause of failure appears to be want of attention, so that impressions are but feebly made, and are very rapidly effaced. This slight degree of failure should be carefully distinguished (by an experimental reference to the power of attention) from that more serious condition, in which old ideas and associations are blotted out, or at all events rendered useless. The latter change is referrible to interference with the conditions or processes of ideation. (See p. 24.) iv. Modifications in the power of directing thought. The condition of the mind during dreaming and quiet delirium, is that of thinking, apart from volitional control. Li hysteria, wo often find the patient mentally tortured by ideas which are IXTKIXSIC SYMPTOMS. 1 7 perfectly free from voluntary restraint: she surrenders herself without effort to the chain of morbid notions. In opposite cases — for example, in some forms of mania — we find examples of the power which a morbidly-active will may use in pervert- ins; ideas from their true relations. It is often a matter of much difficulty, but always one of importance, to separate the elements of disease, and interpret them correctly ; and I believe it often happens that we overlook this class of derangement, which in great measure depends upon the individual, and for which he is responsible; and by referring its phenomena to some morbid physical conditions, lose the right direction for successful therapeutics. The epi- leptic and the hysteric have to be taught self-control, if we would gain any influence over their direful maladies. b. Volition in its relation to emotion. Normally, there is a controlling and directing power, with regard to the influence of feeling upon thought, with regard to the intensity of the former, and the freedom of its expression. In disease this relation is disturbed, and we find many whose life is entirely guided by emotion, and though often guided correctly, is as often wrong. There are, as we know full avcH, constitutional dif- ferences in respect of the intensity and moulding influences of " the heart." Their treatment is one of the branches of educa- tion rather than of scientific medicine; but we too often have to deplore derangements arising from imperfect attention to the former, which no skill in the latter can avert. In disease we may recognise very frequently — i. Diminished control of emotion. It is a striking fact that many diseases anticipate the work of time, and present us, even in youth and middle age, with the characteristics of mental decrepitude. Insanity, chronic softening of the brain, epilepsy, hysteria, chorea, and many other nervous affections, produce in their sulijocts this loss of volitional control, which is so common when the powers of life are worn out by their long battle with the world. The loss of voluntary direction exists sometimes alone, but much more frequently it is asso- ciated with — D 18 ELEMENTS FOR DIAGNOSIS. ii. Diminished control of expression. The patient laughs, and cries, and acts out his impulses without any attempt at their suppression. The two need not co-exist; the former is an internal change, sometimes to he discovered only by dili- gent search, and by gaining the "confidence" of the patient; the latter betrays itself at once in his tone, manner, and gesti- culation. c. Volition in relation to sensation. This relation is the " perception" of sensation ; or, the mental intuition (formed idea) from a recognised external impression, as to the nature of its cause. The normal exercise of this faculty results in the establishment of a due equation between the inten- sity of its objective and subjective elements. The hypo- chondriac, never reaching such a correct interpretation, when afflicted with a pimple on his toe, feels all the tortures of the gout. i. Morbid quickness of perception may be recognised as an element of disease. It is indicated by the rapid formation of ideas from all impressions (which ideas may be right or wrong, but) which evince a quick and keen intuition of meaning. This condition exists not unfrequently in children, whose nervous system generally is delicately constituted and unduly susceptible: it is found also in the hypochondriac, who not only exaggerates all his sensations, and with unhealthy rapidity interprets them to his own discomfort, but who can create them in accordance with his preconceived ideas. The maniac affords another instance of the manner in which a morbid Will can, with marvellous quickness of intuition, adapt everything that the individual hears, feels, or sees, into some confirmative evidence of his own delusion. ii. Diminished perceptive power is evidenced by precisely the reverse condition. Perception may be absent altogether; and nothing which is said or done can then attract the atten- tion of the patient. There may, however, in this state be distinct evidence not only of reflective sensibility, but of sensation itself. Sensori-motor phenomena occur; but there is no evidence, either from the phenomena of the time, or from INTRINSIC SYiirTOMS. 19 the subsequent statements of the patient, that any mental perceptive power was present. An indi\idual in this state presents two conditions of ideation. When he lies perfectly motionless, cannot be made to utter a sound, and makes no attempt to do so spontaneously, we say that there is "loss ol' consciousness :" when, on the other hand, he is talking, coherently or incoherently, upon matters totally distinct from those around him, we say that he is " delirious." The expression, " loss of consciousness," appears to me objectionable, since it is merely an assumption that such loss exists — an assumption which the after-evidence of many cases has proved to be incorrect, if by that expression it is intended that the mind is inactive, and no self-conscious- ness remains. If, however, we mean that there is no conscious- ness of external impressions, the phrase is a bad one, since there is some consciousness of sensation (using that term in its literal meaning), as demonstrated by sensori-motor phenomena. What we do mean is, that there is no mental, internal con- sciousness (or appreciation) of external, physical change; and this circuitous expression is much inferior to the phrase, " loss of perception ; " the latter conveying what exists in fact, so far as we are able, from direct observation and dim memory, to ascertain. This expression will be used in the succeeding pages, and will mean what is commonly understood by " loss of consciousness." In delirium it is evident that consciousness exists; but there are, at the same time, evidences of a still farther and more complete removal of that consciousness from surrounding objects: and this condition gives additional support to the statement made above, that we arc not justified in asserting such an absence, when all that we know is the absence of perception. d. Volition in reference to motility. The relation between these two (like that which we have just considered) is not direct or immediate; neither is it possible for us to judge of its conditions, except indirectly or mediately. We can discover the presence of sensation and perception in others only by the D 2 20 ELEMENTS I'Oii DIAGNOSIS. signs which they may make : we can recognise the conditions of motility only by motion (objectively), and its described relation to the will of the patient (subjectively), as he may please to inform us. Thus the difficulty is sometimes very great to distinguish between immobility, the result of some lesion cutting off the muscles from their functional connexion with the centre of volition, and immobility from a simple want of exercise of will. The paralysis of haimorrhage and of hysteria, for example, illustrate this difficulty. The morbid relations between volition and motility may be referred to one or the other of the following divisions: — i. Power of occasioning movement. The normal standard of this faculty varies with the individual, and with his con- dition of health at different times ; so that we can only regard extreme or unduly persistent variations from his habitual power in the light of morbid phenomena. a. Excessive voluntary movement is often a marked feature of the maniac; violent actions are witnessed far beyond the ordinary strength of the individual; and, in other instances, where there is no increase of momentary energy exhibiting itself in excessive action, there is no less distinct evidence of increase, in the persistence of some movement, movements, or attitudes, during successive days and nights, without the shadow of apparent fatigue. /3. Defective volition in relation to motility. In certain conditions of general apathy and intellectual debility this state is observed, independently of any other nervous disease. It is one marked characteristic of hysteric paralysis, or rather apparent powerlessness. It is often observed in the organic weakness which follows excesses of various kinds. Patients of this kind loll about on sofas all the day long ; and cannot, because they " will" not (have not the wuU to) move. Sometimes a certain group of muscles is fixed upon for inaction ; sometimes the wdaole body is thus volitionally palsied. The characteristics of such a condition are — the manner of the patient, which shows the deficiency of will in all of its spheres for action ; the occasional production of movement under the infiuence of INTKINSIC SYMPTOMS. 21 Strong emotion, or any accidental impression tlirowing the individual off his guard; the increase of paralysis when attention is directed to the limb, or when the patient is told he can move it, and he protests against such interpretation of his malady ; and the variabiHty of situation which the loss of power may affect. ii; Power of directing movements. In many chronic para- lyses the earliest indication of disease is a dhninution of this faculty. (See " Anaesthesia Muscularis," chap, xiii.) It is much less a failure of the will itself than of the physical organism through which it acts. We may more confidently anticipate real disease from such a loss than from the decrease of power. In commencing paraplegia, it is the commonest symptom and the most perplexing. Often, however, it appears to be dynamic only, and there is much good to be derived from a cultivated exercise of volition in relation to certain movements. I have seen this well exemplified in the cure of stammering, by deter- minate readincj aloud for hours together. iii. Control of involuntary movement. The relation of volition to a-volitional movement is a subject of much import- ance, and of no little difficulty. The text of this treatise is not the proper place for its discussion, but I have placed in the Appendix,* some points which we may consider estabhshed, and which will aid in the appreciation of the present section. It is certain that the power which some individuals possess is very great, and it is evident that this faculty is diminished in others. In many spasmodic diseases having, probably, a real and uncontrollable origin, the movements persist after such primary cause may have been removed, owing to the want of attempt at their volitional control. There are instances in which the grotesque movements, often persistent when the general signs of chorea and allied aflections have passed away, have been removed and overcome by a process of volition-education. In other cases such ugly phenomena remain, and afford very fre- quently the evidences of a faulty will, and not an unfortunate constitution, to which they are very often attributed. * >:!cc Appendix C. 22 ELEMENTS FOR DIAGNOSIS. 2. Symptoms referrible to ideation ; or, modifications in tlie processes of thought. ' These changes we can only observe in- directly in words, expressions of countenance, and actions ; we are, therefore, uncertain in our knowledge, and open to many falla- cies of construction. Some remarks have already been made upon the relationship of thought to will. We have now to consider : — a. Ideation as related to external impressions. Normally, there is consentaneity up to a certain point among different in- dividuals. We are so constituted, that certain phenomena, or the impressions which they make upon our organism should, in accordance with definite laws of thought, induce determinate mental processes, having a generic similitude in the whole human race. Naturally our minds are open to these sugges- tions from without, which not only furnish it with the mate- rials of thought and action, but which, when wandering away from realities amid the mazes of its own varied reflections, can bring it back again to common sense, and give it a new point of contact with the truth. In disease : — i. Ideation may be removed from the influence of external impressions ; and then, by no means wliich we can adopt, are we able to arrest or change the course of thought. Though roughly handled, and loudly addressed, the patient wanders on, pursuing his own line of cogitation as if nothing had oc- curred, and yet in a moment we may see, by some accidental occurrence, that the faculties of sensation and perception are persistent. This form of delirium is by no means uncommon, but is to be distinguished from the following, in which, ii. Ideation is in relation, but a perverted relation, with sensa- tion. The individual in this state listens to what is said; he takes notice of surrounding objects, but construes them erro- neously, sometimes in harmony with a fixed delusion which may have taken possession of his mind, sometimes without any link of this kind which others can discover. The patient of delirium tremens presents, not only this perversion, but, as is often the case in disturbed thought, a condition of hyper- ideation in which the mind is excessively fertile in conjuring up, with rapid succession, all kinds of egregious ideas, some- INTRINSIC SYMPTOMS. 23 times brilliant as the creation of Eastern fancy, sometimes darkened with the presence of " more devils than vast hell can hold." b. Ideation in relation to internal sensations. Those per- ceptions which do not arise demonstrably from modifications induced by external impressions belong to this category. It is difficult to draw anything but an artificial line between the processes of sensation arising from some change in the organic conditions of the body, when on the one hand those conditions occur apart from, and on the other in dependence upon, external impressions. Still, the ideation which results from them is different: a man rarely understands, or interprets correctly, those so-called suljjcctive sensations; and the hypochondriac presents us with the most absiu'd and gigantic inferences (ideas) from the most common-place and trivial sensations. This appears to be a distinct element of disease, and one which in its lower degrees may occasion much confusion. c. Ideation as an independent process, that is, as taking place without immediate dependance upon impressions ab extra. The relations of thought to each other are manifold, and may be expressed under various denominations; but there are two great classes which we have to separate, and which it is the province and business of our inner life to separate, viz., the real or essential, and the unreal or accidental. The first mode of relation is an expression of, and is dependent upon, the logical or true affiliation of ideas, resulting from the nature of the ideas themselves; the second includes those accidental or unreal associations which pertain to words (the investiture of thought), such as their similarity of sound, &c., or Avhich may have arisen from their simultaneous origination. It is an im- portant property of mind that thoughts should suggest one another, and that they should do this in various ways. " Imagination" is a word employed to expres's the faculty and the product of novel associations which are created by the mind. '* Fancy " is rather the unrestrained play of thought, than its directed creative action. " Memory" is an important link or element in the process, when we mean by that word 24 P]LEMEXTS FOli DIAGNOSIS. retentivcness of impressions and ideas: it is the product of that process when used in the sense of "Recollection." The exercise of " Judgment" is shown in the appreciation (by a volitional effort) of the true links of association, i.e., the truest or most logical arrangement of ideas which we can arrive at in the present state of science and of human intelligence. These faculties meet at various points, and are mutually inter- dependent; but their essential elements may be distinguished by careful observation and no less careful thought. The symptoms which we may recognise in various forms of disease may be placed under these heads: — i. Loss of power to appreciate the logical sequence of ideas. The patient becomes bewildered when he attempts to pursue a train of thought. He may succeed up to a certain point, but then fails to continue. This is observed in many chronic diseases of the brain, such as softening, chronic meningitis, &c. ii. Sequence of ideas rapid, but accidental (or, at all events, illogical). The patient rambles hurriedly from one thought to another, and has little or no power for their control or regu- lation. This is found in many forms of disease of which delirium is a symptom. iii. The absence of all discoverable sequence : the conversation being utterly incoherent, and out of all due relation to external impressions. This is the case in some cases of softening, but is more common in the complete fatuity of dementia. iv. Loss of memory, in its more severe forms; the absence of any useful recollection of past impressions. This is, of course, an important element in the production of incoherence, but sometimes we are unable to judge accurately of memory from the mere fact of incoherence. V. Positively exaggerated ideation is the important feature of some forms of delirium. (See Vohtion in relation to Idea, p. 15.) There is intense rapidity and energy of thought which may be to a certain extent correct and sequential, but which is beyond the limits of average health. The over-anxiety and worry of business and professional life induce this con- dition of mind, and incapacitate men for active work, when INTRINSIC SYMPTOMS. 25 there is no evidence of any further derangement. When such exaggeration of ideation (attended, as it often is, with insomnia, or harassing dreams), is complicated with ii. or iii. (de- ficient appreciation of sequence), the man is delirious ; when combined with vi. (delusion), he is insane. vi. Perverted ideation, or the existence of fixed delusions, which no external impression and no power of volition can remove, or demonstrate to he false. This is, i^o tanto^ " insanity of mind," d. Ideation in relation to motility. The excessive influence of ideas upon muscular action is witnessed in a certain class of people as their congenital or acquired constitutional pecu- liarity: the "table-turners," and "electro-biologic-subjects" are examples of such misfortune. As disease, the same tendency may be found in the hypochondriac, the hysteric, and choreic patient. The muscles are moved often in opposition to the will, and peculiar convulsive attacks occur, with strange palpitation, &c. &c., from the simple concentration of thought upon the subject. Ideas may be seen to affect muscles which are para- lysed in respect of volition. {Vide motility, p. 33.) 3. Symptoms referrible to emotion. Under this group are included all those modes or frames of consciousness in which the individual may think, act, or be acted upon; the feelings of pleasure, displeasure, joy, or sorrow, &c. &c. (those states of consciousness), which an idea or sensation may produce; the wishes or motives which induce any course of thought or con- duct. Thus, under the term emotion are grouped two classes of elementary processes ; the one active, the other passive, the former representing those feelings and instincts which are the sources and impulses of much personal and social action; the latter representing the condition of the individual, during his various forms of intercourse with the world, and in the recesses of his own heart. a. Emotion considered as the source of action. Attention has already been directed to the relation between emotion and volition ; and it has been pointed out that this relation is often disturbed in disease, and that sometimes such disturbance is (as 26 ELEMENTS FOR DIAGNOSIS. in liysteria) one prominent characteristic of tlie affection. The combination of diminished will and exaggerated emotion is such, that each morbid perversion adds intensity to the other. Emotion, considered as embracing the various instincts, has to be taken into account in this enumeration of symptoms; the nutritive, sexual, and maternal impulses undergo various modifications, relating, however, rather to the natural history of insanity, than to the diagnosis of cerebral disease. It is suffi- cient for the purpose of this chapter to point out the fact, that these instincts may be exaggerated, perverted, or diminished, since, in the present state of science, their alterations throw little light upon our immediate object. The relation of emotion to motility will be discussed under the latter head. (See p. 34.) b. Emotion considered as a state (rather than an action). i. The "spirits," or frame of mind, may be unnatural. In children this is frequently one of the earliest indications of dis- ease. It is the fact of change from the habitual condition, rather than the precise nature of that change, which it is im- portant to observe. Unusual gaiety or cheerfulness is to be looked upon with as much suspicion as despondency or dulness. In old age an undue hilarity is often the only symptom of approaching decay. Some diseases are well known to have among their group of features, special conditions of emotion. In phthisis, " the temper, though irritable, is singularly hope- ful. Every one has seen cases in v»diich arrangements for future years are made within a few days of death ; and I have actually known the question of a change of profession com- placently considered within three hours of the fatal event. . . . Hopefulness constitutes a special clinical feature of the disease, and cannot by any means always be explained by the absence of pain. Contrast the phthisical with the cancerous patient in this point of view." * Dr. Walshe is here writing of thoracic diseases, but the same characters are to be observed Avhen the locality is different. The cachexice of carcinoma and tubercle present their own special features, whatever may be the structure in which their organic development takes place. * Wiilshe,— Diseases of the Lnngs and Heart, p. 386. INTRINSIC SYMPTOMS. 27 ii. The temper is rather the occasional than habitual frame of mind, and, like the latter, may allbrd in its changes early indications of disease. We have to recognise as symptoms : — a. Excessive Irritability. /3. Perverted character (or unusual), •y. Rapidity of change from one to the other extreme. B. Symptoms not mental, but intrinsic ; and therefore de- pendent upon modifications in the functions of some portion or portions of the nervous system. These resolve themselves into morbid conditions of sensibility and motility : the two poles, as it were, or points of contact between the individual (or inner life), and the general (external world), by which he is sur- rounded. The media by which self is placed in relation with not-self; the means by which objective and subjective pheno- mena become each translated into terms of the other. By sensibility (using that word in its widest range of meaning, and including perception) is intended tliat process and property by which certain parts of the organism are capable of converting impressions from without, or properties of the external world, into phenomena of consciousness, the passage from the objec- tive to the subjective. By motility is intended the reverse ; the process by which mental conditions become translated into physical acts. By sensibility, the individual is acted upon from without; by motility, the world is affected from within. But there are relations between these two processes or properties into which consciousness does not enter as the necessary link ; there are others of which it takes no cogni- zance whatever ; these are the sensori-motor and reflective' phenomena, and their modifications by disease are no less im- portant than the former. The most valuable information we can obtain in respect of diagnosis is found in the examination of these changes: their value depends upon their objectivity, which frequently renders them as free from the control of the patient, or the moulding influences of his mind, as are many of the physical signs by which we judge of diseases of the heart and lungs. 1. Symptoms rcferrible to sensation or scnsibiUty. These E 2 28 ELEMENTS FOR DIAGNOSIS. are manifold, as the qualities of matter to be appreciated are various. There is a certain definite proportion between the intensity of an impressing cause, and the sensational effect which it produces ; and this proportion, though differing with individuals, is, in the main, restricted during health within certain limits. It is important, therefore, to know both the typical amount, and the individual peculiarities. The physio- logical exaltation or depression of sensibility is sometimes general, but this is by no means universally the case ; for fre- quently we meet with great acuteness of one sense, and great obtuseness of all the others in the same individual. In diseased conditions there is sometimes partial, sometimes general change : the latter usually indicating a condition of general organic dis- ease; the former, some structural lesion of a definite nervous element. One other remark should be made, viz., that the intensity of a sensation depends upon several conditions, (a.) The inten- sity or force of the impressing cause, (b.) The amount of attention bestowed upon its recognition, (c.) The degree of change which is induced in the organism, dependent upon the novelty of the impression, or its habitual production, (d.) Con- stitutional peculiarities, (e.) The perfection or imperfection of the materia,! organs for its reception and conveyance. We must, therefore, take all these conditions into account when inter- preting the sensations of a patient. Some of the terms which will be used in this section are new, but they contain only the elements of expressions which we are constantly employing in re^'ard to other symptoms, and they will be at once understood, and, I believe, seen to be more explicit than those which are more frequently in use. a. Increased sensibility. " Hyperoesthesia," the word gene- rally employed to express this condition, has included two very different modifications of sensibility : one being true hyperass- thesia, i.e., the increase of impression-effect, undue acuteness of sensation ; the other, hyperalgesia (as it has been somewhat inaptly termed), marked by the occurrence of pain upon the production of any sensorial imj^ressions. The difference be- 1^■TRINSIC SYMPTOMS. 29 tween these two elements of disease is more than one of words, each modification has its own cHnical relations ; and there is little tendency for them to co-exist. A simple contrast of the patients with meningitis, or tumor, who shun the light, and bmy their heads in the bed-clothes to avoid all sounds, from the increase of pain which such impressions cause, but who neither of them present any real morbid acuteness of sight or hearing ; with the man of unsound mind, or the ana^miatcd and hysteric woman, either of whom can hear and see thino-s which are hidden from the ordinary sense, but who may, at the same time, experience no pain from such sensation: — this con- trast — will at once make evident the kind of distinction which is intended. By hyperossthesia, therefore, is intended tlie simple augmen- tation of sensorial power, apart from any relation to pain ; and except in minute degrees it is by no means a common symp- tom. It exists most frequently as a general condition, and is, therefore, probably referrible to the central portion of the sen- sorial apparatus. For example, the muscse and tinnitus of anai- mia (which indicate an hyper-acuteness of sensation), exist in common with generally exalted susceptibility, and are, pro- bably due to the manner in which the organic condition of tlie body affects the brain. Genuine hypera^sthesla is most com- monly attendant upon some mental change, or upon general systemic disease. h. Diminished sensibility. The word " Anaesthesia " ex- presses the absence of sensibility, and this is more than is in- tended. It may be useful to restrict its meaning to this extreme, and for the several degrees of diminution short of this (absolute loss), to employ the term " liyp-ajsthcsia." The condition which it expresses may be general or partial. In the former case, it is most commonly the result of systemic disease; e.g., some abnormal blood conditions, typhoid, typhus, &c., or general cachexia, from the depravation of vital energy itself, as seen in tubercle and carcinoma. When partial, hyp- ajsthesia is more commonly dependent upon local disease. The essential characteristic is loss or diminution of scnsi- 80 ELEMENTS FOR DIAGNOSIS. bility; exhibited in the eye by confused, misty, ill-defined vision; in the ear by deafness, &c. ; in the general cutaneous sensibility by diminished tact. The focal distance, the amount of light required for reading print of fixed size, may be the means of measuring sight ; the hearing-distance for the watch-tic, and Weber's method with the compasses, may measure audition and tact; placing sapid substances (colocynth, quinine, sugar) upon the tongue, and presenting odoriferous matters (assafoetida, lavender, &c.) to the nose, will become measures for the diminution of smell and taste. The cutaneous sensibility should be examined in different manners; since there are different properties with regard to the recognition of which sensibility is not always simultane- ously or equally effected: e. g., changes of temperature may be recognised when pinching and pricking are not. Weber's method is probably the most accurate measure of the proper sense, tact. The sense of sight presents similar complexity ; there may be colour-blindness, though distinct appreciation of form persists. Hearing, also, may be lost for sounds above or below a certain pitch, but retained for every other. c. Modified sensibility. In uniformity with the preceding words, this change may be termed " Met-asthesia ;" and it implies something more than a simple alteration of plus and minus. Hypera3sthesia, and anaesthesia, with their inter- mediate hypsesthesia, refer to changes in quantity; metsesthesia includes all changes of quality. The first to be noticed is: — i. Dyssesthesia, or painful sensibility. By this term, I do not mean the occurrence of spontaneous pain here or there, but the definite production of pain by sensorial impressions from without. This, which is now frequently termed " hyper- algesia," has often been confounded with hypereesthesia (see p. 28), but I have already mentioned examples and illus- trations of their difference. The characteristic of dyssesthesia is, that sights, sounds, contact with foreign bodies, &c. &c., induce pain, without any necessary augmentation of the sen- IXTEIXSIC SYMrXOMS. 81 sation. Meningitis affords, perhaps, the best ilhistration of dysccstliesia. ii. Pseud-sesthesia, or the occurrence of false sensations. These inchide a great variety, which it is difficult to reduce to order, and for which it is often very difficult to account. Per- haps the recognition of the two following groups may aid towards their future appreciation of their morbid elements: — a. Sensations arising from external impressions, but modified by subjective conditions. The modifications induced are mani- fold, and may be in respect of either of the following : — (1.) Quahty of sensation. Hot, taken for cold; noises, giving appearance of light, &c. (2.) Quantity. A single body appearing double; diplopia. (3.) LocaHty. The impression upon one part being re- ferred to another; from arm to leg, and vice versa, &c. &c. /3. Sensations purely subjective in their origin, or arising, so far as can be ascertained, independently of all external im- pression. It appears that we are correct in believing, that with regard to sensation it is always the central change of the organism which the mind perceives, and that it is not the property of external, material objects. If so, a central change (analogous to that which the impression from without induces), arising spontaneously, may be referred (mentally) to the con- ditions which, experience teaches us, are usually the causes or occasions of such modification. Thus the so-called subjec- tive sensations have their origin; but Ave are incompetent to assert whether this origin is purely mental, or whether it depends upon some central organic (physical) change. It may be that sometimes one, and sometimes the other, is the case; and there are reasons for thinking that the delusive appearances of insanity are the product of a disordered mind, whereas the pseudo-sensations of hysteria are those of a diseased nervous system. Whether this be the case or not, we may distin- guish : — (1.) Sensations referred outside the body; the spectra which haunt the vision of the insane man, and the suflerer from 32 ELEMENTS FOR DIAGNOSIS. delirium tremens; the sounds wliich tliey hear; and the op- pressive weight which they feel thrust upon them, &c. (2.) Sensations referred to the body itself. These are exem- plified by various neuralgias, by globus hystericus, vertigo (of subjective form), and the thousandfold sensational creations of the hypochondriac. Occasionally they may have a peripheral organic basis, but more frequently they depend upon some centric conditions, or are to be regarded as phenomena of dis- ordered mind. 2. Symptoms referrible to motility. These resolve them- selves (phenomenally) into muscular contraction, or its absence; and their diagnostic value depends upon our recognition of the various causes or conditions of such contraction, and the relations wliich may subsist between them. We have separated for us by disease the following groups of variation : — a. Modified relation of motility to volition; which may be:— i. Increase of voluntary movements and power. This is observed in mania, and in some cases of violent delirium. The facts presented are the augmented force, persistence, and often variety of voluntary motion; and whether this excess is due to the augmented energy of will, to the increased contractility of the muscles, or to a combination of the two, we may be un- able in all cases to decide; but the fact remains, and is gene- rally connected with some derangement deej)ly and extensively aflPecting life in all its spheres of action. ii. Decrease or absence of voluntary power. " Paralysis" is the familiar term to express this condition. Phenomenally, the patient is unable, by an effort of the will, to move his muscles. Volition itself may or may not be present; when it is present the attempt is made, but Avithout success. When there is loss of perception we may not be able to determine accurately whether or not consciousness and volition remain. The two are probably generally, but certainly not always, co- etaneously affected. However, when consciousness is so far excluded from communication with the outer world that we can obtain no direct evidence of volition (by speaking to the INTRINSIC SYMPTOMS. o'.) patient, find watching the eiFect), we inay often gather that some limbs are cut off from its influence, by observincj their motionless condition, when the patient makes an attempt to move ; by the lifeless manner in which they fall, when raised by the observer; and by the attitude of inaction which they assume. It should be mentioned here, that besides the diminution of j)ower, there is often loss of direction and combination in the voluntary movements, which, so far as practical utility of a limb is concerned, often renders it almost as useless as if completely paralysed. (See relation of motility to sensation, p. 35.) b. Motility as induced by ideation. The relation between these two vital properties has only recently received the attention it deserves from the physiologist and pathologist. It is with much pleasure that I refer the reader to Dr. Car- penter's " Principles of Human Physiology," 4tli edition, for an able resume of our knowledge on this subject in its physio- logical relations. In disease, we may recognise most dis- tinctly : — i. Increased ideo-motility. This term sufficiently explains itself, but some illustrations will render it more readily ap- preciable. The gesticulations of many patients when suffering from cerebral disease, their emphatic manner (quite unusual to them) when talking of the most trivial subjects, is striking evidence (when taken, as it is commonly found, in conjunction with other signs) of disorder in the processes of ideation. The Influence of idea upon the choreic patient, in exaggerating his grotesque movements; its power to induce an attack in the epileptic; the ease with which palpitation of the heart or spasm of other muscles may be set up, when the mind is directed towards them, afford farther illustration. Catalepsy, tarantulism, &c., are phenomena of a similar character, and are to be separated in their clinical history (with those just men- tioned) from emotional phenomena. Farther, ideo-motion re- mains in limbs paralysed to volition, not only m the cataleptic, hysteric, and asstatic patient, but in other cases of paralysis loss questionable In their origin. f 34 ELEMENTS FOR DIAGNOSIS. ii. Diminished ideo-motility takes the form of diminished power of motion, from the presence of a fixed idea that it is impossible. This is often seen in so-called hysteric paralysis, and in some abnormal cases in which there are no distinct evidences of the hysteric constitution. c. Disordered relation of emotion and motility, A limb that is paralysed to the will trembles under strong emotion, sometimes more notably than that on the healthy side. Emotion is the occasion of movement. In disease we find — i. Emotional movements in excess. Chorea, hysteria, epi- lepsy, &c. &c., present us with examples. Grimaces are made; laughing and sobbing noises occur; any excitement produces tremor; the slightest fright causes starting; and all these move- ments are beyond the pale of volitional control. Volition is, however, generally positively diminished, and this adds in- tensity to the involuntary movements. ii. Diminished emotion-motility. This is seen sometimes as an isolated phenomenon in the muscles of the face; but the observation of emotion-motility is of more importance in relation to the question whether paralysis (in respect of volition) is due to lesion of the brain or spinal cord. Stated gene- rally, in the former case the emotional movements remain, in the latter they are absent, d. Motility in "relation to sensation. The paralysed limb often starts (with the rest of the body) at a sudden noise, or a flash of light. It is in obedience to sensation (although fre- quently such sensations are, mentally, unperceived) that many of our movements are guided and controlled. As Mr. Mayo has said, " we lean upon our eyesight as upon crutches," and although the due relation between sensation and motility is almost unconsciously preserved, and thus unnoticed, during health, an undue relationship at once reveals itself by marked and distinctive symptoms. i. Increased sensori-motility. This commonly co-exists with the last hj'percinesis, but it is a separable element. The constitutional peculiarities of individuals are widely different ; one man can have his arm amputated, without the contortion of a INTRINSIC SYMPTOMS. 35 muscle, without the escape of a groan, or " long-drawn breath;" not only this would be utterly beyond the power of another, or of the majority, but the shghtest suffering, or uneasy sensa- tion even, in many people, induces attitudinizing, sobbing, sighing, groaning, and every expression of bodily torture. These movements are not voluntary, though they are in health subject to volitional limitation. The startings of patients upon sudden noises, their shrieks when touched, and their grimaces and groans, are the signs either of a defective volition, of a morbidly susceptible sensori-motor apparatus, or of the two combined. Squinting is produced in the child by a sudden noise; and this, with the peculiar automatic movements of the limbs now and then observed in softening of the brain, tuber- cular meningitis, and other cerebral affections, are probably examples of this kind of motion; since the combinations ob- served are frequently such as transcend any explanation by reference to idea or emotion. There is an irritability of bladder and rectum in hysteric patients (leading to frequent micturition and defecation), which is merely a phenomenon of this kind. ii. Diminished sensori-motility. The paralysis to sensation, or that form in which, although sensation may be ^;er se im- affected, there is an absence of sensational guidance. An object is held in the hand, and is grasped firmly, so long as the eyes are directed to the act, or so long as the attention is steadily fixed upon its maintenance; but the moment that the mind or the eye is turned away, the muscles relax, and the object falls. The eye may thus keep up movements that the muscular sense cannot, but the reverse is also true. This form of paralysis, which has been referred far too exclusively to some condition of the cerebellum, is not due to the absence of volitional power, for the latter is frequently entire, and the patient can contract his muscles with their habitual force. Neither is it owing to the loss of cutaneous sensibility, for frequently this remains intact ; but the involuntary relation between the two is lost, and hence most disorderly movements occur when any volun- tary motions are attempted. The combination of this condition with that in which the individual cannot tell, without looking P 2 36 ELEMENTS FOR DIAGNOSIS. at them in what position his limbs may be placed, has led to the expression, " loss of muscular sense." It is not necessary, nor would it be appropriate, to discuss the theory of such a sense In this treatise, but it may be remarked that we do not know of this sense except in its relation to movement, and loss of uitrinsic power for muscular guidance appears to be a less exceptionable phrase. This phenomenon I have frequently found to exist alone in patients who have been termed paraplegic, and it is certainly one of the earliest signs of that affection ; but it ought to be carefully separated (semeiologically) from paralysis in the ordi- nary sense of the word. There is in the same class of patients the antithetic condition of bladder and rectum to that noticed in the preceding section. e. Motility in relation to reflection, or a-sensual impression. The sensori-motor phenomena are reflective, and involuntary; but they dilFer from those of this class in having sensation as a more or less necessary link between the impression and the motor impulse. The essential characteristics of pure reflexion are the absence of any cognizable sensation, and volition ; the peculiar jerking, sudden, transitory movement, immediately following the application of a stimulus ; and the necessity for re-application of the stimulus to induce the movement. In health, the reflective functions are (as Dr. Hall, to whom we are indebted for our systematic knowledge of the subject, has pointed out) those processes of involuntary motility, which sustain the ends of our organic (nutritive) life,*by placing it in relation with the material world, by which it is surrounded, and from which it is to derive its support ; the movements of respiration, ingestion, and ejestion, which go on so constantly, and so independently of the will, that their existence is scarcely noticed. But in its pathological conditions the reflective func- tion presents us with many of the most obvious and most li'iglitful symptoms of disease. In this chapter only two classes <_)f alteration will be noticed: — i. Excessive reflection. By this term, is intended a general exaltation of the property, whetlier represented phenomenally INTRINSIC SYMPTOMS. 37 by increased power, I'reqiiency, or persistence of movement. The special characteristic of reflex actions must be borne in min d ; they may be found existing as an isolated condition of disease, but more commonly underlying some extreme symptoms, from which (latter) several diseases have derived their specific names. It may be well to point out now some illustrations of the pheno- mena in question. They commonly exist in childhood, espe- cially during the first dentition, and are reproduced to some ex- tent with the second, and I have found them accompanying tlie protrusion of the dentes sapiential. This increase of reflective activity, forming one of the physiological peculiarities of child- hood, acts as a predlsponent to pathological results, should any abnormally intense stimulus be brought to bear upon the child. The increase may exist, however, to a pathological degree, and then we find a train of symptoms calculated to aid us in the diagnosis of essential or idiopathic convulsions. The same train is to be found in the epileptic and hysteric patient. The phe- nomena are essentially those of exaggerated motility : thus, in the muscles of the face contractions occur, causing various gri- maces ; and these are especially common around the mouth, in- ducing clicking noises with the lips ; the eyelids wink, the eye-balls do not act consentaneously, but strabismus is fre- quent, and a peculiar "roll of the eye," showing the white sclerotic beneath the upper lid ; oscillation of the eye-ball, and flickering movements of the lids take place during sleep; there is grinding of the teeth, occasioning a peculiarly unpleasant sound when the patient sleeps ; and when he is awake the teeth are commonly clenched. Occupation of the mind in- creases some of the contractions, others, verging upon the " expressive" movements, are exaggerated by any emotion. These two elements (of emotion, and reflective-motility in excess), so commonly combined in the same patients, may be separated by a study of their relation to sleep, or to the with- drawal of attention: the choreic movements, for example, cease ; but the essentially spinal phenomena not only persist, but are exaggerated. In the muscles of the neck reflective movements arc very 38 ELEMENTS FOR DIAGNOSIS. common. Dr. M. Hall has advanced that this region is, par excellence, the seat of emotional and reflective movement. It has not yet been shown with what relative fre(][uency contrac- tions take place in it, and in other parts of the body ; but from my own examination (of eighty cases of epileptics, for exam- ple), I cannot find that the neck is more commonly affected than other parts of tlie body. It is very difficult to arrive at a posi- tive conclusion on the subject, since so many of these phenomena pass unnoticed by the patient, and we are unable to assert what occurs during the intervals of observation. Under the head of " epilepsy," there are some further re- marks upon the subject. We may, I believe, infer the exist- ence of muscular contraction from some of its secondary results: for example, occasional diplopia may give a suspicion of strabismus, although we do not witness the latter : and so the feelings of vertigo, with darkened face, confused thought, &c., accompanying a sensation of constriction in the throat, as they not unfrequently do, may warrant a suspicion (I do not think more than a suspicion) of trachelismus (see hysteria). Deglutition and respiration are clumsily performed : the latter is often suspirious, yawning, and irregular; and, frequently, during even the waking state, accompanied by a peculiar semi- stertorous sound, especially when the mind is absorbed by some other consideration. The muscles of the extremities exhibit similar tendencies. Clonic spasms occur in any of them, and often interfere with the execution of volitional movement. The most common phenomena are the carpo-padal contractions. The sole of the foot is turned inwards, the toes bent downwards, the hands are clenched, and the thumbs drawn in. These are of great fre- quency in children, and may be observed most readily during sleep, both in them and in the adult. Reflex movements of the lower limbs, and even of the whole body, may be induced by tickling the soles of the feet. The extreme symptoms of reflex exaggeration are found in general spasm and convulsion. There is, in conj unction with these phenomena, very frequently constipation of the bowels, and this condition, taken in connexion INTRINSIC SYMPTOMS. 39 with tlie changes of respiration and dcghitition described above, leads us to ask the question, whether there is, in some cases, anything more than a morbid transference of reflective activity from its proper sphere, the apparatus of organic, to its unna- tural sphere, the muscles of animal life? The existence of reflective excess when in combination, as it often is, with paralysis to volition, may be judged of by the readiness and force of contractions arising from peripheral irri- tation, such as pinching, tickling, or applying heat to the soles of the feet, palms of the hands, &c., and by the occurrence of clonic spasm. ii. Diminished reflection. When there is general and abso- lute loss of reflection, life is immediately extinct, from asphyxia. But the loss may be partial. This is the case in those traumatic or " spinal paralyses " (as Dr. M. Hall terms them) which arise from " exclusion of the cord," either by its intrinsic dis- ease, or by injury to the nervous trunks; but spinal disease, suf- ficient to sever volition and sensation from a segment of the body, does not necessarily induce true spinal paralysis. The movements of respiration may be Hmited by cutting ofl" the abdominal and intercostal muscles from their centre of motor impulse. The bladder and rectum may be reflectively palsied in the same manner, and accumulation of urine and fa3ces takes place; the erection of the penis is impossible. Deglutition may be rendered difficult in the same manner ; the signs of reflective paralysis are the absence of reflection-movements; retention and palsy. It is the absence of such paralysis that it is important for us to discover, in many instances, and this is to be ascertained by the presence of those movements, from irri- tation of the skin, which are described in the preceding sec- tion. We must distinguish between the sensori-motor actions, the true reflex, and the centric spinal, which will fall under our notice now. The bladder and rectum afford a diagnostic means of great importance. /. Motility in relation to centric irritation : the tonic contrac- tion or spasm of muscles (the former in health, the latter in disease). This nppears to be a function of the spinal cord (not 40 ELEMENTS FOR DIAGNOSIS. reflex), which normally results in the steady firmness of the limbs, maintained by a constant, but equable contraction of their opposed muscles. The contraction is persistent, and hence a notable difference from the reflective. Pathologically we may recognise : — i. Excessive tonic contraction. The rigidity of limbs in hasmorrhagic apoplexy, in chronic softening, and various orga- nic changes of the brain, are phenomena of this kind. Menin- gitis of the cord presents a striking example of the condition . There is not in this kind of hypercinesis distortion of the limbs as there is when, from simple muscular tonicity, the flexors overpower the extensors ; tonic spasm of centric origin is not so persistent as this muscular contraction; it is increased by attempts at movement; the attempt occasions pain, and often centric disturbance. ii. Diminished tonic contraction. When this affects the muscles of an extremity, or the wliole system of animal life, the result is a loss of firmness and resistance ; together with a want of steadiness in movement, and an absence of perfect rest (positive equilibrium), when no voluntary efforts are being- made. Tremor and paralysis agitans afford examples of these conditions when well marked. When, however, certain mus- cles (whose tonic contraction is of some farther mechanical service to the body) are deprived of their stimulus to persistent action, secondary results ensue, which are often dangerous, and always excessively annoying. Allusion is, of course, made to the sphincters, whose tonic contraction resists the egress of their contents from those organs whose orifices they are intended to oc- clude. The loss of sensori-motility and reflex action induces retention of urine and faeces; but the loss of tone in the sphinc- ters is followed by involuntary micturition and defecation. A similar condition of the palatal and faucial muscles causes stertor ; of the larynx, fearful and even flital dyspnoea. There are two classes of conditions upon which these secondary phenomena depend, convulsive action and paralysis. In the epileptic fit, if urine and faeces or semen are passed involuntarily, it is from inordinate action of the expulsor muscles; but wlien the INTRINSIC SYMPTOMS. 41 ejections occur in spinal injury it is from deficient action of the sphincters. This aflfords an important example of the utility of arriving at a diagnosis of the " nature of affection," using those words with the meaning assigned to them in the first chapter. g. Motility in relation to electric stimulation. I have thought it desirable to represent this as a separable element, because I do not find that its modifications take place j^^^^^ passu with either of the foregoing, or the following. It is variable in limbs equally paralysed to volition, and bears no constant relation to tonicity, or irritability to percussion. Tlie mode for testing it is either the volta-dynamic, or the simple galvanic current : in either method it should be of low intensity, and small in quantity ; or otherwise the result is a measure of strength, and not a test of irritability, as pointed out long since by Dr. IMarshall Hall. i. Excessive electric irritability. This may be judged of absolutely or relatively in certain limbs. For example, if we know the lowest number of plates of a given battery which usually affect a healthy limb, we may compare the individual peculiarity with the average of several others; but the vaz'ia- tions in individuals are wide; and a more satisfactory method is to compare the limbs differentially in the same person, ob- serving always carefully the direction of the current. An excess of irritability may thus be detected in some cases. The lowest power which will ailect a certain group of muscles is a better test of irritability than the difference of contraction be- tween this group and another from the application of higher power. There appears to be an excess in some cases of cerebral paralysis, and also in some hysteric and rheumatic affec- tions. ii. Diminished electric-irritability may be ascertained in the same manner. It is said to occur only in cases of disease ex- cluding the spine, and in general muscular paralysis, not that of insanity. These statements are not correct. In the present state of science, the information we possess is meagre; there is (as I can assert positively from my own experiments;) by uu 4)2 ELEMENTS FOR DIAGNOSIS. means such consistency as various authors represent. If the electric-irritabihty is much diminished, and a fortiori, if it is absent altogether, there is reason to suspect some local aiFection of the nerve-trunks, or serious injury to the cord, rather than paralysis from simple cerebral causes. (The reader is referred to an article in the Medico-Chirurgical Review, for January, 1855, for some further account of the recent researches of Du- chenne, Meyer, Guitard, and others, upon this subject; but a more complete resume of the question will be shortly presented by myself, based upon a series of experimental and clinical observations.) h. Proper motility of the muscles. Although I fully be- lieve that contractility is the inherent property of the muscular tissues themselves, and not a faculty bestowed upon them by the nervous or any other organs, I have preferred to introduce a notice of its modifications here, rather than under the deno- mination of extrinsic symptoms. My first reason for this pre- ference is the convenience of bringino- all the variations of motility under one general head; and the second is, that the modifications which we are studying are generally the second- ary results of nervous change. This property may be examined most directly by percussion of the pectoral, brachial, and other muscles; and it may be de- sirable to add, that I have carefully ascertained that its modifi- cations are in no constant relation with those of motility in dependence upon either volition, sensation, reflexion, electricity, or tone. A sharp " tap" of the skin immediately over the belly of a muscle is the easiest method of production, and we should then compare the result with that obtained by pinching the skin, or striking the skin over a bono, in order to exclude reflection. I have found, in many cases, the irritability to per- cussion much greater in the paralysed (to volition) than on the non-paralysed side; and this irrespective of appreciable tone (when the muscles have been relaxed or contracted ; flaccid or firm), when there is precisely the reverse condition in respect of electricity; and when, at the same time, I have been unable to induce any muscular action as the reflex of irritating the INTRINSIC SYMPTOMS. 43 skin. It has, however, yet to be shown whether or not the modifications of" this propei'ty do not depend upon some changes in the nutritive condition of the muscular tissues. i. Proper irritability in excess. There is considerable diffi- culty in obtaining any contraction by percussing the muscles of a perfectly healthy man in a condition of good nutrition; but when there is any emaciation it is extremely easy. Cases of phthisis exhibit excessive irritability very frequently (as every one who has examined the chest by percussion must have observed) ; in tubercular meningitis I have found the irritability most highly marked. In many instances of hemiplegia the difference of the two sides has been notable in the extreme, the slightest concussion of the muscles causing extensive movoinent of the hand and fore-arm. ii. Diminished irritability. This is, of course, difficult to ascertain absolutely; but I have no hesitation in asserting that, considering the imperfect nutrition of many epileptics, there is less irritability to be discovered in their muscles than in those of healthy individuals. I have scarcely ever been able to pro- duce the slightest contraction in the muscles of an epileptic, although 1 have endeavoured to do so repeatedly in cases pre- senting every variety of organic condition. The diagnostic value of these symptoms has yet to be ap- preciated; but their relation, both in its negative and positive aspects, to pathology is interesting and important, and leaves us some room for hope that by the examination of objective, phy- sical phenomena, we may perhaps ultimately reach far greater certainty in diagnosis and prognosis. i. The simple tonicity of muscles. This, though directly dependent for its modifications upon the organic (vegetative) state of the body generally, may be, and often is, inlluenced indirectly by changes in the nervous system. Thus, the muscles of a paralysed limb are nourished defectively as the result of inaction ; and on the other hand, the presence of long-continued spasm induces an increase both of nutrition and tone. The simplest test of tonicity is the size and firmness of the mus- cular tissues. G 2 44 ELEMENTS FOR DIAGNOSIS. i. Excessive tonic contraction is often observed in paralysis; the contracted hand or arm evincing' the increased energy of the flexor muscles. It is not simply the loss of tone on the other side, for we may find open-hand with paralysis ; and very frequently it is a mere assumption that the extensors are inac- tive. It is commonly found, that _when;^closed-hand exists, all the muscles are firm. Some cases of torticollis are probably examples of undue tonic contraction, rather than of anything else. ii. Diminished tone. This is observed to its very highest degree in some cases of lead poisoning; but it is found in other varieties of paralysis. The muscles undergo degeneration (of fatty and fibroid character), and hence the property they pos- sess in virtue of their special structure is pro tanto lost. The force and resistance of the arterial pulse ; the colour, tempera- ture, and hygrometric conditions of the skin afford a further means for judging of tonicity; but these are not, properly speaking, intrinsic nervous symptoms, although it remains yet to be shown upon what conditions they do essentially depend ; and the progress of physiology and pathology indicates that in the organic or " sympathetic" system of nerves, and its rela- tion to the cerebro-spinal, we are to search for the cause of such modifications if we would obtain success. The various modifications of motility which have been enumerated are found clinically in almost every variety of combination. Some combinations are, however, much more frequent than others; for example, it is exceedingly common to find diminished voluntary power with increased re- flection, &c. This is, perhaps, the most fitting place to define the meaning of four words in more or less constant use, but of rather varied signification : — Convulsion. Tliis word is taken to mean the occurrence of universal, involuntary muscular contraction, generally of pa- roxysmal (temporary) duration. Spasm is used to denote in- voluntary action of less extent. Epileptoid, or epileptiform attacks. These expressions are EXTRINSIC SYMPTOMS. 45 essentially bad, since the epileptic fit varies l^etween such wide extremes. However, the terms are convenient to express the following syinptoms: — Sudden loss of perception and voluntary power, with more or less generally distributed spasmodic move- ment; the latter being commonly quasi-tonic at first, then clonic, and appearing to impede the respiratory process: the attack lasting from two to twenty minutes, and being followed by some exhaustion and sleep. Coma is a useful word to denote the loss of perception and volition (loss of consciousness), with appearance of profound sleep, from which, however, the patient may be partially aroused. Cams, or profound coma, indicates an intenser form of the same condition. The patient cannot be roused : there is loss of sensation and reflection (as well as of perception and volition), commonly stertorous respiration, flaccid limbs, open eye, and dilated pupil. Betw^een coma and carus there may be present every conceivable intermediate degree. II. The symptoms which are extrinsic to the nervous sys- tem are those morbid phenomena which cannot be considered as modifications of the manner in which that system performs its functions. We do not yet know the precise relation sub- sisting between the various organic processes and the nervous centres ; hence the two groups have to be considered separately. The phenomena referred to extend through the whole range of pathology, but it is only intended to enumerate those which are of the most importance, and to do so as briefly as possible. They may be arranged thus : — A. Symptoms referred locally to tlie regions of the nervous centres, — the head, spinal column, &c. 1. Chanfjes in form, includini;: — a. The condition of the bones, fontancllcs, size of head, &c. b. The integuments; eruptions, deposits, growths, &c. 2. Vascularity of region, judged of by : — a. Appearance; the colour of face, its persistence or alternations; injection of conj iinctivic, Sec. 46 ELEMENTS FOR DIAGNOSIS. h. Temperature; the forehead as compared with the cheeks; the head compared with the body gene- rally. c. Pulsation in the vessels; — carotid, temporal arteries; condition of the jugular veins, &c. 3. Pain in the head, either spontaneous or induced; pain in the spinal column; tenderness under pressure or warmth. This modification of sensibility cannot be considered under all circumstances as a change of function ; it is a morbid super- addition. (See Sensibility, for further particulars.) B. Symptoms referred, not to the nervous centres or their locality, but to some other portions of the body. 1. The system generally: i.e., no one particular organ being affected more than another primarily, although secondarily certain tissues may become the locality of special disease or deposit. a. Pyrexiae. Almost all the " fevers" are attended with some peculiar modifications of the nervous functions, and therefore when certain concatenations of the lattq^' present themselves, it is at once desirable to examine the body generally to discover the existence or non-existence of the former. This treatise is not the proper place to discuss the diagnosis of these afiections, but the more prominent and frequent sources of difficulty arise from : — i. The exanthemata. (Rubeola, variola, typhoid, scarlet- fever.) ii. Gastric remittent fever. These two groups are much more liable to be confounded with nervous aflfections (of primary character) in children than in adults. The sources of difficulty in the latter are more commonly : — iii. Rheumatism. iv. Typhoid, typhus, relapsing-fever. b. Cachexia3; not necessarily febrile, but general conditions of depraved vitality, exhibited in the processes of nutritive life. i. Tubercle. The evidences of such diathesis are to be sought for in the hereditary antecedents, the lungs, the glands EXTRINSIC SYMrTOMS. 47 of the neck, and in the general symptoms of dyscrasia. It is often of the utmost importance to know certainly whether or not such a condition exists. ii. Curciuoina. Age is an important element in the diag- nosis: the general aspect and habitude of the patient must be inquired into, and evidences of deposit in external and internal organs weighed. iii. Diabetes mellitus. iv. Urinsemia. The characteristics of these two conditions are to be souglit for in the special changes of the urine which they induce, and in the symptoms which attend their development. These arc placed among the cachexise rather than in the next gi'oup, because it is not until the local (kidney) affections (which may be considered the primary elements of disease) have induced general and systemic changes that we meet with any nervous phenomena which could be confounded with intrinsic disease of the nervous centres. 2. Symptoms referred to particular groups of organs: — a. Gastro-intestinal tract; both its parenchymatous organs and mucous surface: — i. The teeth and gums in children, ii. Stomach, intestines, liver, &c. b. Respirato-circidatory. i. Cardiac diseases, chronic and acute. ii. Lungs, pleura, bronchi. Tiie pulse-respiratloii ratio: the characters of each element: aeration of tiie blood: the existence of cough, expectoration, &c. c. Genito-urinary system. i. Kidneys, bladder, &c. for calculoid affections, the reten- tion of secreted urine, &c. ii. Uterus, testes, ovaria, &c., including the conditions of menstruation, seminal emission, priapism, &c. All these symptoms taken together, their varied relation- ships to extent, intensity, and time, form the means of diagnosis in those cases where diagnosis is possible. It is from their 48 CLASSIFICATION. course and order of development, taken in conjunction with tlie proportion they bear to each other, rather than from the existence of any special class deserving the name "pathogno- monic," that diagnosis is established. Of this, the most abun- dant proof is given in the chapters which follow; having for their object the differentiation of diseases presenting generic similitude of symptoms, and consequently forming groups whose broader features of distinction from one another may be readily and at once appreciated. CHAPTER III. ON THE CLASSIFICATION ADOPTED. The arrangement employed in the following chapters needs some comment, as it is not based upon the principles usually adopted in treating of the diseases of the nervous system, or of any other group of organs. It would be possible to construct a classification upon a purely dynamic basis, adopting such order in disposing of the subjects as is given in the preceding chapter upon symptoms; and this plan would be the right one to make use of if a treatise upon pathology were in contemplation. We should have, then, to consider the nature of every modification of function j;er se, and its bearings upon the others; the object being to describe the natural history of every function in every morbid condition. For the purpose ol" diagnosis this would be cumbersome ; many diseases which have a distinct anatomical re- lationship would be distributed over various groups of semeio- logic formation, and the derangements as they occur clinically would be altogether out of keeping with the system. On the other hand, it would be comparatively easy to con- struct a classification of anatomical conditions ; and if the purpose of this treatise were to describe the pathological CLASSIFICATION. 49 nnatomy of the brain, spinal cord, and their appendages, this system of classification would be the correct one to adopt. But its purpose being very different, such system would prove utterly inapplicable, as it would leave out of view many dis- eases, presenting- most marked phenomena during life, and would confound too-ether in generic oji-oups diseases Avhich run different courses, and require very dissimilar modes of treat- ment. It is not at all intended that classifications thus formed, if formed correctly, may never be useful or successful; but in the present state of medical science it is impossible so to frame them that when brought together they shall form parallel lines. Instead of mutually explaining each other, they in- evitably confuse, and leave the subject involved in deeper mystery than it was before the attempt was made. The occurrence of similar symptoms from (or with) anato- mically different diseases, and the presentation of dissimilar symptoms by diseases (so far as we can ascertain) identical in their anatomy, are matters of daily observation; and this double discrepancy shows (as it has been already stated) not that there is an entire absence of relation between the two classes of phenomena, but that we are far from having appreciated the nature of that relation. The true point of contact may be undiscovcrable in many instances; in others we may, by future investigation, be led to its detection. One illustration will suffice to show that we must not be over sanguine with regard to this discovery. If the nerve supply- ing some group of muscles is laid bare, and in consequence of something done to that nerve contraction of the muscles follows, the muscular contraction is the symptom, and, sup- posing all but the muscles to be concealed, the objects to be diagnosticated are the locality of lesion, the nature of the symptom, and the static conditions upon which it depends. Strong probability with regard to locality might be arrived at from noticing the particular muscle or muscles affecled : the nature of the affection might be at once stated as an increase of motihtv in obedience to some abnormal excitation: but the oO CLASSTFTCATION. physical causes of irritation may be various, and it would be impossible, judging only from the symptom, to determine whether it was simple pinching of the nerve, the application of a heated wire, of chemical, or galvanic stimulus. It may be that by repeated observations some differences should present themselves in the course of an extended series of such irrita- tions, so that from their consideration the nature of the stimulus might be ascertained; but the symptom itself gives not the faintest outline of such distinction, and it is very much tlie same with regard to more complicated cases, the difficulties being increased in proportion to the number of nervous elements involved. With regard to some diseases, we appear to have arrived at Avhat in the present state of science we must reluctantly term " ultimate facts," such as the " exalted readiness" of involuntary (reflex) motility in epilepsy and hysteria; the condition of " ex- haustion" to be found after great excesses; the double, but apparently opposite, action of certain blood-conditions upon the brain and spinal cord, &c. &c. It is Important to leave as small a number of these unreduced fractions of the truth as possible, but there are some which we must consider to be such, and use as such, at all events for a time, in order to advance. The object of this treatise being neither pathology nor anatomy, but the discrimination when possible of their point of contact, and the recognition of its impossibility when such impossibility exists, a classification, based upon clinical grounds, is adopted, as it appears to my own mind to be the most con- sistent with the two classes of terms to be brought together, and because, farther, it is the most readily applicable, avoiding one of the difficulties which beset the employment of works on diagnosis, that of having to find out what the disease is before being able to turn to the proper part of a book for Information on the subject. The basis of classification which I am about to propose and adopt is formed by the three objects of diagnosis; — locality, nature, and lesion. In some cases the primary lines of division CLASSIFICATIOX. 5 1 are in accordance with one, and in some cases with another, the object being to form cUnical groups which may be readily recognised, ratlier tlian those which shall be open to no criti- cism on the score of system. Thus, although the distinction ot intrinsic and extrinsic diseases is one of primary importance, and so much so that I have given separate consideration to it in an early chapter, it is left to form a tertiary basis of division in other instances, as for example in the apoplectic class. The general lines of arrangement are the following: groups are formed by, — first, the locality or organ ajQfccted; secondly, the nature of its afiection; and thirdly, the anatomical conditions which underlie them. In this place only the head- ings, or those large groups, are mentioned Avhose consideration will form the topics of distinct chapters. At the commence- ment of each of the latter a fuller list is given of the various anatomical conditions which may occasion the phenomena of the group. I. Diseases of the encephalon. A. Acute. 1. Febrile, or inflammatory. Chap. VI. 2. Non-febrile. a. Apoplectic diseases. Chap. VII. b. Diseases marked by delirium. Chap. Vill. c. Convulsive diseases. Chap. IX. d. Diseases marked by pain. Chap. X. B. Chronic diseases. 1. Marked by increased activity. Chap. XII. a. Ideation, its characteristic being hallucination, <.^c. b. Sensation, ,, ,, pain. c. Motihty, „ „ spasm. 2. Marked by diminished activity. Chap. XIII. 3. Marked by the combination of increased and diminished activity. Chap. XIV. II. Diseases of the spinal column and cord. A. Acute. Cluii.. XVII. B. Chronic. (Imp. XVIII. H 2 52 DIAGNOSIS OF LOCALITY GENERALLY, III. Diseases of the nerves. Chap. XX. A. Structural, or organic. 1. Neuritis. 2. Tumor. B. Functional, or dynamic. 1. Neuralgia, and spasm. 2. Anaesthesia, and paralysis. CHAPTER IV. — ♦ — ON THE DIAGNOSIS OF LOCALITY^ GENERALLY. It is the object of this chapter to point out the general grounds upon which some diagnoses of locality are based. This is, as already stated, the first problem to be solved; and although, in its minuter details, many points will be left for consideration in the chapters devoted to particular groups of disease, it is desirable that some of the broader lines of distinction should be defined at the outset. These are, the distinction of diseases of the nervous system itself from the nervous complications of other diseases; the diagnosis of affections of the brain, spinal cord, and nerves from one another; and the separation of meningeal from central lesions. I. The diagnosis of extrinsic and intrinsic diseases. In the consideration of a large number of cases (for example, of convulsions in childhood ; of febrile conditions, with marked delirium, &c., in the adult; of some apoplectic seizures, &c. &c.) the first object to be sought for is the discovery or exclu- sion of extrinsic conditions to which all the symptoms may be referred. These conditions are numerous, but by far the larger number belong to the category of blood-diseases (cachfemiaB). Sometimes, morbid blood-conditions are demonstrably present, but they do not account for all the symptoms ; and we have then to determine for what portion they do account, i.e., what IXTlflNSIC FROM EXTRINSIC. 53 is the amount of rnodiGcation they induce in the course of idiopathic disease. The difficuhy is often very great, as these inter-relations of disease have been only superficially noticed. The particular change which the blood undergoes in many cacha3mise is entirely, or almost entirely, unknown to us; some pliysical, chemical, and vital changes in other diseased condi- tions we have recognised ; but in each group we have made out more or less distinctly some of the vital (dynamic) and physical (static) ellects of such cachiiemic conditions, and by these we must establish their diagnosis when other means may fail. The conditions to be sought for have already been mentioned in Chapter II., under the denomination of extrinsic symptoms. (See p. 45.) It is the intention of the present chapter to point out the grounds for their separation li'om centric (nervousj diseases generally, and not to enter upon the diagnosis of each eccentric condition. We may infer the existence of extrinsic disease, from — 1. The nature of the prodromata (or the precursory symp- toms), which have been of a kind not referrible to primary disease of the nervous system. 2. The presence of physical signs and symptoms over and above those for which the nervous conditions will account; and 3. The general course and proportion (to each other) of the existing symptoms (both intrinsic and extrinsic). First. The prodromata. In extrinsic disease, these may bo slight in degree, and variable in kind, and it is possible that peculiar phenomena of nervous derangement may occur without their previous detection. Thus, cases of Bright's disease of the kidney have been undiscovered until serious nervous symptoms have indicated suddenly how far and how insidiously dis- organisation had been at work. Generally, however, the prodromata have existed in a dis- tinctive form ; and they may have been referrible to the whole body, as, for example, the malaise, anorexia, oppressive headache, vomiting (see p. o6), &c., ol' Impending fevers, or 54- DIAG.NOHLS OP LOCALITY GENERALLY. they may have been local, as, for instance, oedematous ancles, renal pain, albuminuria, or saccharine diabetes. The prodromata which exist in primary nervous disease are, for the most part, modifications of the proper nervous functions, either changes in the mental or emotional disposition of the patient, or some phenomena of deranged motility or sensibility. Thus, the precursory symptoms of centric disease belong to the category of intrinsic symptoms; those of disease elsewhere to that ol" extrinsic symptoms. This is not, however, assumed or stated to be universally the case, but that it is so very generally is not open to doubt: it is so with sufficient frequency and constancy to render the consideration of importance in respect of diagnosis. (For further details, see chapters on febrile, apoplectic, and convulsive diseases.) Secondly. Symptoms over and above those for which any nervous lesion will account. Amono- these we recosjnise at once the following: —Qj^dem a of the ankl-es, albuminuria, meUi- turia, casts of tubes in the urine, swellings of the joints, organic affections of the heart, icteric condition of the skin, exanthe- mata, and peculiar eruptions of specific febrile diseases, irritation of the gums from unprotruded teeth, diarrhoea, &c. &c. It would be vain to attempt an enumeration of all these pheno- mena, but they are to be sought for if not at once discoverable, as some may exist to a slight degree only, and elude observation if not specially directed to their detection. Besides these dis- tinctly morbid phenomena, it is important that we should take into account the conditions (more or less normal in their cha- racter) which are peculiar to different ages, sexes, tempera- ments, and individuals. The tendencies of dentition, men- struation, pregnancy, the climacteric period, and decrepitude, must be weighed in order to ascertain how far they may account for the phenomena presented by a particular case. Again, it is of importance to know the standard of habitual health (mental and corporeal) in order fairly to estimate the kind and amount of variation. Thiiidly. The course and proportion of existing symptoms. In the several chapters on special diseases it will be seen that IXTKIXSIC FROM EXTi;T\s;iC. 55 from tlic relative intensity of two symptoms, more than from tiieir actual co-existence, certain diflerential diagnoses are established. For example, the discrimination of apoplectic haemorrhage, from softening in an apoplectic -form, may fre- ([uently turn upon a consideration of this kind: and the separation of typhoid fever with cerebral complication from meningitis with fever of a low type, may be arrived at by the diilercnce of proportion which exists in the two classes of disease between the elements (symptoms) which each presents in common Avith the other. In the case of intrinsic disease with general complication, there is an absence of the direct ])roportion which usually exists in extrinsic diseases between the intensitv of the general disturbance and that of the motorial, sensorial, and mental functions. Exceptional cases occur; but, as a rule, the nervous system in general disease parti- cipates only and equally with the body at large. In the case of intrinsic disease the nervous system has its own functions primarily and prominently affected, and to a degree for which the systemic derangement will not account. The order of development usually differs : in intrinsic diseases nervous symptoms are the earliest to appear; in extrinsic dis- eases they are secondary in relation to time. This (as is stated already) does not always hold good; but it is generally true, and as such is worthy of consideration. Contrasting these two great classes of disease, we may infer when — 1. Prodromata are of intrinsic character, or absent; 2. Signs of distinct general disease are iindiscoverable ; 3. The intrinsic symptoms precede such general or extrinsic symptoms as may be present, and are of greater relative inten- sity than any which the latter will account for — . . . that the disease in question is intrinsic, or that the nervous system is primarily and principally effected. When, on the other hand — 1. The prodromata are highly marked, and consist of extrinsic symptoms; 2. The signs of general (or extraneous) disease are dis- ci )verablo : 56 DIAGNOSIS OF LOCALITY GEXERALLY. 3. The extrinsic symptoms have not only preceded the intrinsic, but the latter bear a definite and direct proportion to the former ; and the extrinsic derangements are more highly marked than those which the supposed nervous conditions could induce — ... we infer that the disease is primarily and princijDally extrinsic, and that the nervous symptoms are anjong its many and varied phenomena. The diagnostic value of vomiting requires some special comment. The chapter on symptoms (Elements for Diagnosis) could not present the two characters of vomiting in sufficiently distinct antithesis to render their insertion in its pages of much service; and, as the diagnostic value of the symptom is in relation to the separation of extrinsic from intrinsic diseases generally, the present appears to me the most appropriate time and place for its consideration. The " intimate sympathy " subsisting between the stomach and theliead is a matter of daily observation. Head-ache from gastric disturbance is as common as vomiting from cerebral derangement. In children especially the existence of obstinate vomiting is indicative of head rather than of stomach disease. A consideration of the following points may lead to the dis- crimination of its causes: — In gastric or hepatic vomiting there is nausea which is relieved, at all events temporarily, by the discharge. In cerebral vomiting there is little or no nausea, and the vomiting continues in spite of the complete discharge of its contents by the stomach, so soon as anything (liquid or solid) is introduced. In the former the tongue is foul, the conjunctiva often yellowish, and the head-ache secondary in respect of time. In the latter the tongue may be clean, the conjuctiva colour- less or injected, and the head-ache primary. The former is frequently attended with griping pain in the abdomen, diarrhoea, and disordered evacuations. The latter is accompanied by obstinate constipation. In the former there is retchinof and increased salivation. BK'AIN, conn, AXD NERVES. 5, In tlie latter the stoinacli i^ emptied almost without eflbrt, and witliout any increase of the salivary secretion. Thus, vomiting is in one case an extrinsic symptom, depen- dent upon derangement in the gastro-intestinal canal ; in another case it is an intrinsic symptom, depending upon an increased sensori or reflective motility; and, duly considered in this twofold relationship, its character (as an extrinsic or intrinsic symptom) alFords much assistance in the discrimi- nation of centric from eccentric disease, wdiether it is found among the proih'omata or existing phenomena of a given case. II. The diagnosis of diseases of the brain, spinal cord, and nerves from each other. Some of the symptoms which result from disease of one uervous centre may arise from lesion aflecting another. Para- lysis of motion in respect of volition may (tor example) depend upon a morbid condition of either the brain, the cord, or the nerves. Without entrenching upon the subject-matter of those chapters devoted to special groups of disease, it is the object of this section to state generally the means by which allections of these three primary divisions of the nervous system may be clinically separated. The general grounds upon which diagnosis of disease in other organs is based are partially applicable to the group of nervous derangements, and partially inapplicable. Modifications in the processes of thought, and in the conditions of perception, are referred at once to direct or indirect interference with the functions of the brain ; but the absence of such phenomena (when motor paralysis exists, for instance) does not exclude the brain from the attribution of disease. Thus, while on the one hand the actual disturbance of its special function indicates that a certain portion of the nervous system is the locality of disease; on the other hand, the absence of such special derange- ment by no means proves the reverse. As it is well under- stood that, in the case of motility in relation to volition, it is necessary, for the passing over of a volitional impulse to the contracting muscle, that each portion of the nervous system 68 DIAGNOSIS OF LOCALITY GEXKKALLY. engaged in this transference should be intact, so it is equally obvious that the two extremes (volition and motion) maybe severed by lesion of any part {i. e., either nerve-trunk, cord, or brain) which lies between them; and thus the simple fact of paralysis (to volition) gives no indication with regard to the locality of disease. The same is true with regard to sensation as a whole. Thus, one common ground of diagnosis (in respect of other diseases) is removed to a certain extent, since the complete performance of many important nervous functions is the com- bined product of its three great divisions. These special considerations are, however, of some value ; and, taken in conjunction with the distribution and combination of symptoms, enable us generally to arrive at a diagnosis. Attention is directed to — First. The special functions involved. We infer — A. That the brain is the seat of disease when there is a positive change in the processes of volition, ideation, emotion, and the perception of sensorial impressions — i. e., when that class of functions is disturbed whose special consideration formed Section I., A., 1, 2, 3, in the chapter on " Elements for Diagnosis" (see p. 14 and seq.), and when certain extrinsic symptoms (see. p. 45) are referred locally to the head; and when emotion yet preserves its relation to motility. B. That the spinal cord is the organ affected when, no signs of brain disease being present, perceiDtion, volition (phe- nomenally sensation, and voluntary movement), and often emotion are cut off more or less completely from some portion or portions of the body: these portions yet preserving their motile relationship to the cord, as exhibited by reflex and tonic spasm, by associated movements, and electric irritability; and when the exti'insic symptoms are referred locally to the spinal region. Further, the occurrence of spasm and convulsion, especially of tonic character, and of all abnormal involuntary movements in excess, indicates a probability of spinal rather than of cerebral injury. C. That the nerve-trunks are originally affected when there DIIAIX, COKD, AND NEliVES. 59 are signs of local injury in their course, when the special I'unc- tions ol' particular nerves are alone involved; the brain and spinal cord presenting no positive change in their actions; and, ii' motility and sensibility are lost, when the loss is complete, no reflex actions, and no electric irritability remaining. Although considerations of this kind may, under certain circumstances, lead to a diagnosis of locality, there is always some uncertainty from the unsatisfactory manner in which negative evidence is interpreted. Disease of the brain (for in- stance) need not affect volition or ideation, and disease of the cord may present the features of " nervous '' disease. There arc, further, many complicated cases in which positive evidences of disease in the medulla spinalis are found in conjunction with the negative signs of cerebral allection; for example, hemiplegia with exalted reflex activity: and there are two modes in which this relation may be explained — (a) that the simple fact of removed or diminished cerebral power exaggerates, per se, the activity of the spinal cord ; and (b) that the reflex phenomena are due to a morbid spinal condition, not necessarily associated with the cerebral, but in particular cases developed [either co- taneously or subsequently to the lesion of the brain. The first explanation rests upon, and is at the same time taken to prove the supposition of an antagonism between these two nervous centres ; an antagonism which, if not entirely imaginary, is at all events very incorrectly stated (see Appendix C.) : and the second mode of explanation appears therefore to be that which we are alone warranted in adopting. We shall have, then, to consider some diseases which have been referred exclusively to the brain, as dependent upon some primary lesion of tliat centre, plus an induced, it may be dynamic, condition of the cord. We come now to consider the second mode by which this diagnosis (of brain, spinal cord, and nerves from each other) may be established. Secondly. The distribution of symptoms (their locality, ex- tent and limits). The assistance derived (roni these considerations is based u[)on the tendency of our mind, a tendencv of which I 2 60 DIAGNOSIS or LOCALITY GENERALLY. experience confirms tlie truthfulness and utility, to refer a similar modification of dissimilar organs, not to the simul- taneous change of both ors-ans, but to a chano-e in somethino; which is common to the two. And again, we are disposed to assign the smallest possible change which can produce the eflfect as the sufficient cause of the symptoms presented. Thus, in a case of perfect hemiplegia, we, in accordance with the first tendency or law, refer the symptoms to some part of the organism common to all the nerves of sensation and motion on one side (the cerebrum), rather than to the nerves and muscles themselves; and in a case of local paralysis, in accordance with the second disposition or rule, we refer the symptoms to some lesion of the nearest nerve-trunk which is common to all the muscles involved. By careful examination the exact seat of injury may some- times be discovered, especially in spinal diseases, although tliese limitations are always liable to error. However, we conclude, — A. That the brain is the seat of lesion when several of the special senses are simultaneously affected ; when the muscles and general sensory nerves are implicated longitudinally and uni- laterally (hemiplegia); when muscles situated so high as those of the face and tongue are involved, and the or1)icularis of the eyelids does not share in their affection. In those rare cases of bilateral (or transverse) paralysis (paraplegia) resulting from some cerebral change, the symptoms at some period of the case have generally referred to the head (by their special character), so that by a combination of the two classes of observations, the diagnosis may be almost universally established. B. That the spinal cord is the organ affected when the symptoms of motor and sensory character are distributed transversely or bilaterally, inducing paraplegia or transverse spasm. The precise locality may be estimated sometimes from the anatomy of the spinal nerves. If the lesion or disease is liigh, speech, deglutition, respiration, &c., are impaired. There is often erection of the penis, the retention or involuntary (lis- BKAIX, COlil), AM) XEKVKS. 61 cluirg'C of faeces, and urine iiccording to the conditions already described (see p. 39, and Chaps. XV. and XVI.). C. That the nerve-trunks are the seat of lesion when the symptoms are i-eferrible to an isolated muscle or group of muscles, or to a small portion of the sensory surface. When paralysis is the symptom, the irritability of the muscles to electric stimulation is quickly lost; and the symptoms show no disposition to wander from the special localities affected. The means of distinction may be resumed thus : — 1. When perception, ideation, volition, and special sensa- tion are alfectcd; and motor and general sensory changes exhibit a unilateral distribution, the brain is commonly the seat of disease. 2. When the mental functions are unchanged, and motility and general sensibility are affected bilaterally, we infer the spinal cord to be the locality of lesion. 3. When the relations between motility, volition, and re- flexion are lost, the mental functions being unchanged, and when the motor and sensory disturbances arc purely local, we refer the disease to some of the nervous trunks. In each case the extrinsic symptoms are referrible to the special locality or region affected. III. The diasfnosis of disease in the nervous centres them- selves from disease of their meninges. We do not know that the meninges have any dynamic functions to perform : their properties and uses appear to be physical only, serving as the media for vascidar supply and for protection from shock. The symptoms which their morbid conditions present resolve themselves into modifications of the nervous properties; they are, in fact, dvic to changes in the contiguous central organs; intrinsic symptoms, or modifica- tions of tlie manner in which the latter ]>erform their actions. The peculiar character of" the change which meningeal aflbc- tions induce is sometimes sufficiently marked to distinguish them from central disease : often the two elements co-exist, and we are able to arrive at approximative certainty only with re- gard to the part which each plays. (12 DIAGNOSIS OF LOCALITY GEXERALLY. Leaving aside (for tlie consideration of subsequent cliapters) the differences between individual diseases, and takinjx a ireneral view of the whole range, we may, I think, advance the fol- lowing distinction: — A. Centric diseases are marked from the outset, or at all events from an early stage of their development, by the loss of some one or more of the proper nervous functions, such as ])aralysis, anaesthesia, loss of memory, &c. Further, they are not commonly attended by highly marked exaggeration of function (such as furious delirium, convul- sions, intense hy pergesthesin , &c.), or by the epiphenomcna ol' pain, tenderness, &c. Centric diseases exhibit commonly little vascular excitement, or any of the group of extrinsic symptoms referred locally to the affected region ; nor is there frequently any hiiihly marked general disturbance. B. Meningeal diseases are not characterised, except after some time, by the diminution or loss of function; and such losses are almost invariably preceded by. Extremely severe excitement or exaggeration of function, such as furious delirium, dyssesthesia, convulsions; and by well marked epiphenomcna, pain, tenderness, &c. In meningeal affections there is commonly much local vas- cular excitement, with general disturbance. The paralyses and anoBSthesite, losses of volition, ideation, perception, &c., characterise cerebral: spasms, convulsions, pain, and dehrium, are the features of meningeal disease. The two classes of symptoms are very commonly combined, inasmuch as their organic conditions are frequently combined; but we may separate the preponderating elements in individual cases, and the mode of doing so will be found more fidly elucidated in the chapters which follow. (See Chapter VI. for Cerebral Meningitis ; and Chapter XVII. for Spinal Meningitis.) PART II.-DISEASES OF THE BRAIN. CHAPTER V. THE DIAGNOSIS OF BRAIN DISEASES AS TO THEIR GENERAL NATURE. Bkkore proceeding to the discrimination of particular diseases from each other, it is desirable to state the means by which we may diagnosticate the several clinical groups, which are formed for us by nature, and which have been placed as the limits of division, based simply upon symptomatic characters, in the chapter upon Classification (p. 51). The diseases which fall under these headings are not all of them primarily intrinsic; but the symptoms they present being essentially brain symptoms, they are brought into this category for the sake of convenience. It is unnecessary to add anything liirther upon the separation of acute and chronic diseases. The distinction is one readily appreciated and applied; and such re- marks as appeared to me necessary to make have been already placed in the chapter referred to. We have, under the former division, the acute, to recognise four groups, the febrile, apoplectic, delirious, and convulsive: under the latter, the chronic, to distinguish three, viz., those marked by excessive activity of some functions; those charac- tt'rised by diminution, and those presenting, in combination, the features of the latter two. 1. Febrile. The diagnosis of these diseases turns mainly upon, — A. Extrinsic symptoms — viz., the presence of general signs of lever, such as heat of skin, thirst, anorexia, frequent pulse. 04 DIACiN(3sr,S OF PRINCirAL ffROUrS. disor.lered sccvetions, general oppression, and disturbance, witli liead-aclie, pain in the limbs, and sensorial discomfort. B. The intrinsic symptoms are of various kinds, frequently passing through two or more successive stages, marked by tlie following characters (a. and b.) 1. Intellectual, a. Delirium of various kinds, and com- mencing at different periods; wandering thought, or furious excitement; to be followed by, — h. Loss of perception and volition; coma, with no sign of persistent ideation or emotion. 2. Motorial. a. Spasmodic action, affecting particular groups of muscles, and producing every variety of contraction, from twitching of the smaller limbs to violent general convul- sions. The axes of the eyes are distorted, and strabismus occurs, with subsultus tendinum, carphology, &c. These phenomena are commonly followed by, — • h. Paralysis, more or less generally distributed, the para- lysis sometimes co-existing, at other times alternating, with spasm. 3. Sensorial, a. Dysaisthesia, marked by intolerance of light and sound, or of any sensorial impression: violent pain in the head and often in the limbs, succeeded by, — h. Anaes- thesia, and apparent loss of general sensibility. II. Apoplectic Diseases. Although the word apoplexy in its correct etymological meaning refers to the particular or- ganic or static condition of extravasation, it is so commonly employed without any intention thus to limit its meaning, that it is retained in this treatise and used in its widest sense — i. c, it is employed to characterise a certain group of symptoms ir- respectively of the anatomic conditions upon which they may depend. The symptoms thus included are familiar to every one; after a period of varying duration (from a few seconds to weeks, months, or years), marked by sundry derangements of the nervous functions (such as loss of memory, dulness of sensation, or diminished power), the individual is more or less suddenly deprived of perception and effective volition : he falls ACUTE DISEASES. 65 to the ground insensible, or may only stagger and cling to some object for support: the respiration and circulation maybe unafFected, or the former may be stertorous, and the latter laboured: some group of muscles, a side of the body, or the whole body is paralysed, flaccid, and motionless; or on the other hand, rigid with tonic, or convulsed by clonic spasm. In this state the patient may die; or from it, he may recover partially or entirely; in the former case leaving some mental, motorial, or sensorial faculty impaired, for weeks, or for the whole of after life. The diagnostic symptoms ai'e, the sudden loss of perception and volition in their relation to sensation and motility; or, in more common but less distinctive terms, the loss of conscious- ness, with paralysis. The degree or intensity of the affection varies widely, from slight obscuration of intellect, with embar- rassment of a particular group of muscles, to the most complete abstraction of all apparent consciousness and power of move- ment. The same organic change, for example, htemorrhage, may cause the former degree, or the latter. In extent, also, the symptoms vary within no less widely separated limits; one or two muscles may be affected, or memory may be lost for certain classes of ideas; and, on the other hand, the whole muscular system may be paralysed, and no trace of mental action be dis- cernible. This sudden loss of function takes place (as a second cha- racteristic) without febrile excitement at the time; it may occur subsequently, and is then probably due to secondary changes, in the same manner that spasm and rigidity of the muscles occur. The essential nature of apoplexy is the occur- rence of some static or dynamic change which, pro tanto, severs volition and perception (the brain functions) from motion and sensation: the other symptoms that occur, spasm, hypergesthesite, &:c., are additional phenomena, often depending upon induced secondary conditions of the parts which are primarily the seat of lesion. They are useful in tlie diagnosis of individual diseases, as will appear hereafter. III. Diseases marked uy Delirium. Although de- 66 DTAGXOSIS OF PRINCIPAL GROUPS. lirium occurs in the febrile, and also in the apoplectic diseases, it does not constitute their main feature. As a simple oc- currence it is of little diagnostic value; but of some morbid conditions it forms, for a time at least, the most prominent symptom ; and around it others are grouped, which constitute a class of great interest and of no less obscurity. The simple fact of delirium is the expression of ideas erro- neous in their relation, either to each other or to sensation. If such a condition existed with loss of motility (affecting speech and gesticulation), there would be great difficulty in ascertain- ing its existence: we do not know, therefore, the exact nature of distinction between coma and delirium. There are two degrees of delirium to be separated — viz, that of volition, and of idea; the former is usually violent and maniacal, the latter quiet and inoffensive. The class of diseases to be recognised under this head have as their characteristics, — 1. Delirium, or erroneous ideation, as the prominent symptom, and — 2. The absence of fever. It is very important that this should be borne in mind, in order to exclude the febrile affec- tions. IV. Diseases marked by Convulsion. This group is intended to include those cases of which convulsions form the only or the prominent feature. The conditions upon which such symptoms may depend are extremely various, but there is some attempt at their reduction given in Chapter IX. Although some of the anatomical changes which induce con- vulsions are to be found also vmderlying delirium and apoplexy, and although we are unable to assert upon what quality the difference of symptoms may depend; yet we cannot fail to recognise the importance of the difference, and to believe rather in the existence of some static discrepancies which may hitherto have escaped our notice, than in the identity and equality of the diseases whose phenomena during life have presented such vast dissimilarity. Although, therefore, it will be found that softening of the brain (for example) occurs in the apoplectic, delirious, convulsive, and quasi-febrile form, I ACUTE DISEASES. fi7 prefer considering that peculiar condition of the l)rain in con- junction with its several groups of symptoms as representing four different conditions of disease, rather than looking upon them as variable phenomenal phases of the same malady. A disease is not to be made out by either its symptoms alone, or its anatomy alone, but by a conjunction of the two; and, with this principle in mind, we are justified in separating the phenomenal forms of disease into distinct groups, until it can be shown upon wliat the dilferences between these forms depend. It is probable that convulsions, from whatever remote cause they may derive their origin, depend directly, in exact proportion to the similarity existing between them in different cases, upon the same conditions. We may often obscure the progress of science as much by drawing artilicial lines, as by failing to observe those which are laid down by nature. The names epileptic, hysteric, centric, sympathetic, &c. &c., do not create a difference, except in our own minds, and that certainly a fallacious one until it is shown wherein the distinc- tion lies. Phenomena which are identical should be considered to be so, although they may be separated widely by nosolo- gists ; and that which is held to be the immediate cause of convulsion in one case should be held to be its cause in ano- ther, although there may be ulterior phenomena of various kinds which influence and direct us in judging of the disease as a Avhole. The diagnosis of these ulterior conditions is the object we lla^'e in view; and although the nature of the con- vulsive phenomena themselves may sometimes aid us in its establishment, much more frequently the diagnosis turns upon secondary considerations — i.e., those not immediately forming a part of, nor dependent upon, the attacks themselves. The term convulsion has already been defined : its cha- racters are unfortunately too well known to need farther com- ment, than to repeat that its essential features are the loss of volition and perception, with violent (partial or general) invo- luntary spasm; occurring paroxysmally, and presenting embar- rassment of respiration and circulation, often followed by stupor and stertor. ^8 DIAGNOSIS OF PKINCIPAL GROUPS. The chronic diseases, marked by derangement of the cerebral /unctions, are divisible into three groups, whose general features are sufficiently distinctive to render the diagnosis so far {i.e., into those groups) comparatively easy. ( See Chap. III., p. 51 . I. Diseases Marked by the Exaltation of Function. These are extremely common and widely various, including all those chronic aflections which are characterised by aug- mented ideation, sensibility, and motility. Some diseases present the perfect isolation of a particular nervous function — i.e., in its morbid relationships; others are marked by the combination of derangements. We may readily recognise in many cases the distinct predominance of a particular element of disease, such as hyperaesthesia, or hypercinesis ; in other cases, so many of the properties of nervous action appear diseased, that we can give some name to the combination, but find it very diffi- cult to appreciate its true nature. The diseases which will come vmder consideration in this group (see Chap. XII.), may be recognised by the following characters : — 1. Chronicity, often carried to its extreme, and hence their, — 2. Little danger, in respect of life. 3. Irregular course of development, the symptoms being often paroxysmal, or occasional only. 4. Special functional derangements, which may be grouped thus : — A. Hyper-ideation, of a morbid and quasi-melancholy cha- racter. The patient is "possessed" by ideas for whose origin he can give no account, but whose power is manifested in the course and direction of his mental life, and often reveals itself in the sphere of nutrition, inducing secondary changes. These ideas relate commonly to personal health and capacity, rarely (if ever, per se) involving life in its social relations, ex- cept as a secondary result. Hypochondriasis aiibrds the typical example of this condition. B. Hypcrsesthesia, or the presence of abnormal sensibility of rilKOXIC DISEASES. Gf) au exalted kind. Pain is the common plienomenon, lor example, in liemicrania; morbid sensations, not necessarily ])ainful, are the features recognised under the head of halluci- nations, and vertigo of sensation. C. Hypercinesis, or exaggerated motility. The phenomena of this class are various forms of muscular spasm — e. g., chorea, paralysis agitans, &c. The diseases which come under this denomination form a group which has well-marked features, and which are com- monly dynamic in their origin, so far as we can ascertain in the present state of medical science. II. Diseases marked by the decrease of functional ACTIVITY. The most common afiection presenting simple decrease is that peculiar form of disease known as anjesthesia muscularis. It id thought desirable merely to mention this morbid condition here, and to refer the reader to Chap. XIII., for its special characteristics. III. Diseases marked by excess of some functions, AND diminution OF OTHERS. We have here a large and highly-important group of chronic diseases. They may be diagnosticated from all others by — 1. Their chronicity. 2. Their irregular, but in the main progressive, development. 3. Their special nervous characters, resolving themselves into various combinations of the following kind : — A. Hyper-ideation, with acincsis. The common features being delirium, occasionally presenting at night, and of mild character; or simply irritability of temper and restlessness, with slowly and imperfectly developed paralysis, or simple loss of power. B. Hyperaisthesia, Avith acinesis. Thus we meet with pain in the head, and intolerance of sensorial impressions, in con- junction with paralysis. C. Hypercinesis, with anaesthesia. The combination of more or less spasm, with loss of sight, or hearing, ibr example. Every variety of conibiiuitiun may exist; such as convul- 70 FEBRILE DISEASES. sions, Avith slowly diminisliing intellect; pain, accompanied by spasmodic movements ; delirium, with convulsions, &c. &c. (See Chap. XIV.) The changes of function are commonly but not invariably persistent in some: they are endlessly variable in others. The group is one of great importance and interest, not merely from the difficulties of diagnosis which it presents — difficulties which I shall not anticipate by their statement here — but from the evidently beneficial results which may follow well-directed treatment in some, and from the utter hopelessness of others: a difference which, })erhaps, more than any other, indicates the value of their successful discrimination. CHAPTER VI. THE DIFFERENTIAL DlAGi\OSIS OF ACUTE FEBRILE DISEASES AFFECTING THE BRAIN. The general characters of these diseases have been already stated: they may be more or less readily confounded with each other, as they present similar symptoms, and a similar general disposition. However, carefid examination may lead to a diagnosis of the following affections, although some of them present aberrant forms, with regard to which there may be considerable difficulty. The first five present the greatest amount of difficulty : the last three may ordinarily be separated withovit much labour. I. Meningitis, or inflammation of the pia mater, distin- guishing — A. Simple — «.e.,non-diathetic, or primary, when affecting — 1. The convexity of the hemispheres. 2. The base of the brain. B. Tuberculous, accompanying deposit in the pia mater. C. Rheumatic, or meningeal rheumatism. JI. Inflammation of the dura mater. IVIENINUITIS. 71 III. Ccrebritis, commonly meningo-cerebritis. A. General, and then always meningo-cerebritis. B. Partial, or limited (red softening). IV. Continued fever (typhoid and typhus) with cerebral complication. V. Gastric remittent fever of children. VI. Simple hypera^mia, or " determination of blood." VI I. Delirium tremens, in its febrile form. VIII. Mania, with marked febrile symptoms. These dilfcrent diseases will be now considered seriatim, in respect of those symptoms which present diagnostic value. § I. Meningitis. The symptoms of this affection differ widely, both in their intrinsic and extrinsic characters, when meningitis is, on the one hand, simple, or, on the other, connected with some diathetic condition. The phenomena of A. Simple Meningitis will be described first; and that form of disease will be taken as the type in which — 1. The convexity of the hemispheres is affected generally. This disease ordinarily passes through two or three stages, characterised by diflerent symptoms; and whether these phe- nomena may or may not be rightly interpreted in their relation to pathological anatomy, they are sufficiently marked, clinically, to require a separate notice. Sometimes one, and sometimes the other, may be absent, but I have seen cases passing through the three, and presenting, at each period, symptoms so definite and distinctive that they would have satisfied tlie most " systematic author." a. Prodromata. The most important facts to be ascertained are those relating to the previous health of the individual, considered generally — viz., the absence of any signs of a cachectic condition, such as the tuberculous, rheumatic, or syphilitic ; and the presence of any occasional causes of local disturbance, such as a blow upon the head, exposure to the sun, disease of the ear or nose, intense application to study, or 72 FEBRILE DISEASES. to the cares of business. Actual morbid proclromata may be trifling, or absent altogether; the most common are, slight but increasing pains of the head, sensorial disturbance, and irritability of temper, or restlessness, with some general malaise. h. First stage commences with a combination of extrinsic and Intrinsic symptoms. i. Extrinsic symptoms. Rigor, or simple chilliness, with cutis anserrlna, and pallor of surface, quickly followed by febrile reaction. The rigor may be supplanted by an attack of convulsion, and this occurs most frequently in children. It Is by no means common In the adult, and must be considered as taking the place of the Initial shivering, and not as indicative (from Its simple presence) of very severe or advanced lesion. The fever Is commonly high ; the pulse sharp, hard, and fre- quent; respirations Irregular, susphious, and often moaning; skin is hot ; the bowels obstinately constipated ; the evacuations, "when occurring, are dark and offensive. There Is, in this stage, little or no prostration of strength. The headach of fever is supplanted by acute, Intense pain ; the face flushes and turns pale alternately; the eyeballs are staring, and conjunctivas injected. 11. Intrinsic symptoms may be referred to three groups — a. Mental. The temper Is extremely Irritable; there is marked somnolence, or wakefulness, and the two sometimes alternate for several days. The most marked feature is delirium, commencing early, and of furious character; the patient screams and gesticulates in the wildest manner ; the expression of countenance is savage and malignant, or sometimes has the fierce aspect of the brute. j3. Sensorial. Marked, continuous cephalalgia, with exacer- bations of darting, violent character, eliciting from the patient, and especially from children, a sharp piercing cry. Pain is Increased by movement, and hence the patient holds the head with his hands. It is Increased by sensorial Impressions (dysassthesia), and to avoid them he buries the ears and eyes in the bed-clothes, and keeps the latter obstinately closed. :\FE>iNGiTis (snirLi:). 7.'> Diplopia, tinnitus, formicatio (pseud-jestliesiae), and subjective sensations of various kinds are present. The sensorial dis- turbances are, as a rule, highly marked. •y. Motorial. There is incessant restlessness, general or partial : the muscles of the face and limbs twitch involuntarily ; there is strabismus, or unsteady eye-ball, with contracted or oscillating pupil; little or no prostration of strength; frequent vomiting, without epigastric pain or tenderness, and often without nausea. This stage lasts generally from one to four days, its charac- teristics being — the combination of great nervous hyperaction, with marked fever, peculiar cry, cephalalgia, vomiting, and constipation. c. Second stage. This is of transition character, presenting the features of the first and third in various combinations. i. Extrinsic symptoms. The fever diminishes; the pulse sinks in frequency and force, becoming variable in frequency between very wide limits, and in very short intervals of time. Respiration is peculiarly irregular; the bowels continue con- stipated; tongue becomes furred and dry; the heat of head persists, but the body generally Is cool. ii. Intrinsic symptoms may undergo remarkable intermis- sions, sometimes disappearing altogether for a few hours, or for a] day or two. This stage is not unfrequently absent : it consists only of transition phenomena, and a violent general convulsion may throw the patient at once Into the tlilrd. o. iMcntal. Dolirlnm becomes quieter, and jxasses Into coma, or the patient may appear quite collected and well. [3. Sensorial. The excitement diminishes and disappears; anaesthesia or hyp-a^sthesia taking its place; cutaneous sensi- bility is rarely affected; the cephalalgia is little noticed; and drowsiness is the most common leatiu'e. y. Motorial. Muscular twitching imdergoes some general increase, and Is seen on both sides of the body; convulsions are common in the child, and spasm is found alternating with paralysis. 74- FEP.RILE DISEASES. d. Third stage. This may exist immediately after the first, or it may be separated from the first by a week's duration of the transition (combined) phenomena of the second. i. Extrinsic symptoms. Sunken face, and cold extremi- ties; retracted abdomen; sordes on gums and teeth; pnlse fluttering, thready, very feeble, and uncountable; marked general prostration. ii. Intrinsic symptoms, are those of absent function. a. Mental. Loss of perception, volition, and ideation, so far as can be ascertained by corporeal signs. /3. Sensorial. Total anaesthesia. -y. Motorial. Absolute paralysis to almost every forin of stimulus: first observed in the eyelids and eyeballs, then in the limbs: the muscular relaxation is complete, as evidenced by dilated pupil, stertorous breathing, involuntary micturition, and defecation. The characteristics of the third stage, are the absence of nervous action, and the dying out of organic life. The characteristics of the second stage, are the combination of transitional conditions, with a low organic state. 2. Meninffitis of Ihe base. This cannot always be distin- guished from the preceding; but in some cases there may be probability of such a location, when the signs of sensorial and mental excitement are less marked : intelligence being preserved for a time (without delirium), and coma, or somnolence, occur- ring very early in the disease. Duchatalet and Martinet consider profoundly-marked coma and spasm, when they occur in children, subsequently to fever and transient delirium, with suborbital pain, as highly cha- racteristic of meningitis of the base.* Andral very fairly criticises this distinction, and cites instances of such occur- rence when the inflammation has affected other localities. f Although this differentiation cannot be considered abso- lute, it probaldy expresses some approximation towards the truth. * De I'ArachnitiM, p. 231. f ('lii)ique M(?dicale, tome v., p. 64. AIEM>(J1T1« (TUliEliCULAli). 75 B. Tubercular Meningitis. The older medical re- cords of cases alFord little assistance in the discrimination of this variety, since the tubercular condition of the membranes was not observed ; nnmy of the instances of this disease being placed, iu all probability, under the head of simple (idiopathic) menin- gitis, others falling into the group of acute hydrocephalus. Dr. Whytt, in 1768, published an account of the symptoms to be noticed in so-called acute hydrocephalus,* and showed that they might assume two generic forms: the first being that which will occupy our attention now; the second, hurrying rapidly to a fatal issue, the " wasser-schlag " of Golis, will be noticed hereafter. (See Chap. IX., Convulsions.) The symptoms of tubercular meningitis dilFer in the child and the adult, and must be considered separately. 1. Tiihercular meningitis in the child: — a. Premonitory symptoms are of great importance; they are referrible mainly to extrinsic conditions. The general state of the patient has been that of ill-health ; nutrition has been im- pei'fect; for some weeks there may have been disturbance ol febrile character ; there are evidences of a scrofulous diathesis in either the child or its parents; the occurrence of irregular febrile attacks, which cannot be explained by apparent disease, or derangement of other organs, is suspicious ; " frequent, short, dry cough" is placed by Dr. West among the premonitory symptoms ; h vomiting and obstinate constipation of the bowels belong to the same category. Among the intrinsic premonitory symptoms, it is found that the child complains, or has complained, of pain in the head; that it has bometimes staggered as if giddy, or has dragged the limbs in walking ; that its manner is restless, and its temper capricious, sometimes appearing well and cheerful, at other times ill, cross, or peevish. These symptoms may be so slight as to escape notice altogether, or at all events that notice which they require. 6. First stage. (It appears to ine desirable to describe se- * Observations on Dropsy of the Brain. + Uiejeases of Infancy and (.'liildKood, y. 61. L 2 76 FEEKILE DISEASES. parately the features of " stages," which may certainly in many cases be distinguished clinically, although it is by no means certain that they are related in the manner commonly described to anatomical conditions.) i. Extrinsic symptoms. These are the occurrence of febrile disturbance, with slight thirst and anorexia; irregular, some- what quick pulse; vomiting and constipation, or clayey evacua- tions, deficient in bile; red and moist tongue; dry, but not very hot skin ; and other phenomena of general derangement ; assuming an irregular, fluctuating, but not definitely remittent course of development in a previously unhealthy, and often scrofulous child. ii. Intrinsic symptoms, often feebly marked. a. Mental. Irritability of temper, peevishness, some slight delirium at night, rarely commencing early in the disease; dis- turbed sleep, and restless manner. /3. Sensorial. Pain in the head, dysaisthesia (intolerance of light and sound); vertigo, indicated by staggering, or clinging to objects for support. y. Motorial. Grinding of teeth, vomiting, unsteady restless movements, drao-o-inor of limbs. c. Second stage. This arises after three or four days. i. Extrinsic symptoms. Heat of head, flushed face alter- nating with pallor; irregular pulse, commonly when the child lies still it is of little frequency, but rises rajiidly if the child is disturbed. The vomiting ceases, but the constipation persists, with retracted abdomen. ii. Intrinsic symptoms become more marked, but occasionally undergo marked diminution; for a few hours, or for a day, the child appearing comparatively well. a. Mental. The little patient keeps very quiet in bed, resisting attempts at disturbance, which appear to augment the pain. There is delirium, often fugitive, but sometimes per- sistent. /3. Sensorial. Cephalalgia increases ; the expression of coim- tenance is that of great suffering, and the face ages remarkably. The pain induces a peculiur piercing cry (" cri hydrenci- MENINGITIS (TUBEHCULAK ). t 7 plialique" of M. Colndet). Tlie eyes are closed, and tliere is a tendency to drowsiness. 7. Motorial. Strabismus, and muscular twitchings occur; the pupils are variable, often oscillating; and the eye-balls have a pecidiar oscillating movement. d. Third stage, may be the gradual intensification of the second ; or may bo rapidly entered by an attack of convulsions. i. Extrinsic symptoms, are those of approaching dissolution ; cold extremities, clanimy perspiration, excessively rapid but feeble pulse, &c. ii. Intrinsic; are at first those of exalted spinal action, then the signs of general prostration (cerebral and spinal). a. jNIental. Drowsiness passes into stupor, with an idiotic expression of face (to which Sprengel, Gblis, and others at- tached great importance). There is loss of perception and volition. /3. Sensorial. All signs of activity have given place to anaesthesia, the eyes are half open, and nothing appears felt. -y. Motorial, Convulsions, with partial paralyses, subsultus tendinum, clenched hands, retracted head, and automatic move- ments; giving "way to general relaxation, with occasional fibril- lar contraction of the muscles. The characteristic symptoms are, the occurrence of slight fever in an unhealthy child, with headache, obstinate vomiting and constipation; passing into a second stage of increased pain, Avith intolerance of disturbance, irregular pulse, delirium, and di'owsiness; these pursuing an irregular course, and ending in convulsions, loss of perception, rapid pulse, cold extremities, and death. The most important distinctions are from simple meningitis, and remittent fever: .from the former it may be separated by the general condition and hereditary tendency of the child, and by the less degree of febrile excitement, and of sensorial hyper-action ; from the latter, the distinction will be rendered obvious by a reference to Section V. 2. Tubercular meningitis 171 Ihe adult ■pvcsenis many varieties in the course of its symptoms: occasionally they assume an 78 FEBRILE DISEASES. apoplectic, sometimes a convulsive, form at the commencement, but more commonly tliey pass through phases of development bearing considerable resemblance to those of simple meningitis. Louis describes three stages, and sometimes they are extremely obvious. The febrile character is generally but imperfectly marked. a. Premonitory symptoms. These consist essentially of the tuberculous diathesis, in its common form phthisis pulmonalis. Meningitis may occur in any stage of the lung disease. The first point to be ascertained is the presence or absence ol" deposit in the lungs; for although, in rare cases, exceptions are found to the general law of Louis (that after puberty tubercle is not found in any organ without its co-existence In the lungs), yet the truth of that law is such that its ap})licatlon (deduc- tively) to the class of cases under consideration is of the utmost importance. If there is, demonstrably, a healthy thorax, the probability is great that the meninges are free from tubercle: if, on the other hand, the symptoms mentioned below occur in a phthisical patient, the probability is great that his meninges are the seat of deposit. h. First stage, which lasts from three to twelve days, is marked by : — i. Extrinsic symptoms. The existence of demonstrable tubercle; and frequently some remission of the chest symptoms, cough, expectoration, &c., with vomiting, heat of head, flushed face, and injected conjunctiva}. ii. Intrinsic, very variable in their course. a. Mental. The intellectual state may be natural; or there is simply a bewildered look; a dull, heavy, expressionless face, often highly characteristic ; mutism is not uncommon; Dr. Walshe * has mentioned the occurrence of this symptom in several cases which have fallen under his observation, some of Which it was my advantage to observe when acting as his ch- nical assistant; and I have subsequently witnessed the same phenomenon in other patients. It probably depends upon a peculiar intellectual state, rather than upon any interference * Diseases of the Heart and Lungs, p. 392. MKXIXiilTlS (tUBEECULAk). 7.9 with the mechanism of articulation : the patient appears to understand what is said, or asked ; looks at the inquirer for a few seconds, and then turns the head away without a reply. There is often marked somnolence. j3. Sensorial. Tlie most striking symptom is pain in tlie head, fixed to one spot, generally the forehead; of considerable intensity, and persistent for many days. There may be some intolerance of light and sound, but it is very rarely a markf d phenomenon. •y. iNIotorial. The first symptom may be, as I have had occasion to observe, an attack of convulsions. Dr. Brinton rcj)ortcd a similar occurrence to the Pathological Society (No- vember 4, 1854). In another case, falling under my own ob- servation, the first symptom was sudden loss of articulation. (In both instances, however, fixed pain in the head, great ob- scurity of perception, and dull, expressionless countenance were rapidly established). Louis states that paralysis is rare at an early period,* and this statement is (so far as I have seen) certainly correct. c. Second stage; of verv variable duration. i. Extrinsic symptoms. The pulse is higbly irregular; and alternate flushing and pallor of countenance are common. ii. Intrinsic symptoms: these are either a simple intensifica- tion of those already mentioned, or some additional phe- nomena. a. Mental. Duhiess persists, sometimes alternating with mild delirium : the face becomes increasingly stupid-looking. j3. Sensorial. There is general obtuseness, or diminished impressibility. y. Motorial. Some paralyses to volition, alternating or co- existing with spasm of clonic or tonic character, strabismus, and occasionally convulsive attacks. The muscles are unduly sensitive to percussion; and in two cases which I have observed the contraction was not only highly marked, but took place only in the spot percussed, the fibres rising into a pyramidal eleva- tion, and not extending along their course (towards the insertion * (»n Phthiais, Syd. Soo. Ed., p. 281. 80 FEBRILE DISEASES. bl' the muscle), as is usually tlie case, unless very forcibly im- pressed. It has appeared to me, although I cannot state it positively, that the percussion irritability in these cases was much greater than is ordinarily found in cases of phthisis. It does not exist in the chest muscles only, but in those of the limbs, and is generally more marked in those exhibiting some paralysis, than in others retaining their volitional motility. d. The third stage is marked by increasing stupor, immo- bility, and involuntary defecation and micturition. The characteristics of this affection are, the occiu'rence of fixed pain; vomiting; dull intellect and face; with partial paralyses, or convulsions ; slight fever ; and diminution of the chest symptoms in a patient demonstrably tuberculous. The indications of inflammatory action are only feebly marked (not only during life, but post mortem); and very often the febrile state (hectic), which had existed before, becomes less noticeable at the onset of cerebral symptoms. Still, heat of head, injected conjunctiva?, and flush of face, denote a con- dition of vascular excitement. Although tubercular deposit may occur in any portion of the meninges, we are unable to determine, from symptoms during life, the locality it occupies. It is well known that the fissure of Sylvius is very commonly the part affected, but the symp- toms from such localisation resemble closely those which occur when the meninges of the upper surface are alone implicated. C. Rheumatic jMeningitis, or, as it may be more cor- rectly termed, meningeal rheumatism, since there is little or no evidence of true inflammation, is prone to occur in the course of acute articular rheumatism. The symptoms should be looked for with great care, to separate them from those " sympathetic" phenomena wliich accompany pericarditis. The probability of tlieir appearance is great in proportion to the intensity of the rheumatic fever, as judged of by the articular condition in respect of severity, and the number of joints implicated; and also in proportion to the general debility, or previous ill-health of the patient. It has been supposed th:it tlie symptoms in question (fi'e- MENINGITIS (rheumatic). 81 quently inexplicable by the post mortem condition of the meninges) are due solely to cardiac complication; but exami- nation after death has proved that they may occur when the heart is free from disease, and hence a physical demonstration of eudopericarditis does not destroy the probability of (idiopathic) cerebral complication. The symptoms resemble very closely those of simple meningitis; pain and delirium, during which the patient throws his limbs in all directions, utterly regardless of tlieir rheumatic state, are the most marked phenomena at the outset. " Taciturnity and a strange waywardness" characterise some cases from the commencement.* Convulsions, coma, paralysis, and the train of symptoms mentioned under the head of simple meningitis follow, and death is the most common result. The diagnosis is based upon the facts of: — 1. Rheumatic fever being present in a — 2. Weak or exhausted subject; and the sudden occur- rence of — 3. Delirium, of marked, furious character, 4. Cephalalgia, and 5. Spasmodic movements; partial or general; followed by a— 6. Comatose condition, with paralysis. The occurrence of meningitis as a phenomenon of blood disease is generally to be distinguished only by the extrinsic symptoms which pertain to that blood-condition: thus the meningitis of syphilis may be* distinguished, and not by any special character to be observed in the intrinsic symp- toms. Throughout the preceding pages, attention has been directed to the diagnosis of febrile afiections involving the pia mater and arachnoid ; this is what we commonly understand by me- ningitis, but the dura mater may be primarily and principally afiected, and often its inflammation may be separated from that of the pia mater by certain extrinsic symptoms and etio- logical considerations. * " RheuuiatiiiUi, Khcuiuatic Gout, aud Sciatica," by Di'. Fuller, p. 278. 82 FEBRILE DISEASES. § II. INFLAMMATION OF THE DURA MATER. The most important facts to be elicited are: — A. The prodromata, or premonitory symptoms and con- ditions. Inflammation of tlie dura mater commonly arises from : — 1. External violence; a blow or fall upon the head; or — 2. Disease of some contiguous part; as, for example, caries of the bones of the skull in any part, but most frequently when affecting the internal ear, or the bones of the nose. The occurrence of head-symptoms subsequent to chronic discharge from the ear is always a highly suspicious circumstance. B. The developed symptoms are of different characters, but generally assume one of the two following forms: — 1. Those of meningitis in its simple form (seep. 72), the pia mater being then commonly involved in the inflammation. 2. An Insidious form ; for example, pain in the ear or nose extends to the head, and increases in violence ; the patient be- comes drowsy, oppressed, and comatose; and may die without any other symptom. In other cases delirium and convulsions supervene, but they have no pathognomonic characters : the im- portant points to be sought for are those mentioned above (A. The prodromata). § III. CEREBRITIS. This inflammation occurs in two very distinct anatomical and chnical forms; the first is general, and is commonly combined with meningitis; the second is partial or local, and though rarely assuming a febrile form, does so occasionally, and requires a short notice in the present chapter. A. General Cerebritis, meningo-cerebritis, phrenitis, or encephalitis, as it has been termed at different times, is pre- sented under two different clinical phases, according to the pre- dominance of inflammation (and its symptoms) in the meninges or the cerebrum itself. 1. First stage. This is of short duration ; a few hours only, or three or four days. There may have been no premonitory symptoms. CEKEBRITIS. 8.'> a. Extrinsic syinptoms. These are but feebly marked (un- less meningitis predominates): there is some heat of head, and of surface generally: pale face: low and irregular pulse: vari- able and suspirious respiration: slight feverish oppression : headache, and vomiting. b. Intrinsic symptoms; generally highly marked, and in proportion to the cerebral affection (as distinct from the menin- geal) are those of diminished functional activity. i. Mental. The patient is sullen, and his faculties become obscured; there is confused thought (rather than delirium, which occurs only in a mild form when the patient doses). ii. Sensorial. There are no hypera2Sthesia3 (except when meningitis is present); but there is deep-seated, violent, op- pressive pain; described as shooting from the centre to the vertex, the temples, eyes, or ears; it (the pain) is out of pro- portion to the intensity of the fever, and does not diminish, as the latter very generally does, in the course of twelve or twenty-four hours. 2. Second stage. This may be ushered in by convulsions; or, after the first stage of two or three days, the patient may become simply comatose, and die in a few hours or days. a. Extrinsic symptoms are unimportant: the pulse usually becomes rapid and weak. b. Intrinsic symptoms are those of nervous (cerebral) inaction ; coma, paralysis, anaesthesia, commonly following two or three convulsive paroxysms. The distinctions from meningitis are the absence of excite- ment, and the rapid transition to marked loss of function : but as it has been already stated meningitis commonly complicates cerebritis, and thus the phenomena proper to each element are presented in various degrees of combination. When the signs of meningitis are unusually severe, the pain deep-seated, and followed after twelve or twenty hours by con- vulsions and coma, there Is commonly meningo-ccrebritis of considerable extent. B. Partial or Local Cerebritis. The symptoms at- tending this form of inllammation, commonly termed '* red M 2 84 FEBRILE DISEASES. softening," or " acute ramollissement," resemble more closely the non-febrile than febrile affections. (See Softening, Chap- ters VII. VIII. and IX. Apoplectic, Dehrious, Convulsive.) When combined, however, as they frequently are, with those of meningitis, they appear in a quasi-febrile form, and conse- quently require some notice in this place. 1. Premonitory symptoms, of intrinsic character, are by no means uncommon. They may be resolved into: — a. Mental. Some loss of intellectual vigour, failure ol memory, confused ideation, consciousness of weakness, &c. b. Sensorial. Pain in the head, deep-seated, fixed, pro- tracted; tingling and nimibness in one limb or side; imperfection of the special senses ; dimness of sight, dulness of hearing, &c. c. Motorial. Loss of power on one side. 2. The developed symptoms assume various forms. In that under consideration now there are : — a. Extrinsic; more or less fever, in proportion to meningitis; heat of head, vomiting, and general malaise. h. Intrinsic ; the signs of meningitis feebly marked ; or con- vulsions, followed by coma, and partial paralysis, with rigidity, returning more or less rapidly, and ending fatally in a day or two, or from two to three weeks. Thus there may be the symptoms of meningitis or of cerebritis, or of the two together, occurring after certain prodromata, and leaving little doubt of the existence of partial cerebritis. § iv. CONTINUED FEVEE. No greater difficulty of diagnosis can occur than that which Is sometimes presented by a case in which the question arises, whether the symptoms are due to meningitis with fever of a low (or typhoid) type, or to typhoid fever with cerebro-menin- geal complication. The question is not so much whether actual inflammation is or is not present (for it may exist in the latter) ; but whetlier that inflammation (or cerebro-meningeal condition) is primary or secondary ; in other words, whether the fever is the result, or secondary product of the inflannna- tion, or whether the inflannnation is one of the many secondaiy CONTINUED FEVER. 85 plieuomcna of the fever. (The term " fever " being here em- ployed to denote the general organic condition induced by a speciHc morbid poison). The diagnosis can only be established by a consideration of each class of symptoms, in their absolute and relative develop- ment. In the following paragraphs the contrast will be drawn between typhoid and typhus fevers on the one hand, and idio- pathic meningitis on the other. A. Prodromata, or those symptoms which occur prior to the appearance of marked cerebral symptoms. 1. Extrinsic. These are rigors followed by febrile reaction, its oppressive headache, anorexia, and general (systemic) dis- turbance; often by vomiting and diarrhoea (in typhoid). The pulse is frequent and feeble, and the expression of countenance dull and heavy. 2. Intrinsic. JMcntal confusion or incapacity Avitli sensorial disturbances, such as tinnitus aurium, musca;, &c.; and general restlessness, with occasional twitchings of muscles. It is to be borne in mind that these symptoms, so common in continued fever, rarely exist to such a marked degree in me- ningitis, without being accompanied by others of much greater intensity and more serious character. B. Developed symptoms. In the majority of cases the ex- trinsic signs of general disturbance are sufficient to account for all the intrinsic phenomena, the latter bearing a direct propor- tion to the former; but in others doubt arises, and in order to remove it we have to consider seriatim: — 1. Extrinsic. There may be the special signs of typhoid, or typhus, viz., the peculiar exanthem of each (rose-coloured, lenticular spots, or the mulberry rash). In either case these are demonstrative evidence of a specific disease. But they may be only doubtfully developed, and we have to carry the investigation further. Epistaxis, and enlargement of the spleen, are common. The pulse is frequent and often irregular; but it does not present the notable variations observed in meningitis. The expression of face is peculiar, and its colour "muddy-looking" in tyjihus, (See intrinsic symptoms, 86 PEBRILE DISEASES. mental). In typhoid there is abdominal pain, tenderness of the iliac fossae, f^urgling in the right, and diarrhoea, with evacua- tions of peculiar character: none of which is constantly or equally marked in meningitis; whereas there is not the frequent, abundant, and persi>tent vomiting of the latter. In typhus, there is a degree of general prostration almost unknown in other diseases. Complications of bronchitis and pneumonia occur much more frequently than in cerebral affections. The conjunctivEB may be injected, but not to the degree ob- served in meningitis. 2. Intrinsic symptoms (or derangements of nervous func- tions). a. jNIental. The expression of countenance may be natural in typhoid; in no one of forty-three cases of typhus was it natural throughout (Jenner).* In typhoid, as a rule it is op- pressed and heavy; in typhus the oppression is still more marked. Dr. Jenner describes it as that of " a drunken man just disturbed from sleep." This is a notable distinction from meningitis; but in rare cases of typhoid the expression is highly vivacious. Delirium is present in a large majority of cases of fever ; it may commence on the third day, but is more common in the second week. In general, it is of mild inoffensive character, and is preceded by confusion of thought. The dulness of delirium is most marked in typhus; and although, in exceptional instances, it may be vivacious in typhoid, it rarely, if ever, assumes the violent, fierce character found in meningitis. In continued fever, deli- rium is in proportion to the febrile state; in cerebral affections, it is more highly marked than the fever will account for. Somnolence is frequent, and often profound, but its approach is more gradual than in meningitis. Thus typhoid, much more commonly than typhus, is the source of difficulty; but its ex- trinsic characters are more distinctive. h. Sensorial. HyperEesthesise, or more properly dysesthesias, are extremely rare. Pain in the head is rarely absent ; but it is of much less intensity than in inflammation ; it is rarely within * Typhus, typhoid, and i-elapsing fevers, p. 20, and seq. CONTINUED FEVER. 87 tlie patient's powers of description, (cither from his confused intellectual condition, or the dilHised extent and unmarked cha- racter of the pain itself); and it almost invariably disappears when delirium sets in. These characteristics differ widely from those of inflammation, the patient with meningitis constantly screaming with pain in his wildest delirium. The sensorial changes which occur in fever are commonly those of deficiency, such as deafness, and general unimpressibility. c. Motorial. Spasmodic twitcliings occur in the muscles of the typhoid patient: general convulsions sometimes occur in typhus. Retention of urine, and its involuntary discharge when present in the latter, are observed at an earlier period than when resulting from primary cerebral affections. If all these differences are duly considered, there can be little doubt, except in rare cases; and these rarer cases are those in which, most probably, in addition to the effect of a special poison circulating in the blood of the nervous centres, there is more or less variation from the healthy standard in respect of its physical conditions of supply; viz., congestion of the cere- brum, its meninges, or both; and of this congestion, the symp- toms referred to are the vital (dynamic) phenomena. The important object for diagnosis is, not the precise ana- tomical condition of the encephalon, (whether there is inflam- mation, or congestion), but whether the cerebral state (whatever it may be), is idiopathic, and is to be treated as such ; or whe- ther it is merely one of many results produced by a general, systemic disease: and this object we may attain, in the greater number of cases, by the indications already pointed out. § V. GASTRIC REMITTENT FEVER. This form of disease has greater resemblance to tubercular meningitis of the child than to any other acute febrile affection involving the nervous centres. It is niore likely that tubercular meningitis may be mistaken for remittent fever, than vice versa. The following symptoms are the basis for their separation: — 1. Extrinsic, (forming the most important distinction). The fever is more marked; has a distinctly remittent cha- 88 FEBRILE DISEASES. racter; and the pulse is in proportion to the febrile excitement; not exhibiting the notable changes of tubercular meningitis. Remittent is rare before the sixth year, almost unknown before the fourth. The tongue presents a thin fur at the base and centre ; but is red elsewhere, soon becoming dry. There is urgent thirst, and great heat of skin. Vomiting is frequent, though not so per- sistent as in acute hydrocephalus, and it is often bilious: the bowels are commonly relaxed, and the evacuations olfcnsive: the abdomen is tender, especially in the iliac fossae. There may be no evidences of a scrofulous tendency. 2. Intrinsic, often very slightly marked. The headache is less severe than in tubercular meningitis: delirium occurs early, but is in proportion to the fever : the expression of countenance is unchanged, or is not changed in the peculiar manner described : and there is a general absence of the essential ner- vous symptoms, enumerated at p. 75 and seq. § VI. HYPEli^MIA CEKEBKI. This state resembles very closely the first stage of meningitis of which it is probably the earliest anatomical condition; but the symptoms arc less intense ; have some special characters (negative); do not pass into more complicated stages of de- velopment; and are more amenable to treatment. The pain is not of violent intensity, or darting character; being more commonly general, dilTiised, and oppressive; with a sense of weight. There is less tendency to vomitingj and constipation is acci- dental only, and easily overcome by medicine. There may be the general signs of plethora ; with bounding, full pulse; and there is commonly some distinct occasional cause to which the symptoms are referrible. There are no positive indications of anything more than hypersemia. § VII. DELIRIUM TREMENS. The specialcharactcr of this disease in its most common form DELIRIUM TREMENS. 89 will be found in Cliap. VIII. Its symptoms sometimes assume a febrile development, and may thus be confounded with those of meningitis. A diagnosis may, however, be very generally established, without much dilTiculty, by attention to the follow- ing points, — 1. Extrinsic symptoms. The fever is not highly marked, there is a pecidiar, clammy sweat upon the skin ; the tongue is Ibul; the secretions highly offensive. The antecedent conditions have been related to alcoholic stimulation (see Chapter VIII.) 2. Intrinsic symptoms. There is very little pain in the head ; it is never in simple dehrium tremens of the marked intensity commonly found in meningitis. The delirium is mild, and usually inoffensive. The patient's mind is haunted with spec- tres that produce a suspicious, fearful expression of countenance. I'here is great restlessness, most intractable insomnia, and a peculiar tremulous condition of the limbs. The symptoms resolve themselves into disturbances of idea- tion, perception, and emotional movement, rather than of sen- sation and volitional motility; and the general condition is that of a morbid blood-change (all the secretive processes being out of order), rather than a state of febrile reaction, the result of a local inflammation. § Till. ACUTF. MANIA. There are not many cases in which mania wovild be con- founded with meningitis. The febrile disturbance, which occurs at the commencement of the former, being much too indistinct in character to be mistaken for that of the latter. However, the onset of mania may resemble very closely that of inflammation, and doubts may occur as to the nature of the malady. It is not my intention to enter at any length upon the diagnosis of mental diseases; they will be only alluded to so far as they may be the sources of fallacy. A. The premonitory symptoms of mania have generally ex- isted in the s])here of intellectual or moral life. Some change of manner, of the mode of thought, of the habitual frame of mind, or of the emotions, may have been noticed, and traced to a mental cause. This is not the case in moningiti.-^. 90 FEBRILE DISEASES. B. The developed symptoms. Allowing that fever exists (in the cases at present under notice), it is of less marked character than in meningitis: and the intrinsic symptoms are peculiar: — 1. Mental. There is some one, or there maybe several fixed delusions, false ideas, upon which the individual reasons more or less correctly, and upon which he acts. 2. Sensorial. There is little complaint of pain in the head (the patient's erroneous ideas absorb his attention). There are not the dysaasthesiaj of meningitis, (sights and. sounds do not occasion pain), but there are true hyperDssthesic-e, often of most extreme intensity, (the patient hearing and seeing things which escape the notice of those in health); and there are metiBsthesise or false sensations, referred to the patient's own body, or to the space surrounding him. These are of subjective origin, and ordinarily coincide with, and support his delusive ideas. 3. Motorial. The phenomena are not of distinctive cha- racter; but their negativity (the absence of paralysis and spasm) is sometimes of service. There is often an apparent increase both of the force, and persistence of voluntary move- ment. The peculiar condition of the mind, and sensorial functions will generally serve to distinguish mania from every otlier alTec- tion, even at the onset; but its subsequent course is still more distinctive, presenting the absence of those stages of develop- ment (implicating the motorial, and sensory powers), wliicli have been described under meningitis. CHAPTER VII. THE APOrLECTIC DISEASES. It has been already stated (Chapter V. p. 64), that the word " apoplectic" is here employed to define a clinical group of symptoms, and not a pathologico-anatomical condition. Loss of CONGESTIOX. 91 perception, voluntary motion, and sensation, (the external phenomena of apoplexy ), may be owing to one or more of the followinoj structural chan2;es : — I. Congestion of the brain ; or " coup clc sang." II. Hiemorrhage; extravasation of blood. ("Apoplexy" proper.) A. Haemorrhage, into the substance of the hemisphere- B. Ventricular haemorrhage. C. Arachnoid htemorrhage. III. Serous eiliision in large quantity. (" Serous apo- plexy.") IV. Local cerebritis; or " softening of the brain." V. Tumor of the brain, or meninges. VI. Tubercular meningitis. VII. Urinaemia, and diathetic states. VIII. Anaemia; morbus cordis; vascular obstruction. § I. CONGESTION; OK, COUP DE SANG. M. Sandras, in his recent treatise upon nervous diseases, makes the distinction between this congestive form of apoplexy, and another which he terms " apoplexie nerveuse," in which there is found post mortem " no vestige of a material lesion."* The symptoms which he states to accompany this form of dis- ease are not of the kind most commonly observed in cerebral congestion ; but on the other hand, they are not sufficiently dis- tinct to separate the two ; as it is impossible, from the negative evidence of post mortem examination, to demonstrate the ab- sence of vascular (dynamic) changes during life. It may be that hyperaemia in some cases, and anaemia in others, have been the occasional causes of the apoplectic seizures: and, therefore, it is not my intention to constitute nervous apoplexy into a distinct class, although this has been done from the earliest time to the present. This is not because it has been demonstrated that morbid symptoms never occur without some coo;nisable structural chan2;e; but because it is exceedingly difficult to arrive at certainty Avith regard to the * Tviiito pratique dcs luaadies nerveuse?. Tome 1, p. 'S'26. N 2 92 APOPLECTIC DISEASES. existence or non-existence of those clianges which me dyna- mic; and because the phenomena which liave commonly formed the features of nervous apoplexy, are of such a character as to warrant the inference that such (dynamic) alterations do take place. (See appendix B.) All the apoplectic diseases will be considered in respect of three periods : — 1st. The premonitory, or period of prodromata. 2nd. The attack, including its immediate precursors and sequelte. 3rd. The stage of recovery, or the reverse. 1. Precursory symptoms. As congestion frequently accom- panies or precedes all the apoplectic diseases, its symptoms are often present as their prodromata. When congestion, however, forms the whole anatomic basis of developed apoplexy (the case now under consideration), they are of more marked in- tensity, and have commonly existed for a longer time. These symptoms are so familiar that it is not my intention to detail them, farther than will suffice to point out those which are the most prominent, and ^^'llich it is the most important to observe, in order to arrive at some conclusion whether congestion alone, hremorrliage, or softening is the cause of an apoplectic attack. a. Intrinsic; (in this case the most valuable.) i. ]\Iental. There is diminished intellectual activity and power; a general confusion of thought, with deficient memory. This state is increased by any attempt at mental exercise, by the recumbent position, and by emotional disturbance. There is a tendency to inaction (of body as well as of mind); sleepiness, with laboured respiration, especially after meals. This mental condition is not permanent; there is no special and persistent loss ; but a readily induced state of general confusion. ii. Sensorial. The senses are obtuse; the hearing is dull; and there are heavy, rumbling noises in the ears; the sight is dim, and often black spots appear on the field of vision; there is vertigo, with a sense of fulness and oppression in the head ; numbness and weight of the limbs; dull, heavy cephalalgia. These symptoms, however, change their localities, and are only occasional in their occiu'rence. Abercrombie speaks of the absence of pain as a distinction from haemorrhage; but this CONGESTION. i)'S cimiiot be considered of much diagnostic value, although the occurrence of acute (severe) pain would be indicative of some- thing more than congestion. iii. IMotorial. There may be little jerkings of the muscles generally, and occasional diplopia probably indicates irregu- larity of the ocular muscles; but the most common feature is sluggishness of movement. There is no definite loss of power on one side, or in one limb. b. The extrinsic symptoms, referred to the head, are in- creased vascularity of the lace, scalp, and conjunctiva:; a dusky, venous tint of skin; warmth of surface; fulness of the jugular veins, and increased pulsation in the carotids. Those which are referred elsewhere, are a foul tongue, nausea, constipated bowels, laboured respiration and pulse, with cold extremities. 2. riienomena of the attack. The seizure commonly takes place during some muscular exertion, such as lifting a heavy weight, blowing the nose, straining at defecation, &c. ; or upon a change of posture, such as stooping, &c. The precursory symptoms have generally been more intense for a few minutes or hours. a. Intrinsic symptoms of the attack. i. ^lental. Perception is rarely completely absent; some evidences of its presence may be obtained by loud noises, speak- ing to the person by name, pinching, &c. If quite extinct for a few seconds or minutes, it soon partially returns; and there is confused thought, with very little volitional power for the direction of idea or movement. ii. Sensorial. The changes are slight, except for the first few moments of attack, and then they are general in extent — I. e., not limited to one side. The patient, however, usually appears to feel (although distinct perception as a mental act may be absent), the limbs are withdrawn if pinched, and sen- sibility is rarely, if ever, ailected without a corresponding im- plication of motility. iii. Motorial. All the limbs are more or less paralysed, to a slight degree, and I'or a short time (there are exceptional occurrences ol' hcmi[)lcgia and para[)k'gia, but they arc rare): 94 APOPLECTIC DISEASES. stertor, and involuntary evacuations do not occur, unless there have been some convulsions. (Tlie morbid state is not sufli- ciently severe to affect tonic contraction.) There is no rigidity of the limbs; but clonic spasms are not unfrequent. The symptoms begin to abate rapidly ; generally in the course of a few minutes: they rarely last for an hour. Paralysis dis- appears with the return of consciousness (perception and volition) ; and sensibility scarcely ever retains any lesion. Exceptions occur, but the rule is as stated above. b. Extrinsic symptoms are the absence of oedematous ancles, albuminuria, or other signs of diathetic disease. The pulse is variable in its characters, not so much laboured as in hgemorrliage : there is great vascularity of the surface of the head, with violet lips, and throbbing carotids. c. Manner of appearance, and proportion between the three groups of intrinsic symptoms. i. They are developed simultaneouly. There is either ii. Distinct loss of perception (profound coma), and general paralysis, without rigidity or convulsion. iii. Imperfect loss of perception, with general paralysis. iv. General paralysis, incomplete in degree; and sensation unimpaired, or but little affected; or, — V. Paralysis complete in degree, but without stertor or rigidity. These are the most frequent combinations, any one of which affords evidence of congestion rather than of hemorrhage, or softening. 3. Period of recovery. If active and judicious measures are employed, the recovery may be rapid, and complete; but if this is not the case, there is a return to the chronic condition of liability to attacks of congestion, the phenomena of which are described in the paragraphs upon the period of prodromata. It is exceedingly rare for paralysis or anoesthesia to remain. § II. HEMORRHAGE. A. Hemorrhage into the Substance of the He- mispheres. 1. Period of prodromata. Very dillerent statements have H.=I^MORRHAGE. 95 been made witli regard to Its phenomena. In some cases there may be absolutely no premonitory symptoms. Durand Fardel states, that in thirty-five of a hundrcd-and-forty cases, " the absence of all prodromata has been positively recorded."* Rostan says that their occurrence is exceptional.j- GrisoUe that they occur in one-tenth only.;}; Gendrin remarks, that it is rare for them not to occur, and he accounts for the frequent statement of their absence, by the fact, that the data upon which it is based are furnished mainly by hospital patients, who belong to a class of society not in the habit of paying much attention to slight derangements of health. § It is evi- dent that not much stress can be laid upon the diagnostic value of positive prodromata. Pain is present in some cases (13 of 140, Durand Fardel) immediately before the attack; but the most important point to bear in mind is, that the non-existence of precursory symptoms in a given case, is in favour of hremorr- haoe rather than of con<2;estion or softeninc;, since in each of the latter their presence is exceedingly common. By far the larger number of cases which have fallen under my own observation have been free from ascertainable prodromata, or have presented only occasional congestion. 2. The attack is sudden, and rapid in its development to a certain point of intensity. Sometimes, after a few hours, there may be an aggravation of symptoms (suclr as deepening coma^ &c.) ; but the second occurrence is also siidden, and is generally the result of renewed extravasation. The patient, as a rule, if standing, falls instantly as if knocked down. Exceptions, however, occur to tliis : Abercrombie relates two cases in which the symptoms were developed gradually.^ a. Intrinsic symptoms arc almost exclusively important. i. Mental. Loss of perception and volition are commonly complete at the onset; the patient appearing, at all events, lor a few seconds, utterly deprived of intellectual power: after a * Maladies dea Viuillards, p. 247. + Gazette des Hopitaux, 1850. + Pathologic interne, tome i., p. 646. § Traits Philosophique de M^deciue Pratique, tome i., p. 378. ^ Diseases of the Brain, Spinal Cord, &c., p. 234 k seq. 96 ArOPLECTTC DISEASES. few minutes (in sliglit cases), but more commonly after some hours, perception and ideation partially return; and there is confused thought, sometimes passing into delirium. The momentary occurrence of profound coma is not necessarily an indication of extensive haemorrhage ; but after the first few minutes or half-hour has passed, the degree of intellectual ob- scuration may be taken as an approximative measure of the amount of extravasation. It must be remembered, however, that in some cases of haemorrhage, the mental faculties are very slightly, if at all, implicated. These are exceptional, and rare in their occurrence. After some days the intellectual powers are often entirely restored; but in many cases confusion of thought, and partial losses of memory, remain. If, however, the coma does not continue profound, and the case terminate fatally, it is usual for the patient to recover to a notable extent; and this restora- tion is one strong presumption of lia^morrhagc, as distinct from softening. ii. Sensorial. Sensibility is less commonly, and less in- tensely affected, than motility. When cutaneous anaesthesia is complete (even though limited in extent), it indicates severity iDf lesion. The hypaesthesia assumes a uni-lateral distribution; and in slight cases there is only numbness and tingling of the tips of the fingers. Evidences of sensation may be obtained when there is no proof of distinct volition. Pain in the head, and affections of the special senses, are of rare occurrence. Daring the profound coma of the attack at its commencement, the dilated pupil, and the half-open eye, indicate that the retina has lost its impressibility; but this condition, and its analogues in the senses of hearing, taste, and smell, speedily disappear. Such lesions are an indication of severity of liaemorrhage; their persistence a sign of extremely evil omen. Generally, the return of sensibility takes place long before that of motility. Hyperossthesia is of verv rare occurrence. iii Motorial. The changes of motility are of two kinds, the loss or diminution of volitional, and the increase of avo- litional contraction, o. Paralysis is present in the immense H.TIMORRHAGE. 97 inajoritj of cases. (Abercronible relates two instances of its absence.*) The characteristic form of its distribution is hemi- plegia; but sometimes it is general (the former occurs in "84, the latter in '16 per cent.) When, however, the paralysis is general, the htemorrhage is rarely limited to the substance of tlie hemispheres. During profound stupor, the deviation of the face indicates unilateral paralysis; in less severe cases, the condition of the limbs, in respect of volition, is the guide. The tongue commonly deviates to the paralysed side; and any extreme movement of the face, such as laughing, crying, &c., renders the inequality of action more apparent. The orbi- cularis oculi generally escapes paralysis, or is much less impli- cated than the other muscles of the face. The loss of motility is most complete at the first; it is commonly absolute in degree, especially in the arm, which is more profoundly affected than the leg. When both sides are paralysed, one is usually more completely paralysed than the other. Stertor, with involuntary defecation and micturition, are common. There is generally no loss of spinal motility (except during the state of shock existing immediately after the extravasation); when signs of such deficiency are present, they indicate severity of lesion. The immobile pupil, and difficulty of deglutition, with slow and laborious respiration, are common at the moment of attack ; but their persistence for some hours is incompatible with the existence of a slight haemorrhage. |3. Involuntary contraction. This may be of two kinds, clonic and tonic; but either is extremely rare in hosmorrhage limited to the cerebral substance. The presence of either with limited hicmorrhage is more rare than their absence, when extravasation has extended farther. (See Ventricular Hxmor- rliagc, p. 100.) b. Proportion between intrinsic symptoms. i. Profound coma, with hemiplegia (limited in extent to one side, but) of marked intensity, and witliout rigidity. ii. Paralysis of botli sides, but one more profoundly alfected than the other (rare in limited hnsmorrhagc). * Diseaaoa uf the Hraiii, Spinal Conl, kc, p. 330. 98 APOPLECTIC DISEASES, iii. Coma slight, but paralysis liemipleglc and complete. These are the more common combinations from which the existence of haemorrhage, limited to the medullary substance, might be inferred. c. Extrinsic symptoms. The special object to be borne in mind is the exclusion of diathetic diseases. The probability of haemorrhage is greater in cases of hypcrtrophous heart, than in healthy individuals. Not much importance can be attached to this observation. During the attack, the pidse and respi- ration are generally laboured, the face and scalp are of deep livid tint, and there is often increased pulsation of the carotids. There may be, however, precisely the reverse of these con- ditions in cases of marked hgemorrhage. 3. The period of recovery. Unless the lesion is very severe, and in this case rapidly fatal, the symptoms diminish in a short time. The process is much more slow than that observed by congestion, but much more distinct and more rapid than that of softening. The commonest occurrence is the perfect recovery of mental faculty, and the progressive, but much more gradual, return of motility and sensibility, or the per- sistence of motor paralysis in some groups of muscles, such as those of articulation, of the fore-arm, and hand. Sensibility is restored first; then the motility of the lower extremity; then that of the arm; and, lastly, that of the fore-arm and hand. Duchenne has pointed out the existence of two conditions of paralysis — one dependent directly upon the central lesion; the other being merely the secondary result of habitual inaction for some time past (this inaction having been primarily caused by the cerebral injury). In the Ibrmer case, he affirms that it is common to find contraction of the muscles (the evidences of spinal action, increased by the fact of persistent central changes, removing cerebral control): in the latter the muscles are flaccid. Duchenne further states that active tonic contraction of the muscles (distinct firom simple shortening of the flexors) indi- cates some inflammatory action in the w^alls of the cyst.* This distinction appears to me based upon insufficient data; but it * De r Electrisation localist^e, 1855, p. 713, ct seq. HAEMORRHAGE. 99 may be borne in mind, iiud either corroborated or contradicted by subsequent observation. With regard to the condition of the muscles, in respect of electric-stimuhis, there are many different statements. Dr. Hall was of opinion that they were more irritable than those of thenon- paralysed limb. Dr. Todd and others held precisely the reverse. Duchenne, Meyer, and Guitard agree that the irritability is not diminished (as it is in spinal or traumatic paralysis) ; but, from my own experiments, I have found the irritability notably less (in the paralysed limbs), in a very large majority of cases. The causes of such discrepancies arc not very apparent. B. Ventricular HiEMORRHAGE. This cannot, in some cases, be distinguished from ai'achnoid extravasation, and in others, from effusion into the cerebral substance only : but there are other cases in which very little room is left for doubt. There are the general signs of apoplexy, but with these distinctions. a. Mental state. The coma is very profoundly marked at the commencement of the attack, and remains of equal inten- sity; or the patient, after partially recovering from a 'slight seizure, is again suddenly plunged into profound coma, from which there is no recovery. (In the latter case, the earlier attack indicates simple medullary ha!morrhage ; the second attack, the rupture of haemorrhage into either the ventricles or the arachnoid cavity). h. iVIotility is affected in two directions. i. Paralysis is complete in degree, and is developed simulta- neously in both sides ; or, after having been hemiplegic for a short time, there is a second attack (marked by profound coma, &c.), and the paralysis becomes general. There is marked stertor ; involuntary evacuations ; dilated pupil ; difficult and dangerous deglutition. General paralysis succeeding hemiplegic, and, attended by profound coma, is almost pathognomonic of ventricular hemorrhage of considerable extent : since hmitcd haemorrhage, or softening, would not occasion the general paralysis, and the profound coma is inconsistent with the idea that congestion is its only cause. 100 APOPLECTIC DISEASES. ii. Rigidity, or tonic contraction of the muscles, is present in many cases of liseraorrhage (in two-thirds, Durand Fardel); it generally (19 of 26) occurs in the paralysed limbs: some- times is seen in those of the healthy side (4 of 26). This symptom has been carefully recorded only of late years, and its diagnostic value has been somewhat misinterpreted. Lalle- mand stated that it was not a sign of hemorrhage.* M. Boudet pointed out that its real significance was the bursting of hasmorrhage into the ventricles, or the arachnoid cavity ;t and Durand Fardel's cases confirm the truthfulness of this general statement.^ In all cases (of haemorrhage) in which rigidity was present, blood was found in the ventricles, or arachnoid cavity; but in four cases with these anatomical conditions there was, during life, simple resolution of the muscles. The presence of tonic contraction is, therefore, a sign of extensive, lacerative hajmorrhage; but its absence does not prove the reverse. According to Durand Fardel, rigidity is more com- mon in cases of ha?uiorrhage (ventricular) than of softening. Convidsive phenomena sometimes occur, but they are of greater rarity. The most frequent combination of symptoms presented by ventricular hasmorrhage is that of profound coma, with general paralysis and rigidity. C. Arachnoid Hjemorrhage. AVhen extending from the hemispheres, and bursting through the pia mater and arachnoid into the inter-membranous space, its symptoms cannot be distinguished from those of ventricular extravasation; but when occurring primarily (and especially when sub-arachnoid in its locality, and limited in extent), it may be diagnosticated with some approximation to certainty. 1. Precursory phenomena. It is not at all uncommon lor pain in the head, of somewhat severe character, to have ex- isted for a certain time. There may have been slight impair- ment of motility or intellectual oppression. These symptoms * Lettres siir TEiicephale, II., p. 259. + Mdmoiro .sur rhcmorragie des Meuiuges. J Maladies des Vieillards, p. 255. SEROUS EFFUSIOX. 101 are probably related to an unhealthy condition of the meninges. 2. The attack is not so sudden as in congestion or central haemorrhage, although in some cases it is precisely similar. The symptoms are developed seriatim, and rarely simultaneously. 3. The following combinations of phenomena indicate a probability of arachnoid hemorrhage. i. Complete loss of perception (profound coma) without pa- ralysis; or with general paralysis very slightly developed in in- tensity. ii. Complete loss of perception and volition without paralysis; but combined with rigidity or clonic contractions of the limbs. iii. Paralysis of hemiplegic distribution as regards the limbs, but witliout deviation of the features (muscles of the face not implicated). iv. An apoplectic attack without anaesthesia. Prus thought this absence of anesthesia pathognomonic ; but it is not so. V. Imperfectly developed coma (partial loss of perception and volition), with general paralysis. vi. An apoplectic attack of which the symptoms are some- what interchangeable, and assume a remittent course. §111. SEROUS EFFUSION ("SEROUS APOPLEXY"). There is no certainty, or even approximation to certainty, in the diagnosis of this condition, and it was long since pointed out by Dr. Abercrombie that much doubt should he enter- tained with regard to the commonly received opinions upon the relation between this pliysical condition and the apoplectic state. It has not yet been shown that the efRision is the cause of apoplectic symptoms; or that it necessarily and per se in- duces any. The advance of our knowledge Avill probably place many cases of serous apoplexy into the category of blood- diseases ; and many others will find their proper pku'c through the revelations of microscopic anatomy. The work recjuired with regard to this disease is that of the Pathologist: its special clinical history is at present unknown. ] 02 APOPLECTIC DISEASES, The cases on record resemble, on the one hand, hsemorrhaglc effusion or acute softening; and on the other, simple con- gestion. Dr. Abercrombie relates instances of hemiplegia and paraplegia; and other authors detail symptoms from which it is impossible to construct a succinct and specific history. The only real guide that we have, is negative evidence; or want of resemblance to other forms of apoplexy; and, what is much more important, the recognition of serous effusion in other organs of the body ; whether arising from toxajmic (diathetic) conditions, or from these, plus mechanical obstruc- tion in the circulating organs. In Bright's disease, when apo- plectic symptoms have occurred, and the patient has died comatose, serous effusion is frequently discovered in the ven- tricular and arachnoid spaces ; but the symptoms are due* more probably, to the poisonous material in the blood, I'athcr than to the mechanical pressure of effusion: the coma is of peculiar toxajmic character (see urinasmia, post. p. 109), and not that which results from compression. In the present state of medical science we must leave the diagnostic signs of " serous apoplexy " to be miravelled by further investigation. § IV. PARTIAL CEREBRITIS, OR ACUTE RED SOFTENING. It Avould be quite out of keeping with the intention and scope of this work to enter upon any discussion of the qua^stio vexata of the nature of this affection. With regard to its pathology, if one thing is Ijeyond all question, it is that its clinical history closely resembles that of cerebral hajmorrhage, and that some of the greatest difficulties of diagnosis arc to be encountered in the attempt at their separation. And it may be here stated at the commencement of this section, that in some cases the differentiation is impossible — i. e., that some cases occur in which the probability is about equal (so far as we can ascer- tain) that haemorrhage or softening may be present. In another group of instances, the diagnosis may be established without much difficulty by attention to the following points : — 1. Precursory symptoms. These may be entirely absent. M. Rostan, wlio speaks confidently of their presence and soFTExrxG (acute). 103 importance, relates one half of his cases as free from them.* Durand Fardel observed their absence in a still larger propor- tion (in 18 of 3"2).t AVhen present there is nothing very- distinctive in a considerable number of instances, the phe- nomena being simply those of occasional cerebral congestion. (See p. 91). In other cases they aiford strong probability of softening. This is felt if cephalalgia of dull cha- racter, feelings of numbness, and confusion of thought, Avith defective memory, irritability of temper, and slight motorial deficiencies, have been observed for some time; and especially if these changes have been somewhat persistent in their character and locality, and have been referred more to one side of the body than the other. The imperfection of movement or sensation in one limb or side is the most important ; but while the presence of such symptoms is of much value in revealing the probability of softening, their absence is of by no means equal value in establishing the reverse. There is not unfrequently a peculiar, dull, expressionless, or silly face for some little time before the attack. The patient loses control of emotion to a certain extent, and complains of pain in the limbs. These are, however, more common phenomena of softening in its chronic form. It is by no means rare to find that the patient has sullered for some time from an extrinsic chronic disease. + 2. The attack may be gradual or sudden— i. e., there may be a progressive diminution of intelligence, motility, &c., for some hours or days, at the end of which the patient is in an apoplectic condition ; or the seizure may be sudden and instantaneous. In the latter case, the attack is, however, due to congestion; the symptoms of wlaich passing away, those of softening remain. a. Mental. Transient excitement or mild delirium may precede the abolition of perception, and wlien this does occur, it is highly characteristic. Coma is frequently developed al)ruptly, and is often of this peculiar character. The patient * llamollissemeut du Cyrveau, aud Mddcciue Cliuitiue. t Ramollissement du Cerveau, et Maladies des Vieillards, p. 98. t Valleix. Guide dii Mcdccin Praticien. tome iv.. p. 488. 104 ArOPLECTIC DISEASES. lies still, apparently in prol'ound sleep, Ijut immediately gives the hand, or puts out the tongue, if told to do so. Sometimes, although the other symptoms are well marked, the intelligence remains intact. The loss of perception and volition (though often not so complete after the first few minutes as at the onset of the attack, owing to the removal of congestion) is not recovered from, as in cases of hasmorrhage or hypersemia; but dulnessand obscuration of thought and perception remain, and this often to a marked degree. h. Sensorial changes are less frequent and less marked tlian motorial. Generally there is anaesthesia or hypaesthesia in the paralysed limb ; but in exceptional cases hyperesthesia has been observed. Some authors have attached great importance to this symptom, considering it pathognomonic of ramollissement. This it is not; but it is more common in softening than in other apoplectic diseases. Numbness and a sensation of cold are not at all unfrequent: pain in the head occurs, but with no special frequency. c. Motorial symptoms are of two kinds: — i. Paralytic. The face-muscles act unequally, producing deviation of the features. This is sometimes very slight, at other times highly marked. Speech is affected (impaired) with great constancy ; and after slight recovery there is nothing like the power of speaking which retiu-ns in haemorrhage. Para- lysis is commonly limited to one side, sometimes to one limb, l)ut in rare cases it is general. ii. Spasmodic contractions occur in two forms (tonic and clonic), lligidity or occasional spasm may be found in either the paralysed or non- paralysed limbs: most commonly in the former. 3. The proportion between the symptoms, and their various combinations are of more diagnostic value than the simple fact of their presence. Those which may be, with most proba- bility of correctness, referred to softening are the following: — i. Imperfect coma (partial loss of perception and volition), with rigidity of the limbs (since congestion does not induce rigidity, and ventrieidnr ha^morrliage developos prol'ound coma). SOFTENING (aCUTE). 105 ii. Perfect coma (complete loss of perception and volitional power), without rigidity. (Since congestion does not induce profound coma: and ventricular haemorrhage causes rigidity.) iii. Paralysis without loss of consciousness. iv. Paralysis with hyperjesthesia. V. Rigidity coming on after the return of perception and volition. 4. The after symptoms. There is not the sudden disappear- ance of morbid phenomena observed in congestion : nor is there the gradual improvement which takes place in haemorrhage. Most commonly, the mental state persists as one of enfeeblement: the motorial phenomena remain: slight apoplectic seizures recur: convulsive movement and riolditv increase: and some little febrile excitement is set up. (The extrinsic symptoms are unimportant, except so far as their negative evidence excludes the idea of diathetic or sys- temic diseases.) § V. TUMOR OF THE BRAIN, OR MENINGES. There is a general improbability of tumor (whatever may be its supposed nature) in a characteristic case of apoplexy. Its most common course differs widely from that of the apoplectic diseases : but occasionally its development is insidious np to a certain point; although precursory symptoms have presented, they have been unrecorded; and the case ha.s the immediate features of an apoplectic seizure. This may occur with tumors of very different character, and upon their distinction some remarks are made in Chapter XIV. The means of distinguishing tumor from other causes of apoplexy are found principally in the precursory symptoms. 1. Pain has commonly existed for some time, it has occa- sionally been severe, and has had a fixed locality. 2. There have been some modifications of the special senses; such as dimness of sight; dulness of hearing, &c.; and these changes have been limited to one side, and are generally per- sistent after having been once develbped. 3. Some slight failures of motility, in an hemiplcgic or para- lOG APOPLECTIC DISEASES. plegic form, may have existed for a long time, and have in- creased very gradually, and very insidiously. 4. Occasionally, convulsive attacks of variable intensity and extent may have been witnessed, and have been by no means understood. 5. The intellectual condition, and the general bodily health continue normal. The attack itself may present little of any diagnostic value, resulting as it sometimes does from congestion, and sometimes from haemorrhage : but sometimes it occurs in a manner (i.e., by a mechanism) which we cannot explain; but probably through some convulsive agency, of which it is the result. Post mortem we find neither haemorrhage nor marked congestion and during life the paralysis and apoplectic symptoms have usually been limited in extent, and of leeble intensity. It (tumor) is sometimes the cause of anomalous symptoms, the explanation of which may be impossible during life. Thus, a mass of tubercle impinging upon the brain substance has given rise to slight confusion of ideation and sensation as a very occasional thing, until suddenly the patient loses the power of one side, or one limb, with some sensation of numb- ness or tingling, but without any real loss of perception. This diminished motihty persists; there is slight pain in the head; and after a few days or weeks a convulsive attack appears, or coma suddenly supervenes, and the patient dies. The attack of paralysis (though imperfect) comes under the head of apo- plectic seizures, as I have formerly defined them (p. 64); but in the case described, although we might guess at the existence of tumor, it would be untrue to say that its diagnosis was possible. The reader is again referred to Chapter XIV. for the special diagnosis of tumor. § VI. TUBERCULAR MENINGITIS. In the adult tubercular meningitis assumes a quasi apoplectic form, sometimes as the commencement of cerebral symptoms, but more commonly as their second or third stage of /" MEXINGITIS (tUBEUCULAK). 107 development. The diagnosis turns upon two classes of symptoms, — 1. Extrinsic. The recognition of the tubercular diathesis (phthisis) is the most important; but besides this there is (as already noticed, pp. 76 and 79) a peculiarly irregular pulse; slight febrile excitement, with heat of head; and alternately pale and flushed face. 2. Intrinsic. The attack is generally preceded by, — a. Prodromata, such as pain in the head, fixed to one spot ; dnlncss of intellect ; and expressionless face. b. The attack is rarely very sudden or severe. i. Mental. Coma is not profound, the patient may be roused by loud speaking, or .any other kind of disturbance; he looks around in a stupid, sleepy manner, and then relapses into a state of quiescence. ii. Sensorial. Tliere is only slight hypassthesia even of the paralysed limbs; occasionally there appears to be some intole- rance of sensorial impressions generally; and I have found several patients complaining of spontaneous pain, or uncomfort- able sensations in the extremities. iii. IVIotorial. Paralysis is incomplete in degree, and limited in extent; being often exhibited by a peculiar slowness of movement. Clonic spasms and rigidity are frequent; the latter being variable (in the same patient, from hour to hour), both in locality and amovnit. c. The proportion bet\Aeen the symptoms (imperfect coma, with rigidity and only partial paralysis), is sufficient to exclude the idea of haemorrhage and congestion; but occasionally there is great resemblance to acute softening. The special mental characters, and the imperfect paralysis, toirether with the extrinsic (tubercular) symptoms, and the general proo-ress of the case (its assimilation to that described in the precedino- chapter, p. 77, &c.), will, however, commonly furnish a satis- factory basis of distinction. § Vir. UllIN.'EMIA, AND DIATHETIC CONDITIONS. 'Jlic " diathetic conditions" are intended to include Icterus V 2 108 APOPLECTIC DISEASES. and Diabetes, when they have so far affected the organic system generally, as to induce marked nervous symptoms. By far the most important is, — A. Urin.emia; — its most frequent causes being the various conditions known as " Morbus Brightii;" the special anatomical bases of which are different forms of diseased kidney. Whether the renal disease is the cause of the diathetic, or general and systemic change, or whether it is the result of a peculiar cachexia or cachasmia, it is not the object of this treatise to enquire; inasmuch as a solution of the question would neither aiiect, nor a fortiori assist, the diagnosis of urinasmic from those other forms of apoplectic disease which it most closely resembles. Urinajinia may be induced by the retention and re-absorption of secreted urine; or by some peculiar, and by no means satisfactorily explained, condition accompanying pregnancy. Under these various circumstances of origin, the general symptoms may differ; but, in the main, the intrinsic nervous phenomena are the same. Attention will therefore be directed to the diagnosis of urintemia, independently of any farther consideration of its mode of induction. Such diagnosis may be interred from some intrinsic symptoms, but it is to be demon- strated by extrinsic. 1. Intrinsic, may be divided into two periods: — a. Premonitory (or prodromata), sometimes absent altogether. i. IMental. Drowsiness, heaviness, listlessness of manner, or despondency; with confusion of ideas, loss of memory, and some tendency to slight delirium during sleep, or when falling asleep. ii. Sensorial. Anaesthesia of the special senses, especially of sight; transient amaurosis, partial in extent, and incomplete in degree; muscas voUtantes ; tinnitus aurium ; occasional deaf- ness, &c. iii. Motorial. Clonic contractions of the muscles, of variable intensity and locality; general sluggishness of movement, &c.; and often a peculiar slight stertor, even when the patient i^ awake: a less dc<;"ree of that described hereafter. I'lllXJ^MIA. 109 h. The attack very commonly occurs with some epileptitbrm convulsions; but without any such phenomena there may arise marked apoplectic symptoms of somewhat peculiar character. i. Mental. The patient lies in a comatose condition, often marked by stertor, and thus apparently profound (the mouth open, the eyes half closed, and the pupil variable); but if he is addressed loudly, he instantly starts, opens his eyes, may make some effort to answer a question, and even answers it correctly, but then almost instantly relapses into his stertorous sleep. The coma is, however, often much more profound than this, all perception and volition being apparently lost {i.e., as purely intellectual acts), but still the patient starts at a loud noise, and for a moment the stertor ceases.* Sometimes the comatose condition is preceded or accompanied by mild delirium ; which has (as Frerichs remarks)]- a peculiar tendency to monotonous expression; the clinging to and repeating innu- merable times one idea or word. It is certainly not infrequent, but cannot be considered either positively or negatively, pathognomonic. ii. Sensorial. General sensibility is very rarely completely lost, but it may be defective in some parts. The special senses are often altered. Amaurosis is by no means uncommon: deafness is less frequent. Sensation is attected mainly tx * This peculiar form of coma is often described as characteristic of narcotic poison, especially by opium; but I have observed it in the great majority of urinsemic cases which have fallen under my own notice. The urinous element (whatever it may be) in the blood acts probably in a somewhat similar maimer. There is not, however, in all cases of uringemia the notably contracted pupil that is observed in poisoning Vjy opium. It is interesting to observe that the sensori- motor system af)pears to resemble, in its pathologic conditions, the spinal (or re- flective) centre, rather than the cerebral (or intellectual). It is m a state of exalted rather than depressed activity, although both sensation and motion are severed from their purely cerebral relations (i.e., from forming parts of perceptive and effective voUtiou). There are several poisons which appear to act in a directly opposite manner upon cerebrum and spine (inducing at the same time coma and convulsions), but whether they contain different elements whose action is thus separated, as Dr. Walshe once suggested in a clinical lecture the poiaon of urinajmia might be, 1 leave for future researches to decide. t Die Bright'sche Nioicnkiankiieit, &c.. p. 88. 110 APOPLECTIC I)I8EASES. reference to perception (as a mental act): the patient starts' Avhen a noise is made, a limb is withdrawn if pinched, the iris acts upon exposure to light, although there is no evidence of ideation in reference to these impressions, and the movements are evidently involuntary in their character and mode of production. iii. Motorial. In the slighter degrees of coma, general voluntary movement may remain when the patient is roused : in other cases there is partial (volitional) paralysis. Avolitional movements occur with considerable frequency, in the form of clonic spasms, very generally distributed; rigidity, varying in locality and amount, sometimes being excessive, and much increased by movement of the limb; and in the Ibrm of epi- leptoid convulsions. Sensori-motillty appears often in relative excess, and the irritability of the muscles to percussion is, in many cases, highly marked. The stertor exhibits a jDeculiarity, first noticed by Dr. Addi- son.* It is not of low, guttural tone, but of much higher pitch, and appears to be caiised by the mouth rather than the throat, either by some position of the tongue against the roof of the mouth or teeth, or by some movement of the arches of the palate, not like that causing ordinary stertor, from which (although its mechanism is obscure) it presents the most obvious difference. (In several obscure cases — i. e., obscure from the fact of the patient's not having come under notice until cerebral symptoms had appeared, and consciousness was so far lost that little or no commemorative history could be obtained, and in which no cedema of the ankles was perceptible ; this pecu- liarity of the respiratory stertor has at once awakened my suspicions; has led to an examination of the urine and the breath, and to the discovery in the former of albumen and fibrinous casts, and in the latter of an undue quantity of ammonia.) The peculiar muscular condition causing this stertor, I am disposed to consider as the result of spasm rather than paralysis, and the spasmodic contraction may be either of sensori-motor, simply reflex, or tonic origin, forming only one of many phenomena which indicate excessive or perverted con- * Guj's !Iospil;il KciM.rtri J-oi- JSSn, No. YI. TUTN.iaiTA. Ill ditions of those groups of motor action. This hypothesis is, of course, as unimportant as the fact of the dilicrcnce is valuable. 2. The extrinsic symptoms afford demonstration of Bright's disease, or of retained urine. With regard to the former, it is not my intention to detail the diagnosis, except so far as it relates especially to the determination of urinasmia. a. General. These are the signs of debility and cachexia: an anteniiatcd tint of skin, and impaired nutrition, often accom- panied by vomiting of a peculiar fluid, pale yellow in colour, and exhaling ammonia, as shown by the contact of a glass stirrer with hydrochloric acid. Diarrhoea is not uncommon, and the evacuations sometimes have a character similar to that of the vomited iluid. The expired air, in many cases, contains an excess of ammonia, the presence of which may be demon- strated by hydrochloric acid held near the mouth. The ankles are commonly cedematous, the eyelids and sides of the face exhibit the same condition: but all oedema may have disap- peared when the case falls under observation. h. liocal. The urine affords the most satisfactory evidence in three particulars. i. The presence of albumen. In the immense majority this may be readily recognised; but it is by no means conclusive evidence (either negatively or positively). It is said that albumen is often present in the urine, passed within a few hours, after convulsive seizures, not associated with renal disease, and that it disappears in the course of a day or two. I have sought for this after repeated epileptic attacks, but have failed to discover it; however, the observations of others leave lltdc doubt as to its correctness, and the source of fallacy Avhich it may prove. ii. Casts of tubuli uriniferi to be detected by the microscope. iii. Diminution of urea, to be ascertained by chemical ex- amination. The reader is referred to the treatise of Frerichs, or to that of Dr. Owen ilees, or to the last edition of " Wliat to Observe" (published by " the London IMedical Society of Observation"), for the methods to be employed in this inquiry. 112 at'oplectk; diseases. In the urinfRmia, of prco-nant and parturient women, the most common symptom is convulsion, and to this I shall return in Chapter IX. That which arises from the retention of secreted urine has its own special physical signs, upon which it would be out of place to dilate in this treatise. B. Icteric Disease. In the majority of cases of jaundice, the head-symptoms are trifling; but sometimes they are severe, and this occurs most frequently when the affection is acute, and accompanied by fever. Delirium is usually present for some days, and is then followed by gradually deepening coma. In a case recorded by Andral,* the coma resembled that of urin- aemia, in having the characters already described (p. 109); in three other cases it is mentioned that the patient could be roused, and made attempts to answer. The jaundiced tint of skin is the ground for diagnosis. C. Diabetes Meelitus. There is nothing special to be said with regard to the occurrence of apoplexy in the diabetic patient. His wan, pinched, and wasted look, voracious appe- tite, inordinate thirst, emaciation, copious micturition, and saccharine urine furnish the means for diagnosis. § viii. morbus cordis, anemia, and vascular obstructions. These three causes of apoplectic symptoms have been grouped together from the fact of their presenting in common some changes in the blood as respects the conditions of supply, and from a generic similitude of their phenomena. Very few words will suffice to make apparent the diagnosis of such conditions, so far as it has been yet established. A. Morbus Cordis. Hypertrophy of the left ventricle has been commonly thought to hold some causative relation with cerebral haemorrhage ; but the bases upon which this idea has rested are insufficient and unsatisfactory. It is now probable, as Dr. Walshe has suggested, f that coetaneous fatty * Cliuique M^dicale, tome iv., p. 272. + Diseases of the Lungs and Heart. Ed. 1st — p. 471 ; and also Clinical Lectures (in Lancet), p. 279. VASCULAR OBSTRUCTIOXS, ETC. 113 degeneration of the heart, and cerebral vessels is the real link between this form of apoplexy and morbus cordis. Hyper- troplious heart, however, not unfrequently occasions attacks of cerebral congestion (having the symptoms already described, p. 92); and this mode of causation should exercise its proper influence upon the treatment. It is not to these forms of so-called cardiac apoplexy that attention is directed now, but to that which assumes a syncopal character, the diagnostic features being pallor of the countenance and surface generally, Avith imperceptible radial pulse, and often imperceptible action of the heart. Arising sometimes from valvular disease, some- times from depraved nutrition, and more frequently from dynamic changes (such as irregular, imperfect, or painful ac- tion) the recognition of a cardiac cause depends upon the previous diagnosis, or the present signs of such heart-diseases. The apoplectic symptoms are general in their distribution; re- sembling in this respect the congestive form of apoplexy, alike dependent upon a morbid condition (though a generically different condition), in respect of the supply of blood. B. An.t:mia. Owing to any sudden exertion, mental ex- citement, or moral emotion, an anajmiated person may lose consciousness and voluntary power, and for a few moments, or even for a longer time, appear in an apoplectic condition. The urina^mic coma, and some cases of cerebral hcsmorrhage, present marked pallor of the surface, and, as the preceding section shows, morbus cordis may be attended with syncopal apoplexy. From these conditions, simple anaimic apoplexy may be distinguished by,- 1. The peculiar tint of skin, and mucous membrane (tlie latter being examined in the mouth and conjunctivae) differing somewhat from that of urinaimia. 2. The absence of previous history, or the present signs of Bright's disease or of cardiac affection. 3. The very feeble pulse (less marked than that of urina^mia, or cerebral haemorrhage in a weakened subject, but much more distinct than the piilse of an individual in a state of cardiac syncope). 114 APOPLECTIC DISEASES, 4. The general distribution of the apoplectic symptoms. 5. The evidences of anosmia, in cardiac murmur, and in the arterial and venous trunks. C. Vascular Obstiiuctions. Apoplectic symptoms oc- casionally arise, assume the form of softening, and prove fatal in persons who have been the subjects of valvular disease of the heart. It has been shown, post mortem, that " vege- tations" fringe the valves of the heart, that a vessel of the brain appears more or less obstructed by a fibrinoid body, re- sembhng these growths upon the valves; and that softening of* the brain exists in that portion to which this vessel is distri- buted. The inference has been drawn, — that a vegetation (or part of a vegetation) has become detached from the valves; that it has travelled through such large vessels as would allow of its passage; but that having reached a small cerebral artery it has been detained, in consequence of the diminished calibre of the latter ; that it has more or less obstructed the current of blood; and has then caused softening of the brain by simple innutrition.* The diagnosis of such a case would be very difficult ; only an approximation to probability could be arrived at from the oc- currence of symptoms in a person known to be the subject of valvular disease. * My friend, Dr. Saukey (of Hanwell), directed my attention, some weeks since, to the occurrence of oat-like masses of fibrinoid, atheromatous matter in the cerebral arteries of a man who had died of softening, but without any valvular disease of the heart. These deposits, which were very numerous, ap- peared to be on the free, inner surface of the lining membrane of the vessels, and were detached with great readiness by the finger-nail, or by simply dividing the vessel longitudinally, and rendeiing its inner surface convex. Dr. Sankey remarked that he had frequently observed them in other cases, where the vessels of the brain were much diseased ; and that they often presented a greater resem- blance than those which we were at the time examining to detached vegeta- tions. It is therefore necessary that this source of fallacy shoiild be excluded from the interpretation of cases presenting analogous conditions. 1 15 CHAPTER VIII. DISEASES MARKED BY DELIRIUM. The essential elements of delirium, and the general character of those diseases which this chapter is intended to include, have been already described (see Chapters II. and V.)- It is there- fore unnecessary to dilate upon them here; and the only point to which allusion need be made again is, that, for the placing of any disease in tliis category, it is important that fever should be absent; or that it should be present in such degree only as will not account for the delirium. The diseases to be diagnosticated are the following : — I. Hypersemla of the brain and meninges. II. Partial cerebritis, or red softening. III. Delirium tremens. IV. Extrinsic diseases, including, Urinajmia, icterus, diabetes. § I. HYPEREMIA CEREBRI. It would, a priori, appear probable that the functional activity of an organ, bearing direct relation to the interstitial changes which it undergoes (from the contact and intussusception of blood, and its own disintegration), should be in proportion to the quantity of fluid circulating through it ; and this supposition is in the main correct. There are, however, other conditions (besides those of mere quantity) which influence the activity of function: and these we are by no means able to explain satisfactorily. There are abundant reasons for thinking that both the quality of the blood, and the rapidity of its move- ment, are highly influential; but the precise conditions of variation in respect of those properties are unknown. Post mortem, we find evidences of increased vascularity, when during life there liave been either apoplectic phenomena or the signs >■ of delirium; and it may be that in the former case there has a 2 116 DISEASES MARKED BY DELIRIUM. been increased quantity of blood, witb interruption or impedi- ment to its movement: whilst, in the latter, the augmented quantity has been accompanied by normal, or even exaggerated, force and rapidity of its circulation. Delirium, uncomplicated with other nervous phenomena, occurs most frequently in persons of advanced age. It is not, however, confined to this period of life ; being present some- times in the child or adult, and this commonly after exhausting diseases, more or less dependent upon blood-changes, such as rheumatism, &c., in persons of delicate constitution. There are two degrees of the affection : in the first, speech only is afi^ected; in the second, action. The diagnosis of a simply hyperasmic cause is founded upon : — 1. The mode of attack. It is commonly somewhat sudden and unexpected: may be induced by a fall, or by fright; but, when occurring spontaneously, is first observed at night. 2. The character of the delirium. It is sometimes preceded by depression of spirits, rapidly passing into that of alarm, or of great and very unnatural liilarity ; loud talking, laughing, &c., with a wild or simply animated expression of countenance. In old people, the first symptom often is, getting out of bed at night, and the patient (in hospitals, &c.) walking about the wards, and attempting to get into the beds of the other patients. Short of this, however, there may be merely non- sensical talking. It is very rare for violent excitement to be present; although, in some cases, alternate laughing and cry- ing may present a certain resemblance to hysteria. More commonly the patient is employed for hours or days together {i.e., at the return of the delirium) in arranging the bed- clothes, or his dress ; or in catching (gently) at imaginary objects. 3. The simplicity of the delirium — i.e., its freedom from complication with other intrinsic nervous symptoms. This is the rule; but there are some exceptions, the presence of certain: — 4. Other intrinsic symptoms, such as: — a. Mental. Loss of memory; and, after the attack of de- ACUTE SOFTENING. 117 llriuin, confusion of thought, with failure of intellectual power; but then very slightly marked, and of temporary dura- tion only. b. Sensorial. Pain in the head, which sometimes precedes and accompanies the deHrium, in conjunction with general sensorial disturbance, such as tingling sensations, numbness, &c. False sensations, of subjective origin, appear common, the patient talking to, and grasping at imaginary objects. c. Motorial. Sometimes there is spasmodic contraction, sometimes paralysis; but they commonly assume a general, or variable distribution. The delirium has sometimes been pre- ceded by attacks of quasi-apoplectic character, having their origin in congestion. (See p. 92 for symptoms.) 5. Extrinsic symptoms. Vomiting occurs sometimes; but it is rare. Durand Fardel remarks, that it is common to find " a mucous secretion, clear and viscid, produced on the eyelids, or in the interior of the mouth, and sometimes in extraordi- nary abundance, running over the whole face."* This is not peculiar to simple congestion, but Is found in old people with softening, &c., into Avhose symptoms congestion enters as one causative element. § II. ACUTE SOFTENING. As with the apoplectic form, so is It with that characterised by deHrium, the symptoms of softening bear a close resemblance to (because partly consisting of) those of congestion. For some httle time It may be impossible to affirm with accuracy the existence of more than the latter; but the course of symptoms renders a diagnosis possible. In some cases, the nature of the case may be made out from the first. 1. Precursory phenomena. Enfeebled intelligence, motor, and sensory changes, especially when either of the latter two have been observed only, or principally in one side of the body, indicates the existence of something more than simple hyperannia; and the limitation of the symptoms (In respect of loi;ality) announces a probability of softening, in direct propor- * Maladies des VicilUudt^, p. 27. 118 DISEASES MARKED BY DELlitlUM. tion to tlie length of time during which they have been developed. 2. The developed symptoms. a. Mental. Delirium is mild and inoffensive; very different from that of meningitis (and in those few cases marked by considerable excitement, it is probable that some limited meningitis exists). In the intervals of delirium there is distinct mental weakness, loss of memory, confusion of ideas, &c. b. & c. Sensorial and Motorial ; — are the signs of paralysis and anaesthesia of variable intensity, limited to one side, and some- times accompanied by pain and rigidity in the limbs affected. 3. The after-symptoms. That which characterises softening is the persistence of diminished intellect, motility, and sensibi- lity, when the delirium has passed away. (See p, 102 et seq.) § III. DELIRIUM TREMENS. This disease may have its main features, as expressed by its name, accompanied by two different groups or classes of organic conditions. In the one, there is more or less vascular excite- ment; in the other, the reverse. The first form is likely to be confounded with meningitis, or acute mania; the second is not liable to be mistaken for any other disease. We cannot, however, from the occurrence of the latter, assert (as is some- times done) the previous abuse of alcoholic stimulus; delirium tremens may arise from the introduction of other poisonous matters, and also from venereal excesses. 1 . Precursory history will, however, in many cases, establish a diagnosis which might, in the absence of such knowledge, be open to doubt. a. The conditions which precede the attack are most com- monly one or more of the following: — i. Sudden discontinuance, or diminution of the habitual stimulus; and this whether occurring from a spontaneous (volitional) resolution, or from circumstances over which the patient has no control, such as an accident, placing him under restrictions imposed from without. DELIRIUM TREMENS. 119 ii. Great excess of drinking, in an habitual " tippler," or in a person whose habits have been very moderate. iii. Habitual, long-continued " tippling," or taking too much stimulus, without the occurrence of complete intoxication, iv. Moderate drinking, with great privation of food. V. The habitual or occasional employment of opium, or stramonium, or other narcotic drugs; or the sudden discon- tinuance of such habits. vi. Venereal excesses in yoiuig and weakened subjects. h. Extrinsic symptoms. It will depend upon the nature of the preceding conditions whether or not we should seek for other precursory symptoms, which, although presented by the habitually excessive drinker, are to be foxxnd in by no means every case of delirium tremens. Those which are most common are, — feverishness, with foul, furred tongue; thirst and anorexia, clammy perspiration, irregular and suspirious respirations, with frequent but soft pulse. c. The intrinsic symptoms resolve themselves into, — i. Mental. Dejection, melancholy, restlessness, with dis- turbed sleep, and irritability of temper, or some change in tlie manner of the individual, very variable in its character, ii. Sensorial Pra^^cordial oppression, vertigo, nausea. iii. Motorial. Tremulousness of the limbs and tongue, loss of muscular power generally, with cramps in the extremities. All these precursory symptoms may have existed for a long or a short time : they are usually of less duration in young subjects than in those of advanced age. They are especially noticed in the morning, and for weeks may disappear daily, as soon as the habitual stimulus is taken. 2. Developed symptoms, which may be presented almost immediately after a debauch, or after a precursory stage. a. The extrinsic are merely an exaggeration of those akeady described; in some cases assuming a sthenic form, with vascular excitement, dry, red tongue, and heat of surface. (See Chapter VI., p. 88.) But much more commonly the patient is in a notably asthenic condition, with moist, foul tongue; clannnv, tenacious, fetid perspiration, and I'ool :*uvlace; small, 120 DISEASES MARKED BY DELIRIUM. feeble pulse; dark and fetid evacuations, or constipation; and nausea, with total anorexia. b. The intrinsic symptoms are pathognomonic. • i. Mental, There is extreme confusion of thought, accom- panied by delusions, generally of frightful character. These appear to be pure creations of the disordered mind; the patient filling a perfectly vacant room with all kinds of imaginary objects of horror and torment; screaming at them, or attempting to hide himself from them by the bed-clothes, but finding them then in even closer proximity to himself His aspect is that of terror and mistrust; he is suspicious of every one around him; but may generally be soothed and comforted by kind but firm assurance. The delusions are rarely of the fixed character observed in mania; the patient does not reason about them, he cannot command his thoughts as the insane man often can; he is Avandering involuntarily amid fanciful but frightful creations of his own perverted mind, rather than, with disordered will, bending all his powers to appreciate and corroborate the truth of his delusion. Gene- rally the patient is tractable; but, if violently contradicted or thwarted, may become sullen and malicioiis. There is perfect insomnia, so that the unfortunate sufferer finds no relief; and his power of realizing the falsity of these tormenting im- pressions diminishes as the case advances. Besides these mental creations, there are false perceptions (from sensation). The objects of the room appear distorted and hideous, generally into some form corresponding with the delusive ideas. The delirium in fatal cases (of non-febrile type) becomes of low, muttering character; the patient sinks into coma, not lasting +or many hours, and he dies in a coma- tose condition. (See Chapter VI., p. 89, for the diagnosis of cases marked by excitement, &c.) ii. Sensorial. Pain in the head is not complained of when delirium tremens is uncomplicated. Although pseudaesthesla^ (see p. 31) are common (i.e., there are subjective sensations and false perceptions), there are no marked dysaesthesiae (see p. 30), or any true hyper?esthesije. When the two latter CONVULSIVE DISEASES. 121 occur, there 13 pro tanto reason to suspect meningitis; and then there is injected conjunctiva, llushed cheek, &c. (see p. 72.) iii. Motorial. The characteristic phenomenon is the tremor ; and this, though noticeable when the patient is lying still, becomes much more so when the limbs are extended, or the tongue is protruded. In the sthenic form, convulsions occur, and are followed by stertorous coma: in the asthenic (more common) type, subsultus tendinum, and a comatose condition come on; and convulsions of general extent are extremely rare, except in articulo mortis. The characteristic symptoms of this disease, are; — delirium of fearful, wandering, but tractable type, with delusions ; a peculiar muscular tremor, wakefulness, a non-febrile state with clammy, cool skin, and disordered offensive secretions. § IV. DIATHETIC DISEASES. Those which may sometimes be confounded with other diseases are, urinnemia, icterus, and diabetes. The diagnosis in each instance is to be founded upon extrinsic symptoms, and upon the special characters of the intrinsic. (See p. 107.) The delirium is commonly mild, and " loAV-muttering " in its character, attended by subsultus tendinum, or clonic spasms. CHAPTER IX. DISEASES MARKED BY CONVULSIONS. We enter now upon the consideration of a class of diseases replete with pathological interest, social importance, and clinical difficulty. The confessedly great obscurity of convulsive affections induces some diffidence of the attempt which I have made for their classification and diagnosis. It is not my inten- tion to enter upon the many inviting questions which their pathology proposes for solution, further than ta say, that, 122 CONVULSIVE DLSEASE.S. although it is questionable whether the phenomena under con- sideration should be referred directly to morbid processes in the brain alone, there are many diseases which leave post mortem changes discoverable only in that organ, and of these diseases convulsions form a prominent feature during life. Whether, therefore, the relation between convulsive phenomena and a cerebral lesion is direct and necessary, differing not only in degree, but in kind, from that which subsists between the former and any morbid organic condition of other parts of the body; or whether the cerebral lesion acts only in the same manner as (i. e., does not differ in kind, although it may in degree from) eccentric irritations; or, in other words, whether the phenomena of convulsion are dependent directly upon the cerebral state, or are the result of some coetaneously (depen- dently or independently) induced condition of another por- tion of the nervous system, are questions beside the object I have in view: since there are acute diseases of the encephalon, of which convulsions are the most striking symptoms; and these diseases may often be diagnosticated from each other, and from those of demonstrably eccentric origin, by the pre- cursory conditions, intensity, special character, distribution, and sequelae of the convulsive paroxysms. The primary division of convulsive diseases is into those of centric (intrinsic) and those of eccentric (extrinsic) origin: and with regard to this division, or its diagnosis, one general remark is important; viz., that inasmuch as the physiological peculiarities of childhood afford a greater proclivity than do those of adult age to the occurrence of convulsions from ex- trinsic as well as intrinsic causes, the probability is greater that they are of eccentric origin in the child than in the adult, and vice versa. The following conditions and diseases may be diagnos- ticated : — A. Convulsive diseases, of extrinsic origin (eccentric). I. Blood diseases, or toxaemiae. 1. Introduced poisons, including the acute specific diseases, the exantliemata, mineral poisons, &c. TUX.KMLE. I'lS 2. Ketained poisons, dr excreta, sucli as urlnaiinia, icterus, rlieuinatism (?), &c. II. Eccentric irritations (not toxsemiaj). 1. Gastro-intestinal. Dentition, dyspepsia, worms, constipation, &c. 2. Bronchio-pulmonary. Laryngismus, pertussis, &c. 3. Genito-urinary. Morbid uterine conditions, calcu- loid allections, &c. B. Convulsive diseases of" intrinsic origin (centric). III. Idiopathic, without assignable static cause. IV. Congestion of the brain, and meninges. V. Softening of the brain (local acute cerebritis). VI. Tubercular meningitis. VII. Tubercle and tumor of tlie brain. VIII. Cerebral haemorrhage. IX. Cerebral hypertrophy. X. Acute chorea. A. Convulsions of Eccentric Origin, or Extrinsic. § I. BLOOD DISEASES (TOX^MLE). 1. Acute specific diseases. It is of the greatest importance to discover this cause when it exists; to exclude it from con- sideration when it does not. In the adult, convulsions rarely arise from the acute febrile diseases; but in the child, under six years of age, they are of frequent occurrence, and may be present before any marked symptom of a specific fever is apparent. In Chap. VI. p. 87, the occasional presentation of convulsions, in continued fever, has been alluded to; and it is not to paroxysms appearing in that manner, or at so late a period of disease, that attention is now directed, but to the convulsive attacks which sometimes usher in febrile affections in childhood ; taking the place of, and not exceeding much in importance, initial rigors in the adult. The prognostic importance of convulsions at the onset of fever in a child isvery httle; but after ten or fourteen days it is very great, and is eminently unlavourable. The diagnosis in the latter case is easy; in the Ibrmer it is often diflicult, and it u 2 124 CONVULSIVE DISEASES (EXTItlNSIc). is to the former that we are now attending. It is upon the following points that the diagnosis will turn : — i. The child is under six years of age, and has previously been in general, or habitual, good health. ii. There is no hereditary predisposition to tubercle, convul- sions, or insanity. iii. There has been no distinct occasional cause, such as "fright," exposure to the sun, a fall, the exhibition of nar- cotic drugs, &c. &c. iv. There have been no previous indications of head- affections. V. No irritation can be discovered in any organ. (Dentition, worms, overloaded stomach, or constipated bowels.) vi. There has been no complaint of pain in any region. vii. Some general malaise, loss of appetite, restlessness, or feverishness, may have been present for a few days or hours. viii. Some exanthemata are prevalent in the house, or neighbourhood, or even on the child itself (for this has been overlooked). ix. It has been exposed to infection. x. The convulsions have not recurred frequently, nor have they been very severe, nor followed by deep coma. xi. Between the attacks there is no paralysis nor rigidity. xii. The child has not been vaccinated, or has not yet had all the ordinary exanthemata, particularly scarlet fever, and measles. Under these circumstances, the probability would be very great, that the convulsions were due to the presence of an acute specific disease in its initiative stage: at all events the sus- picion might be entertained so strongly that sufficient time should be allowed to pass, before taking active measures, for the disease to reveal itself by appropriate symptoms, or for further phenomena to correct the erroneous judgment. It is not until this source of convulsions is excluded from the diagnosis that we can fairly enter upon a considera- tion of: — 2. Tox(2inmjroin retained cjccrela; such as uriaicuiiu, icterus, TOXJEMIiE. ] 25 &c. The diagnosis of tliese conditions is based upon the re- cognition of their extrinsic symptoms; and certain peculiarities of the intrinsic, when any of these have occurred in the form of prodromata. a. UrincBmia, when occurring in conjunction with acute dis- ease of the kidney, coming on after scarlet fever, or during its period of desquamation, has so distinctive a group of symptoms that it cannot readily be mistaken for other aifections: but when occcurring in the course of chronic Morbus Brightii; appearing as the sequela of typhoid, or cholera; or as an ac- companiment of pregnancy, there may be some surprise felt at tlie first occurrence of convulsions, and there is difficulty of diagnosis imtll the extrinsic origin has been established. In all these cases the preceding drowsiness and llstlessness, Avith the organic condition of the patient, and the form of coma (described p. 109) which is presented, awaken suspicions; and an examination into the extrinsic features of the case rarely fails to establish a diagnosis of its true nature. h. Icterus, is at once recognised by its peculiar modification in the tint of skin, conjunctivas, and secretions. c. Rheumatism. The articular condition ; the general febrile state; and the peculiar mental excitement, with clonic spasm, &c. (see p. 80), indicate the existence of this cause. In an o])scure case, perhaps, unmarked by any articular affection (though pain in the limbs is complained of) the heart should be carefully exainlned, as percarditis may be the first local deve- lopment of rheumatism. If none of these conditions is discoverable, there is another class of extrinsic causes (eccentric irritations) to whicli the convidsions may be due; and sometimes the two kinds of causation co-exist, and this possibility must be remembered. § II, ECCENTRIC IRRITATION. IVIM. Barthcz et Rilliet group together convulsions of this character, which they term " sympathetic," Avith others which they denominate " primary" or " idiopathic," * because they ' Tr.iite clin. (.-fcprat. ilos Maladies clus Eufauts. Tome ii., p. 270, &o. 126 CONVULSIVE DISEASES (eXTUINSIc). present this fact in common, that they are not "symptom- atic" of any discoverable lesion in the nervous centres. It is, doubtless, of great importance to know whether or not the symptoms in question indicate the existence of centric disease ; and for this very reason it appears to me injudicious to place in the same category sympathetic and idiopathic convulsions; since the name of each indicates that the latter depends upon centric, and the former upon eccentric causes. During child- hood there is greater relative activity of avolitional motility, and less of volitional than in after life; and this relation, ^jer se, is a predisponent to convulsions. When, therefore, an in- tense eccentric irritation is followed by an attack, we do not necessarily infer the existence of any morbid condition : but when convulsions occur apart from such irritations, or as the sequence of such occasional disturbances as other children are subjected to without any ill effect, we must infer that there is some abnormal condition of the centric organs, in the case under consideration. Although post mortem examination can reveal no static (anatomical) change, the simple fact of convul- sion is proof of dynamic (functional) disease. It may be simply an exaggeration of avolitional motility, the limited pre- ponderance of which is natural to this period of life, and which is doubtless designed to accomplish, and in the majority of instances does accomplish important ends. The convulsion in the former case may be but the normal reaction of the nervous system upon abnormal stimuli : in the latter it is the consequence of abnormal reaction upon normal stimuli. The distinction is not one of words, or of pathologic speculation only; but it is of the utmost clinical importance in respect of treatment ; and hence it appears to me very desirable that the diagnosis of the two conditions should be satisfactorily made out. This may generally be accomplished by attention to, — a. The precursory symptoms and conditions. 1. Age. The child has not exceeded its sixth or seventh year. 2. Habitual health, has been good; and especially, there ECCENTRIC lERITATIOX, 127 liave been no signs of undue spinal activity (see p. 36), which will be noticed under the next section, nor have there been in- dications of cerebral disease. 3. Management, has been generally judicious, in respect of sleep, diet, Sec. (considered quantitatively and qualitatively). 4. Hereditary predisposition to disease is absent. 5. There has been no exposure to infection. fj. The immediate precursors of the attack, — 1. Some general indisposition, of not very marked cha- I'acter, or, — 2. Distinctly developed disease, of, — a. Gastro-intestinal organs; such as dentition irritations, an overloaded stomach, ascarides, lumbrici, constipation, muco- enterite, &c. [5. Bronchio-pulmonary ; e.g., pertussis, pneumonia, pleuritis, bronchitis, laryngitis, croup, &c. &c. -y. Genito-urinary. Uterine disturbances, calculus in kidney or bladder, &c. &c. 3. Exposure to direct nervous disturbance, such as fright, the rays of the sun, a fall, &c. &c. c. Phenomena of the convulsive seizure. 1. Perception and general sensibility are rarely com- pletely lost: in the exceptional cases it is only during the ex- treme intensity of the paroxysm. 2. The attacks are rarely repeated. Although there are exceptions to this rule, it expresses the general truth as recorded by Brachet,* and MM. Barthcz et Rilliet. 3. The attack is commonly of short duration. 4. After the paroxysm, there are no evidences of centric disease, such as prolonged and profound coma, or paralyses, &c. When the circumstances detailed exist in combination, there is strong probability that the convulsions are sympathetic in origin; i.e., that they depend upon some excess of irritation rather than excessive irritability. In doubtful cases, the diagnosis must be postponed; but when none of the charac- teristics mentioned above can be discovered, there is reason to * Traitd fles Convulsions dans I'lMifance. 128 CONVULSIVE DISEASES (INTRINSIC). fear that the disease is idiopathic (and dynamic), or that it may be symptomatic of some cerebral lesion. The diagnosis of these two classes and the differentiation of the several elements of the latter, form the next topics for consideration. B. Convulsive Diseases of Centric Origin, or Intrinsic, § III. idiopathic, or dynamic. Convulsions of centric origin occur without the detection, post mortem, of any structural disease. It cannot be positively asserted that none exists; but, until it is shown to be present, we are justified in using the word dynamic. (See Appendix B.) The group of idiopathic convulsion takes an intermediate position between those of eccentric, and those of centric (static) origin. Its diagnosis is arrived at per viam exclusionis, or by negative, and also by positive characters: the bases of distinc- tion being : — A. The absence of any evidence of eccentric irritation. B. The absence of diathetic diseases. C. The absence of any distinct symptoms of organic (ner- vous) lesion. D. The presence of certain conditions and phenomena , which indicate a tendency to increased spinal activity (see p. 36). E. The special characters of the attack. It is unnecessary to make further commentupon A. B. and C, their value is great, but it is to be appreciated by negation only; and for the symptoms whose absence is to be ascertained, see pp. 36, 124. The other two classes of phenomena require further comment, in relation to, — 1 . The precursory symptoms, these are found in the chapter upon Elements for Diagnosis, under the head of augmented reflex motihty. Brachet has described, with great clear- ness, many of them, as they are presented in childhood;* but there is much doubt whether these may not often be depend- ent upon temporary eccentric irritation. These are grinding * Loc. cit., p. 31, IDTOPATIIIC (DYXAMIc). 129 of the teeth, carpo-padal contractions, strabismus, starting spasmodic movement of the limbs, &c. MM. Bartliez et Hllliet recoo-nise, on the other hand, intellectual changes (e.g., sleepiness, or irritability of temper) as among the prodromata.* It is by the habitual occurrence of such phenomena, for (lays or weeks before the attack, and this independently of any distinct external cause, that we are led to infer the exist- ence of an idiopathic morbid condition. There is nothing in either the negative or positive prodromata of idiopathic convul- sions (rarely occurring except in early life) which distinguishes them from the first attack of epilepsy. The latter is essentially a chronic disease; and the nearer the patient has advanced towards puberty, the greater is the probability of its existence (or rather, the less is the probability of eclampsy). The dif- ference between these two appears to be, that epilepsy presents not only a pathologic degree of the relationship between voli- tional, and avolitional motility, but one of greater intensity and persistence ; inasmuch as it exists apart from the presence of any physiologic tendency of the same kind, because at a period of life which is normally exempt from such disturbance ; and more than this, it assumes the chronic form. Normally, the child grows out of its convulsive tendencies, and the probability of eclampsy is at an end; but when epilepsy exists, as a chronic disease, it shows that the tendency persists, and the existence of such tendency after puberty is in itself pathologic. 2. Phenomena of the attack. The convulsions may be general or partial; but are usually of short duration; and they rarely return with any great frequency. The loss of per- ception is neither so marked nor so persistent as in epilepsy. The spasmodic movements are not so violent as those of symp- tomatic convulsions; aTid the general character is therefore that of medium intensity. 3. Sequela) of the attack. There is some tendency to stupor, but it is not of severe character. There are no signs of para- lysis affecting limited groups of muscles; tlie intellect is natural when the stupor has passed away; and then^ are no phenomena ♦ Op. cit. tonip ii.. p. 2f!S. 130 CONVULSIVE DISEASES (iNTRINSIc). of extrinsic disease. The attacks do not return until some days or weeks have elapsed; and the same is true with regard to epilepsy. If, therefore, the convulsive phenomena are very severe, or if they rapidly return after a temporary cessation, there is reason to suspect the existence of something more than a dynamic cause. § IV. CONGESTION OF THE BRAIN AND MENINGES. Congestion of the brain may be the cause of convulsions at any period of life; and when not the sole cause (or occasion of all the symptoms), it is usually one of the more marked phe- nomena, and may probably have very much to do with the dis- turbance of cerebral functions, such as the temporary profound coma, and the subsequent stupor. Cerebral congestion as a primary event is not so apt to occur in early life, as in advanced age, or that period at which matu- rity is passed. As we have found its symptoms assuming an apoplectic and delirious form, and thus resembling for a time those which belong to hgemorrhage, and ramollissement ; so we find the convulsive form of congestion, occurring under the same aspect as convulsions from those two diseases. The reason for this is evident in each case — viz., the part which congestion takes in the production of symptoms; the diagnosis of either hle, the tight cravat, or trachelismus. During the attack, perception and volition are commonly completely lost for a variable, but rarely for a long time. The peculiar epileptic cry is absent (according to Durand Fardel.*) Convulsive movements affect the body generally or partially ; and often one side more than the other when both are impli- cated. The i'acial muscles are involved: respiration is sus- pended for a few moments; then becomes laboui-ed, and often stertorous : the pulse is irregular ; and the extrinsic phenomena resemble those of epilepsy, except that they are commonly less marked. However, the face darkens, the patient foams at the mouth, the jugidar veins are distended, and there is marked throbbing in the neck. It is rare for the attacks to be repeated at short intervals, and the stupor is less profound and persistent than that which occurs in epilepsy. 3. Scrpielai of the attack. There is dulncss of intellect, cephalalgia, sometimes limited paralysis, but more frequently general muscular feebleness, or exhausted irritability; and these phenomena rapidly disappear, leaving the patient in his usual condition. There is not the distinctly limited and marked paralysis of ramoUissement or haemorrhage; and tlie absence of these signs, together with the rapid disappearance * Maliidies tics Vicillardts, p. '60. 132 CONVULSIVE DISEASES (INTRINSIC). of the symptoms generally I'urnish (as in apoplexy) the bases of diagnosis. § V. SOFTENING OF THE BRAIN. Although some amount of convulsion may accompany the progress of softening, when its symptomatic character is in the main apoplectic, the diagnosis of softening under such circumstances turns upon the points alluded to in Chapter VII. p. 102 et seq., and this class of cases is not referred to now. Convulsions occur in the course of chronic softening, but neither are they alluded to in the present instance. A con- sideration of their characters will be Ibund in Chapter XIV. There is another class of which convulsions form the pro- minent feature, and often the earliest indication of disease, and it is to this class that attention is directed. 1. Preliminary symptoms. These have usually been present in the form described at p. 103, as the prodromata of softening when its symptoms have an apoplectic type. The most im- portant are pain in the head, mental decay, and some limited impairment of motor power. In conjunction with such signs of disease, it is not uncommon for the patient to have pre- sented transient and slight convulsive attacks, resembling " le petit mal," of the French authors. (For the cliaracters of " le petit mal," see Epilepsy.) 2. The attack may be very sudden and unforcwarned, or there may be some immediately preceding symptoms, such as vertigo, or other modified sensations of no very definite cha- racter or diagnostic value. The convulsions are usually epi- leptiform or epileptoid (see p. 44), that is, they pass through stages, and present general features having a resemblance to the developed paroxysms of epilepsy. The spasmodic move- ments may be limited to one side, or they may be much more marked on one side than on the other. They may be extremely violent and quasi-tetanic; or they may be very feebly marked, consisting in simple tremor of the lunbs. 3. Sequela; of the attacks. The convulsive seizure having passed away, some of the muscles which were previously ct>n- SOITKXINO. I'io ti-actiug clouicuUy arc ibund to be paralysed, or in a state ol' rigidity. Sometimes the paralynit; is loiuid in the Umbs oi" that side which was tlie most convulsed, sometimes in those oi" the othei'. a. Mental. There is not the marked stupor of epilepsy, but the mind is obscured; perce[)tion is diminished; the ideas are confused; and memory nmch impaired. There is a marked diilerence from congestion, not only in the degree, but the per- sistence of these symptoms; always an important aid in the separation of static from dynamic diseases. I). Sensorial. Cephalalgia, pain in the limbs, with imphca- tion of general sensibility, accompanying paralysis. c. Motorial. Paralysis, limited in extent, but marked in degree, and accompanied by clonic contractions or rigidity. It is thus the occurrence of symptoms besides those of con- vulsion, and over and above those for which congestion will account, that gives rise to the suspicion of soltening. It is very important, however, to exclude the existence of urinsemia, which may prove a source of fallacy ; and the age of the patient may allbrd some assistance in the diagnosis, softening being most Irequent after the middle period of life, whereas epilepsy and meningitis very rarely connnence except at an earlier age. ^ VI. TUBEKCULAK MENINGITIS. It is in the child especially that tubercular meningitis some- times assumes the convulsive form (i. e., that convulsions become its most marked characteristics); but the disease may (as stated p. 79), commence by convulsions in the adult. Under either condition in respect of age, the diagnosis may be subsequently estal)lished by the general course of the afiection, the proportion between its symptoms, and by the extrinsic signs of a tuberculous diathesis. This is, however, much more fre- (juently the case in the adult than in the child; some difhcul- ties occur with regard to the latter which recjuire separate . 258. T 138 HYPERTEOniY OF THE BEATN. at by finding, that the patient had been exposed to lead- poisoning, and that the cerebral symptoms were preceded by those of saturnine colic, &c.; the ordinary signs of lead- poisoning being at the same time present in the system. Convulbions occur frequently in an acute form, and prove fatal as the termination of chronic diseases. To these atten- tion will be directed hereafter, and the reader is referred to Chap. XIV. for the diagnosis of hydrocephalus (chronic), from hypertropliy. § X. ACUTE CHOREA. Using the term convulsion in the sense defined at p. 67, chorea does not properly fall into the same category, nor does it resemble those diseases, the differential diagnosis of which has been the object of this chapter. It is extremely rare for chorea to assume an acute, or rather hyper-acute form, and prove fatal in a short period of time. This does occur, how- ever; but the diagnosis is not difficult, nor does it differ essen- tially from that of the disease in its more ordinary course; and, accordingly, the remarks to be made upon that subject will be postponed until chorea, in its common form, is the topic foi- consideration. (See Chap. XII., § yjii., Chorea.) CHAPTER X. ACUTE HYPER^STHESIiE. CErilALALGIA, It is desirable to introduce some special observations upon this subject: for although almost all the diseases which the term includes have been already mentioned, or will be described hereafter, the contrasts which exist between their relations to hypercEsthesise, and particularly to cephalalgia, may be more readily appreciated by their separate consideration. Pain in the head is so common an attendant upon every one of its organic diseases, or sympathetic disturbances, that we r'EPIIALAL(iT\. 139 have encountered it in each oi' the four preceding chapters. As an acute affection, it does not exist alone, and as a chronic disease it will he found in Chap. XII., § ill., Hemicrania. The modifications of sensihility arising from its excess have diagnostic value of a subordinate character only, and hence do not form the prominent features of any well marked group of acute diseases. Neuralgias are for the most part chronic, and do not therefore come under consideration now; but, besides this reason, there is the fact of their frequent de- pendence upon local (and not central) causes; upon disease of the nerve trunks, and not upon lesion of the brain. The extent and limitation of neuralgiie, and their relation to particular branches, or trunks of nerves, indicate their peripheral origin. Cephalalgia accompanies extrinsic as well as intrinsic disease, and there are but few essential characters {i.e., modifications of its own features), by wdiich one may be diagnosticated from the other. The central (or intrinsic) origin is inferred from the complication of pain with other nervous phenomena, or modi- cations of nervous function; such as changes in the mental, sensorial, or motor properties: whereas the eccentric (or ex- trinsic) origin is recognised by the signs of disease or disturb- ance in other organs, or in the general system, over and above those for which the nervous conditions will account. A. Cephalalgia of exfrinsic origin. 1. In the acute specific diseases, it is rare for the patient to be able to describe the character of the pain ; it is general in extent, and though often very severe and oppressive, is rarely intense and ao-onisinof, as in organic centric disease ; and there are the proper extrinsic symptoms. (See Chapter VI. § iv.) 2. Rheumatic cephalalgia, accompanies other signs of the rheumatic diathesis; the suffering is augmented by pressure, and by movement of the muscles of the scalp, or eyes. (See Chapter VI. p. 80.) 3. Sympathetic headache, connected with disorders of tlie stomach, liver, or intestines, occurs in the morning; is often relieved by food; is variable in locality, but commonly difllised over the whole head, or most marked in the temporal regions ; T 2 140 ACIIE UY1'ER.ESTHE8I.T:. is cliangeable in cliaructer ; is relieved by vomiting, or purgation ; and is accompanied by distinct signs of derangement in the gastro-intestinal system. When cephalalgia is sympathetic of uterine disorder, it is commonly stated that the occipital region is affected : but this local distinction is of little value, the vertex is often the seat of pain, and occipital headache occurs also from biliary derangement. B. Cephalalgia of intrinsic origin. 1. Congestive. The pain is dull, heavy, oppressive; not commonly intense; generally diffused; of short duration; in- creased by stooping, or lying down ; is accompanied by vertigo, or some temporary mental and sensorial obscurations. The colour of the face, heat of head, fulness of vessels, throbbing of carotids, prominent eyeballs, &c. &c., indicate its origin, (See Chapter VII. § i., Congestion.) 2. Inflammatory. The suffering is intense, and undergoes paroxysmal exacerbations; the pain is of darting, agonising character; is accompanied by various dyscesthesiai, and the general signs of inflammatory disturbance. (See Chapter VT § I., Meningitis.) 3. Organic diseases (such as tubercle, tumor, ramollissement, &c.) are attended by persistent pain ; more or less confined to one spot; althovigh radiating from this spot in various direc- tions. The pain often undergoes paroxysmal exacerbations of great intensity; during the occurrence, or in the intervals of which, various other phenomena indicating disturbance of the nervous fvmctions may be presented; such as loss of sight or hearing, confused talking, or some clonic convulsive move- ments of the limbs. (See Chapter VII. § ii. and iv., Chapters IX. and XIV.) 4. Neuralgic headache is chronic in duration; intense in degree ; and of lancinating, darting character, but limited extent. There are no additional signs of intrinsic, or of extrinsic disease. (See Chapter XII. § in., Hemicrania.) It is sufficient to have pointed out these generic distinctions ; the reader is referred to the several chapters mentioned above for the diilcrentialion oi specific diseases. HI CHAPTER XI. CHUONIC DISEASES, GENERALLY. It is more dilllcult to separate chronic and acute diseases of the nervous system than of any other group of organs. This arises from the frequency Avith which some chronic diseases assume a latent form in respect of symptoms until they have arrived at a certain point, when, by the a])parently accidental direction of their development, they impinge upon some more important parts than those which they have hitherto involved, and a group of striking symptoms is suddenly developed, assuming often an acute course, and terminating fatally in a sliort period. So far as symptoms are concerned, the disease has been acute ; but anatomically it is chronic ; since structiu'al changes have proceeded with equal rapidity (or rather slow- ness) throuo;])out. This is observed with rc2;ard to various tumors, chronic inllammatory (or at all events, exudation) processes, and some extrinsic diseases. Again, disordered nutrition of the cerebral organs may not be altogether latent; but as it has advanced chronically to a certain point, it has been accompanied by a particular group of symptoms, which have given it the name and place of a chronic disease. Suddenly, however, a new group of phenomena is in- duced, liaving a rapid progress, and speedy termination; and thus tlie patient may be said to have died of an acute (separate) intercurrent disease, \vhile post mortem examination reveals, as in tlie former case, a morbid condition of essentially slow deve- lopment; and there may be no means of relating the sudden change of symj)toms (both in respect of special character, se- verity, and acuteness) to anything beyond the gradual progress of the disease. The course of urina^mia is thus marked occa- sionally, when, after long-continued drowsiness and sensorial deliclencies, sudden convulsions occur, and terminate the case i'utally in a few hours. 142 CHRONIC DISEASES. There is another difficulty with regard to the (paroxysmally) convulsive diseases. The idiopathic eclampsy of children and the epilepsy of adults present no definable pathological dif- ference, except that the former is an acute, and the latter a chronic disease. If so, these difficulties occur, — a child, seven or eight years of age, is seized with idiopathic convulsions, and we have to determine whether the fits are those of an acute affection (eclampsy), or whether they constitute the first attacks of the chronic disease (epilepsy). Time will solve the problem, which sometimes cannot be solved by other means; but the question occurs, whether chronicity or acuteness may be made more than a secondary or tertiary basis of division, and consequently whether these commonly separated diseases should not be placed into the same list, and denominated by the same word. Sometimes in the adult, two or three fits take place, having all the features of developed epilepsy, but its chronic recurrence. Are we in such cases to say that the attacks were not epileptic, or are we to give up epilepsy from the category of chronic diseases ? The division of acute from chronic is apparently one of degree, and not of kind; although its clinical value is, in the present state of medical science, very great, as it enables us to form two large groups of diseases, the general characters of which are sufficiently distinct. With regard to the classification of chronic diseases, there are many difficulties, and these are of the same character as those occurring in respect of the acute. The groups which may be separated clinically are found to have similar anato- mical conditions; and, conversely, those which are separable anatomically present often the closest clinical resemblance. But this is not the only difficulty; another arises from the great frequency with which we find as phenomena of one disease, and in the same individual, exaltation of some functions and diminution of others. There is not often (in chronic disease) the simultaneous loss of perception, volition, sensation, and motility, as in apoplexy; or the coetaneous increase of ideation, sensibility, and motility as seen in menin- GENERALLY. 143 gitis; but there is disordered ideation, with increased motihty (spasm) and loss of some particular sense; or any and almost every conceivable combination of derangements. This being the case, we have to form groups according to the predominance of particular pathologic states; separating those in which the signs of exalted activity, or morbid " irri- tation" are the principal features, from those in which decrease of functional activity, or depressed action occupy the same relation; and forming a third group of those cases which pre- sent, as their habitual characteristics, the combination ot both classes of derangement. (See p. 68.) It remains for me to add some few remarks upon the reasons which have led me to place epilepsy, catalepsy, hysteria, chorea, and paralysis agitans among the chronic diseases of the brain. We cannot but admit that the precise locality of their cause is uncertain ; although it appears probable that epilepsy and catalepsy are closely related to functional derangement of the spinal cord, and that hysteria and chorea have their stai'ting place in some morbid condition of the emotional and sensori-motor centres. But, how far diseases of the blood are connected with any or all of these we cannot at present say ; the symptoms of epilepsy, catalepsy, hysteria &c., are, many of them, essentially modifications of the cerebral functions; and the lesions which are discovered, post mortem in the former, are most commonly present in the enccphalon. Deficiency, or a perverted condition of the will in many of its relationships, are as constant phenomena of these diseases as are the signs of spinal activity: the mind, in its relations to motility, and sensation, is often more deeply affected than any other separa- ble vital element; and, until it can be shown that all the symptoms of these various and ever-varying maladies are clearly referrible to particular derangements of definite nervous centres, it appears to me most judicious to leave the question so far open as it is left by the present chapter, and the subse- quent position of those diseases — i. e., to group them with clinically-allied allections, involving (as they most certainly do to a notable extent) the proper functions of the brain. It has 14-4 CITRON re diseases. been necessary to do this with reg'ard to acute convulsive affections (see p. 121): and the reasons for adopting this mode of classification are the same in each instance. CHAPTER XII. DISEASES CHARACTERISED BY EXALTED ACTIVITY. As it has been already stated, these characteristics rarely exist in an uncomplicated form; but there are some morbid con- ditions (which may be termed separable " diseases,") in which there is such marked predominance of one particular derange- ment, or class of derangements, that it gives the essential features of the cases in question; and although various epi- phenomena occur, they are of subordinate importance only, and produce little modification in the general character or progress of the disease. INIany of the affections Avhich form the subject-matter of this chapter, are, so far as we can ascertain, dynamic only; but it is probable that future researches will reclaim several from that list; by showing that some are dependent upon definite physical lesions, and others upon morbid conditions of the blood. We have to diflerentiate the following:: — A. Excessive ideation. I. Hypochondriasis. II. Tarantism. B. Excessive sensation. HI. Hemicrania, or hyperalgesia cerebri. IV. Hallucinations. V. Illusions (vertigo of sensation, &c.) C. Excessive motility. VI. Vertigo of motion (rotatory movements). VII. Co-ordinated spasm (muscular tic). VIII. Chorea. IX. Tremor fparalvsis agitans). HYPOCHONDRIASIS. 145 A. Diseases marked by Excessive Ideation. § I. hypochondriasis. The diagnosis of hypochondriasis from diseases of the nervous system is more easy than from organic diseases in other regions of tlie body. But although sensation, motility, and the nutri- tive processes are more or less disturbed in many cases, the predominant character is derangement or exaggeration of ideas in reference to self. It is because the primary element of disease in hypochondriasis appears to consist of this change in the feelings and ideas, the affection comes under notice in this treatise. When, at a subsequent period, the nutritive processes become derano;ed in various organs, their morbid condition is secondary; and inasmuch as they then add intensity to the erroneous action of tlie mind, they afford an interesting illus- tration of the reciprocal influence which the material substrata and immaterial properties of our complex organism exert upon each other. From eccentric diseases hypochondriasis is diagnosticated by the absence (at all events) at its commencement of any physical or objective signs of disease at all commensurate with the patient's account of his subjective symptoms, and also by the variable character of the latter. They are upon one day re- ferred to a particular group of organs, and upon the next day to another ; and they often present combinations utterly incon- gruous with the interpretation of them given by the unhappy patient, and also with any relation to definite organic derange- ment. Further, these variations may be traced to, and found correspondent with, certain mental states, which are more or less accidental in tlieir occurrence, and dependent upon ex- ternal suggestion. Hypochondriasis is the exaggeration, or increase to a morbid degree of intensity, of that property which every one possesses, more or less, by virtue of his physiological and psychological endowments, viz., of creating around him, or witliin himself, sensations, which (are not the residt of external impressions or corporeal conditions, but 146 EXCESSIVE IDEATIOX. which) having their origin in the mind, are, as it were, pro- jected outwards, and represented objectively in the material organs. It is not the translation of an objective, physical con- dition into a subjective phenomenon of consciousness (the ordi- nary process of sensation and perception); but the transference of the latter, subjective in its origin and essence, into an apparently, and sometimes a real, objective or external change. From melancholia, the diagnosis is based upon the hypo- chondriac's constant self-regard, and the habitual reference of his delusions to the corporeal sphere. Mental and moral dispositions are unchanged in their social relationships ; but the individual is constantly (i. e., when undiverted) dwelling with misery and apprehension upon his own miserable state. Every external or internal change is watched with fear; and the patient is an habitual valetudinarian — carefidly selecting his diet, and examining his evacuations Avith a scrutiny that would do credit to the most earnest pathologist. The most prominent subjective effects of ideation thus morbidly exag- gerated and misdirected are painful and very anomalous sensations. In protracted and severe cases physical derange- ments occur in the organs thus carefidly tended ; and such changes only add intensity to the previous morbid propen- sity of mind. Sometimes motor phenomena, such as sj^asm and palpitation, are induced ; but more commonly there is prostration of strength, incapacity for exertion, and general lassitude. From hysteria, one important distinction is sex ; the male being much more subject to hypochondriasis, and the female to hysteria. But exceptions occur in each direction : and there may be — as I have seen not unfrequently — a com- bination of the two groups of symptoms. Romberg says that he " should feel inclined to designate it (hysteria) the only contrast of hypochondriasis ; "* but this appears to be Avithout due reason. Each has its base and starting-place subjectively, and is reproduced or represented objectively: sensations are commonly the result of hvpochondriasis, and motor phenomena * Tlie Nervous Diseases of Man. Syd. Soc. Trans., vol ii., p. 185. ^YPocHo^'DlaA8IS. l-i? of hysteria ; but neither is confined exchisively to one or the other ; and one prominent feature of each is perverted ideation with regard to self. The hysteric patient, however, exhibits morbid (objective) phenomena ; wliile the hypochondriac does not (until an advanced period) ; and the predominance of motor disturbance will generally serve to distinguish the former. (See Chap. XIV., Hysteria.) To resume. The male sex: the predominance of sensorial disturbance, the special direction of mental activity upon sell", with dread of impending danger and present disease, without other changes in the mental and moral faculties, and without any discoverable organic basis for the symptoms, constitute the features by which hypochondriasis may be diagnosticated. § II. TARANTISM, DANCING MANIA, ETC. Very few words are necessary with regard to these diseases. In their exaggerated form — sometimes occurring endemically — no difficulty can be felt as to the diagnosis. In less marked intensity they present some resemblance to co-ordinated spasiu. (See § VII. of this chapter). There is, however, this dil- ference between co-ordinated spasm and certain varieties of the dancing mania, that in the former there is no discoverable relation to sensation and ideation., whereas in the latter there is. Sonorous impressions, or the sight of particular objects, appear to be the occasioning causes of its extravagant phe- nomena; an excess of sensorial, emotional, and ideo-motility, constituting the essence of the disease. The prevailing idea of the time may mould to its imperious mandates the whole being of many individuals ; and thus certain classes of ideas take possession, not only of the mind, but also of the life ; the mental state passing out of the sphere of consciousness into that of action. The essential features of tarantism, dancing mania, Sec, are the grotesque spasms of co-ordinated character, occurring in connexion with perverted ideation and emotion, and in innnediate dependence upon sensation. u 2 148 INCREASED SENSATION. B. Diseases marked by Excessive Sensation. The term excess of sensation has been used instead of hypersesthesia, as the latter expresses simply an exaltation or increased acuteness of the particular faculty by which we become acquainted with the properties of the external world, and consequently does not apply to the class of morbid phenomena now under consideration. The first of these is characterised by pain, the second by false sensations, the third by modifications of real (objective) sensory impressions. Each is an example of increased sensation ; but neither is an example of true hypersesthesia.* § III. HEMICRANIA. This disease, known also by the names neuralgia cerebralis and la migraine, may be confounded with meningitis, but more probably with sympathetic cephalalgia, or with neuralgia of the frontal branch of the fifth pair of nerves (see Chap. X. for Cephalalgia, and Chap. XX. for Neuralgia); but its diag- nosis may be established by a consideration of the following points : — 1. Relation to age. Hemicrania occurs at any period of life; but it most commonly commences at puberty (although it may appear earlier); rarely, if ever, makes its first attack after completion of the twenty-fifth year, and generally dis- appears before the fiftieth year. 2. Relation to sex. The female sex is more subject to its occurrence than the male ; and in the former it is apt to recur at the menstrual periods. It may, however, exhibit no periodic tendency. 3. Precursory symptoms may be wholly wanting ; or they may consist of various extrinsic phenomena, such as gastric and hepatic disturbance, with pain in the epigastric region, ano- rexia, nausea, &c. More commonly they are intrinsic, such as irritability of temper, chilliness, &c., of no very definite character. The prodromata which are of some importance in the diagnosis are the following : — Imperfection of vision in one * See Chap. II., p. 28, for Modifiuations of Sensibility. HEMICRANIA. 149 eye ; and the presence of variously coloured spots, exhibitinir ciliary motion, also conlined to one eye. Less commonly, the ear is affected in a similar manner, the symptoms being dulness of hearing, with tinnitus on one side only. 4. The attack consists essentially of pain; limited to one side of the head; most intense in the supra-orbital and temporal regions of that side; but not following closely the course, or distribution, of particular nerves. Sometimes the pain is not clearly defined at the median line, and it may become general : it commences with trifling severity, but soon reaches a very high point; is accompanied by throbbing sensations; and is much increased by strong sensorial impressions, or by movements. Slight contractions, or temporary paralyses of the facial muscles, sometimes occur; and the patient is always deeply affected in temper and spirits, becoming irritable and desponding. The duration of an attack is seldom less than six hours; it rarely lasts longer than two days ; and most commonly is between twelve and twenty-four hours. At its decline, nausea and vo- miting sometimes occur, followed by refreshing sleep; or, in some cases, l^y rather profound stupor. The period of return is variable, and may be regular, or ir- regular ; the latter is tlie more common. In respect of frequency there is great variation : the attacks may occur every week, or only two or three times in the year ; and they are less frequent at the commencement and decline of the disease. They com- monly run the same course, and affect the same side of the head (usually the left) in the same individual. There are, however, exceptions to this rule.* 5. The intervals of attack are commonly marked by no symptoms ; the patient may be in perfect health. If cut off by intercurrent disease, there are no anatomical conditions discover- able to account for the symptoms; so that, in the present state of our knowledge, it must be considered as a dynamic (or func- tional) affection. 6. Differentiation from other diseases. Meningitis is ex- cluded by the absence of delirium, febrile excitement, and the ■' Saudra.-j. Traits des Malatlics Nerveuse.s, tome i., p. 340. 150 INCREASED SENSATION. subsequent stages of an inflammatory process. Sympatlietic headache is also excluded by the non-appearance (except suIj- sequently) of distinct eccentric disturbance. The idea of neu- ralgia of the fifth pair is precluded by the absence of limitation to particular branches of nerves, and by the peculiar character and duration of the pain; while its own special (positive) features are sufficiently distinctive to render the diagnosis com- paratively easy in the majority of cases. § IV. HALLUCINATIONS. Under this head " mental delusions" are not included, nor are " sensorial illusions ;" they are the phenomena from which hallucinations require to be diagnosticated. By the former are intended those fictitious products of a diseased mind which constitute the pathognomonic features of insanity : by the latter, the simple distortion of an actually existing sensorial impression. The individual experiencing delusions believes fully in their existence as realities; to him the false creations of the world within supply the place of that which is true without ; there is a want of correspondence between what objectively exists as fact, and that which is subjectively received as truth; and from the condition of such a person, that of the subject of hal- lucination differs. From the delusion of insanity, hallucinations are separable by their relation to intellectual belief. Delusions take possession of the entire consciousness; and are frequently of such sort that they do not come in contact with objective impressions; as, for example, when referring to the individual's own motives or past conduct, the intentions and feelings of his friends, or his own relation to the Supreme Being, and to time. In these cases, mental processes, in their innermost and most distinctly subjective spheres, are disturbed; and such delusions are in no danger of being confounded with hallucinations. Sometimes, however, the individual projects his creations out of himself, and out of the range of metaphysical conditions, into the external world, which he fills with the images of material objects, in correspondence with his own disordered mind. When this is HALLUCINATIOXS, 1.'31 tlie case in de[)enclence upon mental derangement, tlie (subjec- tive) images are presented to each sense; occupying, more or less correctly, tlie relation to each which they would occupy if possessed of real existence. Either no attempt is made to correct the appearance to one sense, by the application of another, or, if the attempt is made, it fails; the mental dis- turbance which produced the one being equally capable to effect the other : the man thus sees no reason for doubting the (objective) reality of his perceptions; since the phantasm which fills his field of vision is not only seen, but heard and felt. Unless a man believes that his delusion is not a delusion but a reality, it cannot be said that he is of unsound mind. But he who cannot convince himself of the unreality (or fictitious character) of these phantasms, is in effect, pro tanto^ mentally insane. The milder term, hallucination, has been employed sometimes to designate this condition, because the individual presenting it has been, upon every other point, in mental health ; but the difference is merely one of degree, and the case cannot be separated from monomania. Hallucinations differ, then, in this most important character from mental delusions, that the subject of the former, although his phantasms may have the appearance of reality, does not beheve in their objective existence; whereas, the subject of the latter does. The distinction from sensorial illusions is one simply of ob- servation; the latter being of two classes (see § v.) one referred directly to the organ affected, such as tinnitus aurium, &c.; and the other to external objects, such as objective vertigo, &c. Sensorial illusions consist essentially in the distorted perception of a real external impression. § V. ILLUSIONS. There are many phenomena which must be considered as sensorial illusions, and their study is one of great interest in relation both to physiology and psychology. In a treatise upon diagnosis, however, they rec^uire Ijut a brief notice, and will be divided into two groups: — 152 IXCREASED 8ENSAT10X. 1. Those which are immediately referred to the organ affected, from their presenting no appreciable resemblance or connexion with surrounding objects; such as muscse, tinnitus aurium, &c. 2. Those which are referred externally; but which follow and depend upon recent or present impressions, and consist essentially in a modification of the latter, or of their resulting perception; for example, sensory vertigo of objective character, spectra, &c. I. Illusions of the former class are occasioned most com- monly by morbid systemic conditions, and these may be of very different character. It is probable that any state which differs from that which is habitual may be the cause of some- what similar phenomena, from the simple fact of change acting as a stimulus (or occasional cause) of nervous action. Thus anasmia, hyperasmia, and toxaemia are alike attended by tinni- tus aurimii, &c. The distinction of illusions from hallucinations has been proposed and urged on the one hand ; criticised and discarded on the other. To my own mind, it appears that it is one of real existence, and of no less real importance ; as there are reasons for thinking that the former depend upon some abnor- mal condition of the peripheral extremity of the sensory nerves, and the latter upon some change in the sensorial centres. Prac- tically the two may be separated, by hallucinations assuming a definite and meaning form ; corresponding to and occasioning a distinct mental picture, but independent of any present objec- tive impression : while, on the other hand, illusions have no defined or intelligible form ; induce no intellectual change (except that of annoyance, from their disagreeable nature); and very frequently depend upon external causes, or are dis- tinctly referrible to the organ affected. Thus, hallucinations of hearing resemble voices in conversation, and distinct sen- tences may be heard; whereas, illusions consist of humming and droning noises (which convey no appreciable idea). Hal- lucinations of sight are distinct phantasmata, human or other forms, landscapes, &c. ; but illusions consist of sparks of light. ILLUSIONS. 153 black spots upon objects looked at, the easily relerreJ (peri- pheral) spectra of external objects, or the apparent motion of the latter. The distinction of illusions dependent upon centric from those rcferrible to eccentric causes (and among the latter must be included physical defects in the organs of sense), is to be arrived at by the general differences already described as the means of diagnosticating extrinsic from intrinsic diseases. (See Chap. IV., p. 52.) II. The most important illusion belonging to the second category, is, — vertigo of sensation. Its diagnostic value is not great, as it is very readily induced by trilling changes in the encephalic circulation, by sympathetic disturbance, and by almost every organic disease of the brain. However, it is sometimes almost the only intrinsic symptom of which a patient may complain, and then it becomes very important to know whether it depends upon eccentric or centric disease. There are two varieties of sensory vertigo, which appear to be perfectly separated by different cases, and which are influ- enced differently by sensorial impressions; one is objective, the other subjective: in the former, external objects appear to move; in the latter, the patient feels as if he were himself moving. It is important to distinguish, — a. Vertigo of eccentric origin — i.e., dependent upon sympa- thetic disturbance. This may be known by the following characters: — i. It is induced without objective causes, such as the motion of siuTounding objects, or of the patient's own body. ii. It is commonly subjective in claaracter. This is not invariably the case, but in vertigo of eccentric, especially when of toxgemic origin (such as that resulting from alcoholic and urinremic intoxication), it is extremely common. iii. It is relieved by the impression of some fixed object, such as a steady gaze, lying down at full length, grasping some body with the hands, &c. iv. It is increased by closing the eyes, thus shutting out iii. v. It is accompanied by the signs of extrinsic disturbance in lot INCREASED SENSATION. the gastric, hepatic, or .other organs ; some of these are pecu- Harlj prone to induce vertigo — e.g., hepatic disturbance, with the suppression of secretion, or the excess of bile in the intestines, and its regurgitation to the stomach. vi. There are no other (intrinsic) symptoms of centric disease. h. Vertigo, of centric origin, has generally some of the following characters : — i. It is commonly induced immediately (i. e., in respect of time) by some sensorial impressions; such as movement of the body, or of surrounding objects, ii. It is most frequently objective in character. iii. It is relieved by shutting out external objects (closing the eyes, observing perfect quiescence, &c.). iv. There are no eccentric phenomena of note. V. There are certain intrinsic symptoms of nervous derange- ment, such as cephalalgia, other illusions of sensation, a tendency to vertigo of motion (see § vi.), delirium, &c. &c. There is a form of vertigo which has appeared to me not at all uncommon, and to which Dr. Marshall Hall was the first to direct attention. It occurs from derangement of the cere- bral circulation by impeded return of blood, owing to con- traction of muscles situated in the neck. From experimental and clinical observation, I feel confident of the reality of this occurrence; but its frequency and importance have yet to be discovered. The diagnosis of such vertigo can only be ascer- tained by observation of a spasmodic contraction in the muscles; it may be suspected from the existence of a feeling of constriction in the neck, or from the fixation of muscles; with flush, or darkened tint of face. Pathologically, this form of vertigo is one of the phenomena of increased reflective (spinal) activity. (See Chap. II., p. 37.) Its special features are not accurately known; but in those cases which have appeared to me the most distinctly trachelismal, the vertigo has been of subjective character. Spectra belong to the second category, and it is important to distinguish ihera from hallucinations. They commonly pre- ILLUSIONS. 155 scut close resemblance to objects which liave recently made impressions upon the organs of sense; and there is this differ- ence between these spectra, which result from conditions of the peripheral extremity of the nerve, and the phantasms which are due to central changes, that they occupy different relations to the organs as physical instruments. Illusions of sight exhibit a peculiar, oscillating, vibratory, or ciliary motion; and the spectra, which may be formed by gazing upon certain objects, increase in apparent size if the eyes are removed to a more distant object, and diminish if they are fixed upon some- thing nearer to the individual. Thus the greater the appa- rent distance to which the spectrum is thrown, the larger it appears, and vice versa; whilst, in true hallucination, the image, if it moves, obeys the ordinary laws of objective vision with regard to apparent distance, viz., that of diminution with removal from the individual, and apparent increase upon approximation. It is very easy to confirm this observation with regard to ocular spectra, and its rationale is sufficiently obvious to require no farther comment. There is but one further remark necessary Avitli regard to the distinction of sensorial illusions when of centric from those of eccentric origin; and it is, that, while the latter are com- monly general in their distribution, affecting not only differ- ent organs of sense, but those of opposite sides, the former are very frequently limited to one side, or even to one special sense. In the discrimination of sensorial illusions dependent upon the external organs from those induced by central dis- turbance, the organs must be examined carefully for any signs of disease in them; and, in the event of its absence, we may infer that the cause is cerebral (or scnsori-gangliar) if more than one sense is affected, and if there are other phenomena of cerebral affection ; whereas there would be strong suspicion of their dependence upon the external organ of sense, if the symptoms were referrible to that one organ only, and were developed apart from any other signs of intrinsic disease. C. Diseases marked by Excessive Motility. The form of motility which is in excess is essentially 156 INCREASED MOTILITY. avolitional ; and the true pathology of the conditions included in this suh-division is very doubtful, but the diagnosis of four separable diseases is comparatively easy. §. VI. MOTOR VERTIGO. This variety of disordered motility is extremely uncommon, as a well-developed phenomenon; and, when present to any marked degree, it indicates serious disturbance, generally organic lesion of some part of the sensori-motor apparatus — i.e., of the cerebellum, or the sensory ganglia, or of some of the fibres placing the two former in functional relationship. Falling forwards lias been observed in connexion with disease of the corpus striatum,* or of the pons Varolii,! or of the crura cerebri.ij: Rotatory movements have been witnessed when the cerebellar peduncles are diseased,§ &c. &c. ; but it is impossible, in the present state of medical science, to arrive at any positive diagnosis of locality from the special character or direction of the symptoms. Some of the many facts con- nected with this obscure branch of pathology I have already endeavoured to group together and interpret in a pamphlet on Vertigo, 1 1 to which the reader is referred for a sketch of our knowledge upon the subject, and the means by which it has been obtained. Though rare as a well-developed vertiginous movement, some of the slighter degrees of motor vertigo are by no means uncommon. For example, the staggering movements of quasi-rotatory character which very frequently attend the sensation of giddiness may be considered of this character. The man who has taken more alcoholic stimulus than he can bear, has slight subjective vertigo (sensorial). The increase of stimulus induces objective vertigo, but consciousness may be * Manual of the Nervous Diseases of Man. Romberg. Syd. Soc. trans., vol. ii., p. 158. + Romberg, loc. cit., p. 159. X Case by Dr. Paget. Medical Times and Gazette, Feb. 24, 1855. § Anatomie Compar(5e du Cerveau. Serre.s. Tome ii., p. 623. II Vertigo (a paper read to the North London Med. Soc. by) J. Russell Reynolds. CO-OEDINATED SPASM, ETC. 157 unimpaired ; still further stimulation produces vertigo of motion, and the man staggers in his attempt to walk; excessive quantities of the poison produce complete absence of perception and effective will. These relations to volition are interesting- and important : the involuntary movement does not occur unless there is some separation of the will from muscular contraction. Motor vertigo, as a sympathetic phenomenon, is by no means uncommon in connexion with functional deranfrement of the heart. It is carried only to the extent of stafffrerino- movements, with a somewhat rotatory tendency ; and it has appeared to me more common than sensory vertigo (from heart affections), or than motor vertigo, from gastric and hepatic disturbance. It by no means indicates morbus cordis of organic character, though common as a phenomenon of left hypertrophy : generally it arises from a nervous temperament, and easily disturbed heart; and has, for its occasional causes, gastric and emotional changes, the former commonly depending upon flatulent accumulation. § VII. CO-ORDINATED SPASM. This term is employed by Romberg* to denote those general disturbances of motility which result in the definite movement of the whole body into some peculiar attitude, resembling that which might be produced by the will, but which occurs inde- pendently of volition or idea, and often in direct opposition to the former. Dr. Marshall Hallf has used the expression ^'■muscular tic,'' to denote a less general disturbance of the same character. The former term simply expresses the fact; but the latter, perhaps unintentionally, conveys a theoretical explanation (viz., that the spasm is muscular in its origin), which may be correct, but which is open to some question. It is therefore preferred to group these phenomena, which differ in degree rather than in kind, under one name, and the former is preferred. * Ri)iiiberg's Manual, vol. ii., p. 1C7. t Clinical Observations, &c. Lancut, 1852. 158 INCREASED MOTILITY. 1. Co-ordinated spasm may be distinguished from tarantism by the peculiar features of the latter, and their dependence upon sensational and ideational changes. (See § ii. of this chajDter.) 2. The distinction from chorea is based upon the localisation of co-ordinate spasm and its duration. The former is more limited : special groups of muscles are affected, such as those of expression; those of the hand, employed in painting or writing (the "writer's cramp"); or those of expiration and inspiration, inducing peculiar and often very disagreeable noises. The duration of co-ordinated spasm is much greater than that of chorea : it is an essentially and obstinately chronic affection in the majority of instances. There are no other derangements of the nervous system, or the general health. § VIII. CHOREA. Two important questions occur as to the position of this disease in any system of classification : the first is, with regard to locality; the second is, in reference to its nature. They may be stated thus, — 1. Is chorea an intrinsic or extrinsic disease; and, if the former, to what portion of the nervous system are the symptoms due? 2. Is it, strictly speaking, a chronic affection? 1. With regard to the first question, it must be allowed that there are many reasons for thinking that the blood is (at all events in some cases) primarily diseased. The precise nature of blood-change is, however, not only unknown, but we cannot say with any positiveness, whether such changes, as may be inferred to exist, are to be sought for in its physical, vital, or chemical properties: and, further, there are many cases of chorea, which, if not demonstrably nervous in their origin, are almost exclusively intrinsic in their phenomena. Although rheumatism, or other cachtemias, may" appear to be the cause of chorea in some instances, there is an equally large number in which the symptoms are clearly traceable to emotion; and, until it can be shown with more certainty that the disease CHOREA. 159 is extrinsic in its origin, and in the modus operandi of its matcries niorbi, we arc compelled to retain it among the intrinsic diseases. The frequent existence of rheumatism, &c., without chorea, and vice versa, indicates that something more than the simple presence of the former is necessary to induce the latter; and leads to the conclusion, that when the two co-exist there is not any necessary or direct relationship (of cause and effect) between them, but that the blood con- dition is only one of many occasional causes, the real essence of the disease being a perverted nervous function. Considering chorea from this point of view, we have next to inquire what portion of the nervous centres is specially involved : and the following facts appear to indicate that it is not the spinal cord; or, in other words, that the spasmodic phenomena are not those of simple reflection, a. Clonic spasm ol' this incessantly repeated character is not a phenomenon of persistent spinal irritation. (Tonic spasm is the mark of such a condition.) b. The movements (unless very severe, and even then to some extent) can generally be somewhat controlled by the will ; and it is certain that the purely (asensuous) reflections are not amenable to volition, at all events to the same extent. c. The spasmodic contractions cease during sleep; whereas the phenomena of excito-motor character are increased by this removal of volition. The direction of attention to some other object likewise diminishes the intensity of choreic movement. d. The special occasions of increase, or of induction of choreic movements, are the attempts at volitional action, and emotional clianges. The essential phenomena may be resolved into more or less active disturbance of the co-ordinating function ; but Avhether this is dependent upon the sensational, or the motorial elements of that twofold property, cannot be positively asserted. There is no reason for suspecting derangement of the former, as there are no evidences of sensorial change; and, farther than this, the movements are of a violent, and independent character, by 160 INCREASED MOTILIIT. no means referrible to simple interference with — i. e., absence of co-ordination. 2. Ought chorea to be placed among chronic diseases? Its ordinary duration is about eight weeks (from six weeks to two months and a-half — Barthez and Rilliet) ; but in slight cases it is much less; and in more severe, it is often prolonged for many months — i. e., the patient continues to exhibit choreiform movements of moderate or feeble intensity, especially when under the influence of emotion. I have seen several cases of persistent choreiform movements in girls who have had occa- sional epileptic attacks. Four or five such cases have been under my notice for more than two years, and the movements remain, although the epileptic attacks have diminished both in frequency and severity. Choreiform spasms are, then, in many cases, of very great persistence ; but there are two further reasons for including this disease in the category of chronic affections. The symptoms are developed gradually, reach a certain point of intensity, remain at such a point for a very variable period, and it is often a long time before all traces disappear. The })rogress of development is slow in the majority of cases; and, again, it is common for the disease to recur in the same individual ; and, taken in connexion with the frequent persistence of some choreic movements in the intervals of attack, this fact appears to indicate, that the motor symptoms are but the exacerbations, and external phenomena of a diseased condition ; essentially chronic both in its duration and character. The occasional occurrence of chorea in an acute and fatal form, in which com- monly there is more distinct general disturbance both of intrinsic and extrinsic character (although the essential choreic symptoms are the same), renders the position of chorea, as- suming its ordinary course and duration, among the chronic diseases. (See Chap. IX., p. 138.) The diagnosis of chorea is not often attended with much difficulty : — 1. Precursory conditions. The female sex, nervous tempera- ment, and approximation towards the period of puberty, are CHOREA. 1 61 the most frequent frencrnl conditions associated with chorea. More rarely it occurs in the adult, and appears to bear some relation to the cessation of menstruation, or to pregnancy. Tt may happen at this period of life (and this is commonly the case) in those who have not suffered from previous attacks. Distinctly morbid prodromata are neither frequent nor characteristic; a certain susceptibility of nervous disturbance and irascibility of temper are not uncommon, but they are not always present. The rheumatic diathesis is apparently a pre- disponent. It is not rare to find that the child has been out of health for some time; and this may arise from various causes, such as the delay of menstruation, general diseases, exan- themata, &c. 2. Developed symptoms. Their commencement, although occasionally sudden (following some emotional disturbance, such as "fright," &c.), is more commonly gradual, and at the first insidious; consisting simply of restlessness, or hurried, and somewhat clumsy movements. The left side and the upper limb are frequently affected first; subsequently the whole body is involved. The essential phenomena of chorea are motorial ; spasmodic (involuntary) contraction of the muscles; and these contractions are of twofold character. i. Clonic spasms; unattended by pain; of great frequency, but of not very marked intensity ; passing through no definite series of gi'oupings (as the epileptoid convulsion does); and resemblina: the restless movements of a child wlio has been irritated, or put out of temper. These spasms occur inde- pendently of any attempts at voluntary movement; are in slight cases almost unobserved ; and when the eyes are closed, and attention is completely absorbed, may be absent altogether. ii. Every kind of disordered movement in the muscles and limbs, when the patient makes any attempt to perform volun- tary actions. The fingers, liands, arms, legs, trunk, and head are thrown into every possible contortion; and the expression of the face is nothing more tlian a series of grimaces. Speech is ol)strncted; and it becomes, in severe cases, utterly im- 162 INCREASED MOTILITY. possible for the patient to do anytliing which requires the co- ordination of movements. Tlie spasms are increased by emotion; persist through the day, but ahnost invariably disappear during sleep, unless the patient dreams, when they are said to recur. Sometimes there are periodic exacerbations. Muscular power is enfeebled, especially in persistence, but somewhat in force. Tire heart acts irregidarly (both in force and rhythm) ; and murmur, probably of dynamic origin, may be often heard at the mitral (left) apex. The diaphragm exhibits spasmodic action; and the interference with deglutition, indicates that not only the external muscles (of the life of relation) are affected, but also those which are placed in more immediate connexion with the organic (individual) life. h. Mental. Intelligence is not essentially changed, but there is, in many cases, apparent diminution of appre- hension. c. Sensibility is normal. Sometimes pain of aching charac- ter is found in the limbs; but this is not common. d. The organic functions are generally performed as in health; but It is very common to find that chorea is associated with some amount of spanamia and innutrition. 3. Course and termination. The most common course is that already described, gradual decline, and complete removal of the spasms. Sometimes, however, slight symptoms remain for a very lengthened period: sometimes the disease is fatal, and this is observed most commonly when the affection supervenes during pericarditis, and when it assumes an acute form. The prominent symptoms are the same ; but the patient loses rest at night, and becomes exhausted: the spasms are exceedingly violent; involuntary micturition and defecation occur; the mind wanders ; nourishment is not taken; ema- ciation progresses rapidly, and death occurs in a few days (nine to twenty). It is a curious fact, that if one of the exanthemata is de- veloped during the existence of chorea, the latter commonly diminislics, and may disappear altogether, 'i'his is denied l)y CIIOKEA. 163 many authors; but there is sulllcicnt evidence to prove the occasional relationship described.* There is but httle danger of confounding chorea with any other disease if its earlier symptoms, mode of developineut, and special characteristics arc examined with ordinary care. Pathological anatomy reveals no constant lesion to which the phenomena may be referred; and those cases which depend upon, or at all events accompany, the progress of organic disease in the encephalon, spinal cord, or nerves, cannot be diagnosticated from the dynamic affection during life, except in rare instances; and it is then by the addition of symptoms over and above those which are proper to chorea itself. § IX. TREMOES. (paralysis AGITANS.) The term paralysis agitans is essentially bad, as paralysis does not necessarily exist in the condition relbrred to, and when present, as in some cases, is not primary ; the relation of muscular power to volition and involuntary motility beiofn- somewhat analogous to that of chorea. The patient can do little with his allected limbs; but it is because of their constant agitation, not because of their paralysis. Tremor of this character is very common in advanced aoe, and especially in debilitated subjects. Although variable in intensity, it rarely leaves the patient in wliom it has been once fully developed. The movements are for the most part general in their distribution; consist of alternate flexion and extension; and are much increased by emotional disturbance: they interfere with the performance of voluntary elfbrts; but are present when no attempt at motion is being made: they com- monly cease during sleep ; but may be so violent as to prevent sleep altogether. JNIuscular power is generally deficient; the intelligence is enfeebled; emotional movements often become excessive, passing altogether the limits of volitional control; the head nods forward upon the sternum, and there is every sign of physical and mental decrepitude. Tremor of this kind occurs sometimes with a partial dlstri- * Biirtliez et Killiet. Op. cit., tome ii, p. 304. Y 2 104 INCREASED MOTILITY. bution, and at an earlier age, the individual presenting, it may be, no other symptom of disease. The pathology of such conditions is quite undetermined. Dr. Paget has drawn atten- tion to the fact of " the peculiar tendency to fall forwards," the patient, to save himself from falling, " being under the necessity of walking on his toes, with short, quick steps;"* and he has further suggested that the crura cerebri should be examined in such cases, and in those of which nodding move- ment of the head is a characteristic symptom. Dr. Paget's suggestion is well worthy of consideration (it is based upon the observation of a case of " falling forwards " in a man who died of disease in the crura cerebri; and also upon Flouren's experiments) ; f but there are not sufficient data (and there are some opposed in their character) to warrant the supposition of any necessary relation between either falling forwards, or paralysis agltans, and disease of the crura cerebri. (See § vi., Motor Vertigo.) CHAPTER XIII. DISEASES MARKED BY DIMINUTION OF FUNCTION. The chronic diseases which are characterised by deficiency of functional activity, or loss of nervous vitality, are exceedingly numerous; but they rarely exist in an isolated form, or even so much separated from other nervous phenomena as do the opposite conditions of augmented activity. They may occur in distinct dependence upon local cavises, such as disease or injury of the nervous trunks; which are considered in the fourth part of this treatise: and they may also persist as the chronic conditions of some primarily acute disease (such as, for e.g., the paralysis remaining after cerebral haemorrhage), * Medical Times and Gazette, Feb. 24, 1855. t Recherches Expiirimcutalus, ed. ii., p. 48t>. ANiESTUESIA MLSCULARIS. 165 the diagnosis of tlieir cause being then based upon a recog- nition of the carUcr symptoms. It is not my intention to consider either of these groups in tlie present chapter; but to refer only to one easily separable disease, viz. : — ANESTHESIA MUSCULARIS. This is liable to be confounded with paralysis; but is most certainly a distinct morbid condition. In many cases of esta- blished paralysis, and especially in those which have assumed a bilateral (paraplegic) form, it is found that the earliest symptom, which attracted the attention of the patient, was, not absolute loss of power, but a diminution in the faculty of controlling movements. It has occurred to me in several instances to recognise this condition at an early period, marked as It is then by the following characteristics: — 1. Cutaneous sensibility is unimpaired — i.e., as judged of by mechanical irritation, changes of temperature, and the special sense of tact. 2. The special senses (sight, hearing, &c.) are normal, with an occasional exception, to be pointed out. 3. The mental and emotional conditions are natural. 4. The reflective functions are not interfered with; defjlu- titlon and respiration are natural; there is no exaltation of susceptibility. 5. Motility Is In a peculiar condition. a. There Is no absolute loss of power; the patient can grasp firmly and equally with either hand; he can strike out the legs Avith force, or even violence; he can perform any acts (i.e., in slight, or commencing cases) to which attention is directed, and upon which sensational guidance can be brought to bear; but he performs them clumsily. b. Without lookinvv to see, however, he does not know the position of his limbs; nor can he execute instantaneously the movement he intended, but sometimes succeeds only after one or two unsuccessful attempts. c. Movements or positions which were assumed voluntarily (as, for exauiplo, by the aid of siglit) arc nut niaiutaiued, If the 166 DIMINISHED ACTIVITY. patient removes his attention to some other object. If the eyes are closed, objects fall out of the hand; and, upon any attempt to move, the patient reels like a drunken man, or may fall to the ground, d. Finer movements, requiring delicate muscular adjust- ment, may be utterly impossible, or accomplished only by dint of great volitional eflbrt and care. e. Diplopia is not unfrequent: the patient sees well with either eye, tried separately, but when the two are used, their axes are not made to converge properly. /. Tliesc changes are often limited locally to one or two limbs, and are most common in the lower extremities. The condition is not one of simple want of the co-ordinating faculty, for the latter remains to a considerable, and sometimes perfect extent, when the eyes are employed (whereas, when the power of co-ordinati(jn is lost or diminished, no actions can be properly performed, even although sensational guidance is allowed). It appears to be due to diminution, or the absence of one most important sensory condition, and instruction (if the term may be used) of the co-ordinating function, viz., the mus- cular sense, or the intuitional perception of muscular states. In the present state of science we are unable to refer anses- thesia inuscularis to any particular organic change of a special organ. It may, in some instances, be dynamic only ; and most probably is so in those cases of so-called paraplegia (of which it is, in reality, the only definite symptom) where there is ex- haustion as the effect of previous excesses, and in which the condition is one of temporary existence. The beautiful physiological researches of Sir Charles Bell, MM. Flourens, Longet, Magendie, and others, render it highly probable that the cerebellum is the organ by which motorlal impulses from volition are combined, and rendered effectual in the attainment of definite ends ; the cerebellum moulding, as it were, the power which is supplied by another source in con- formity with, and under the direction of sensational guidance. In the cases to which reference is now made, it can haixlly be that the co-ordinuting function is injured per se, for visual ANESTHESIA MUSCULARIS. 167 impressions may afford most accurate direction ; but one class of sensorial impressions is suspended, viz., that of muscular sensation. It appears most probable (especially since this is the first change in cases which subsequently exhibit perfect paraplegia) that the centripetal tract of fibres is affected; and that tlic locality of lesion is very variable, but that it bears definite and perhaps discoverable relation to the locality of ana3Sthesia. CHAPTER XIV. DISEASES CHARACTERISED BY THE COMBINATION OF INCREASED AND DIMINISHED FUNCTION. The most important chronic diseases of the brain, and nervous system generally, present this combination of exaggerated acti- vity in some portions, and diminished function in others. The effect of an organic lesion {e.g., a tumor, or deposit) upon function is determined partly by the time and manner of its development, partly by its degree, and partly by the secondary dynamic changes which it may set up. If the development is very gradual, there may be merely tlie signs of irritation, induced from time to time by dynamic vascular conditions, and represented phenomenally by pain, spasm, and sensorial hyper- ffisthcsiffi. If the morbid change is rapidly, or suddenly effected, or if it has gradually passed beyond a certain limit, there may be the diminution of function, or its complete arrest, and anassthesise and paralyses are the symptoms. And, further, the nature of the organic change may be such that it destroys some vital properties, and leaves others unaffected ; or it may be so situated as to sever the functional continuity of organs, and place each in a state of irritation, or exalted activity in respect of other and independent properties. Thus, disease of the spinal cord may obstruct the passage of sensational and (volun- 168 INCREASED AND DIMINISIIM) FUNCTIONS. tary) motorlal impulses; but at the same time, induce reflective exaggeration in the parts below, and hyperajsthesise in those above, the seat of lesion : or a tumor in the encephalon may cause volitional paralysis, with acute pain in the Head, or deli- rium, and convulsive or spasmodic seizures. The diagnosis of organic lesion is framed in no one case by any special or pathognomonic symptoms; but (as in regard of the acute diseases) by the mode of their development, their combination, relative proportion, and the order of their sequence, taken in conjunction with certain extrinsic (general or local) phenomena. Two of the diseases which are present:.! for examination, are in many instances (so far as can be ascertained) dynamic; and the reasons have already been given (see Chap. XL, p. 143) for their position among chronic diseases of the brain. In treating of each separately it will be shown that their proper place is among those affections whose consideration forms the subject of the present chapter. Those of which the diagnosis is now attempted are, — I. Hysteria, and allied affections, catalepsy, &c. II. Epilepsy, " le haut," and "Ic petit mal." III. Tumor of the meninges, cerebrum, and cerebellum — 1. Carcinomatous ) ■ , i \ sometimes separable. 2. Tuberculous ) 3. Aneurismal, fibroid, hydatid, &c., not separable. IV. Chronic meningitis. V. Chronic softening. VI. Induration of the brain — 1. In the adult (from epilepsy, lead-poisoning, &c. 2. In the child. (Hypertrophy of brain.) VII. Chronic hydrocephalus. VIII. Urinsemia. § I. HYSTERIA. The nosology of hysteria is so confessedly undetermined that a discussion of its position in this treatise would be quite out of keeping with the general scope and intention of the book. This IIYSTEEIA. 169 may, however, be said, that whether it is, in respect of its ori<^In, a primary or secondary neiiropathia, it is, phenome- nally, a nervous disorder, and hence forms part of the subject- matter of this work; further, that its course is chronic; and lastly, that all the nervous functions are involved, and present every variety of alteration. Although the most characteristic features of hysteria are certain motorial changes of a convulsive nature, there are other morbid conditions more persistent, and of great importance in arriving at its diagnosis. The presence of the former (paroxys- mal attacks) being tlie demonstration of developed hysteria, such precursory symptoms as may occur have to be considered as prodromata; but if the disease is viewed more generally, and the convulsive seizures are regarded as being only the occasional (although extreme) phenomena of a persistent de- rangement, which reveals itself at other times by various and complicated symptoms, these, whether intercurrent or precur- sory, in respect of time, are essential features of the hysteric condition, and should not be placed among the prodromata. It is, however, convenient to consider some of them separately, and only such will be referred to as are of real importance in the diagnosis. 1 . Precursory conditions and phenomena. a. Extrinsic (or general and systemic). i. Sex. The female sex is by far the most prone to hysteria; and, according to some, the disease is exclusively limited to that sex. This statement is, I believe, essentially erroneous ; there are cases presenting every symptom of hysteria in the male, and it would be absurd, on account of some preconceived pathological dogma, to separate such cases from their evident nosological posi- tion. But the rarity of hysteria in the male, and its frequency in the female, are notorious, and are sometimes of diagnostic value. ii. Age. The majority of hysteric patients present symp- toms of the disease between the fifteenth and twentieth years. Sometimes they commence earlier ; rarely however before the tenth, or after the thirtieth year; although, when once esta- blished, they may persist to a much more advanced period. 170 IXCEEASED AND DIMINISHED riTXCTIOXS, iii. Condition. The unmarried (or continent) state is appa- rently a predisponent : and we may also reckon among the general conditions, sometimes of assistance in the diagnosis, town-life, luxurious or lazy habits, dissipation (with its moral and physical effects), warmth of climate (or the spring and summer seasons), and hereditary predisposition. iv. Morbid states. The most important are uterine disturb- ances, such as amenorrhoea, dysmenorrhoea, monorrhagia, &c. b. Intrinsic prodromata resolve themselves into slightly de- veloped degrees of the symptoms persistent after, or present between, the attacks; such as cej^halalgia, various spasmodic movements, pain in the limbs, irritability of temper, depression of spirits, emotional displays, eructations, globus, &c. &c. 2. Developed symptoms ; the most important being, — a. Intrinsic, — and these of various kinds. i. Mental. Volition is defective, and misdirected; idea and emotion exhibit excessive activity; and the combination of these two morbid conditions produces most characteristic features. The patient asserts that she cannot control her thoughts, emotions, expressions, or general (involuntary) move- ments; or that she cannot move this or the other limb, cannot open the eyes, cannot stand or walk; and if she makes the attempt (or apparent attempt) under this impression, she cer- tainly fails, and may simulate real inability so aptly that it seems almost incredible that the real source is defective will : but should some strong motive, or emotion, or sensation come into operation, and the patient for a moment forget her condition, she may clap the moveless hands together, open the hitherto closed eyelids, and, with the rapidity and energy of robust health, run across the room, or up the staircase, with her quasi- palsied limbs. This kind of simulation is by no means un- common, but I must most distinctly state that I do not believe there is necessarily any intentional deception practised by the patient upon any one. It is the will which is in a morbid con- dition, and the patient personally believes in the reality of her symptoms. Volition is defective in relation to idea, but ideation is often excessive; there is a kind of delirium, in which non- Hl'^TERIA. 171 sen^lcal sentences are pronounced in an excited manner; und sobbing, sighing, and laughing, are alternately produced. v>oinctinics volition and ideation are apparently in abeyance tor a time; or there may be somnambulism and extasis. Hysteric coma is a rare phenomenon, but one which some- times occurs; its diagnosis is established by the recognition of preceding hysteric symptoms, and especially the convulsive. (See Motorial Symptoms.) Emotion is commonly excessive, both in respect of the jpatient's own I'eelings and their expression; and she is hurried {'rom one extreme to the other with marvellous rapidity. Laughing and sobbing not only alternate, but sometimes accompany each other, and they are quite free from any voli- tional restraint. Often there is an inane expression of the face, an utter listlcssncss, and abstracted look, as if the indivi- dual cared nothing for the things of time and sense ; and this accompanies restlessness and impatience of temper, with mono- syllabic talkmg. ii. Sensorial. True hyperesthesias occur not unfrequcntly; but various metassthesiai are more common. Cephalalgia is ifilmost invariably present, with muscaj, tmnitus aurimu, and every modihcation of the special senses. There is also epigastric constriction; the globus hystericus; and pains in the left mammary region. Hysterical pain is always intense, " horrible," agonising, etc., and it is mainly increased by the direction of consciousness to its perception. The patient shrieks if the skin is touched, but withdraw her attention by conversation, and somewhat rough pressure may be applied without any notice being taken. Articular pain is not accompanied by swelling or deformity of the joints: and it is increased more readily by excitation of the surface than by movement, or succussion of the limb. iii. Motorial phenomena exhibit endless variety; and, gene- rally speaking, there is an excess of motility in relation to idea, emotion, sensation, and reflex stimulation, whereas voluntary movements are performed sluggishly and imperfectly. There are, however, two proiuiaent groups of motor pheno- z 2 172 INCREASED AND DIMINISHED FUNCTIONS. mcna, convulsion and paralysis, the former of which is by far the more common. a. Convulsion. Hysteric attacks resemble, and may be mis- taken for epileptic, or eclamptic; but their differentiation is in the majority of cases easy. They are almost always presented by the female; and rarely occur except at the time of puberty; frequently attend t]\e menstrual periods; are preceded by the hysteric prodromata; can be to a certain extent warded off by a strong effort of the will ; are accompanied at the onset by constrictive feelings in the throat and epigastrium ; by plaintive cries, laughing, and sobbing, which re-appear towards their close; there is probably never complete loss of sensibility and perception; tlie spasmodic movements are general; the fixce undergoes little alteration; there is commonly a twinkling movement of the eyelids, and the patient appears to see; there is no marked change of tlie pupil; there is very rarelv foaming at the mouth, or bitten tongue; the attacks are sometimes of considerable duration ; respiratory movements become very disorderly ; and after the paroxysm has passed, there is no marked stupor, but only general exhaustion ; their recurrence during many years is sometimes followed by mania (of a peculiar character); but very rarely (if ever) by dementia. j3. Paralyses are almost invariably preceded by hysteric con- vulsions, and, from the character of the paroxysms, and the presence of other signs of the hysteric condition, the diagnosis may be very generally established. h. Extrinsic symptoms are not of any diagnostic value. Those which are most frequent are the following: — nausea, and eructations; with borborygmi, or tympanitis ; palpitation of the heart, with syncopal feelings, and sometimes syncopal attacks; frequent micturition of clear, pale urine (most com- mon after the attacks, but by no means characteristic of hysteria, as I have observed it to an equally marked degree after distinct epileptic seizures in tlie male); disordered or per- fectly healthy digestion; and, more commonly than any other disturbances, uterine irregularities, such as those already alhided to in the paragra})hs upon prodromata. CATALEPSY. 173 Catalepsy pomctlmcs occurs as one of tlic plicnomena of hystciiu; it dillcrs from the latter, however, in affecting the two sexes with about equal frequency. I have observed a cataleptic condition in cases of chronic ramollissenient of the brain, and in tubercular meningitis; and Dr. Lay cock has very beautifully compared it to the state presented by so-called " brown-study."* Its essential features are pathognomonic — viz., the removal of perception and volition ; and the persistence of the limbs in a state of balanced inuscular contraction ; so that they retain the position in which they were placed at the commencement of the attack. They may, however, be made to assume other postures by passive motion {i.e., induced from without), and to retain the most volitionally impossible attitudes for hours, or even for days. § II. EPILEPSY. The tendency of the present time is to connect the pheno- mena of so-called epilepsy with pathologico-anatomical lesions of very various kinds; such as diseases of the brain, and its meninges; tubercles, tumors, chronic inilammation, &c. ; dis- eases of the kidneys, inducing urinainiia; diseases of the blood, of no very distinct nature ; certain general dyscratic con- ditions, specific (such as syphilis or scrofula), and non-specific (such as general debility), &c. &c. The tendency is of no questionable utility if it proceeds so far as to reclaim from one large and ill-defined group many cases (only half comprehended by their detention in such a category), and to place them in their proper position, among the extrinsic and intrinsic dis- eases: but it is unquestionably injurious, if it leads to the denomination, by the word epilepsy, of many affections dif- fering widely in the general course of their symptoms, and in the nature of their anatomical conditions; and only agreeing in this, that they present a somewhat similar group of* paroxys- mal phenomena; those of the epileptic or rather epileptoid seizure. * Nervous Diseases of Womcu, p. 316. 174 INCREASED AND DIMINISHED FUNCTIONS. If we can succeed in distributing all the cases hitherto known as epilepsy among the several classes of better defined diseases, we ought to reject the term epilepsy from our noso- logy; but if we cannot accomplish this distribution, and arc compelled to recognise the existence of many, or even of a few, cases distinct from any more general condition of systemic or local disease, then we must employ the term (epilepsy) in a restricted sense, implying only those cases which, in the pre- sent state of medical science, are irreducible. Notwithstanding the reduction which has proceeded within the last twenty years, owing to the progress of pathologico- anatomical research, and its results, there are many cases in which the epileptic phenomena have recurred during a long period, and of which the post mortem examination (death having taken place by some intercurrent alFcction) reveals nothing to which the symptoms can be referred. We cannot, therefore, do away with this, or some word to denominate these cases; but it is of most essential importance that we should apply it to no others. Endless confusion must follow from such expressions as renal epilepsy, epilepsy from tumor of the brain, or meningitis; gastric and uterine epilepsy, &c. &c.; since it is from cases of urinajmia, from tumors of the brain, and from every other distinctly recognised pathologic condition that the disease epilepsy has to be diagnosticated. Idiopathic epilepsy has been placed among the diseases of the brain, because one of the most marked groups of pheno- mena, occurring both during the paroxysms and in tlie inter- paroxysmal period, is rcfcrrible to the cerebral functions (loss of perception and volition in the attacks, and diminution of volition, attention, and memory in the interparoxysmal state): and it has been placed in the category of affections marked by the diminution of some properties, '"and the excess of others, because this combined character is presented (in the loss of mind and excessive motility) during both the attacks them- fc-elves, and the intervals of their recurrence. The diagnosis of epilepsy (idiopathic) is to be framed from a consideration of the characters of two periods. EPTLErSY. 1 75 A. Litcrparoxysmal plienomcna; and by this term I do not intend the immediate prodromata, or sequela3 of the attacks, but the condition of the patient when quite free from their occurrence. Sometimes the symptoms are extremely charac- teristic; sometimes the deviations from health are slight, and it is then principally (and at all times importantly) by their negativencss, that they are of value, by enabling us to exclude extrinsic and (structural) intrinsic diseases. 1. Intrinsic symptoms, of two classes. a. Mental. In respect of their intellectual state, by far the greater number of epileptics exhibit deficiency of volition in its relation to thought, emotion, sensation, and motility. (See Chap. II., p. 15, et seq., for explanations of these relationships.) The mind is wandering, half abstracted, and without energy of purpose; there is little or no power of attention, and, as a consequence there is slowness of apprehension and defective memory; the emotions and their expression are undirected and imcontrolled ; the patient can give only unsatisfactory, and often totally unmeaning accounts of his sensations; he feels something wrong, but hardly knows where it is; and when he can point out its situation (in the head, thorax, abdomen, or limbs), is very rarely able to say what it is like ; there is at the same time a slusfC'ishncss and clumsiness of voluntary move- ments; the walk and manner of the patient are ungainly, he stumbles over objects in his way, and has often a peculiarly gauche and awkward appearance ; involuntary movements, such as starts inir upon the occurrence of sudden noises, &c. &c., are uncon- trolled ; and there is a dull, expressionless, or morose countenance. These phenomena may be very slight, and may escape notice : they may in many cases be overcome by an education of the will ; but in other cases they are extremely well marked, and graduate into utter stupidity and dementia, with general paralysis. They are not unfrequently combined with a some- what antithetic condition of idea and emotion, considered as separate properties; and then a rapid but rambling succession of thoughts and feelings is present, and may find utterance, constituting a quasi-delirious state. 176 INCREASED AXD DIMINISHED FUNCTIONS. The symptoms referred to are generally increased in intensity, cither immediately before or after the attacks; it is commonly observed that the deficiencies are more prominent as the sequelae, and the semi-delirious phenomena as prodromata; but this is not without exception; and I am perfectly convinced, from careful examination of the subject, that these mental phenomena are not to be considered as simple consequences of the attacks. b. Motorial. The symptoms are those already enumerated, as cEaracteristic of reflective action in excess (see Chap. II. p. 36), and as being presented by the subject of idiopathic convul- sions. (See p. 128.) They are tremor, rigors, and clonic spasms, and are to be found in the great majority of cases. Sometimes they are slight ; but sometimes they are very highly marked and excessively annoying. In several cases I have noticed choreiform movements of considerable inten- sity. There is very commonly an excess of emotional and sensational motility, which is enhanced by the (positively) defective amount of volition. Beyond this there is no mo- torial change, such as paralysis or tonic spasm. Dr. Marshall Hall has directed attention to the occurrence of spasmodic contraction in the muscles of the neck (trachellsmus), which he considers to be, in some cases (the " tracheleal "), an important link in the production of the fits. It is quite certain that trachellsmus occurs in some epileptics, and that it may (by impeding the return of blood from the head) induce temporary congestion; but I have very rarely found that epileptics suffer from trachellsmus during the intervals of their seizures; and although it is sometimes highly marked at the onset of the attacks (when spasm is universally present), I have observed many cases in which the tracheleal muscles were quite flaccid, notwithstanding the darkness of face and leaden hue of the body generally. c. Sensorial phenomena are by no means characteristic. Sometimes, but, so far as I have seen, rarely, the patient complains of cephalalgia and vertigo; creeping feelings, numbness, &c, 2. Extrinsic symptoms of idiopathic cpilc[)^;y are by no EPILEPSY. 177 means striking. I liavc seen almost every variation witliin the range of ordinary health, and can by no means concur in the statement that there are either constantly, or very frequently present, the signs of general organic debility. Epilepsy occurs in the robust as well as in the feeble, but probably with greater frequency in the latter; and this common association (of debility and spasm) has been made the basis of an ingenious theory of the disease by Dr. RadclifFe.* Some morbid extrinsic conditions, when once developed, are persistent; others are occasional. Among the former we must range a general depression of vital energy, characterised by toneless muscles, a feeble pulse, cool skin, and dusky tint of surface. Among the latter we find every variety of irrita- tion; such as that from cutting the teeth (either the first, second, or dentes sapiential), dyspeptic disturbances, consti- pated bowels, uterine irregularities, &c. &c. In respect of distinct prodromata little can be said ; epilepsy affects the two sexes about equally (being rather more common in the female than the male), and it may occur at any period of life. Its most frequent occasional cause appears to be emotional shock, such as sudden fright or alarm. There is perhapij some hereditary inlluence active in the production of a few cases, but it is undiscoverable in the majority; and many of the conditions commonly considered to occupy some causative relation to the disease, have probably no spccilic action, but merely conduce to general organic dcranoement. B. Phenomena of the paroxysms. Apart from any theories, with reirard to their causation, we cannot fail to recoonlse two or three varieties of attack. The distinction by the French authors into " le haut" and " Ic petit mal,"is one which we may readily apply and find useful; but it is not sufficiently definite to answer every purpose. Dr. Marshall Hall describes abor- tive and syncopal forms of attack as contrasting with the more developed paroxysms, which he considers either laryngis- mal, or trachelismal, in their origin. It would be very inte- resting to recount the various explanations of epileptic fits * Epilep.sy and allied affections. 178 DIMINISHED AND INCREASED FUNCTIONS. which have been given and received at various periods; but it does not form any part of my present object to occupy space with such details. Premising only that the essential features of the epileptic paroxysm are the combination of spasmodic muscular contractions, with loss of perception and volition; and that this occurs as a paroxysmal event, we naay at once recognise a distinction of the attacks into two groups. 1. Those marked by equal derangement of the mental and motorial functions, or by complete loss of consciousness, and violent spasmodic movements; " le haut mal," of the French authors; the laryngismal and tracheleal epilepsy of Dr. Marshall Hall. 2. Those in which one element predominates much over the other, or even to its entire exclusion ; and these are neces- sarily subject to further division into, — a. Attacks in which the loss of perception and volition is complete, but in which there is little or no spasmodic move- nient ; some trifling tremor, or general twitching of the muscles (producing no locomotion of the limbs) taking its place. This class includes " le petit mal," or " vertigo epi- leptiforme" of the French, and the syncopal attacks of Dr. Marshall Hall. h. Attacks in which there is marked spasm of the muscles; sometimes general, but more commonly partial (and then affecting the neck and upper limbs with the face most fre- quently), the spasm being of somewhat tonic character, but attended by no loss of perception and volition, or at the most by some slight obscuration. These seizures constitute the " abortive" attacks described by Dr. Hall. That the nature of the paroxysmal phenomena cannot be made the primary basis for a classification of epileptics is at once obvious from the fact, that one individual frequently presents every variety : but, on the other hand, either form may exist alone, and may therefore constitute true epilepsy. 1. The diagnosis of the first form of attack is by far the most easy, the disease can rarely be confounded with any other. Its essential features arc. — • EPILEPSY. 1 79 i. The absence of any necessary prodromata (such as those described as preceding the hysteric convulsion, or the signs of congested brain). ii. The simultaneous occurrence of the following symptoms, — a. Complete loss of perception and volition. /3. General quasi-tonic contraction of the muscles. y. Impeded respiration (probably differing in its me- chanism in different cases). S. Darkened face, and surface generally, with distended jugulars. E. Dilated pupil, distorted features, throbbing carotids, iii. These phenomena being quickly followed by, — a. Persistent unconsciousness. (5. Clonic, violent contraction of the muscles. y. Laborious respiration, with tracheal gurgling noises. 8. Slight return of colour in the face and body generally. £. Oscillation of pupil and eyeball ; chewing movements of the jaws, with foaming at the mouth, often of bloody tint, iv. The cessation (gradual) of iii. and the production of an- other stage, marked by the following characters, — a. Some return of perception and volition for a short time; with an aspect of astonishment, alarm, or sus- picion; and this followed by drowsiness, or profound coma. /3. Occasional half voluntary (or sensational?), half invo- luntary movements, such as change of position, &c. y. Laboured, slow respirations, with stertor and tracheal rattle. B. Paleness of face, coldness of surface, with perspiration. f . The pupil often contracted ; and the conjunctiva; injected. V. After sleep of variable duration and profundity, the patient becomes more natural in his manner ; feels some head- ache and general soreness, but exhibits (i.e., in idiopathic epilepsy) no paralyses, anassthesiae, nor any intrinsic pheno- mena characteristic of organic disease. 2. The diagnosis of the second form of attack is rendered A A 2 180 DIMINISHED AND INCREASED FUNCTIONS. easy when either of its subdivisions occurs alternately with the first; under other circumstances there may be considerable dilHculty. a. " Le petit mal" may be confounded with syncope; but it is to be distinguished by the greater suddenness of its appear- ance ; the absence of syncopal prodromata ; the complete loss of perception and volition; the slightly darkened lip, and gene- rally pallid face, not so absolutely blanched, however, as in syncope; and further, the pulse is extremely feeble, but not absent as in the latter; perception and volition return more quickly; and there is generally some spasmodic movement of sliglit extent. Ijctwecn the attacks, and after their repeated occurrence especially, the signs of mental decay are usually well marked; and there are the phenomena of depressed or- ganic vigour. b. Abortive convulsive seizures may be diagnosticated from other diseases by their distinctly paroxysmal occurrence; the ])atient during their intervals presenting no signs of intrinsic disease; and more especially by their alternation with distinct epileptic seizures. In the foregoing paragraphs I have intentionally omitted the so-called "epileptic cry," because it is frequently absent. Urine is often passed as copiously after these attacks as after hysteric; but having examined it in many cases I have failed to detect albumen in any one instance in which albuminuria did not exist as a chronic condition; and which cases do not form examples of idiopathic epilepsy. Considering epileptics apart from the peculiar form of their attacks (which varies in the same individual), they may be divided into three large groups, easily recognised by the follow- ing characters. A. Those who present no deviation {i.e.., positive deviation), from the condition of mental or organic health. li. Those whose minds exhibit marked degeneration. C Those in whom the organic processes (although presenting no evidences of distinct and tangible disease), are performed in an inefficient or j^erverted manner. EPILEPSY. 1 81 It is common to find, closely associated with the second class, paticntd in whom there are (in addition to mental failure of the negative character already pointed out, p. 175), the signs of intrinsic organic diseases of the nervous centres. The siOTs referred to are pain, paralyses, anresthesite, tonic contractions, delirium, delusions, &c. ; the cases thus marked are not instances of idiopathic epilepsy; and their diagnosis must be attempted by a consideration of the points adverted to in the following sections of this chapter. It may be that epilepsy is secondarily induced by some of these diseases, or vice versa ; and, although an accurate differentiation is not possible in all cases, it is to be attempted during life, and should always be borne in mind when endeavouring to interpret symptoms by the aid of post mortem examination. Wherever, on the other hand, we find epilep- toid symptoms in persons presenting distinct organic disease of extrinsic character, we should ascertain whether the latter can directly account for the former. If so, the disease is not epilepsy, but epileptiform convulsions attendant upon eccentric disease. If the latter is of such a character that we cannot, upon any known pathological grounds, attribute the convulsions to a direct influence of the morbid condition upon the nervous system (as is the case in uringemia, &c.), but only to a secon- darily induced state of the centric organs, the disease is epilepsy ; and we have then to consider carefully what part has been taken in its production by the deranged organic condition on the one hand, and by an idiopathic tendency on the other. There is but one more remark to be made upon this obscure disease, and it is upon the relation between the inter-paroxysmal period and the attacks themselves. When the patient belongs to the first category (A.) the attacks are commonly of the kind first described, viz., the combination of mental and motorial disturbances in their most intense form : when the patient belongs to the second group (B.), his attacks are most frequently those of " le petit mal;" and these are also very often observed in those of the third class (C): when the patient presents the cha- racters of the third group (C.) the attacks are of very variable kind. The third I'orni of fit (described p. 17S) is much less 182 DIMINISHED AND INCREASED FUNCTIONS. common than the other two, but it may occur as an occasional phenomenon in any case. These statements present the general results of examination into a large number of cases, but they are general only, and are of course subject to many exceptions. § III. TUMOR. In considering the diagnosis of tumor, it is convenient to reverse the order of topics usually adopted, and to describe, first, the general bases for belief in the existence of such a lesion; secondly, the reasons forjudging of its nature anatomi- cally, and how far this is practicable; and thirdly, the means by which we infer the locality it occupies. A. Tlie diagnosis of tumor generally ; — and more especially from chronic softening, and chronic meningitis. 1. Intrinsic symptoms (very variable; but often conclusive by the peculiarity of their combinations). a. Mental. These are of two kinds ; some resulting from excessive or irritated action, and others from the reverse; or they may be absent altogether. i. Increased action, in relation to idea is sometimes, though very rarely, observed (two of forty-four cases — Abercrombie). The delirium which occurs is mild and inoffensive, and con- sists of the confusion rather than exaggeration of thought. When marked delirium is present, there is most probably meningitis, or hyperaimia cerebri as a concomitant phenomenon. Irritability of temper may exist. ii. If convulsions occur, there is commonly loss of perception and volition, followed by moribund coma; and this form of diminished mental action exists in about half of the cases of tumor, for two or three days before death, Partial losses of memory, and generally enfeebled intelligence, with depression of spirits, are the most frequent symptoms. In the majority of cases intelligence is intact. h. Sensorial phenomena, of two kinds. i. MetaBSthesic-e (or modified sensations) are the most common symptoms, and cephalalgia is often the most characteristic. It TUMOR. 1 83 is slight at the commencement, but afterwards becom.es of great severity; is confined to a definite pointer region of the head, and persists in the same locality; it undergoes occasional exacerbations of almost intolerable sufiering, eliciting from the patierit agonising cries, but is rarely absent altogether during the intervals of paroxysm ; it is augmented by intellectual or physical exertion, by emotional disturbance, by sensational impressions, and by forced respiratory movements. It is some- times almost the only symptom, but in a few recorded cases it has been altofjether wantino-. Certain dysaisthesiaa (see p. 30) are often present; and they are erroneously placed under the name hyperKSthesise, the latter being excessively rare, although occasionally observed. The most common variety of dysresthesia is that (already al- luded to above as one of the characters of cephalalgia) in which sensorial impressions augment the intensity of pain in the head; and hence patients with tumor close the eyes, and bury their heads under the bed-clothes, to avoid the light and sounds of the room. There are also various modifications of sensibility, such as pains in the limbs, numbness, formication, &c. &c., of common occurrence, but of no distinctive character. Vertigo is fre- quent, but its special relationships have yet to be discovered. ii. Hypaisthesise and ana^sthesite of variable extent and in- tensity are induced either suddenly or gradually; more com- monly the latter. The sense of sight is often lost in one or both eyes, and this is found more frequently than deafness, or anosmia. There may be simple mistiness or imperfection of vision, with dark or bright spots before the eyes; or there may be complete double amaurosis. The iris does not often lose its irritability. Cutaneous sensibility is sometimes diminished in particular regions, but it is rarely lost. c. IMotlllty. In the cases which have been placed on record, convulsions have occurred more frequently than paralyses ; and among those which have presented the latter, one half have exhibited the former. i. Convulsions occur not unfrequently for a few days before 184 INCREASED AND DIMINISHED FUNCTIONS. death, sometimes at an earlier period, and they are commonly of epileptoid character. When no general paroxysms have been present, tliere are often clonic spasms, or tonic contractions, of limited groups of muscles; sometimes shifting their place, but not to so marked a degree as in urinremia, meningitis, &c. il. Paralysis. Articulation is sometimes impeded without any further implication of motility: the muscles of one eye may be paralysed, and every other part of the body retain its motor functions. In some cases hemiplegia, and much more rarely paraplegia is present. The paralysis is generally slowly and imperfectly developed; and may be preceded by pain in the limbs. Sometimes, but much more rarely, it is produced as an apoplectic phenomenon. (See Chapter VII., § v.. Tumor, p. 105.) 2. Extrinsic symptoms. These, although sometimes want- ing, may constitute almost the only, certainly the most pro- minent, features of a few rare cases.* They are, — heat of head, general febrile irritation, with anorexia, vomiting, and constipation. There is commonly paroxysmal head-ache, or the vomiting occurs in the morning without previous head- ache, or sense of nausea. Society and diversion commonly increase the disturbance, which (as Abercrombie remarks) is not the case in dyspeptic head-ache. It is of great importance to recognise the general or consti- tutional state of the patient; to exclude the existence of urin£emia, and in some other cases to determine the presence of a tuberculous or carcinomatous dyscrasia. But in many in- stances nothing distinctive can be discovered from extrinsic symptoms; the only deviation from health being general debility and exhaustion, the result of long continued pain, and mental depression. Tumors on the scalp, or in other regions of the body, such as glandular (tuberculous) swellings, scirrhus, aneurismal dilata- tion of vessels, &c., would enhance the probability of intra- cranial growths; and they would be of especial value when * Abercrombie's " Practical Researches," p. 337, contain a graphic delinea- tion of cases of this kind. TUMOR. 1 85 of those kinds wliicli are dependent upon some general dyscratic condition. 3. Combination of symptoms, and resume. The existence of an intracranial tumor would be rendered highly probable, if in a certain case we found — violent, paroxysmal, limited cephal- algia ; with loss or imperfection of vision ; without motor paralysis or with partial paralysis, slowly and imperfectly developed. If, says Durand Fardel,* there are joined to these symptoms epileptiform convulsions, without paralysis in their intervals, the probability of tumor is still greater; and this is especially the case if articulation and the intelligence remain intact. B, The differentiation of tumors, in respect of their special character. There are no centric signs by which this may be accom- plished ; it is a matter of inference only, based upon the con- sideration of extrinsic symptoms. 1 . Tuberculous deposit {en masse) is the most common form of tumor existing in the child or young adult ; and we might infer its presence, if we found distinct evidences of the scrofu- lous diatliesis, either in the hereditary antecedents or actual condition of the patient. Negatively this test is of greater value than positively ; since after puberty a healthy state of the lungs is rarely coexistent with deposit of tubercle in the cranium, or elsewhere. 2. Carcinoma. The general probability of this form of tumor is in direct proportion to the age of the individual ; but carci- noma may exist at any period of life. ^I. Rostan draws atten- tion to the occurrence of lancinating pain in the limbs of persons suffering from carcinomatous tumors of the encepha- lon ; t but this is not of any real value, either positively or negatively. The only signs upon which any reliance can be placed are, — the presence of a cancerous cachexia, and the co- existence of tumors ekewhere, and especially of such as affect the integuments and bones of the skulL * Maladies des Vieillards, p. 144. t llecherches sur Ic Rainolli^souicut, p. 404. 186 INCREASED AND DIMINISHED FUNCTIONS. 3. Aneurism might be inferred if similar arterial disease were demonstrable in other regions of the body. 4. Other forms of tumor can only be guessed at from the absence of any signs of the three already mentioned, and the occasional discovery of peculiar growths (such as hydatids, fibrous tumors, &c.) in other organs. Post mortem examina- tion, and this of microscopic character, can alone reveal their true nature. . C. Diagyiosis of the special locality of tumor. It is utterly impossible, in many cases, to arrive at any cer- tainty upon this point; still there are some data by which the localisation may be carried to a certain degree. L Diflerentiation of the two sides (right or left hemisphere). The pain is most commonly situated on the same side as that in Avhich the tumor exists; but this is not without exception. Motor phenomena (both spasmodic and paralytic) are observed ahnost invariably on the opposite side. The special senses (cranial) arc affected on the same side. 2. Dilferentiation of anterior and posterior lobes or their meninges. The locality of pain is of some service, but its indications amount to probability only, since frontal cephalalgia may arise from cerebellar tumor. Upon analysing a considera- ble number of cases, I find that convulsions are most frequent in tumors of the cerebellum, and that they diminish in fre- quency as the seat of lesion advances forwards— i. e., through the posterior and middle to the anterior lobes of the cerebrum. Amaurosis, on the other hand, is most common in tumors of the anterior cerebral lobes; and it becomes relatively less frequent as the seat of tumor retrogrades. The same is true to a certain extent with regard to impaired intelligence and arti- culation. 3. Distinction of upper surface and base. The implication of special senses generally (but not exclusively) indicates a loca- tion near the base; its absence does not preclude the possibility. Romberg has hinted at an important method (if confirmed) to accomplish this differentiation.* He asserts that in cases of * Manual of the Nervous Diseases, Syd. Soc. Trans., vol. i., p. 159. TUMOR. 187 tumor affecting the upper surfiice, forced expiration increases tlic pain; whereas, when the base is their locality, this effect is produced only by inspiration; and this he readily explains l)y tlie alternate rising and falling of the brain, during the respira- tory movements, causing pressure of the tumor against the walls of the cranium. A case which I have recently seen of tumor of the base (affecting the cerebellum), confirmed Rom- berg's statement with regard to the effect of forced inspiration, the pain being thereby much increased, but not at all by ex- piration. 4. Diagnosis of meningeal from cerebral tumors. It is com- monly stated, that the former are especially characterised by pain and irregular convulsive movements; whereas the latter are attended by less pain, but with sensorial disturbances, paralyses, and intellectual failure. The data, however, upon which this statement is founded, are unsatisfactory; and by far the greater number of tumors must necessarily affect both the nervous substance and its meninges at the same time, although commencinf' sometimes in one and sometimes in the other. 5. The differentiation of special portions of the cerebrum, or cerebellum, as the seat of tumor, is at present impossible, although some facts are recorded which tend to show that this may be accomplished hereafter. Paraplegia rarely occurs from encephalic tumor, unless the cerebellum is its seat; and various forms of vertiginous and allied movements are found to coexist with disease of the sensori-motor ganglia, the cerebral, and cerebellar crura. We need, however, much more accu- rately recorded observations, and a greater number of them, to arrive at any certainty with regard to the effects of lesion iu these several parts. § IV. CHRONIC MENIXGITIS. The cases hitherto placed on record have usually presented chronic meningitis in complication with other diseases. Cal- meil's beautiful Treatise upon Paralysis in the Insane,* contains * Do la Paralysie coiiaidcrce choz Ics Alidiics. BB 2 188 INCREASED AND DIMINISHED FUNCTIONS. examples of inflammation occurring towards the close of life in tlie subjects of dementia, and hence the symptoms of the latter have masked or altogether hidden those which are the appropriate phenomena of the former. Again, chronic menin- gitis frequently accompanies the development of tumors, and it is difficult to determine which symptoms belong to one and which to the other lesion, although some approximative cor- rectness may be arrived at occasionally. The term chronic inflammation, although consecrated by usage, is pathologically inapplicable to the static conditions implied, and is probably injurious in its influence upon thera- peutics. Hypera3mia is a less important element of the disease than exudation and perverted nutrition; there may be some local and general irritation (or increased activity) as the result of these static changes; but there is not the systemic state of true inflammation. The anatomical results, discovered post mortem, are — thickened membranes (by the deposit of fibrinous matter, interstitially or superficially), adhesions of contiguous parts (dura mater and bone, two layers of arachnoid, &c.), osseous deposits, sub-arachnoid infiltration, and these with or without vascular changes (such as increased injection of various kinds), or any distinct signs of perverted nutrition (such as tubercle, carcinoma, &c). The symptoms of meningitis, in the chronic form, are by no means so distinctive as when they occur in the acute ; they are the following: — 1. Intrinsic (sometimes the only phenomena). a. Mental. The most common feature, at an early period, is great irritability of temper, with restlessness : to this succeeds occasional, mild delirium at night, with loss of memory, and impaired power of attention and apprehension during the day. Subsequently there is increased dulness of intellect, and in many cases complete fatuity. The mental deterioration, in many instances, takes place as the immediate sequence of con- vulsive attacks (of very variable character), each one leaving the patient somewhat more confused, and less able to control his thoughts, words, and actions, than he was before. It is CHRONIC MENINGITIS. 189 very rare for the mind to retain all its faculties; and although in some mild cases it is unimpaired (motorial and sensorial phenomena having occurred alone), in a great number of in- stances its changes are the most prominent, the first to appear, and the most characteristic throughout. b. Sensorial. Pain in the head is almost universally present ; it is of dull, diffused character; is not liable to the severe exacerbations of pain from tumor; is not hmited so accurately to one spot; and it is exaggerated especially by organic dis- turbances, such as dyspepsia, general malaise, &c. Vertigo is commonly complained of, and sometimes it is so severe that the patient may fall to the ground, without any distinct loss of consciousness (i.e., of perception). True hyperassthesiae are by no means uncommon ; the patient sees, hears, and feels with abnormally exaggerated acuteness; and often the sensorial process, especially when impressions are intense, is attended by pain (dyscesthesia). In rheumatic subjects, pains in the limbs are frequent, and movement of the eyeballs, or of the frontal muscles, is painful. Hypossthesise and anaesthesia occur after some time; the sight or hearing (for example) becomes con- fused and deficient, or may be lost altogether; and there are modifications of cutaneous sensibility, ending in its deficiency. c. Motorial. The commonest features are, — disorderly spasmodic movements, in combination with local or general paralyses. jSIuscles of the face, tongue, and eyeball are peculiarly prone to suffer at an early period; producing (phenomenally) grimaces and distorted features, with strabis- mus and diplopia, or dlUlcuIty of articulation. Paroxysms of convulsions occur, and these may be epileptiform in type, but more commonly they are of anomalous character; the patient may or may not lose consciousness; there is little respiratory disturbance; ami the spasmodic movements arc partial (or local) in their distribution; of no great intensity, but of considerable duration. There is not, as a rule, the marked sopor, or coma, which follows the paroxysms of epilepsy. l^^ralyses are generally limited to particular groups of muscles, rarely allccting more than one limb {i.e., rarely astum- 1.90 INCREASED AND DIMINISHED FUNCTIONS. ing a complete liemipleglc or paraplegic form) ; and they arc veiy commonly associated with tonic contractions of the flexor muscles, and increased sensibility of those muscles to the irri- tation of percussion. 2. Extrinsic symptoms. These are of no marked character; being, for the most part, heat of head, flushing of face, injection of conjunctivae, vomiting, constipation of bowels, nausea, and nocturnal febrile excitement. They are more marked, how- ever, than in tumor or softening. It is important to exclude the presence of such elements as urina3mia, and to estimate the aitiologic value of such cir- cumstances as, — blows upon the head, disease of the bones, or proper sensory organs, and the existence of dyscrasiaj, such as tubercle, sypliilis, rheumatism, &c. § y. CHRONIC SOFTENING. This condition of the brain may be the result, or at all events the sequence, of an acute apoplectic seizure, whether the latter has had, for its anatomical basis, haemorrhage, softening, or congestion; and when thus occurring, its diagnosis is sub- stantially that which was pointed out in Chapter VII. p. 117. When, however, it is idiopathic in its mode of origin, and chronic in its course from the commencement, it may be recog- nised by the following characters: — 1. Intrinsic symptoms (alone of positi^'^e value). a. Mental. There is diminution of intelligence. At first, apprehension and attention are enfeebled, and the individual is incapable of receiving any new ideas. Subsequently, memory is impaired : the patient cannot recollect past ideas, and there is consequently general confusion and incoherence. This condition is sometimes, but rarely, accompanied by a certain degree of excitement, revealing itself as delirium; more com- monly there is a monotonous dwelling upon one idea or group of ideas; the patient repeating the same word, sentence, or action, over and over again, by the hour together.* * TliLU, I have seen a man employ himself fur hours and days sueeessively iu carefully arranging the bed-ulothes, and this with an air of great gravity and importance. CHRONIC SOFTENING. 191 In regard of emotion the majority exhibit dulncss, or some degree of melancholy; and it is not uncommon to find that the expression of feeling is very little under control. In other cases laugliing and crying are very common; but they occur without assignable cause, and without the apparent existence of any correspondent emotion. In the first case volition is defective in relation to emotion (see p. 17); in the second motility is excessive in dependence upon the latter. (See p. 34.) The intellectual weakness increases and the patient becomes drowsy. At first he may be aroused, but subsequently there is profoimd coma, and the patient dies comatose. In rare cases, however, the intellect may be preserved throughout. The gradual failure, one by one, of the intellectual faculties is, per se, one of the most characteristic symptoms; and the peculiar monotony (of word or action) has led Durand Fardel to a diasrnosis in some obscure cases. b. Sensorial, i. The most common metresthesia is cephal- algia. It exists in about half the cases; is felt generally among the earlier symptoms; but sometimes does not com- mence until an advanced period, and it generally disappears to- wards the close of life. Its intensity is highly variable, rarely so great as that of meningitis, or a fortiori of tumor; its locality is frontal in the majority, and it is not often confined to one side of the head. When pain is not present there is generally a sense of weight and confusion of head; and (as I have observed in many cases), such a peculiar sensation that the patient says he fears his " mind is going." Painful sensations are often present in the limbs; and they are sometimes referred to the surface, sometimes to the muscles , and in other cases to the articulations. These modifications assume the form of so-called hyperajsthesia^, cutaneous and mus- cular; or of numbness, formication, &c. They are commonly limited in extent to the parts presenting motorial changes; and when this is the case they are highly characteristic. ii. Ilypajsthesiaj are common, but ana^sthesise are rare; and, in respect of the former, they usually exist in conjunction with paralyses. These changes are gradual and imperfect in their 192 INCREASED AND DIMINISHED FUNCTIONS. development; and it is uncommon to find anaesthesia of the special (cranial) senses. c. Motorial. Unless an apoplectiform attack has taken place, the muscles rarely exhibit any sudden changes; but when such a seizure has occurred, there may be complete (i. e., in respect of extent) hemiplegia; the face, articulation, the tongue, and the limbs of one side being involved in paralysis. i. Paralysis (to volition) in the typical form of chronic soft- ening is developed gradually; weakness of the muscles pre- ceding their complete removal from volitional control. Hemi- plegia is the most common distribution; but there may be general paralysis, incomplete in degree. (This is important as a distinction from the persistent paralysis of haemorrhage.) At first, one leg drags in walking, or one hand feels less strong than the other, and grasps less firmly. The diminution pro-. gresses in an intermittent course; paralysis lasting sometimes for a few minutes or hours, and then the power returning. The motorial changes may, however, be limited to particular groups of muscles; for example, those of the face, of speech, of one arm, &c. ii. S2:)asm, of tonic character, exists with great frequency, and may be found in tlie paralysed, or non-paralysed side; though much more commonly in the former. The rigidity increases gradually, and persists uutil within a few days of death, when it usually disappears altogether. iii. Tremors, or epileptoid convulsions may alternate with, or take the place of tonic spasm ; or there may be local clonic con- tractions, and the muscles may be unduly sensitive to per- cussion. iv. Tonic paralysis generally occurs for some days or hours before death; and then (paralytic) stertor, involuntary mictu- rition, and universal flaccidity are present. 2. Extrinsic symptoms furnish nothing of positive diagnostic value; they are of service negatively, inasmucli as their absence serves to exclude the idea of Morbus Brightii, or of tubercular deposit in the meninges. Vomiting, mal-mutrition, the exist- ence of disease in the vessels (as inferred from the advanced age CHRONIC SOFTENING. 193 of the patient, the nvcus senilis, feeble lieart, and rigid arteries) favour tlie sup})ositic)n of softening; and advanced age is of im- portance in rendering tlie probability of softening much greater than that of chronic meningitis. 3. General resume of diagnosis. Wlien softening has ob- served a chronic course throuirhout, its most difficult differcn- tiation is from tumor and meningitis. The three may, however, be distinguished in many cases by the following characters, — a. Tumor, — intense, locally limited, paroxysmal pain ; anres- thesiaj of special senses ; local paralyses ; epileptoid convulsions without paralyses; unimpaired intelligence; coma at close of life. h. Chronic meningitis, — pain, not very severe, not Hmited; mental and emotional excitement; disorderly spasms and paralyses; with frequent, but irregular accessions of fever. c. Chronic softening, — oppres-sive, not intense pain ; witli gradual failure of intelligence, motility, and sensibility. When softening assuines a chronic form, as the sequela of an acute apoplectic seizure, it is from hnsmorrhage that the diag- nosis is most difficult; and it is sometimes im^possible. In many cases, by reverting to the phenomena of seizure, we may infer the existence of softening, if we find that the rigidity or clonic spasms were present at the commencement, and that the sub- sequent course has been one of progressive deterioration. 11' an apoplectic attack occurs without rigidity, and after some hours' consciousness partially returns, but hemiplegia and some mental feebleness remain, we may be perfectly unable (if this state becomes chronic) to determine the precise nature of orga- nic change. The persistence in statu quo, or a progressive, although very trivial and slow, amendment, would indicate a probability of ha:;morrhagc; the slightest deterioration, the ap- pearance of rigidity, or the accession of convulsive movements, would be evidences of ramollissemcnt. § VI. CHRONIC INDURATION. When induration of the brain substance occurs after ossifica- tion is complete, there is no change in the size of the organ ; 194) INfTtEAREI) AND DTMINIRHED PUNf'TIONS. but when the process commences in early life, there is hypertrophy. We have, therefore, to consider separately (inasmuch as their diagnosis is established upon very different grounds) the induration of brain presented by infants, and that presented by adults. A. Hypertrophy of Brain, in Infants. There is nothing distinctive in the purely intrinsic symptoms. They are tlie occurrence of convulsion ; with sensorial changes, such as loss of sight and hearing; intellectual weakness; and paralyses. These follow an extremely irregular course, and sometimes are absent altogether. The extrinsic condition to which alone any diagnostic value is attached is enlargement of the cranium. The head does not attain so large a size as in chronic hydrocephalus (see § vii.), the fontanelles and sutures are not so widely open. Dr. West observes that the " enlargement is first apparent at the occiput, and the bulging of the hind-head continues throughout espe- cially striking. Tlie forehead may, in the course of time, become prominent and overhanging, but the eye remains deep sunk in its socket,, for no changes take place in the orbitar plates, such as are prodiiced by the pressure of fluid within the brain. . . ."* There is no prominence, but actual depres- sion of the anterior fontanelle, and Dr. West remarks that similar depression is sometimes " observable at all the sutures." There is commonly associated with this enlargement a con- dition of depraved nutrition generally. Induration of the brain sometimes takes place in children, as the result of lead poison- ing, but this will be considered with, — B. Induration of Brain in the Adult. 1. Fro)7i. lead poisoning. The intrinsic' symptoms produced by lead are so various that it is impossible to do justice to them, as pathological phenomena, in tlie present work. The diagnosis of lead poisoning, however, rarely turns upon the special cha- racter of its intrinsic symptoms; and those which appear to me alone deserving of notice are the peculiar muscular changes. Paralysis is frequently limited to the extensors of the hands and * Lectures^ aut. cit., jj. 97. CHRONIC INDURATION. 1.95 finger.s. Duchenne asserts that the flexors, the intcrrossei, and the supinator longus are never afiected; and tliat those muscles which are paralysed present great diminution of con- tractility and sensibility to faradisation * It is well known that they very soon diminish in size; but Meyer states that their con- tractility is lessened before their nutrition is affected. f Combined with paralysis, there is sometimes increased cuta- neous sensibility, with perverted cerebral functions, and various disturbances ol' motility, such as spasms, tremors, convul- sions, &c. Extrinsic symptoms and conditions furnish the means of dis- tinction ; they may be briefly resmned thus, — a. Exposure to lead, by trade, accident, or medicine. b. The precursory symptoms of colic (constipation, pain, &c.). c. A general state ofcacha^mia. (/. The blue line on the gums. e. The effects of hydro-sulphuric acid bath. /. Presence of lead in the secretions. 2. Induration of brain from epilejisy. According to the elaborate researches of MM. Bouchet et Cazauvielh,:}: harden- ing of the medullary tissue of the brain is the most common anatomical condition to be discovered in epileptics, whose con- vulsive disease has been accompanied by marked intellectual failure and general paralysis. It is certain that such a static change is not a characteristic of epilepsy, jtjer se ; and it appears to be related only to the co-existent, or subsequent mental deterioration. The existence of induration might be inferred from the pro- gress of general intellectual decay — attention, apprehension, memory, and judgment (as exercises of volition), failing; idea- tion becoming disturbed, and appearing incoherent, or based upon delusions ; general paralysis stealing on ; and the attacks themselves increasing in frequency, but diminishing in violence. * De r Electrisation localisde, &c., p. 507. t Die Electricitiit in ihrer Anweudung auf pi"ict. Med. Abnchn. \V\. t De I'Epilcpsie danf< scs relatione, &c. c c 2 196 INCREASED AND DIMINISHED FUNCTIONS. § VII. CHRONIC HYDROCEPHALUS. This disease, although, in the greater number of cases, de- pendent upon meningitis, is not demonstrably inflammatory in all, and its symptoms are not sufficiently characteristic to sepa- rate, in every instance, the active from the passive form. Its diagnosis is established mainly upon extrinsic phenomena. 1 . Extrinsic conditions and symptoms. In by far the larger number of cases signs of the disease appear before the child is six months old; in many it is demonstrably congenital. There is intense marasmus, although food may be taken eagerly. The size and shape of head are, however, the pathognomonic features. The head is large, and increases in size out of all due proportion to the body generally. Its form is globular; the sutures and fontanelles, especially the anterior, are widely open, and pulsating; the forehead is very prominent; the eye- balls are protruded from their sockets; their axes are directed downwards, with frequent strabismus; the upper sclerotic sur- face is exposed, while the lower half of the iris is concealed by the under lid. There is often rolling movement of the eye- ball, with amaurosis; and the face appears peculiarly small, owing to its disproportionate development. The cranial en- largement is general — i. e. , there are no elevations of particular portions; neither are there bony enlargements in other parts of the body. Fluctuation may be felt at the fontanelles, and through the sutures, when distention has become excessive. It has been stated that a murmur may be heard over the fontanelles; but this is not always present, and, when it does occur, is by no means diagnostic of hydrocephalus. 2. Intrinsic symptoms are very variable. a. Mental. Intelligence may be unaffected; but it is gene- rally enfeebled, exhibiting a peculiar slowness; and, in many congenital cases, there is absolute idiotism. b. Sensorial. Sight ici very frequently lost. Other sensorial chanii'es occur, but thov are of no distinctive value. CHRONIC HYDROCEPHALUS. 197 c. Motorial. Convulsions, or paralysis, or both, may occur in some cases; they may be absent throughout in others. Some intrinsic symptoms commonly precede the exti-insic, but the diagnosis cannot be estabhshed from them alone; neither are there any certain signs by which we can separate external and internal hydrocephalus during life. The former (the collection of fluid in the arachnoid cavity) takes place commonly after arachnoid haemorrhage, and, in such cases, there may be some signs of this event at the period of attack ; but its phenomena in the child are so variable, that the diag- nosis cannot be established with any certainty. § VIII. URIN^MIA. When the nervous symptoms of urinaemia are pain in the head, amaurosis, delirium, or confusion of thought, with con- vulsions, &c., they may resemble tumor, chronic softening, or meningitis. The pain, however, is rarely acute; there is drowsiness, or a peculiar coma and stertor (sec p. 109), and the extrinsic symptoms furnish the means by which a diagnosis may be established. PART III -DISEASES OE THE SPINAL CORD. CHAPTER XV. THE DIAGNOSIS OF SPECIAL LOCALITY AFFECTED. The oenenil grounds for distinguishing diseases ol' the spinal cord from those of the ceiiebrum and nerves are stated in Chap. IV. We have, however, in the case of spinal disease, to carry the local differentiation further, in respect of — I. The region airected (cervical, dorsal, lumbar, &c.). 1. The lumbar and dorsal regions. The lower limbs are alone implicated when the lumbar or lower dorsal regions are diseased, and the most frequent functional disturbance is loss of motility. Sensibility is (in all locaHties of lesion) nuich less frequently, and less severely changed; and its alterations take place at a later period. The bladder and rcctinn are paralysed ; but erection of the penis is not common ; and it is especially rare in affections of the Imiabar portion. Kespira- tion is not changed; the limbs (lower) are cold; with harsh and dry skin, or oedematous ankles; and bed-sores are very readily induced by pressure. When the upper dorsal region is the seat of disease or injury, respiration is impeded by loss of motility in some inter- costal and in the abdominal muscles; but unless the lesion extends above the second dorsal vertebra, the upper limbs retain their functions. 2. Cervical region. AUections of the cord opposite the first dorsal, or the last two cervical vertebnc, implicate the REOIOX. 199 inoveinonts of tlie arms. II' disease extends no higher tlian the sixtli cervical, the arms retain their movements at the shoulders; but the fingers, hands, and fore-arms are paralysed. The abdominal and intercostal muscles have their motility impaired; and thus respiration becomes dillicult and suspirious, being mainly performed by the diaphragm and external muscles. Expiration is more laborious than inspiration, and sometimes the former is considerably impeded. If disease or injury allects the cord al)ove the sixth or fifth cervical vertebra, and the phrenic nerve is impUcated, the dyspnoea is most urgent. The patient appears compelled to attend to his breathing; it is per- formed almost exclusively by voluntary effort; the shoulders are alternately elevated and depressed; and the unfortunate sufferer feels as if life or death depended upon his own exertions. If the lesion exists higher than the I'ourtli or third vertebra, death is extremely rapid, owing to asphyxia from paralysis of the respiratory muscles. Under all circumstances of cervical disease, priapism is common; the intestines become distended with flatus; dys- phagia is frequent; articulation is rendered indistinct, and often impossible ; there is paralysis of the rectum and bladder, with retention of their contents; .and this is followed in many instances by involuntary evacuation. It is very common to find that, when the spinal meninges are diseased, there is a somewhat analogous condition of those in the encephalon ; and thus sensorial excitement and mental changes accompany those which are dej^endent upon the spinal aflection. The locaHty of disease may be discovered l)y the existence ■ of spontaneous pain, or tenderness, at a particular point of the vertebral column; and the latter may be estimated by pressure, concussion of tlie spinous processes, or the application of heat (by means of a sponge, or cloth wrung out of hot water). It happens not unfrequcnlly that this last test indicates the existence of tenderness, which was not felt upon pressure, or percussion. Disease of the bones, or their displacement, may likewise allbrd most important aid in m:iny cases; but it nuist be remembered 200 DIAGNOSIS OF LOCALITY. that the centrnl affection may extend beyond the Ihiiits of disease in the bones, II. The columns affected (anterior, posterior, lateral). In many cases the symptoms are referred solely, or principally, to one function of the cord; but post-mortem examination reveals equal lesion of the anterior and posterior columns. Clinical observation has done little more than exhibit the pal- pable contradiction by fact, of ingenious theories and experi- mental inferences. It may, however, be gathered from recorded cases, that where motility is at the first exclusively affected, the anterior and antero-lateral columns are most probably dis- eased: and vice versa, that, when sensibility is primarily de- ranged, the probability is that the posterior, or postero-lateral columns are principally affected. There is great difficulty in establishing with accuracy tlic primary seat, or amount of lesion ; owing to the probability of injury during removal of the cord, the existence of post-mortem changes, and the fact that disease very commonly involves all the columns of the medulla before it comes under the eye of the anatomist. III. Histological elements (grey and white matter). Physiological experiment has not directly demonstrated its truth, although comparative anatomy furnishes strong evi- dence in favour of the view, that the white tissue is the especial medium of conduction, and the grey matter the (material) instrument of the central functions of the cord. In post mortem examination, and in the observation of patients durinof life, there has not been sufficient attention directed to the inquiry, whether clinical flicts and morbid anatomy can elucidate each other upon this point, and confirm, or refute the physiological doctrines with regard to these two structural elements. In this treatise it has appeared to me desirable to indi- cate the possibility of such a distinction, and the points upon which its formation would depend. They are, in all proba- DIAGNOSIS OF NATURE OF AFFECTION. 201 bility, tlic relations of motility and sensibility to volition and perception on tlic one hand ; and to external impres- sions, apart from mental changes, on the other. In other words, the modifications of centric and conductive functions; which are more fully described in the next chapter. CHAPTER XVI. THE DIAGNOSIS OP SPINAL DISEASES, AS TO THEIR GENERAL NATURE. The physiological functions of the cord being readily divided into two groups, we may make use of this division clinically, by recognising morbid changes in the conducting and centric properties. By the former, the cord is allied to the nervous trunks; inasmuch as it transmits sensory impressions to the cerebrum, and volitional impulses to the muscles: by the latter, it (the cord) is related to the cerebral organs; inasmuch as it is the source and origin of the stimulus of muscular contraction, and contains within itself the means of converting external im- pressions into motor impulses. I. Modifications of conduction. There is nothing to show that this function undergoes any increase of activity ; but we may readily recognise its diminution and perversion. A. Diminished conduction, 1. In respect of sensation. This is subjectively revealed as hypaesthesia or anaesthesia (e. e., diminution or absence of per- cejjtion of external impressions). The special cranial senses are not affected, and such changes as do exist are refcrrible to the extremities, most frequently the lower. Susceptibility of im- pression (as exhibited by asensual reflective movements) per- sists; and although bladder and rectum may become distended, from the patient being unconscious of their condition, the power for their evacuation remains, and there is no involuntary discharge of their contents. The diminution of sensation may 202 NATURE OF AFFECTION. affect the muscles or the cutaneous surface; in the former case, inducing anoesthesia muscularis (see p. 165), in the latter, dimi- nution of tact; estimated roughly by observation of pinching, pricking, &c., but more accurately by Weber's method with the compasses. This diminution of apparent conduction is gene- rally the earliest sign of those chronic spinal diseases wliich end in paraplegia. 2. Diminished conduction of motility. This is phenome- nally represented as paralysis to volition, ideation, and emotion; and the paralysis may exist in any degi'ee (see p. 32, et seq.). The essential features of such a morbid condition are, the sepa- ration of motility from the three above-mentioned sources of motor impulse, and the persistence of tonic (centric), diastaltlc (reflex), galvanic, and proper (vis insita) motihty. B. Perverted conduction is extremely common. 1. In respect of sensation. By this term we may include those abnormal sensations which are referred to the trunk or the limbs (in connexion with disease of the spinal cord); such as numbness, formication, pain, sensations of heat, cold, &c. In some cases, these feelings may depend upon a morbid centric condition; and may be mentally referred to the periphery in the same manner as irritation of the end of a nerve, divided in amputation, is referred to the extremity of the limb, which has been removed. In other cases, they may be the result of a modifying influence exerted, by the medullary disease, upon afferent impressions ; the latter sometimes being originated by extraneous influences, such as the contact of clothes, &c. ; sometimes having their origin in those organic processes, which in health produce their due effect insensibly; but which, in this morbid state, become sensible, and result in referred sensations. Or again, it is well known that spinal disease exerts a marked influence upon the organic (nutritive) processes, and it may be that these sensations are not so purely central as the foregoing suppositions would make them, but that they are indications of morbid processes actually present in the periphery. (See p. 205.) "Whatever may be their precise mode of origin, these per- CONDUCTIVE AND CENTRIC FUNCTIONS. 203 verted sensations are of considerable value in connexion with the diagnosis of spinal diseases, as they commonly indicate the presence of some morbid action, and require treatment very dilFerent from that which hypassthesia demands. 2. In respect of motility. This perversion of conduction is common in epilepsy and allied affections, and also in many organic diseases of the cord. Voluntaiy movements are executed clumsily, and very frequently the patient does precisely the re- verse of that which he intended. (See Volition and Motility, pp. 19, 32, et seq.) II. IModifications of centric fvmctions. It is at once obvious that we cannot assert the existence of any purely spontaneous centric properties; since nutritive changes are incessantly pro- gressing in the cord itself, and there are unnumbered impres- sions from without (/. e., from the organic processes of the body), whicli may be unconsciously received, but which no less surely become the stimuli of spinal action. Some centric func- tions are, however, observed in dependence upon external im- pression, and others are not; and this is an important distinc- tion, inasmuch as it enables us to separate the modifications of tonic (or centric) motility, from those of reflexion (seep. 36 and 40), and we have to consider further, the relation of centric functions to sensibility, and to the organic processes. A. Increase or exaixireratlon of centric functions. 1. In relation to sensation. In health the organic processes are unfelt; in disease they are often attended by sensation; and thus, with regard to those processes which depend upon the spinal cord, they become intensely painful in disease, although we are unconscious of their presence when in a nor- mal condition. Tlius, movement is almost unbearable in meningitis of the cord, and there is persistent pain in the spinal region, as an accompaniment of its spasm. Spontaneous pain in the vertebral column may arise in the same manner as it arises in any other organ when diseased (i.e., from the simple augmentation of its sensibility in dependence upon vas- cular or other conditions), but this does not account for all the sulfering; some part of it appears, as stated above, to be due to D D 2 204 NATURE or AFFECTION. the functional exercise of the organ. Tlie relation of pain to centric properties is thus distinguished (from that in relation to conduction) by its reference to the vertebral region — i. e., to the cord itself. 2. Increase of motility. This is presented in two generic forms, — tonic, and clonic spasm. If we consider the former as essentially reflex — i.e., as being invariably induced by some impressions from without — the two forms diller only in degree, or in some minor quality ; and we have then to study separately the two elements of a reflex action, viz., susceptibility of im- pression, and motor impulse; the exaggeration of the former, inducing increased readiness of action, that of the latter, its exalted force or persistence. If, however, we consider the tonic contractions, dependent upon the cord, as purely centric in their origin (and their persistence after division of the pos- terior roots of the nerves is scarcely compatible with any other ]:)elief), we have to separate their morbid relationships from those of reflexion, by placing the two in distinct cate- gories; and this is the plan which is adopted in the present work. a. Increase of tonic contraction, regarded as dependent upon centric stimulus, and presented as continuous spasm, for example, in meningitis, tetanus, &c. (See p. 40, and Chapter XVII.) b. Increase of clonic contractions, occurring as convulsive movements of the whole body, or as spasmodic phenomena in certain parts; and observed clinically in hysteria, epilepsy, hydrophobia, &c. (See p. 36, &c.) B. Diminution of centric functions. Although the susceptibility of the cord to impressions might be denominated its sensibility, yet it is preferred to consider the changes of this property among those of its reflective (motor) function, by which alone they are phenomenally pre- sented for observation. 1 . Diminution of motility, in its two forms. a. Deficient tonic contraction, recognised by flaccidity of tlic muscles, and their want of contractility under electric DIAGNOSTIC VALUE. 205 Stimulation; and presented clinically by their general tone- lessncss, the relaxation of the sphincters, the dilated pupil, and paralytic stertor. h. Deficient clonic contractility, or diminished reflexion; occurring phenomenally in the form of immobile pupil, im- peded, or rather imperfect respiration, and the absence of any clonic contractions in the limbs upon irritating their cutaneous surface. It is often by the absence of these signs that we are able to diagnosticate the locality and extent of spinal disease ; they are presented in various combinations, some of which will appear in the succeeding chapters. 2. Diminution of organic functions, or their perversion. This very generally follows the changes of centric motility; but the many variations which occur have yet to be reduced to order, in order to possess any diagnostic value. They may be enumerated thus: — a. Changes of temperature and colour. b. Interference Avith nutrition. i. Wasting of muscles, their degeneration, vtc. ii. Gangrene or sloughing of Integuments. c. Alterations of secretion. i. Qildema of extremities. li. Changes in the urine, quantity and quality. iii. Perspiratory alterations, quantity and quality. The distinctions already described, although very important, do not furnish the means of classification for clinical purposes. This arises from the frequency with which aflections of the cord, though at first involving only one group of functions, rapidly extend to the other. Thus haemorrhage and myelitis, which commonly at their commencement impede conduction only, may very rapidly impair the centric functions ; and meningitis, the earliest symptoms of which are modifications of centric properties, at a later stage is marked by derangement or deficiency of the function of transmission. We may judge of the severity of injury or disease by its implication of the proper centric functions; and the manner and proportion in which one 206 ACUTE DISEASES OF THE SPINAL CORD. or the otlier group of properties is involved, is often of essential service in the diagnosis. For clinical purposes, the spinal diseases may be divided into acute and chronic, and we proceed at once to the differen- tiation of the former. CHAPTER XVII. ACUTE DISEASES OE THE SPINAL CORD AND ITS MENINGES. This chapter includes some diseases having a distinct anatomi- cal (or structural) change as the cause of their symptoms, and others to which no discoverable static condition can be thus re- lated. Some are inflammatory, and others are not; but it accords best with the object of this book to disregard these distinctions, and to frame one large group (the several mem- bers of which present many elements in common), and, by thus collocating them, to render their differential diagnosis more perspicuous. Those to which attention is directed are the following: — I. Plethora spinalis, or congestion. II. Meningitis. III. Myelitis (acute softening). IV. Meningo-myelitis. V. Tetanus (idiopathic). VI. Hydrophobia. VII. Haemorrhage, meningeal and spinal. 1. Into the spinal column. 2. Into the tuber annulare. VIII. Concussion of the cord. The first presents generally depressed conducting power; the second to the sixth, inclusive, occur with every variety of combination, both of excess and defect ; the seventh and eighth present duuinished function, and especially that oi' con- PLETHORA SPINALLS. 207 cluction. When the diseases are protracted, they are marked somctunes into " stages," characterised by symptoms, diiFcring in tlieir general relation to functional activity. § I. PLETHORA SPINALIS. The phenomena of this condition are somewhat obscure. Dr. Abercrombie was the first, in this country, to call attention to their consideration, and to indicate their relation to vascular changes in the cord. 1. Precursory conditions are generally those of ill-health, such as are found after prolonged and exhausting diseases. The suppression of habitual discharges, either naturally or artificially, such as the cessation of the catamenia, the lochia, or of ha^morrhoidal flux, are commonly placed among the pre- disposing circumstances which are of some diagnostic value. 2. Developed symptoms may occur suddenly or gradually. a. Sciicrial. There is pain in the lumbar or sacral region; it is somewhat increased by movement; but is never very severe, and may be absent altogether. It commonly travels from below, upwards. Tlie limbs feel heavy, and present numbness, formication, &c.; but very rarely anaesthesia. b. Motorial symptoms are not highly marked. i. Conductive. Tliere is slight {i.e., imperfect) paralysis to volition, occurring most commonly in the lower extremities, but being sometimes limited to the upper, and sometimes general. The bladder and rectum are usually unaffected. ii. Centric. There is neither tonic nor clonic spasm; and paralysis rarely exists in relation to the centric functions. Respiratory movements are slightly retarded; but the pulse exhlTjits no change. c. Mental functions are unchanged. 3. Disappearance of symptoms may be sudden; but this is not common : generally they last two or three weeks. There is not the progressive intensification of symptoms observed in meningitis, myelitis, or haemorrhage ; and when their develop- ment has been somewhat sudden, there is slight amelioration in the course of a few hours or days. 208 ACUTE DISEASES OF THE SPINAL CORD. The persistence of symptoms for a long period renders it probable that something more than simple hyperoemia is their cause; but we are quite ignorant of its precise nature. § II. MENINGITIS. Spinal meningitis is frequently associated with cerebellar disease, or witli inflammation of the intra-cranial membranes, and in such circumstances the symptoms are complicated with intellectual and sensorial phenomena, not essential features of the spinal affection. It is desirable to lose sight of these for a time, and consider only those morbid changes which result from the spinal disease. 1. Precursory conditions. The most common are, — the existence of a rheumatic tendency, the suppression of habitual discharges, diseases of the bones, blows upon the back, or falls upon the nates or feet, and violent exertion. Prodromata are sometimes altogether wanting; but at other times there may be dec]D-seated, dull pain in the back, with slight motorial and sensorial changes, such as aching in the limbs, and general un- easiness or malaise, and lassitude. 2. Developed symptoms are intrinsic and extrinsic. a. Intrinsic, in spinal meningitis, |jer se^ are motorial and sensorial only. i. Sensorial changes are of two kinds (centric and eccentric, or conductive). a. Centric. Pain referred to the spine, at first slight, but rapidly increasing in severity, and becoming almost intolerably violent. It usually occupies the lumbar or dorsal regions, and corresponds in locahty with the maximum of inflammatory action. It undergoes remissions, sometimes periodical, some- times not; it is greatly increased by movement of the body, or by the application of a heated sponge; but it Is not aug- mented by pressure of the spinous processes. /3. Conductive (phenomenally eccentric). Pain is felt in the limbs, and around the thorax and abdomen; accompanied often by a sense of constriction. There are modified sensa- tions in the limbs, such as pricking, numbness, &c., and every MENINGITIS. 209 impression is painful (dysoesthesia); and these conditions generally persist, the occurrence of liypa3sthesia or anesthesia affordino; evidence of myelitis. ii. JNIotorial symptoms, principally centric. a. Centric. The most characteristic phenomenon of spinal meningitis is tonic spasm; commencing, and persisting witli maximum intensity, in the muscles of the neck and Lack; but occasionally presented by almost all the muscles of the trunk and limbs. The degree (or force of contraction) varies from comparatively slight stiff-neck to complete opisthotonos. The jaw and the extremities participate occasionally; but not very frequently. The spasm is much increased by any attempts at movement: respiration is painful and laborious. There is little or no clonic spasm, and this tetanic state appears to be due to an induced condition of increased centric power. j3. Conductive. Paralysis to volition occurs sometimes; but rarely, except after several days have elapsed, and wlien there is reason to believe that myelitis exists in combination with the meningeal inflammation. Feebleness of the limbs is common. The faices and urine are retained (? by tonic con- traction of the sphincters), and this retention may be the only symptom that occurs for some days; or they are, at the first, or subsequently, passed involuntarily ( ? by compression from tonic spasm, or by paralysis of the spincters). These variations are prol)ably due to the condition of the cord itself iii. Mental symptoms are absent Avhen meningitis is limited to the cord : but towards the close of life there is coma; and there may be some delirium of mild character at an earlier period, due in all probability to the febrile state, and differing essentially from the fierce delirium wliicli is presented by com- plication with cerebral meningitis. b. Extrinsic symptoms at the onset are those of highly marked fever; the heart's impulse is forcible, but the radial pulse is commonly small and feeble. There is insomnia, and frequently considerable diaphoresis. Towards the close of life the mouth becomes dry, sordes appear, and tlie patient's con- dition is that of jiroi^tration. E E 210 ACUTE DTSEASKS OF THE SPINAL COED. The duration of meningitis is variable; death may occur from the fourth to the fourteenth day, or the affection may become chronic. Cerebro-spinal Meningitis may be diagnosticated by its presenting the features of its two elements in combination. It occurs sometimes sporadically, sometimes epidemically; and in the latter form is especially prone to occur in the male sex, and in those of the military profession who have been exposed to excessive fatis'ue, or to the violence of weather. It has, however, been observed in children of from seven to twelve years of age; but, under all circumstances, the diagnosis is comparatively easy, and requires no further comment. § III. MYELITIS. Although the course of this disease is frequently rapid, and there can be little or no doubt of its inflammatory character, it is (like encephalitis) unattended by the ordinary organic signs of an acute inflammation; and its symptoms, though acute in respect of time, are often developed in the manner of chronic disease — i.e., gradually and progressively. 1. Precursory symptoms, Ktlologically considered, possess little distinctive character. The rheumatic state, which has been held to be predisponent, may in reality have been nothing more than the early symptoms of myelitis, erroneously attri- buted to this blood condition. Contusions of the back, diseases of the bones, excesses of various kinds, suppressed discharges, &c. &c., may give rise to plethora spinalis, or meningitis, with equal frequency. 2. Developed symptoms are in the main Intrinsic, and are referrlble to changes of motility and sensibility. a. Sensorial (centric and eccentric). i. Conductive (phenomenally eccentric). The earliest changes are recognised In the extremities, the fingers and toes. There is a feeling of cold and numbness, or of pricking and pain; and this gradually extends to the upper part of the limbs. There Is, not uncommonly, a sensation of constriction In the throat, thorax, abdomen,, or lumbar regions, according MYELITIS. 211 to the locality of inllainmation; and the feeling is as if a cord were tied round the part. These modifications (nieticsthesiie) are succeeded by hypgesthesia3 and anaasthesiai ; but the losses of sensibility are much less marked than those of motility. ii. Centric. There is some pain in the region of the cord itself; but it is much less than in meningitis. It is most common in the lumbar region, because myelitis most frequently affects that portion. The pain is not materially increased by movement; but it is augmented by forcible pressure of the spinous processes, and by the application of heat. It is fre- quently so slight as to be taken for simple lumbago, or rheumatism. iii. The cranial senses are sometimes implicated, and cephal- algia occurs; but such phenomena do not belong to myelitis, per se. b. Motorial. (Both conductive and centric phenomena). i. Conductive. Like those of sensibility, the earliest and most characteristic derangements of motility are observed in the periphery. They are those of defective function, viz., difficulty of directing movement, and diminution of motor power in relation to the will. The muscles affected vary with the locality of inflammation ; when myelitis is cervical there is dysphagia, impeded articulation, and laboured respiration; when it is lumbar, the lower limbs are affected. (See p. 198.) Under any circumstances of localisation, paralysis commonly affects one side earlier and more profoundly than the other; and it exhibits a tendency to extend, until whole limbs, or the greater part of the body, become incapable of movement. Retention of urine and fbeces is a comiuon phenomenon at the commencement. ii. Centric. The tonic contraction of muscles is little, or not at all, affected, unless meningitis coexists, or until the disease has existed for some time : in the former case there is tetanic spasm; in the latter, absence of tone, evidenced by in- voluntary micturition and defecation. Reflex phenomena, on the other hand, are extremely common. They occur in the limbs in the form of clonic spasms; and, in children espo- 212 ACUTE DISEASES OF THE SPIXAL CORD. cially, general convulsions arc not nnfrequcnt. When the middle dorsal region is the seat of inflammation, there are peculiar convulsive movements of the trunk, neither the upper nor lower extremities being implicated. There is, not un- commonly, the involuntary (or spasmodic) evacuation of bladder and rectum during the convulsive paroxysms. c. Mental. In typical cases, not involving the upper portion (cranial) of the cord, the mind is unaffected; but in many in- stances coma occurs for some hours or days before death. It is generally a moribund phenomenon, and is preceded by convulsive paroxysms. The absence of intellectual change is an important distinction from general paralysis complicating insanity. Extrinsic symptoms are not sufficiently marked to require any further notice than this, that their absence is often an im- portant means of distinction from meningitis. The affection is commonly hyper-acute, and terminates in a few days; but, if this is not the case, sloughing of the integuments occurs, and hastens the prostration of the patient to a final issue. The duration of myelitis is less when located in the dorsal region than when in any other; and this has been explained by the smaller size of the cord in that portion of the column. jSI. Ollivier* has drawn attention to the frequency with which myelitis coexists with entero-gastritis and pneumonia; but we- cannot, in the present state of medical science, determine whether these inflammations are the result of spinal disease, or whether, by the profound alterations of nutrition which they induce, they are the causes of myelitis. The relation pro- bably differs in different cases; but it is important that such organic changes should be sought for, and should receive due consideration in the interpretation of phenomena. § IV. MENINGO-MYELITIS. This disease is more common than either of its elements in an isolated form; and its diagnosis (as in the case of cerebro- spinal meningitis) consists essentially in the recognition of the * Traits de la Moelle Epiuicie, &l-., p. 640. TETANUS. 2\S two classes of symptoms in combination. S[)inal pain and tonic spasm indicate the existence ot" meningitis; peripheral pain, or aiuusthesia, and paralysis denoting implication of the cord itself. In children this is by far the most common form in respect of symptoms; but in them the existence of tetanic rigidity is not always accompanied by post-mortem evidences of meningitis. § V. TETANUS. It is only to the idiopathic {i.e., non-traumatic) form of this disease that attention is directed. Its symptoms are so cha- racteristic that there is little probability of its being confounded with other allectlons. There are no anatomical changes to which they can be referred; and hence we must, for the present at all events, consider them as dynamic in their origin. Little can be gained from an examination into the precursory condition of the individual; inasmuch as all those which have been described as causative stand in the same relation to meningitis, plethora, myelitis, &c. Prodromata are commonly absent, or, if j^resent, they possess no distinctive character. Developed symptoms are essentially motorial. The first phenomenon of any diagnostic value is tonic spasm; and tliis persists throughout, forming the special pathognomonic sign of tetanus. It usually commences in the muscles of the jaws and of the neck; and gradually extends to the trunk and limbs, placing the whole body (or its parts) into most frightful pos- tures. Deglutition and respiration are impeded by spasmodic action ; there is obstinate constipation of the bowels, with retention or involuntary emission of urine. Every emotional excitement, or sensorial impression, increases the spasm, or may induce violent convulsive movements of clonic character. The mind is unaftected, and the patient often sleeps quietly at night ; there is no febrile reaction ; and the voice is commonly unallected. These general characters are suflicient to diflerentiate tetanus (rom every other disease. Meningitis (which itrcsem- 214 ACUTE DISEASES OF THE SPIXAL CORD. bles in presenting tonic spasm) is distinguislied by the loculity of contraction, the spinal pain, and the febrile condition. Epilepsy and eclampsy are at once recognised by their special forms of convulsion, and their paroxysmal occurrence. Hysteria is known by the antecedent symptoms, by the clonic character of its spasms, and by the co-existence of hysterical phenomena. § VI. HYDROPHOBIA. The symptoms of hydrophobia occur sometimes indepen- dently of any bite from a rabid animal. They are, under such circumstances, less intense, and far less fatal than the genuine disease; resembling the exaggerated and erroneous ideas with regard to hydrophobia, rather tlian that affection itself. The commencement is sometimes sudden, immediately following " fright," violent emotion, or some organic shock. At other times there is a greatly prolonged period of incubation. The first characteristic symptom is horror of liquids (and this may be the only symptom, as is sometimes exhibited by preg- nant women). There is then, constriction of the throat, fol- lowed by salivation, attempts to bite, and general convulsions. Emotional excitement, or sensorial impressions, induce clonic spasmodic phenomena of various kinds. The diagnosis of hydrophobia is attended by no difficulty; but it is sometimes far from easy to distinguish between the real and the spurious affection. The latter may be inferred, if symptoms have occurred immediately after an accident, such as the bite of an enraged animal, and especially if the animal has not been demonstrably rabid; or if they have occurred after a very long interval ; or if they have arisen spontaneously. The persistence of symptoms for a longer period than four or five days is conclusive evidence that the hydrophobia is not that of rabies; since the latter is almost invariably fatal within that time. § VII. HEMORRHAGE. Spinal ha?morrhage may take place into the meningeal cavity, or into the substance of the cord ittelf ; the former occurs mutt HiRMORRHAGE. 2 1 5 frequently in conjunction with cerebral hsemorrliagc, and the latter is most common in the tuber-annulare. It is often quite impossible to determine the seat of haemorr- hage, during life ; but, after pointing out the means bj which spinal apoplexy may be diagnosticated generally, some hints will be given by which its further localisation may be attempted, 1. Precursory symptoms. These may be entirely wanting; and when present they do not afford any very satisfactory indi- cation. The most frequent are, — pain in the back and limbs (often taken for rheumatism); the sensation of painful con- striction around the trunk; general lassitude; shivering; and fatigue from awkward positions, from bearing weights upon tlie shoulders, or from any over-exertion. 2. Symptoms of the attack are induced suddenly in the greater number of cases; but in some slowly and progressively. a. Sensorial. There is acute pain in the spinal region, corresponding with the seat of haemorrhage. The conduction of sensorial impressions is slightly interfered with, but hypas- thesia of the parts situated below the locality of lesion is an unfrequent, and very imperfectly developed phenomenon. Painful sensations in the limbs sometimes precede the occur- rence of paralysis. h. Motorial. There is paralysis (to volition) of bilateral dis- tribution ; it is not often complete, and may be more marked on one side than the other. Sometmles, but rarely, the bladder and rectum are implicated, involuntary evacuations taking place. The parts which are paralysed vary with the seat of hasmorrhage (see p. 198); the lower extremities may be alone affected; or the loss of motility may be general; and dyspnoea urgent. c. Mental. The mind is generally unaffected ; but there may be slight incoherence, or vertigo. 3. Sequelae of the attack. The disease is commonly fatal in a few days; but in rare cases, the patients recover from the immediate symptoms of the attack (pain and marked paralysis), retaining some loss of motility lor a lengthened jieriod. 216 ACUTE DISEASES OF THE SPINAL CORD. Nutrition Is affected early; the limbs waste, and sloughing sores occur on the parts exposed to pressure. Meningeal h(£morrhage, is commonly accompanied by clonic spasms, or by tonic contraction of the muscles jjaralysed to volition. Hcemorrhage into tuber-annular e. The symptoms resemble those of cerebral haemorrhage; there is loss of perception, and volition; and with this — paralysis, of general extent, hemi- plegic, or confined to the arms; extreme dyspnoea, with tracheal rattle; convulsive movements of the limbs, or of the whole body, and, in their interval, tonic spasms. Death some- times occurs instantaneously, and in the immense majority of cases within a very short period. § VIII. CONCUSSION. The most important means for distinguishing the simply dynamic effects of concussion from those of organic lesion, are the following. They occur as the immediate result of violence, most com- monly of physical nature (such as a fall, a violent blow, &c.); but they may follow intense mental or emotional shock. All the functions of the cord are simultaneously involved. There is loss of centric and conductive properties. There is neither marked pain, nor spasm. The symptoms disappear in a comparatively short time. When they persist, there is reason to believe that some i^lterior organic changes have taken place, and this is to be distinguished upon the principles already laid down. 217 CHAPTER XVIII. CHRONIC DISEASES OF THE SPINAL CORD. These, although very numerous and various in their indivi- dual characters, may be readily formed into large groups, the diagnosis of which is comparatively easy. The features pre- sented by chronic myelitis (for example), in different cases, are widely different as to detail, but they have a strong generic similitude; and, although it would occupy much time and space to draw anything like a picture of the clinical history of such cases, it will not take much of either to point out the general characters by which (under various forms of develop- ment) the disease itself may be recognised. Many of the variations which occur are due solely to the locality of cord affected, and into these variations it is not my purpose to enter now; such general remarks as bear upon the diagnosis of locality having been already made, in Chap. XV., p. 198. The diseases which are presented for differentiation, are : — I. Chronic myelitis (or softening.) II. Chronic meningitis. III. Induration and hypertrophy. IV. Tumors, 1. Diathetic, e. ^., tubercle, carcinoma. 2. Non-diathetic, e. ^., hydatids. V. Idiopathic paraplegia (dynamic.) § I. CHRONIC MYELITIS. This is less frequently idiopathic than the acute disease; its most common causes are, — caries or fractures of the vertebra;, and tumors ; but it occasionally remains as the sequela of acute inflammation. 1. Precursory symptoms are sometimes intrinsic only, some- times extrinsic. Among the former, the most characteristic is fixed pain, of very limited extent, in the spinal region: and in F F 218 CHRONIC DISEASES OF THE SPINAL CORD. conjunction with this, there is a peculiar restlessness of the limbs (commonly of the lower); and a sensation of heat in the skin, or some other modification of sensibility. The most common extrinsic symptom is prominence of one or more spinous processes. 2. Developed symptoms are of two classes. a. Intrinsic, affecting both motility and sensibility. i. Sensorial. Pain, assuming a variable course, sometimes persistent, sometimes remittent. ]\feta3sthesia3 in the lower limbs, or in those parts which are supplied by nerves arising from the infi^amed portion. Hypa^sthesife in tlie parts supplied by nerves having their origin below the seat of lesion. Marked anEBsthesia muscularis (see pp. 35 and 165); but very rarely complete cutaneous anaesthesia, until a later period. Ollivier* accounts for the general freedom of sensation from marked change, by the locality of disease (caries of the bodies of the vertebra?) being such as to implicate the anterior rather than the posterior columns of the cord. ii. Motorial. These are changes in the conductive and cen- tric functions, and usually those of the former precede, and are more marked than the latter. a. Conductive. The earliest change is diminution in the power of directing movement (phenomenally a derangement of motility; in reality, most probably, dependent upon ano2Sthesia muscularis). Distinct decrease of motor power follows; it generally assumes a bilateral distribution ; and, when paraplegic (in the legs for e. g.), the patient commonly moves more readily after exercise, the difficulty of movement being greater after rest. Retention of urine is a frequent symptom. The paralysis pro- gresses in intensity. j3. Centric. At the commencement, there are commonly no morbid phenomena. As the case proceeds, and the conductive functions are more completely arrested, there is very com- monly some excess of centric irritability; reflex movements are induced more readily than in health; and coughing produces spasm of the paralysed (to volition) limbs. Slight rigidity and ♦ On. cit., p. 40S. MYELITIS. 210 clonic contractions occur sometimes; but the most frequent condition of the limbs is that of llexion and adduction. The patient has much difficulty in their extension. Various modifi- cations of respiration occur in dependence upon the locality of lesion. (See p. 198.) But unless the disease has advanced so far as to destroy (functionally) some portion of the cord, the tonicity of the muscles remains, and they retain their irrita- bility to galvanic stimulation. h. Extrinsic. These at the first are local, viz., the signs of diseased bone (prominence of spinous processes, and other deformity): at a later period, there are nutrition changes in the limbs, indicated by wasted muscles, cold integuments, un- healthy skin, &.C.; and some general disturbances, such as hectic, and general emaciation. § II. CHRONIC MENINGITIS. This disease rarely exists except in connexion with caries of the bones, or some other affection external to the meninges. a. Intrinsic symptoms are of two kinds. i. Sensorial. Severe, often paroxysmal pain, in the spinal region; and painful sensations in the limbs, with considerable feeling of fatigue, and cramp. Aniesthesia is very uncommon. ii. Motorial. The centric functions are affected before, and to a greater degree than the conductive. a. Conductive. There is deficient voluntary power, which exhibits a tendency to extend upwards; but which is sometimes very curiously limited to particular groups of muscles. When the disease progresses to the cranium, the muscles of the face, eye-lids, and eye-balls become involved ; producing ptosis, or strabismus, with diplopia, e*v:c. /3. Centric. There is stifihess of the muscles in the limbs; marked tonic spasm of those in the neck and back ; Avith clonic spasms occasionally, and sometimes general convulsions. b. Extrinsic symptoms are like those of myelitis. The skin of the extremities becomes peculiarly dry and desquamative (Olhvier); and the lower limbs very frequently ccdeinatous. Cerebral co)//pl/ca(io/ii> arc frc(|uent; there is slight delirium 1- F 2 220 CHRONIC DISEASES OE THE SPINAL CORD. at night; or there may be irritablHty of temper, and various disturbances of the special senses ; that of sight being the most common, and adding much to the difficulty of progression, by diminishing one most important means for the direction of voluntary movement. Chronic Meningo-myelitis is more common than either of the two elements of disease in an isolated form. Its symp toms are those of inflammation in the two structures, presented in combination — viz., chronic paralyses, and tonic spasm, with local (spinal) and referred pain. § III. INDURATION AND HYPERTROPHY. These conditions cannot be diagnosticated with any cer- tainty. They may be inferred to exist from the absence of any signs of disease in the bones, or of tumors pressing upon the cord; and the presence of various motor and sensory changes, such as metassthesiic, and spasms, followed by hypass- thesiai and paralyses; together with extrinsic phenomena of malnutrition. The loss of function gradually extends, and the muscles generally become atrophied, until the whole body is involved, or rendered useless. § IV. TUMORS, ETC. Tumors of the spinal column, implicating the functions or structure of the cord, are of very various kinds; but they may be divided into two large groups, by the presence or absence of certain dyscratic conditions. We cannot positively assert the systemic, or local origin of tumors; but some are attended by general changes, and others are not; and although this distinction may mislead in certain cases, it is of considerable value, inasmuch as the diagnosis of such diseases can rarely be advanced beyond the point to which it (the distinction between diathetic and non-diathetic) may lead. a. Intrinsic symptoms, like those of encephalic tumor, are of variable character, presenting this in common with the latter, that they consist of different alterations in the functions of the parts involved, some being in a state of exalted, and others of depressed activity. TUMOKS. 221 i. Sensorial. Pain in the spinal region, and modifications of transmitted sensorial impressions (conduction), such as numbness, pricking, formication, &c., in the limbs; followed by hypaisthesia and anaesthesia. Pain is more marked in cases of carcinoma than of tubercle. ii. Motorial. Paralyses, and convulsive attacks often alter- nate, and the latter not unfrequently assume an epileptoid character; the paralysis is slowly developed. b. Extrinsic symptoms. These are the means by which tumors of diathetic origin may be separated from the non- diathetic. In carcinoma and in tubercle, there are, in addition to the evidences which may be aiforded by the deposit or growth of their peculiar structural elements in the spinal region or in other localities, the signs of their pecuHar dyscrasiai ; and these are sometimes very highly marked. The absence of such cachexise affords strong probability that the growth is of another nature. Aneurismal tumors may be diagnosticated by the special signs of such vascular diseases. § V. PARAPLEGIA (IDIOPATHIC). Paralysis of the lower extremities appears sometimes to be simply dynamic, or functional — i.e., independent of any organic or structural change which we are at present able to recognise. It may result from over-fatigue, induced by violent or pro- longed exertion ; from excesses of various kinds ; but also from causes which are undiscoverable. The symptoms commence insidiously, and progress slowly. Very frequently, anaesthesia muscularis (see pp. 35, and 165) is the first indication, and subsequently there is loss of power. Sensibility is little affected, as judged of by cutaneous im- pressibility. Sometimes there is slight contraction of the muscles of flexion and adduction, the foot being turned inwards and downwards; but this is probably rare in simple (dynamic) paraplegia. There may be aching in the loins, and fatigue upon the slightest exertion, with general anaemia, and organic depression, but there are no positive signs of structural disease. PART IV -DISEASES OP THE NERVES. CHAPTER XIX. GENERAL CONSIDERATIONS. The nerves are so numerous, and so varied in their functions, that much space would be occupied, and that probably to little profit, if the diseases to which they are severally liable were considered separately, and their individual diagnoses pointed out. It is not my intention to do this. The most important object of this book, with regard to nervous diseases, has been already accomplished in Chapter IV., page 57, where the means for distinguishing them from affections of the brain and spinal cord were entered upon at some length. The first object — viz., the diagnosis of locality, is attained thus far, .without much diflSculty, in the majority of cases; and the recognition of the particular nerve, or branch of nerve, Avhich is the seat of disturbance, can be arrived at only by a knowledge of the anatomical distribution, and physiological functions of each division. With such knowledge, the lo- caHty of lesion may be (in many cases) determined with great precision. In order to appreciate the nature of disturbance, it is neces- sary to know the ordinary healthy functions of the nerves, and then to discover the kind and amount of modification which is induced. The nervous trunks, forming part of the chain of communication between external impressions (or their organic effect) and the mind on the one hand, and between volition, GENERAL CONSIDERATIONS. 223 emotion, sensation, or spinal action and muscular contraction on the other, exliibit, as phenomena of tlieir diseases, modifi- cations of these processes; the cliain of comnumication may be impaired or broken altogether. Paralysis and anaesthesia result; in the former case the efferent (centrifugal), and in the latter the afferent (centripetal) conducting functions being interrupted. It is only at the extremes of a nervous trunk that its functions become phenomenal; and when the conduct- ing properties are alone affected by disease, it is at the ex- tremities only that symptoms are observed. But not only are paralyses and anajsthcsiai peripheral in their distribution, but the exaggerated activity is frequently peripheral also ; the symptoms not being pain in the portion of the nerve diseased, but pain at its terminal expansion in the skin, and spasm in the muscular fibres which it supplies. Thus it appears that the nerves, besides possessing a simply conductive function, have a peculiar property of transforming certain mechanical impressions, coming from without, or resulting from the presence of structural changes, but affecting them in their course (i. e. , not through tlieir peripheral ex- pansion or central origin), into the occasions of sensation on the one hand, or muscular contraction on the other. If a muscular nerve is divided, and the portion in con- nexion with the muscle is irritated (by simple contact, pinching, galvanism, &c.), there is contraction of the muscle. If a sen- sory nerve is divided, and the portion in communication Avith the cranium is treated in a similar manner, pain is the result, and it is referred mentally to the peripheral expansion. These examples from physiological experiment, and others from sur- gical experience, are sufficient to indicate the peculiar property of the nerves alluded to — viz., their capability of inducing two classes of phenomena (motion and sensation) as the result, not of the ordinary physiological causes of those phenomena (voli- tion and external impression), but of a pathological condition of the nerves themselves. Besides these symptoms, which are referrible to the extremi- ties of the nervous trunks, there are others which they exhibit 224 DISEASES OF THE NERVES. in the intermediate portions; and when certain kinds of changes take place, there are extrinsic phenomena, of much importance in the diagnosis. The following modifications of nervous functions may be readily recognised. I. Excessive activity, A. Of sensation; or sensibility. The most common and characteristic phenomenon is pain, or neuralgia. There is not, so far as I can discover, any real hypera^sthesia in dependence upon morbid conditions of the nervous cords. Hypera^sthesia is commonly connected with central changes (see p. 28). Dysres- thesi£e(see p. 30) are frequent accompaniments of the neuralgic condition ; the latter appearing very often to hold no definite relation to the exercise of any normal sensorial process, must be considered as an epiphenomenon, or as occupying a rela- tion to the proper (intrinsic) nervous functions similar to that which pain occupies to the morbid structural conditions of other oro-ans. B. Of motility. The phenomena being muscular spasm, which may assume a tonic, or clonic form. II. Diminished activity, or complete loss of function. A. Of sensation, or rather of impressibility. The symptoms thus produced are hypsesthesia and anaesthesia ; and these symp- toms may be present, whilst the nerve yet retains its power of conducting centripetal impressions which shall be the occasions of reflex action. But the latter power may also be lost, and then it appears that the " nervous" function is absent altogether. B. Of motility. The paralysis which arises from lesion of the nervous cords, affects motility (not only in relation to voli- tion, ideation, and emotion, but) as dependent upon the spinal cord' (see p. 39, et seq.) It may be incomplete, or complete in degree ; and when the latter, the muscles very speedily exhibit defective nutrition. 225 CHAPTER XX. THE DIAGNOSIS OF SPECIAL DISEASES OF THE NERVES. It appears to me most desirable to consider the whole of these aSections in one chapter, as it is to the differentiation of certain groups, rather than to the separate diagnosis of diseases limited to individual nerves, that attention is directed. Clinically wc may divide these diseases thus, — A. Organic, or structural. I. Neuritis (inflammation of the nerve trunks). II. Tumors ; of two kinds, a. Painful sub-cutaneous tubercle. b. Neuroma (of various kinds). B. Inorganic, or functional. III. "Neuralgiae, considering specially, — a. Facial. Neuralgia of the fifth nerve. b. Ischiatic. Sciatica. e. Dorso-intercostal. IV. Plypcrcineses, or spasms, considering specially, — a. Facial. Spasmodic tic. b. Oculo-motor. Strabismus. c. Laryngeal. Laryngismus stridulus. V. Anaesthesias, especially of the fifth nerve. VI. Acineses, or paralyses, and especially that of, — The facial nerve (portio dura of the seventh). § I. NEURITIS. This disease is rare, but it occurs sometimes idiopathically, although more commonly as the result of contusions, lacera- tions, or disease of adj oining tissues. It is to be distinguished from neuralgia, arteritis, and phlebitis. 1. Precursory symptoms are unimportant. There are to be recognised, sometimes, as the occasional causes of this (as well as of every other) affection, exposure to cold and wet; the 226 SPECIAL DI.SEASE.S OF THE NERVES. suppression of habitual discliarges ; cacliexiEe, &c. ; but the most important indications may be gathered from the discovery of local injury, such as that to which the sciatic nerves are ex- posed during parturition, &c. Extrinsic phenomena, for example, general malaise, or febrile excitement, may be present before any local symptoms occur. 2. Developed symptoms are of two kinds — intrinsic and extrinsic. a. Intrinsic are both local and peripheral ; the former being mainly sensorial, the latter motorial. There is extremely severe pain in the course of the nerve; it arises spontaneously, and is continuous, having its maximum of intensity at the point of greatest inflammation, and darting along the course of the nerve to other parts. There is marked tenderness on pressure; and this tenderness is not confined to particular points, but is co- extensive with the spontaneous pain; and further, the tender- ness is constant, and may be discovered by broad, as well as by concentrated pressure. The peripheral phenomena are changes of sensation and motility. Numbness, formication, and pain occur in those parts which are supplied by sensory filaments; and paralysis, with or without clonic or tonic spasm, is present in the muscles. Paralysis is sometimes induced very rapidly, is complete, and persistent for a long time ; its extent is very variable, but is in relation to the size of the nerve involved, and the number of muscles which it supplies; its intensity is in proportion to the severity of inflammation, to the nature of its secondary (organic) results, and to the rapidity of their production. h. Extrinsic symptoms. When the nerve is superficial there are the ordinary signs of inflammation, redness and swelling. A reddened line may be traced along the skin, and the nervous cord may be felt beneath. There are not the nodosites observed in phlebitis; nor does oedema occur at the extremity. Changes of temperature, and of nutrition (gangrene, &c.), do not take place as in arteritis. There is generally distinct febrile reaction (headache, heat of skin, accelerated pulse, anorexia, I'cc), and it is sometimes TUMORS. 227 very highly marked. Tills is one means of distinction from neuralgia. § II, TUMORS. Tumors may be of very different kinds, but the intrinsic symptoms which they occasion present great similarity. a. Intrinsic, are sensorial and motorial. i. Sensorial. There is violent, paroxysmal pain in the tumor itself, and alono- the course of the nerves. The darting; pain proceeds generally, but not invariably nor exclusively, in a centrifugal direction — i. e., from the tumor towards the peri- phery. Paroxysms of pain are induced by pressure, by changes in the weather, by mental or emotional shock, and sometimes without any assignable (occasional) cause. Their duration is variable, from a few seconds to three or four hours. They are apt to occur during sleep; rousing the patient suddenly, as if startled by an electric shock. After the paroxysms, it is found that the skin is tender upon pressure. ii. Motorial. Spasmodic and paralytic phenomena occur In the muscles of the periphery. General convulsions have fol- lowed in some cases, and have been cured by division of the nerve.* b. Extrinsic symptoms are those caused by the tumor as a material object. The " painful tubercle" is of small size, and does not increase ; its form is rounded or oval ; there is com- monly but one, and its most frequent locality is the lower extremity; it causes slight elevation of the skin; is more common in females than in males;! is generally found during early life ; and if removed is rarely reproduced. Scurrlioid and cystic tumors are of variable size, and often of rapid growth. They are commonly attended by general dys- crasia:. Descot states that they exhibit no special tenderness when moved laterally, but that there is severe pain Avhen they are moved longitudinally. + They are not observed before puberty, and they are more common in men than in women. * Portal, Anat. Medicale, tome iv. t Descot, Dissert, sur les Ati'ect., loc. des Nerfs., p. 210. :|: Op. cit., p. 2i8. G G 2 228 SPECIAL DISEASE OF THE NERVES. § III. NEURALGIA. Any sensory nerve may become the seat of neuralgia; but some are much more frequently affected than others. For example, the trigeminal (fifth) nerve of the face is peculiarly prone to suffer; and this is attributed to the constant exposure of its peripheral expansion to atmospheric changes, and to the frequency of direct irritation of some of its branches supplied to carious teeth. Under all variations of locality, the principal features of neuralgige are the same ; and therefore, after describing these (so far as they are of diagnostic value), only those special neuralgias will be alluded to, the symptoms of which present some similarity to those of other diseases. a. Intrinsic symptoms. These exist alone in the great majority of cases, and in all they are notably predominant. i. Sensorial. The characteristic symptom is pain. It is excessively intense in degree, and paroxysmal in its form. Its locality is that of a nerve trunk, and its peripheral distribu- tion, darting from one to the other with almost intolerable violence ; and generally, but not exclusively, observing a centrifugal direction. Tlie development of pain is not so sudden as is generally stated. Valleix finds that, in six-sevenths of his cases, "it was developed gradually, but in a more or less rapid manner."* The earlier symptoms are dull pain, and the sensation of weight and heat. There are two kinds of pain — one continuous, the other paroxysmal; the former is limited to particular portions of the nervous cords (generally their points of exit from osseous canals), the latter extends along the course of the nerves 'to their peripheric expansion. It is from those points in which continuous pain is present that the paroxysmal suffering radiates, and in them it reaches its maximum of intensity. Concentrated pressure, as with the tips of fingers, indicates that these points are tender ; pressure increasing the pain in the locality itself, and causing darts of intolerable agony into the * Guide du Medecin Praticien, tome iv., p. 306. NEURALGIJ3. 229 parts below. These points are soinctimes numerous; but in their intervals there is no morbidly Increased sensibility. Sometimes a particular spot, which at one moment was tender, ceases to be so for a time; the tenderness is greatest during the paroxysms, and is often altogether absent in the inter- paroxysmal period. Muscular movements increase the pain, and not unfrequently induce the paroxysms. ii. Motorial. Spasmodic phenomena occur not uncom- monly, and they may be tonic or clonic. After the attacks, paralysis of limited extent, and incomplete in degree; is sometimes seen; but these changes are generally of short duration. b. Extrinsic symptoms. There is sometimes general indis- position, depression of spirits, sense of weakness, &c. Local phenomena occur but rarely, except during the paroxysms. They arc changes in the vascular and organic conditions of the parts near to the seat of pain ; such as eruptions on the skin, or erythema only; with increased secretion of glandular structures, such as lachrymation, coryza, &c. A. Facial Neuralgia, known as "tic douloureux" and " prosopalgia," is one of the most common forms. Neuralgia may affect the whole nerve, one of its primary divisions, or only a single branch of one of the latter. The essential symptoms are those already pointed out, as characterising neuralgia generally. 1. General and precursory conditions. It is rare before twenty years of age; is more common in females than in males; commences earlier in life in the former; and is usually connected with uterine disturbances.* 2. Developed symptoms. These are rarely induced suddenly. The continuous pain and tenderness (described p. 228) are found at the points of exit of the cutaneous filaments ; supra- orbital, sub-orbital, nasal, alveolar, mental, &c,, and these afford the means of distinction from odontalgia. Some contractions take place in the muscles of the face; the conjunctivae are injected; the schneiderian membrane is * Vallcix. Op. cit., p. 323. 230 SPECIAL DISEASE OF THE NERVES. dry and hot; there is tmnitus aurium, and often profuse lachrymation. B. IscHiATic Neuralgia, commonly termed sciatica, occurs more frequently in men than in women. There are tender points near the tuberosity of the ischium, at the trochanter, the patella, and malleolus. Movement of the hip-joint, although painful, is not so severely painful as deep pressure ; there is no general muscular tenderness (as in fibrous rheumatism), nor does contraction of the muscles (voluntarily, as in walking) cause such intense pain as in either rheumatism or disease of the hip-joint. C. DoRSO-iNTERCOSTAL Neuralgia is much more common in women than in men; and it most frequently allects one side only, generally the left. ■ The painful and tender points are, — vertebral, sternal, and lateral, — where the intercostal nerves supply cutaneous branches. Hysterical symptoms (see Chap. XIV., p. 170), are generally present; and there are no physical signs of disease in the respiratory organs or in the bones of the spinal column. § IV. HYPERCINESES. Spasm, in dependence upon the nervous trunks alone, is comparatively rare. It occurs, however, sometimes in such a form — i.e., with such distinct limitation to the muscles supplied by a particular nerve, and with such perfect freedom from all centric changes, — that we can refer the symptoms to de- rangement of the nervous functions only. The special features of these hypercineses are, — their limi- tation to particular regions ; their frequent chronicity ; their freedom from co-ordination (i.e., their want of that combined, and quasi-voluntary appearance presented by spasms, origi- nating from disturbance of the emotional or sensori-motor centres), and the total absence of other intrinsic symptoms. The spasm may be either tonic or clonic; and although, in some cases referrible to organic disease of the nerve itself, or of some adjacent tissues implicating the nerve; it is, in other cases. HYVERCINESES. 231 independent of such alteration, and must be considered purelv dynamic. A. Facial Spasm is less common than facial paralysis. It is usually limited to one side of the face; and either all, or only some of the muscles supplied by the portio dura of the seventh nerve may be involved. The characteristic symptoms are — distortions of the features ; grimaces of every kind, either alternating or persistent; and, in the latter case, leadino- to deeply marked furrows on the contracted side. These distor- tions arc increased by speaking, laughing, or cryino-. The muscles of the aire nasi, eyelids, and mouth, are peculiarly prone to suffer; and either group may be affected alone. Sometimes the cervical region has its muscles involved; but this is more rare. At the commencement, sensorial clianges occur (such as pain in the face, &c.); but they soon disappear. B. OcuLO-MOTOR Spasm, inducing strabismus, is to be distinguished from the strabismus of paralysis by the persist- ence of some motor power in the antagonists of the contracted muscle (i.e., in the muscles of the opposite side to that towards which the eyeball deviates), and by the combination with facial spasm (rather than with ptosis or lagophthalmla). It is to be recognised as having a peripheral origin by the absence of those other intrinsic symptoms, which accompany strabismus from centric causes. C. Laryngeal Spasm, the true " laryngismus stridulus " of children, may be known by paroxysmal dyspnoea, without cough; the attacks being at first of short, and subsequently of longer duration, and then attended by noisy Inspiration, In the intervals of these attacks, the child exhibits no difllculty of breathing, nor cough, nor any signs of impaired health. The attacks of dyspnoea occur most frequently at nio-ht, or upon first awaking from sleep. They are not occasioned by exertion; but, when severe, respiration may be suspended completely for a variable time; and spasmodic phenomena iu the extremities, or general convulsions, may be induced. The above signs, If carefully considered, are sufficient to 232 SPECIAL DISEASES OF THE NERVES. diagnosticate laryngismus stridulus from pertussis, laryngitis, or paralysis of the laryngeal muscles. § V. AN^STHESIiE. Phenomenally, there is loss of sensation, of reflex impressi- bility, or of both. It is not easy to account for the separation of these functions by disease implicating the nervous cords alone; but it is quite certain that such separations are effected clinically. For example, there may be perfect amaurosis dependent upon lesion of the optic nerve, and yet the iris con- tracts upon exposure of the retina to light; and a similar distinction is not unfrequently observed with regard to the cutaneous nerves. Any nerve may become anaesthetic, and the symptoms induced consist essentially in the absence of its special func- tions, whatever they may be. Absolute loss of sensibility is commonly accompanied by changes in motility and nutrition; which may be coetaneously produced; or may be the result of deficient sensation. Cutaneous anaesthesia is often preceded by modified sensa- tions, of various kinds, such as pain, numbness, tingling, &c. The diagnosis of peripheral from centric anaesthesia has been already described in the chapter on diagnosis of locality generally. (See p. 58, et seq.) The means of distinction are, — the limited distribution of symptoms; their confinement to regions supplied by particular nerves, or branches of nerves; the implication of reflex functions ; and the absence of further centric symptoms. § VI. ACINESES. The special features of paralysis depending upon loss of con- ductive power in the nervous cords are, — limited extent (i.e., isolation to the muscles of a particular nerve, or of one of its branches); loss of tonicity; loss of reflex, and electric con- tractility ; the rapid loss of nutrition ; and the freedom of the patient from centric disease. Notwithstanding the many differences that exist between the ACINESES. 233 opinions of those who have experimented upon the relations of paralysed muscles to electric stimulus, when the paralysis depends upon cerebral causes (such as ha>morrhage, softening, &c.), and ailects a unilateral distribution; there is a general concurrence of testimony upon this point, that when the lesion or disease is of such a nature as to sever muscles from their functional connexion with the cord, the electric irritability is rapidly diminished, and ultimately lost. This was pointed out long since by Dr. Marshall Mall, and paralysis of this kind was denominated by him " spinal paralysis."* (Others, misinter- preting the expression, and understanding by spinal paralysis the loss of motility in dependence upon spinal disease, con- founded two conditions essentially distinct; and asserting, what is quite correct, that paralysis, dependent upon spinal disease, and implicating only the conductive functions of the cord, does not necessarily involve the electric irritability of the muscles, they contradicted the statement of Dr. Hall with regard to spinal pnralysis, but, using that term to denote a very dif- ferent condition from that intended by Dr. Hall, unnecessary confusion and contradiction arose, from its very frequent source, the dissimilar application of the same expression). Lately Duchenne, Meyer, and others, have abundantly confirmed the original proposition of Dr. Hall, viz., that the muscles excluded from spinal influence lose their electric irritabihty ; but they term this kind of paralysis "traumatic," intending by that word, lesion of the nervous cord, whether arising from external injury or from the development of organic disease, such as a tumor, pressing upon and impeding the function of the nerve. Facial Paralysis. Tliis is the most common local para- lysis, and it needs some special comment, as it is liable to be confounded, in certain cases, with facial hemiplegia of cerebral origin. The symptoms are loss of motility in the muscles supplied by the portlo dura of the seventh nerve ; the extent of paralysis, or the number oi' muscles affected, is determined by the seat of lesion — /'. e., its implication of a large, or small division, or of * Medico-cliinirg. Trans., vol. xxx.. p. 207. 234 SPECIAL DISEASES OF THE NERVES. the entire trunk of the nerve; and the degree or completeness of the paralysis is in proportion to the severity of affection. When only the peripheral portion of the nerve is affected, the facial muscles are alone involved; the eye remains open, wink- ing movements cease, the eye loses its natural protection, and the conjunctiva becomes injected; tears are secreted in profuse abundance, and they flow over the cheek. The lips and alse nasi are paralysed, whistling movement is impossible, and food frequently collects between the teeth and the cheek, owing to loss of power in the buccinator muscle. The muscles on the opposite side retaining their functions, there is deviation of the features, and this becomes excessive during the expression of emotion, by laughing, crying, &c. When the nerve is affected within the temporal bone, as, for example, from caries of the latter, there may be extrinsic symptoms, such as otorrhoea, deafness, pain, &c. : and the in- trinsic phenomena differ, owing to the implication of the chorda tympani, and petrosal nerves. The sense of taste is diminished, salivation is decreased, articulation is impeded, and the muscles of the palatine arch and uvula exhibit unilateral paralysis (known by flattening of the arch, and deviation of the uvula). The important distinction from cerebral hemiplegia of the face may be established, by the absence of centric symptoms {e.g., loss of perception and volition, &c.); by the paralysis of the orbicularis oculi, which is very rare in cerebral hemiplegia; by the loss of electric irritability in the muscles; by the extrinsic phenomena of disease in the temporal bone, or along the course of the nerve; or by the existence of such occasional causes as exposure to a draught of air, disease of the parotid gland, &c. APPENDIX. APPENDIX A. THE SENSOKI-MOTOB G.VNGLIA. This term is used to denote certain ganglionic masses, or collections of grey vesicular matter, lying at the base of the brain ; and included partly within the medulla oblonga, and partly within the cerebral hemispheres. These bodies have received the following more or less appropriate names : — 1. The olfactive ganglia; or bulbs of the olfactory nerves. In fishes these are of much larger size, in proportion to the cerebral lobes, than in man. They are distinctly pedunculated, and contain grey matter in their interior. The so-called olfactory nerve has been for a long time recognised to be in reality a tract of cerebral tissue ; the true olfactory nerve is peripheral to the bulb, and the latter constitutes its sensorial centre. 2. The corpora quadrigemina. These bodies are placed in con- nexion with the optic nerves, the third pair of nerves, the anterior division of the spinal cord, and the cerebellum. In fishes, and in the lower vertebrata generally, they are of much larger relative size than in the higher vertebrata and in man. They constitute an important part of the " optic lobes ;" and both comparative anatomy and physiological experiment concur with the results of clinical obsei'vation in showing that they are the true centres of the visual sense. 3. The grey nucleus of the posterior pyramid of the medulla oblongata (situated immediately beneath the floor of the fourth ventricle), which constitutes the auditory ganglion. It is placed in direct conununication with the portio mollis of the seventh pair of 236 APPENDIX A. nerves ; and in some fishes, for example in the carp, is as distinct a body as the optic ganglion. 4. The gustatory ganglion, in close proximity to the latter, to the corpus dentatum, and restiform nucleus. These little collections of vesicular nerve-substance are connected with the hypo-glossal, glosso- pharyngeal, and pneumo-gastric nerves. 5. The thalami optici. The "optic lobes" of fishes (osseous) contain not only the corpora quadrigemina, the true optic ganglia as already pointed out, but also the thalami optici ; and in the human embryo of the sixth week, a distinct vesicle is found for the latter, situated between that of the corpora quadrigemina and that of the cerebral hemispheres. These thalami optici are placed in intimate relation with, and form the termination of, those fibres which constitute the sensory tracts, ascending from the spinal cord, and receiving fibres from the large divisions of the fifth pair ot nerves. It appears probable that they constitute the centre ol general sensation, and of the sense of tovich. 6. The corpora striata. These bodies are homologous Avith the cerebral lobes in fishes, and in the early human embryo. They form the upper termination of the motor tracts ; are placed in com- munication by means of the latter with the spinal accessory, portio dura of the seventh, the sixth, motor division of the fifth, the fourth, and third pairs of nerves, and with the anterior columns of the spinal cord. They appear to constitute the (immediate) centres of motor impulse for the two lateral halves of the body. 7. The cerebellum, connected, by its three peduncles, Avith the sensory centres, and with the motor and sensorial tracts, exercises an important function in the guidance of muscular movements, and in their combination and co-ordination, for the accomplishment ol definite ends. This function appears to be performed in depen- dence upon sensational direction. With regard to the functions of these ganglia, considered col- lectively, the folloAving points may be considered as established : — I. That they constitute the true sensorium, or centres of sensa- tion proper. Experimental inquiry shows that the special senses become extinct when these ganglia are injured or destroyed ; that the removal of the entire cerebral hemispheres (leaving these bodies) destroys all evidence of perception (the intellectual recog- nition, or "intuition" of external inq)ressions) ; but that sensation THE SENSORI-MOTOR GANGLIA. 237 is not affected ia its relation to muscular action. Comparative anatomy, Avhile it shows that there is some general agreement between the size of the cerebral hemispheres and the degree of in- tellectual endo-\vment, exhibits the progressive increase of the sensori-motor ganglia in relation to the cerebral hemispheres, as the descent is made from thq higher to the lower vertebrata. The lowest vertebrated animal presents nothing more than these ganglia as the entire of its intra-cranial nervous system. In the higher Crustacea there is a similar arrangement. It appears, therefore, that Avhere the wants and actions of certain animals are of so linoited a nature that sensation alone is sufficient for their accomplishment and general direction, the sensori-motor ganglia constitute the whole of theu' cranial nervous system. Where, on the other hand, inteUigential perception and spontaneous action are recjuired, there is the super-addition of cerebral hemispheres : and these hemispheres are developed in proportion to the complica- tion of muscular movements required, and to the necessity for their adaptation to new circumstances and conditions. The former class of animals is ineducable ; their habits are essential functions of their physical constitution, and all their movements are restricted within definite laws ; but the latter class may be taught by circum- stances, and new formula; for muscvUar action may be created through the intervention of volition. Clinically it is found that disease of the tubercula quadrigemina induces bhndness ; that lesion of the thalami is attended by loss of general sensation ; but that affections of the cerebral hemispheres, removing perception and effective voHtion, do not at all necessarily impaii" sensation. II. That they are (taken collectively) the organs engaged in tlie performance of a number of actions, not connected with volition, and not simply reflex, because attended by sensation. These move- ments are the sensori-motor, consensual or automatic ; and thus these ganglia are not only the central organs of sensation, but those of certain motor impidses. Physiological experiment shows that varioiis rotatory and allied movements follow the injiu-y or section of these ganglia on one side of the body. Eest is not the residt of inaction, but of opposed and balanced action ; and the inference from such physiological ob- servations is, that the lesions described interfere with the establish- 238 APPENDIX A. ment of this balance, by the unilateral removal of sensational stimulus. The experiments of Flourens upon the ear, and of Longet upon the eye, demonstrate that it is the sensational element in defect, and not tlie motorial element in excess, which is the cause of such phenomena. But they, at the same time, show that sensa- tion is a constant occasion, or remote source of motor impulse ; normally — i. e., when equal on the two sides, producing equilibrium or rest ; abnormally — i. e., when unequal on the two sides, in- ducing rotatory or vertiginovis movement. The reader is referred to a pamplilet upon " Vertigo," * for a succinct history of the physiological experiments which warrant these conclusions. III. That these ganglia have the power, not only of receiving sensorial impressions and of affording motor impidse, but of trans- forming the lirst into the second ; and this without the (necessary) intervention of perception and voHtion. Daily observation proves the accuracy of this statement. There are many physiological movements of purely sensori-motor character, such as the direction of the eye-balls, the sudden starts which are occasioned by noises, &c., and these movements are frequently presented in excess as the result of dynamic or structural disease. The limitation of respiratory movement to one side of the chest in cases of pleurisy, is an exam- ple of the power which sensation exerts in the direction of muscidar action. IV. That these ganglia are in all probability the immediate sources of motor impulse in every act of which volition is the remote occasion. We cannot determine the contraction of a par- ticular muscle or group of mi;scles by any effort of the will directed to the muscles themselves. It is by the direction of vohtion to the resultant movement, that the latter is effected. Many muscular combinations appear to be the result of connate endowments, such as those which the lower animals exhibit in their erect position and progression immediately after birth : others are acquired, or are the result of education, or volitional direction of movement towards the accomplishment of definite ends, under the guidance of sensation. Many actions which at first require the constant direction of consciousness (attention) to their performance, become subsequently so facilitated by practice, that they may be maintained or even originated independently of any distinct volition. Thus, the child has to attend most diligently to its earlier steps ; but the adult * " Vertigo," a paper read to tlic N. L. Med. Soc. THE SENSORT-MOTOR GAXGLTA. 239 walks for hours togetliei', without the slightest consideration of his limbs. These movements are very correctly termed *' secondarily automatic." V. That these ganglia are probably concerned especially in the performance of emotional and instinctive movements. Comparative anatomy indicates that the instinctive actions must, in the lowest vertebrata and the higher invertebrata, be entirely dependent upon these bodies ; and the close resemblance of such movements, and of those Avhich accompany emotion, to the sensori-motor phenomena, in regard of both their special character, and their relation to volition, renders it highly probable that they are functions of the same organs. In the lower dnimals, and also in man himself, the immediate occasions of instinctive and emotional actions are sen- sorial impressions ; and it has been shown by experiment, that many of the former are persistent, when the cerebral hemispheres are removed. The association of emotions Avith sensations and ideas, and the reproduction of such emotions, independently of any re- newed impression, by a simple train of thought, is the cause of apparent complication and difficulty in the interpretation of such phenomena in man ; but there is no reason to believe that the emotions, when becoming objective («'. e., when displaying them- selves by muscular movements, expressions of the face, gestures, &c.), do so in any other manner than the instinctive propensities of animals ; although the emotion itself (subjectively considered) need not be dependent vipon any property of the sensori-motor ganglia. VI. That these ganglia may be affected by disease, either functional or structural ; and that the symptoms of such morbid conditions resolve themselves into modifications of motility and sensation individually, but more commonly and distinctly into changes of tlieir functional relationships. (See Chapter II., p. 34, &c.) The reader is referred to Dr. Carpenter's " Principles of Human Physiology," it being to the lucid discrimination of that author that we owe A'ery much of our information iipon the subject. 240 APPENDIX B. ON THE RELATION BETWEEN FUNCTIONAL CHANGES AND STRUCTURAL LESIONS. Until very lately a large class of diseases was to be found in every nosology, and in the writings of almost every systematic author, denominated " dynamic," " functional," or " inorganic ;" and in the present day, although this group is diminished, there are many affections which, for want of a better word, and a more advanced pathology, are termed " neuroses." The belief is, hoAvever, daUy extending and deepening, that no diseases of any kind (i.e., that no morbid conditions of function, nor concatenations of symptoms), either can or do exist without corre- spondent physical changes in the organs. This belief arises from the fact that many of the so-called neuroses are, or may be, now distributed among more definable diseases, such as textural changes or morbid blood-conditions. Are Ave Avarranted in believing that this distribution is possible Avith regard to all the neuroses, or functional diseases ? If so, the terms " functional disease," " neuroses," &c., must be discarded from our nosology, or be used Avith the distinct understanding that they are provisional only, until further examination has rendered their employment no longer necessary. But if this reduction is not possible, Ave have no right to assume upon a priori grounds the impossibility of purely dynamic derangements ; but Ave shoiUd endeavour to determine the existence or non-existence of ulterior changes as yet undetected ; and to establish the laws of such morbid A'ariations, so far as they may be discoverable by the old and by ncAv methods of examination. In endeavouring to answer the question, Avhether all dynamic disturbances can be referred to any of the pathologico-anatomical conditions at present recognised, the folloAving general statements afford all necessary assistance : — 1st. That there are many diseases, such as epilepsy, hysteria, apoplexy, paralysis, &c., Avhich sometimes occur Avithout our being able to discover post mortem any physical derangement of the ner- vous centres, or of any other SA'stem of organs. RELATION OF STRUCTURE AND FUNCTION. 241 2nd. That there are many diseases of chronic duration, but of paroxysmal type, in which, during the intervals of attack, there is more or less perfect immunity from morbid symptoms. 3rd. That there are found, post mortem, changes of structure in the encephalou and spinal cord of individuals who have, during life, presented no symptoms of nervous derangement. 4th. That the lesions which are discovered in similar cases of disease assuming a paroxysmal type, are of very variable nature and locality ; and, vice versa, that the same lesions have co-existed with symptomatically different diseases. 5 th. That the physical changes which are found in the nervous centres of those who have presented paroxysmal diseases — during the intervals of which paroxysms there may have been complete immunity from, or the presentation of, very different symptoms — are commonly of such kind that their production must have taken much time, and must in all probability have progressed during the in- tervals of seizure. 6th. That the lesions which are discovered are frequently of such a kind, or in such a locality, that they afford no direct explanation of the symptoms. For example, a spiculum of bone pressing upon the brain does not explain the occurrence of epUeptoid paroxysms in the same manner that destruction of the thalami and corpora striata accounts for paralysis and anassthesia. 7th. That the symptoms of many, commonly called dynamic diseases are precisely similar in essential characters to the processes of ordinary health, differing from them in degree, and in the time of their occurrence. 8th. That there are modifications in the functions of other organs analogous to those modifications in the functions of the brain and spinal cord, which are presented by dynamic diseases, without any appreciable change of their structiire. For example, excessive ac- tion of the heart, or its opposite condition of syncope ; modifications of secretion both in quality and quantity, &c., &c. From these general data it must be inferred, — A. That there are diseases — i.e., there are groups of symptoms which must be considered to be functional changes. B. That there are physically morbid conditions which do not reveal themselves by symptoms ; and further, — C. Thnt when the two classes of morbid phenomena (dynamic 242 ArrEXDix b. and static) co-exist, such simple co-existence does not prove tliat tliey occupy the relation of cause and effect. Allowing, then, as it is evident that we must in the present state of medical science, that there are functional derangements, which no anatomical lesions can explain, we are led to ask the questions, whether it is j^robable that these neuroses are the results or phenomena of changes in the essence of the nerA^ous properties them- selves, or whether they are the products of ulterior changes in the structure of the organs, or in the conditions of their stimulation ? The answers given to these questions may be based upon simply speculative grounds, or they may be the result of deduction from more general laws which have been established inductively. Spe- culation is of little or no value in the matter ; the conclusion to which individuals will be led by such a method, will be in accord- ance Avith their several modes of thought, and hence idiosyncratic and diverse ; rather than in any necessary conformity Avith the truth, which is universal and one. If we attempt to answer the question deductively, there are argu- ments on both sides. Those who indulge the hope and belief that further examination Avill lead to the recognition of pathologico- anatomical conditions, similar to those Avith which we are already familiar, do so upon the folloAving grounds, — 1st. That because many diseases, heretofore considered dynamic, have noAV been shoAvn to depend upon a static change ; as — for ex- ample, urina?mic conA'idsions, syncope from fatty heart, &c. — there is reason for believing that all diseases liaA'e a similar organic or struc- tiiral basis, and that the latter Avould be discoA'ered if equally minute observation Avere pursued in the right direction. 2nd. That because many diseases can be shoAA'n to be dependent upon certain physical changes, only of temporary duration, it is pro- bable that some analogous conditions,' as yet undiscovered, exist in all cases. 3rd. Becai\se some organic change accompanies all A'ital activity, the morbid conditions of the latter must be referrible to morbid conditions of the former. On the other hand it may be argued, that none of these com- monly known pathological conditions exist, — 1st. Because, minute examination has failed to discover any per- sistent physical conditions upon Avhich they could depend. RELATION OF .'STRUCTURE AND FUNCTION. 243 2nd. Because there is nutliinjr to indicate the existence of any temporary physical clianges duriilg life. 3rd. Because the kind of organic change accompanying vital activity is merelv a condition, or one of the phenomena of such action, and cannot be considered as its cause. The disintegration of a muscle which takes place diu'ing its contraction, is one of the phenomena of that contraction, and can no more be regarded as its cause than can tlie approximation of its two extremities. 4th. Because the phenomena which present themselves as the intrinsic symptoms of nervous disease, are nothing more in essential characters than the phenomena of health, differing from the latter in their relative intensity, in the form of their combination, and in their persistence. The onus prohandi lies therefore upon those who assert that there must be structural changes to account for functional disturbance, if they mean by such structural changes any of the morbid lesions found in our ordinary pathologico-anatomical categories. If all that is intended is that some physical change in the intimate organic pro- cesses of the tissues in question, must take place as the essential conditions of their activity ; and that some diminution or perver- sion of these processes must attend the decrease or alteration ot their functions, there is not only c/jj/vbr/ evidence, and the deductive application of general laws to warrant such an assertion, but there is direct clinical evidence of its truth : such as that, for example, given by Dr. Bence Jones, with regard to the modifications of the virinary secretion in respect of phosphates and sulphates, in cases of delirium tremens, chorea, &c. But these changes are totally dis- tinct from those which are ordinarily meant by structiu'al lesions, and are, as I have already said, conditions of vital activity, and not its cause. It appears probable that there is a correlation between the several vital forces, similar to that which subsists between the difFerent physical forces, and that the organic (vegetal) changes in the muscular fibres are related to the functional (animal) property of contraction, in the same manner that chemical decomposition is connected with the development of motion, for instance, in the magnetic needle. But neither can be considered as the cauj^e oi- effect of the other. (For this view of the physical forces, we arc indebted [irlniarilv to Professor Grove, wh<> liinl> at tlu- applifatiun 24^ APPENDIX E. of a similar mode of expression, with regard to the organic pro- cesses ; but it is to Dr. Carpenter that we owe our more definite knowledge upon the subject. See " Philosophical Transactions for 1850," in which not only the correlation of the several vital forces is distinctly demonstrated ; but these forces are shown to occupy a similar relation to the ordinary physical agencies, such as heat, light, &c.) This mode of viewing the subject is of importance, not only in relation to those diseases in which no structural changes can be de- tected, but in reference to those which are connected with distinct pathologico-anatomical alterations. The immediate conditions of all such symptoms as result from modified functions being the intimate organic (vegetal) processes of the tissues, we can under- stand why similar symptoms arise from anatomical conditions pre- senting coarse differences, and vice versa, Tlie mechanical changes, such as haemorrhage, congestion, softening, &c., do not cause the symptoms directly, but by the intervention of secondarily induced alterations in the minute organic processes. It appears to me that we may thus solve the vexata qucestio of the existence of functional diseases, by affirming that they are dynamic in the same sense that muscular contraction and sensation are dynamic in their ordinary, healthy exercise ; and the term has, therefore, been retained and applied in the preceding pages. 245 APPENDIX C. ON THE RELATION BETWEEN VOLITION AND INVOLL'NTARY MOVEMENTS. From the clinical history of cerebral diseases, and from the results of physiological experiment, it is evident that the complete removal of volition does not necessarily induce any spasmodic phenomena ; but it is commonly believed, and many facts appear to warrant the belief, that such removal enhances the probability, by increasing the facility of their production. It is said that there is an antagonism between the cerebral and spinal functions, the volitional and avolitional, and this antagonism has been made to account for the occui'rence of convulsive pheno- mena, when cerebral influence is removed ; the loss of volition set- ting free, as it were, the power of involuntary movement. It has appeared to me that this antagonism is an assumption in some cases, and that it is sometimes quoted in explanation of phe- nomena without any suflUcient reason ; and in order to limit the employment of this idea to its proper objects, I have endeavoured to state the facts which are established upon the matter at issue in a propositional form. 1st. Those reflex movements which are normal in character are not ordinarily opposed by volition. For example, deglutition and respiration do not call forth any antagonism from the will. 2nd. If attention is directed to their performance, they at once become unnatural : the movements are postponed, or rendered clumsy, by combination with ideo-motion and voluntary effort, and the conditions of stimulation being deranged or removed, the act may be averted. 3rd. If the appropriate stimidus be brought to bear upon the sensory, or recipient surface, no amount of volition can check or prevent an essentially reflex movement. For example, it is im- possible to hold the brenth, or to restrain a cough or sneeze beyond a certain point. 4th. When volition is removed, ordinary reflex actions are per- formed no more readily than in health, but they continue in pre- cisely the same condition. As illustrations of this we may allude to the contraction of the iris in aiioplexy, the acts of swallowing and 24(i APPENDIX C. respiration when the brain is removed by experimental lesion, which maintain their normal relation to their appropriate stimuli. 5th. When volition is preserved, there is an innate tendency and capacity to resist such involuntary movements as are abnormal ; whether these arise from extraordinary stimuli, or from an excessive susceptibility of impression. Thus we resist the motor effects of tickling, and any spasmodic movements which arise from ex- aggerated reflexion. This power is esj^ecially successful in the control of sensori-motion, but its influence upon the purely — i. e., asensual reflective movements, is trivial. 6th. ^V^len volition is removed, abnormal and pathologic reflex actions are readily induced ; thus irritation of the soles of the feet in paralysed limbs produces contraction of the muscles more easily than in those which are under the control of the will. In some cases this is very highly marked, in others much less so, although equally paralysed to volition ; and it is in cases of palsy from spinal disease, that it reaches its maximum of development ; many cases of cerebral hemiplegia presenting no increase of reflection. From these general data we may infer, — A. That normally there is no antagonism between the will and the reflective actions of healthy life. B. That there is an antagonism to unnatural involuntary move- ments from whatever source they arise. C. That this antagonism being removed by anything which inter- feres with volition, abnormal reflex actions are rendei'ed probable, but by no means necessary or excessive. D. That the removal of this antagonism, by interference with volition, does not account for all the exaggeration of reflex actions. E. That those cases of paralysis, in whicli there are the phenomena of excessive reflection, are compKcated with another diseased con- dition of the reflective centre. INDEX. AciNESES, from disease of nerves, 232 (see paralysis) Acute diseases, meaning of word, 7 of brain, 63 of spinal cord, 206 Albuminuria, 111 Aniemia, with apoplectic symptoms, 113 A nscsthesia, definition, 29 muacularis as a symptom, 21, 35 as a disease, 165 Ansesthesiae from disease of the nerves, 232 Anatomical condition, as third problem, 11 Antagonism between cord and brain 245 Apoplectic diseases, (see congestion, haemorrhage, softening, &c.) meaning of word, 64 list of, 90 Apoplexy, 91 Apprehension, unusual quickness, 15 loss of, 16 Attention, deficiency of, 15 Brain, diseases of diagnosis from those of cord and nerves, 57 from meningeal, fil Catalepsy, 173 Cams, definition of, 45 Centric functions of cord, 203 Cephalalgia, difierent forms, 139 Cerebritis (see softening) general, 82 local, 83 Chorea, acute, 138 ordinary form, 1 58 Chronic diseases, generally^ 8 of brain, 68 of spinal cord, 217 Classification of anatomical conditions, 10 of diseases, 48 Columns of cord, 200 Coma, definition of, 45 Combined excess and defect of func- tion, diseases marked by, 69 Concussion of cord, 216 Conductive functions of cord, 201 Congestion of brain, febrile form, 88 apoplectic form, 91 delirium form, 115 convulsive form, 130 Congestion of cord, 207 Consciousness, loss of_, definition, 19 Continued fever, 84 Control of involuntary movement, 21 Convulsion, definition of, 44 Convulsive diseases, diagnosis of group. 66 248 INDEX. Convulsive diseases, list and classification of, 123 Delirium, definition, 19 diagnosis of^ generally, 65 diseases marked by, 115 tremens, 118 Delusions, definition, 25 Diabetes, with apoplectic symptoms, 112 Diagnosis of three objects, general means for arriving at, 12 Diathetic diseases (see extrinsic, urina3mia, &c.) Diminished function, as mark of group^ 69 Direction of movement, 21 Dorso-iutercostal, neuralgia, 230 Dura mater, inflammation of, 82 Dynamic, diseases, 10, 240 Dyssesthesia, definition of, 30 Eccentric convulsions, 123 Eccentric irritation, convulsions from, 125 Electric irritability, generally, 41 Elements for diagnosis, 13 Emotion, symptoms referrible to, 25 as source of action, 25 as a state, 26 Emotional movements, 34 Encephalon, diagnosis of parts, 3 Epilepsy, relation to brain, 143 relation to other diseases, 173 in terparoxysmal phenomena, 178 symptoms of attack, 179 induration of brain, 195 Epileptics, classification of, 181 Epileptoid convulsions, 44 Exaltation of function, 68 diseases marked by, 144 Extrinsic diseases, definition of, 2 Extrinsic diseases, diagnosis, 52 Extrinsic symptoms, generally, 45 Facial neuralgia, 229 Facial paralysis, 233 Facial spasm, 231 Febrile diseases, 8 diagnosis of group, 63 list of, 70 differential diagnosis, 71 Fever continued, 84 gastric remittent, 87 Fibrinous concretions in vessels, 114 Function, exaltation of, 144 diminution of, 164 excess and defect in combination, 168 Gastric remittent fever, 87 Hsemorrhage, cerebral, 94 apoplectic form, 95 convulsive form, 136 „ ventricular, 99 „ arachnoid, 100 „ spinal, 215 „ tuber annulare, 216 Hallucinations, distinction from illu- sions, 150 Hemicrania, 148 Hydi-ocephalus (see tubercular ren- ingitis) chronic, 196 Hydrophobia, 214 Hypa3sthesia, definition, 29 Hypersemia (see congestion) Hypera3sthesia, definition of, 28 distinct from dysesthesia, 30 HyperaBsthesiae, 138 Hyperalgesia, 29 Hypercineses, 231 Hyjjertrophy of brain, convulsive, 138 in infants, 194 in adults, 195 from lead, 195 IXDEX. 249 Hypertrophy of brain, in epileptics, 195 Hypertrophy of cord, 220 Hypoclioudriasis, 145 Hysteria, 1G8 relation of attacks to iutorpar- oxysmal state, 1G9 mental stixte in, 170 why among diseases of the brain, 143 Icteric disease, with ai)02)lectic symptoms, 112 Ideation, symptoms referrible to, 22 relation to impressions, 23 as independent process, 23 sequence of, 24 exaggeration of, 24 perversion of, 25 relation to motility, 25 excessive, 145 Ideo-motion, 33 increased, 33 diminished, 34 Idiopathic convulsions, 128 „ paraplegia, 221 „ tetanus, 213 Illusions, 151 Induration of brain, 193 (see hj^ertrophy) Induration of cord, 220 Intensity of sensations, how regulated, 28 Intrinsic convulsions, 128 Intrinsic diseases, definition, 3 diagnosis from extrinsic, gene- raUy, 52 Intrinsic symptoms, definition of, 14 mental, 14 non-mental, 27 IrritabOity of muscles, to electricity, 41 to percussion, 42 Laryngismus stridulus, 231 Lead poisoning, induration of brain in, 195 Locality of affection, first problem, 2 . diagnosis of, generally, 52 in spinal cord, 198 Loss of consciousne-is, 19 Mania, acute febrile, 89 Mania, dancing, 147 Meningeal disease, diagnosis from central. 61 Meningitis, cerebral, simple, 71 tubercular, in child, 75 „ in adult, 77 rheumatic, SO tubei-cular, with apoplectic .symp- toms, 107 tubercular, with convulsive symji- toms, 133 chronic, 187 Meningitis, spinal, acute, 208 chronic, 219 Meningo-myelitis, 212 Mental symptoms, 14 Morbus Brightii, apoplectic symptoms, 108 peculiar coma, and stertor of. 109 convulsive fomi, 125 chi'onic, 197 Morbus cordis, with jqioiilf.iii- symptoms, 62 Motility, symptoms referrible to, oi: relation to volition, 32 excessive, 20 (see volition, emo- tion, sensation) Muscular sense, diminution of, 165 Muscular tic, 175 Myelitis, acute, 210 meningo, 212 chronic, 217 Nature of affection, second problem. C Nerves, diseases of, distinguished from those of brain and cord, 57 diseases of, generally, 222 K K 250 INDEX. Nerves, relation to symptoms, 223 Neuralgia, 228 Neuritis, 225 Neuroma, 227 Neuroses, character of, generally, 240 Non-febrile diseases, 8 Objects of diagnosis, 1 Organic symptoms of spinal disease, 205 Painful sensations, 30 Paralysis agitans, 163 Pai'alysis of facial nerve, 233 Paralysis, meaning of word ; varieties of (see motility), 32 Paraplegia, idiopathic, 221 Percussion of muscles, 42 Plethora spinalis, 207 Problems stated, 1 I*seuda3sth8siae, 31 Recollection, 16 Keflective movements, in excess, 36 deficient, 39 Kegions, of spinal cord, diagnosis of, 198 liigidity in haemorrhage, 96 Sciatica, 230 Sensation, in spinal disease, 202 Sensibility, examination of, 30 relation to impressions, 28 Sensori-niotility, 34 Sensori-motor ganglia, enumerated, 4 functions, 235 Serous effusion, apoplectic form, 100 Softening of brain, acute febrile, 82 „ apoplectic, 102 „ delirious, 117 „ convulsive, 132 chi-onic, 190 Softening of cord, acute, 210 chronic, 217 Spasm, co-ordinated, 157 Sjjectra, 154 Spinal cord, object of diagnosis, 5 diseases of, diagnosticated from brain and nerves, 57 locality affected, 198 diseases of, as to general nature, 201 Spinal meningitis (see meningitis) Spinal paralysis, definition, 39 relation to electricity, 233 Spirits the, definition of, 26 Strabismus, 231 Subcutaneous tubercle, 227 Subjective sensations, different kinds of, 31 Stertor, generally, 40 of urincemia, 110 Symptoms, relation to structure, 49 Appendix B., 240 Tarautism, 147 Temper, 27 Tetanus, 213 Thu'd problem, 10 Thought, its direction by volition, 16 Tonicity, variations of, 44 Tonic spasm, relation to clonic, 204 Toxsemic convulsions, 123 Trachelismus, a symptom, 37 in epilepsy, 176 Tubercle of brain, 135 Tubercular meningitis, febrile form, 75 apoplectic form, 107 convulsive form, 133 Tumor of brain, apoplectic form, 105 convulsive form, 135 as chi'onic disease, genei'al diag- nosis, 182 INDEX. 251 Tumor of Brain, special forms, 185 special localities, 186 Tumor of cord, 220 Tumor of uerves, 227 Tremors, 163 Typhoid and typhus, febrile diseases, .S4 Urinajmia, apoplectic form, 107 convulsive form, 125 chronic form, 197 Valvular diseases of heart, detached vegetations, with soften- ing, 114 Vascular obstruction, 114 Vertigo, of motion, 156 of sensation, 153 Volition, symptoms referred to, 15 relation to ideation, 15 „ emotion, 17 ., sensation, 18 „ motility, 19 THE END, Printed by S. Geoghegan, 7, Palsgrave-place, Temple-bar, London. N UC SOUTHERN REGIONAL LIBRARY FACILITY A A 001 409 153 2