MANUAL NEEVOUS DISEASES kY A. B. AKNOLD, M. D. EMKrnTL'.S PKOFEySOK ON Dl.SEA.SES OF THE NeRVOIS SysTEM, CoL LEGE OF Physicians and Surgeons of Baltimore, President of the Section of General Medicine, Ninth Interna- tional Medical Congress SECOND EDITION REVISED AND ENLARGED esi SAN ERANCISCO THE BANCROFT COMPANY 1 S 1) S2620 c € e • • . Entered aecordiug to Act of Congress in the year 1820, by A. B. ARNOLD, M. D. In the office of the Librarian of Congress, at Washington joo )77 P refac e TO THE SECOND EDITION A LTHOUGH the second edition of this Manual has "[J --^ -^ been thoroughly re-written and enlarged, yet the author has not departed from his original design to give a concise description of the essential facts in relation to ^ the study and treatment of nervous diseases. It is hoped jy that the additions to the preliminary chapters on the anatomy of the nervous system and the general sympto- , matoiogy and therapeutics of nervous diseases will be V found acceptable. Experience in teaching has induced ^ the author to adopt the arrangement of the subject matter followed in this Manual. A. B. ARNOLD. San Francisco, 1890. ILLUSTRATIONS. 1. Side view of the human brain 5 2. Median aspect of the hemisphere .... 7 3. Inferior surface of the brain 7 9 4. The monkey brain 11 5. Psycho-motor centers 12 6. Topography of the skull (misplaced, see fig. 27) . 219 7. Schema of the cerebro-spinal system of nerves . . 16 8. Vertico- transverse section of the brain ... 18 9. Diagram of horizontal section of brain .... 19 10. Lateral section of right half of the medulla . . 21 11. Diagram of the chief tracts of the medulla ... 22 12. Transverse section of the dorsal spinal cord . . 25 13. Diagram illustrating diffusion of the electric current . 59 14-20. Motor points . 63-06 21. Diagram showing position of elec;trodes ... 70 22. Distribution of the trigeminus 80 24. Normal medullary nerve fibre 93 25. Alteration of nerve fibre after section ... 93 26. Diagram of reflex paths of the spinal cord . . . 145 27. Topography of the skull 219 28-29. Attitudes of hands and fingers in athetosis . . 269 CONTENTS. CHAPTER I, Outlines of the Anatomy of the Nervous System — The Motor Cortical Areas , 1 CHAPTER II. General Symptomatology' of Diseases of the Nervous Sys- tem — Sensory Disturbances — Vaso-motor Disturbances — Motor Disturbances — Cerebral Symptoms — Spinal Symptoms 28 CHAPTER III. General Therapeutics of Nervous Diseases — Medical Elec- tricity 49 CHAPTER IV. Diseases of the Nervous System — Neuralgia — Varieties of Neuralgia — Neuritis — Neuromata 73 CHAPTER V. Varieties of Peripheral Paralysis — Facial Paralysis — Isolated Paralysis of the Muscles of the Neck, Chest and Back —Isolated Paralysis of the Superior and Inferior Extremities — Lead Paralysis — Arsenical Paralysis — Diph- theric Paralysis — Reflex Paralysis 97 (V) vi CONTENTS. CHAPTER VI. PACK. Varieties of Local Spasm — Convulsive Tic — Spasm of the Muscles of the Neck and Back — Spasm of the Muscles of the Superior and Inferior Extremities (Writer's Cramp)... 112 CHAPTER VII. 3I1NOR Neuroses — Headache — Hemicrania — Neurasthenia — Spinal Irritation 122 CHAPTER VIII. Diseases of the Membranes of the Spinal Cord — Pacchj'- meningitis Spinalis — Pacchymeningitis Cervicalis Hyper- trophica-- Spinal Meningitis-Spinal Apoplexy-Thrombosis of the Sinuses 138 CHAPTER IX. Diseases of the Spinal Cord — Acute and Chronic Myelitis — Acute Ascending Paralysis— Hydromyel us — Syringo myelia — Unilateral Lesion of the Spinal Cord — Con- cussion of the Spinal Cord 144 CHAPTER X Systemic Diseases of the Spinal CoRDr-Loco-motor Ataxia — Friedrich's Hereditary Ataxia — Poliomyelitis Anterior Acuta — Spastic Spinal Paralysis— Amyotrophic Lateral Sclerosis — Progressive Muscular Atrophj- — Pseudo-Hyper- trophy of Muscles— Bulbar Paralysis 15 CHAPTER XL Diseases of the Membranes of the Brain — Hemorrhagic Pacchymeningitis— Tubercular Meningitis— Meningitis of the Convexity 193 CHAPTER XII. Localization of Cerebral Diseases — Aphasia— Topography of the Skull in relation to the Convolutions 20G CONTENTS. vil CHAPTER XIII. ^ PAGE. Diseases of the Brain — Cerebral Hyperjomia — Cerebral Anaemia — Cerebral Heniorriiage — Hemiplegia in Child- hood — Cerebral Embolism and Thrombosis — Cerebral Tumor— Cerebral Abscess— Cerebral Syphilis 221 CHAPTP]R XIV. Multiple Sclerosis of the Brain and Spinal Cord — Paral- ysis Agitans — Chorea — Athetosis — Tetany — Thomson's Disease 258 CHAPTER XV. Epilepsy — Meniere's Disease — Hysteria — Hypochondriasis.... 273 CHAPTER XVI. Paretic Dementia — (General Paresis of the Insane) 299 Bibliography 309 Formul.t: 311 Index 323 CHAPTER I. OUTLINES OF THE ANATOMY OF THE NERVOUS SYSTEM. In the following Sketch of the Anatomy of the Nervous S3^stem it is intended to give prominence to those parts that are of special importance in relation to Neuropa- thology. FISSURES AND CONVOLUTIONS OF THE LATERAL SURFACE OF THE HEMISPHERE. Each hemisphere is marked by furrows running in dif- ferent directions, apparently without any fixed order, but on comparing the brains of the higher mammalia fissures or sulci analogous to those in the human subject are rec- ognized that follow a typical arrangement. Fissures divide the surface of the hemisphere into convolutions, and serve to mark the boundaries of the cerebral lobes. The Fissure of Sylvius. This fissure is already visible in the third month of embryonic life. It commences on the under surface of the hemisphere and divides into two branches — a short vertical branch and a long horizontal branch. The bifurcation of the two branches forms a fossa, which lodges the island of Reil. (1) f MA.\ CAL OF KEHVOCS DISEASES. TJic Central Fissure or the Fissure of Rolando. This fissure runs in nearly a vertical direction from the upper margin of the hemisphere toward the posterior branch of the fissure of Sylvius. The Parieto-Oceipital Fissure. The lateral portion of this fissure is short, and sometimes not recognizable. Its median portion is long and deep, and separates the parie- tal from the occipital lobe. The Interparietal Fissure. This fissure begins at a short distance behind the central fissure, and runs in a horizontal direction toward the occipital lobe. The Paracentral Fissure runs in front and parallel to the central fissure. The Superior and Inferior Frontal Sulci divide the con- volutions in front of the paracentral fissure. The termination of the Calloso-Marginal Fissure is repre- sented by a notch in the superior aspect of the hemisphere between the central and interparietal fissures. The sidcus occipitalis transversus and longitudinalis inferior divide convolutions on the lateral aspect of the occipital lobe. The first and second temporal fissures divide the respective coiwolutions of the tempero-sphenoidal lobe on the lateral aspect of this lobe. The Frontal Lobe and Its Convolutions. The frontal lobe is bounded on its superior aspect by the longitudinal fissure, and forms the frontal extremity of the hemisphere. Its posterior side borders on the fissure of Rolando, and is separated inferiorly from the temporal lobe by the short branch of the Sylvian fissure. OUTLINES OF ANATOMY. S The Ascending Frontal Convolution. The convolution running upward in front of the fissure of Rolando and uniting at both ends with the convolution at the opposite side of this fissure is named the ascending or anterior frontal convolution. The First or Superior Frontal Convolution. This con- volution begins at the upper extremity of the ascending frontal, where it is bounded by the longitudinal fissure. It turns downward and backward, and forms a part of the median and inferior surface of the hemisphere. The Second or Middle Fronted Convolution. This con- volution is separated from the foregoing by the superior frontal fissure, and from the anterior ascending convolu- tion by the paracentral fissure. It extends forward to the extremity of the frontal lobe, and, bending down- ward, forms a part of the under surface of the hemisphere. The Third or Inferior Fronted Convolution. This con- volution is a prolongation of the lower portion of the ascending frontal. It winds around the vertical branch of the Sylvian fissure, and, running forward, forms the lateral aspect of the frontal lobe. The last three frontal convolutions constitute the so-called prefrontcd lobe. Convolutions of the Parietal Lobe. The longitudinal fissure forms the upper boundary of the parietal lobe. It is separated from the frontal lobe by the fissure of Rolando, from the temporal lobe by the fissure of Sylvius, and from the occipital lobe by the parieto-occipital fissure. The Ascending Parieted or Posterior Central Convolution 4 MA N UA L OF NER V OUS DIS EA SES. borders on the fissure of Rolando and runs parallel with the oi^posite ascending frontal convolution. These two convolutions, which form the RoJandic region of the hemisphere, are also spoken of as the Central Convolutions. The Upper or First Parietal Convolution is the longitud- inal continuation of the ascending parietal, and has the interparietal fissure for its inferior boundary. This convolution consists of a number of secondary folds, and is often mentioned as the Parietal Lobule. The Second Parietal Convolution is situated below the interparietal fissure. That portion of it which is a continuation of the ascending parietal curves around the end of the posterior branch of the Sylvian fissure, where it bends downward to unite with the temporal lobe. This portion is also called the Supramarginal Convolution. A fold of the same convolution, which, bordering upon the interparietal fissure below, makes an angular bend downward and then runs forward to unite with the second temporal convolution, is called the Angular Gyrus. The Temporal Lobe. The temporal lobe is separated by the fissure of Sylvius from the whole of the frontal lobe. Its inferior portion fills the sphenoidal fossa, and it is for this reason often named the Tempero-Sphenoidal Lobe, The First Temporal Convolution runs parallel with the fissure of Sylvius. Its posterior portion, directly below this fissure, is contiimous with the supramarginal convolution. OUTLINES OF ANATOMY. The Second Temporal Convolution is a continuation of the angular gyrus, and unites with the occipital lobe. Fif4. 1. — Side View of the Human Brain P. (EOKER.) F Frontal lobe. P Parietal lobe. Occipital lobe. T Temporal lobe. S Fissure of Sylvius. S' Horizontal. S" Ascending branch. C Central fissure (Fissure of Ro- lando.) A Ascending frontal convolution- B Ascending parietal convolution. F^, F.,, F., Superior, middle, infe" rior frontal convolution. /u /■:■> fi^ Superior, inferior, verti- cal frontal fissure (precen- tral /;. Pi Superior parietal convolution. Inferior parietal convolution (Gyrus supramarginalis). P! Gyrus angularis. i-p Interparietal sulcus. cm Extremity of the Sulcus calloso marginalis. Oi, 0.^, O-i, First, second, third Occipital convolution. Po Fissura parieto-occipitalis. o Transverse occipital fissure. o.. Sulcus occipitalis longitudi- nalis inferior. Ti, T.,, T-i, First, second, third temporal convolution. ^1, tj. First, second temporal fissure. The Third Temporal Convolution forms the inferio: 6- MA X UA L OF NER VOUS DISEASES. portion of the temporal lobe. Like the foregoing, it runs backward and connects with the occipital lobe. The Occipital Lobe. This lobe forms the posterior part of the hemisphere. It is separated from the parietal lobe at its extremity by the parieto-occipital fissure. There is no other visible division between these lobes on the lateral aspect of the hemisphere. The occipital lobe is divided by short and indistinct folds, which radiate upward and forward where they unite with the parietal and temporal convolutions. The first occipital convolution borders above on the lon- gitudinal fissure, and joins the superior parietal convo- lution. The second or middle ocrlpital ronvolutinn joins the angular gyrus. The Third or Inferior Occipital Convolution is continu- ous with the third temporal convolution. The two lower folds of the Occipital lobe are separated by the trans- verse fissure and unite at the extremity of the lobe. Fissures and Convolutions of the Median Surface OF THE Hemisphere. Section of the corpus callosum in the line of the longi- tudinal fissure exposes the median surfaces of the hemi- spheres. The calloso-niaryinal fissure runs parallel with the cor- pus callosum. It incloses a part of the way the gyrus forni- catus. This convolution begins by a narrow fold beneath the corpus callosum, curves around the whole length of this commissure, unites with the occipital lobe and then OUT LI N E S O F A N A TO M Y . 7 bending downwards and forwards it forms in that region the gyms hippocampi. The hook-like extremity of this convolution is called the vncus (unciatns or unciform process). Fifi Median Aspeci' of the C, C Corpus callosuni. G, F Gyrus fornicatus. H Gyrus hippocampi. // Sulcus hippocampi. U Gyrus unciatus. C, M Sulcus calloso-marginalis. F Median aspect of the first frontal convolution. C P^xtremity of the central fissure. A Frontal and B posterior cen- tral convolution. (These inner portions of the central convolutions constitute the paracentral lobule.) Hemi.sphkre. (akjkr EcivEK. ) P Precunial convolution (lobus quadra tus). 0, Z Cuneus. po Parieto-occipital tissure. Occipital transverse tissure. 0, C Fissura calcaria, O, C, Superior and 0, C, inferior limb of tlie calcarian fissure. T^ Tiobulus fusiformis. (Gyrus occipito-temporalis. ) 7 J Lobulus lingualis (Gyrus occi- pito-medialis. That part of the median surface of the hemisphere which lies above -the fissura calloso-marginalis, corre- sponds with the superior inner portions of the two central convolutions, and is called the paracentral lobule. 8 MA X UAL F NER VOUS D I SEAS ES . The lobns qnadraUis or precunial convolution is that part of the median surface of the hemisphere which is situated between the ascending portion of the fissura calloso-marginalis and the parieto-occipital fissure. The calcarian fissure begins at the posterior extremity of the occipital lobe, and deeply penetrates it in a vertico- transverse direction. Below the gyrus fornicatusit crosses the parieto-occipital fissure at an acute angle, by which a triangular portion of the occipital lobe is inclosed. This part of the lobe is called the cunevs or cuneiform convolu- tion. The lobuhts limjualis is a longitudinal fold on the median aspect of the temporal lobe. It unites by a nar- row strip with the gyrus hippocampi. The IoJ)ulus fusiformis is separated from the former by a curvelinear fissure. It forms the inferior border of the tem- poral lobe, and runs backwards to join the occipital lobe. THE INFERIOR SURFACE OF THE BRAIN. The frontal inferior surface of the hemisphere consists of portions of the first, second and third convolutions. The first frontal convolution in this region is represented by a very small fold called the gyrus rectus. It is sepa- rated from the under surface of the second convolution by the olfactory fissure. The sulcus orhitalis divides the latter from the inferior portion of the third frontal convolution, which rests on the orbital plate. It curves outward and upward and forms the lateral aspect of the frontal lobe. The gyrus hippocampi forms the central under-surface of the hemisphere. A part of this region is also occupied by portions of the lingualis and fusiform lobules. The rest of the inferior surface of the hemisphere behind the OUTLINES OF ANATOMY. 9 fissure of Sylvius belongs partly to the temporal and partly to the occipital lobes. Fig. 3. — Inferior Surface of the Hemisphere, (after Eoker.) t^ Sulcus occipito-temporalis inferior. 7\ inferior and T.^ middle tem- poral fissure. po Parieto-occipital fissure. DC Fissura calcarina. H Gyrus hippocampi. U riyrus unciatus. Ch Chiasm. C, C Corpora candicantia. K, K Crus cerebri. C Corpus callosum. F^ Gyrus rectus. F.2 second and F3 third frontal convohitions. Fi Sulcus olfactorius. F-^ Sulcus orbitalis. T^ second or middle. 7';j Third or inferior temporal con- volution. 7\ Lobulus fusiformis (Gyrus • occipito temperalis lateralis.) 7'j Lobulus lingualis (Gyrus occi- pito-temporalis medialis. The Cortex. Histologists distinguish five layers of nerve cells in the cortex. The cells are of different shapes and sizes. A 10 MANUAL OF NERVOUS DISEASES. large number of them consist of " pyramidal." or " giant cells;" others are oval or irregular. They give off " branches" that connect them with each other. A fine connective tissue, called the neuroglia surrounds the nerve elements like a cement. Physiology assigns to the cortex of the hemispheres the seat of mental activity. The following considerations point to the intimate relation existing between the cortex and the manifestations of the psychical powers: 1. Intel- lectual capacity is proportionate to the development of the hemispheres. This is shown by the great number and complexity of tRe convolutions in man, which enlarge the area of the cortical substance. 2. Smallness or atrophy of the hemispheres is observed in idiotism. 3. Injury or disease of the hemispheres gives rise to cerebral excite- ment, confusion of ideas, stupor and coma. The Excitable Cortical Areas. In speaking of the " localization of the functions of the brain" it must be understood that in our present state of knowledge, this term mainly refers to the results of the highly interesting experiments of Fritsch, Hitzig, Ferrier and their followers. When according to these experi- ments certain limited areas of the cortex of the brain are excited Vjy the electric current, uniform movements are made V>y the animal; and conversely, when such areas are extirpated, these movements cannot be evoked, at least for a considerable length of time afterwards. Tlius, the animal moves a foreleg, a hindleg, or the eye, when- ever the electric stimulus excites a definite cortical area. OUTLINES OF ANATOMY. 11 Ferrier experimented on the monkey. The accompanying figure gives the topography of the surface of a monkey brain of an inferior species. r / Oh 5 Fig. 4.— The Monkey Braix. (Meynert.) (Cerocebus cinomolgus.) 1 Inferior extremity of the C Central fissure (Fissure of forehead. Rolando). 2 Inferior extremity of the F^ Inferior frontal fissure. occiput. F., Superior frontal fissure. 3 Inferior extremity of the PC Paracentral fissure. temple. IP Interparietal fissure. 4 Cerebellum. PF Parallel fissure. 5 Medulla oblongata. EF External occipital fissure FS Fissure of Sylvius. (monkey fissure). AB Posterior, or ascending OL Occipital lobe, branch. Ferrier mapped the cortex of the human brain into areas that correspond with the excitable areas of the monkey brain. From his figures it appears that the principal ' motor zone" is located in the region of the central convolutions (Rolandic region). It is a significant fact that cells of a large size, resembling those of the anterior cornua of the spinal cord abound, in that region. Sufficient pathological evidence has now accumulated in support of the existence of excitable motor areas in the regions indicated by the experiments. if MA N UA L OF XER VOUS D IS EA S ES . PsYCHo-iMoTOR Centers. Fig. 5. — Side and Upper View of the Brain of Man. [According to Ferrier.) 1 On the posterior parietal (posterior parietal lobe). Advance of the opposite hind limb, as in walking. 2, 3, 4 Around the upper extremity of the Fissure of Rolando. Complex movements of the opposite leg and arm and of the trunk, as in swimming. a,b,c,d On the posterior parietal (posterior central con vohition). Individual and combined movements of the lingers and wrist of the opposite hand. Prehensile move- ments. 5 At the posterior extremity of the superior frontal convolu- tion. Extension forward of the opposite arm and hand. 6 On the upper part of the antero parietal or ascending frontal convolution (anterior central). Supination and flexion of the opposite forearm. 7 On the median portion of the same convolution. Retraction and elevation of the opposite angle of the mouth by meaus of the zygomatic muscles. OUTLINES OF AN ATOMY. 13 8 Lower down on the same convolution. Elevation of the ala nasiand upper lip. 9, 10 At the inferior extremity of the same convolution. Opening of the mouth with protrusion (9) and (10) retraction of the tongue. Region of Aphasia. Bilateral action. 11 Between (10) and fll) and the inferior extremity of the pos- terio-parietal convolution. Retraction of the opposite angle of the mouth ; the head turned slightly to one side. 12 On the posterior portion of the superior and middle frontal convolution. The eyes open widely, the pupils dilate, and the head and eyes are turned toward the opposite side. 13, 13' On the supra-marginal lobule and angular gyrus. The eyes move toward the opposite side with an upward (13) or downward (13') deviation. The pupils generally contracted. Center of vision. 14 On the infra-marginal or superior (first) tempero-sphenoidal convolution. Pricking of the opposite ear; the head and eyes turn to the opposite side and the pupils dilate largely. Center of hearing. Theories of the Motor Phenomena. It should be premised in connection with the theories explanatory of the phenomena observed in the experi- ments, that the intervention of the cortical substance is not necessary, as the movements also occur when the excitable areas are denuded of their gray covering. The latter serves as the medium of voluntary impulses. The question arises: What is the nature of the functional defect, when, on the extirpation of certain circumscribed areas of the cortex, the movements cease to be elicited by the electric stimulation. Hitzig attributes the defect to the loss of the muscular sense: the animal being inconsequence unable to co-ordi- nate the movements of corresponding groups of muscles. U MA NUA L O F NEB VO US D ISEA SES . Ferrier ascribes the defect to a psychical inability to initiate voluntary movements. According to Munk, there is an incapacity to recall the representations of co-ordinate movements ^Yhich the animal had learned by experience. It may be of interest to summarize the conclusions which Munk has drawn from his numerous and well-con- ducted experiments. He localizes the excitable areas of the cortex as follows: 1. The region of the leg. The upper third of the cen- tral convolutions and the upper adjacent portion of the parietal lobule. 2. The region of the arm. The middle third of the central convolutions and lower portion of the parietal lobule. 3. The region of the head. The lower third of the cen- tral convolutions and a contiguous portion of the frontal convolution bordering on the fissure of Sylvius. 4. The center of vision. The surface of the occipital lobe. 5. The center of hearing. The temporal lobe. 6. The ocular region. The gyrus angularis. 7. The region of the ear. The marginal convolution. 8. The region of the nape of the nech. The part of the frontal lobe adjacent to the middle third of the frontal ascending convolution. 9. The region af the trunk. The convex surface of the frontal lobe bordering on the precentral fissure. The results of the recent investigations of Luciani, Horsley and Shaefer agree in the main with those of ]\[unk. Ferrier, since the first publication of his celebrated U TL INES OF ANATOMY. 15 experiments, has somewhat modified his views in regard to the so-called psycho-motor centers. There is now a tendency among neurologists to consider the excitable cortical areas in the light of sensory-motor centers as will be inferred from the following summary of Munk's late contributions. To the cortical zone of the Rolandic region he assigns the function of elaborating perceptive images of the tactile and muscular sensations, that are constantly conveyed to the intelligence. The feelings attending the action of muscles, tendons and ligaments in voluntary and reflex movements are registered in memory as repre- sentatives of special movements. When these mnemonic images, which consist of components of the registered sensations are destroyed by the method of extirpation, the corresponding movements can no longer be innervated by voluntary impulse or artificially excited. Decortation of the visual center produces " psychical blindness." The animal sees perfectly well, and avoids objects that are put in his way, but does not recognize the food set before him. He has lost the power of associating the perception of the food with the object of his sight. When the audi- tory center is destroyed the animal is unable to recall auditory images although he hears the sounds well enough. This is "psychical deafness." The animal does not recognize the voice of his master, although it hears the sounds. Systems of Nerve-Fibres of the Brain. Three main divisions of nerve fibres may be distin- guished in the white substance of the brain. 1. The association system of fibres connect contiguous and remote convolutions of the hemisphere. They are arched, and present their concave side to the surface of the brain. 16 MANUAL OF NERVOUS DISEASES. 2. The commissural system of fibres connect symmet- rical parts of the hemispheres. They present in their course the shape of the letter U. These fibres constitute the corpus calossum. Fig. 7. Schema of the Cerekro-Spinal System of Nerves. (Landois.) U TL INES OF A KA T (J M Y , 17 The pyramidal tract. Fibres connecting the cor- pus quadrigemina and tegementiim. Their further course. Fibres connecting tlie cor- pus striatum and lenti- cular nucleus ^vith the crusta. Their further course. Course of sensory fibres. Transverse section of th spinal cord. Anterior and r, W, pos- terior roots of nerves. Associating fibres. Co:niidssuial fibres. ?). The system of radiating fibres (corona radiata, pedun- cular fibres). These nerve fibres come from the hemi- spheres, and converge at the base of the brain, where they go to form the internal capsule. c, c Cortex of the brain. 5, 5 Cs Corpus striatum. 6, 6 NL Lenticular nucleus. TO Optic thalamus. V Corpora quadrigemina. m P Crura cerebri. 8, 8 H Tegementum. P Crusta. 1,1 Eadiate fibres of the cor- pus striatum. m 2,2 Those of the lenticular S, S nucleus. R 3,3 Those of the optic thala- mus. \,\ 4, 4 Those of the corpora quad- rigemina and tegemen- a, a tum. c, c The Internal Capsule. The connection of the medullary substance of the hemisphere with the deep-seated parts of the brain, and finally with the spinal cord, is effected by the conver- gence of parts of its constituent fibres toward the large ganglia at the base of the brain, where they present a white strand of fibres called the internal capsule. That part of the capsule in front of the head of the caudate nucleus and behind the lenticular nucleus, constitutes the anterior limb of the internal capsule. As the cap- sule passes along the internal margin of the lenticular nucleus, it makes a bend (genu) and runs between the 18 M A X U A L F X E R \ ' 6^9 DISE A S E S front of the optic thalamus and behind the lenticuhir nucleus, where it forms the posterior limb of the internal capsule. The continuation of the tract of fibres of which the capsule consists, forms part of the peduncle of the brain; and passing on through the pons, and then to the medulla oblongata, it decussates in the anterior pyra- mids, from which circumstance it has been named the pyramidal tract. The fibres of this tract chiefly come from the two central convolutions, the paracentral lobule and the supra-marginal gyrus. In its dow^nward course it forms a distinct fasciculus of the cord, nnd disappears after having connected wdth the successive motor cells in different regions of the cord. Claustrum Lenvith the iris. Derangement of any of the integral parts of this reflex mechanism is manifest by abnormal reaction of the pupils. 12. Optic neuritis is a symptom of great frequency in cerebral disease. The change in the optic nerve when the fundus of the eye is examined by the ophthalmo- scope, is characterized at the beginning by congestion and oedema, and if the inflammation does not subside, very marked changes take place, which are implied by the term '"choked disk." The arteries are reduced in size, the veins are enlarged and tortuous, and finally atrophy of the disk ensues. Vision is often unimpaired, although the alterations discovered by the ophthalmoscope show the existence of optic neuritis. The optic neuritis observed in cerebral disease is bilateral and must be dis- tinguished from that form which results from local causes. Primary optic atrophy tending to amaurosis occurs in locomotor ataxia. The ophthalmoscopic appear- ance of optic neuritis bears great resemblance to that of albumenuric retinitis. 13. Paralysis of ocular muscles. Isolated and com- bined paralysis of ocular muscles occur in diseases affect- ing the pons, the crus and base of the brain. Paralysis of the external ocular muscles is manifested by the occur- rence of strabismus, diplopia or ptosis. In paralysis of the ciliary muscles, there may be loss of accommodation, or the reflex contraction of the iris in looking at near Jf2 MA N UA L OF NER VOUS DIS EA S ES . objects may be intact, whilst the pupils do not contract on exposure to light. This symptom is known as the ''Argyle-Robertson pupil." It is sometimes observed in locomotor ataxia and cerebral syphilis. Inequality of the pupils is often an early symptom of general paresis of the insane. Pupillary changes are observed in disease of the spinal cord when the oculo-spinal center is aftected. Reflex irritation of the cervical sympathetic is probably the cause of dilatation of the pupils in migraine, nephritic colic and in children troubled with worms. It should be remembered that pupillary changes and paralysis of external ocular muscles frequently depend on local causes. Hemianopsia, which means blindness of one lateral half of the retina, is a sympton of much diagnostic importance. The most common form of hemianopsia is blindness of the nasal half of one eye, and of the temporal half of the other eye. The usual test, if a perimeter is 'not used, is to close one of the patient's eyes with the finger and to request him to fix the open eye upon one spot or a near object. Standing in front of the patient, the examiner passes the unemployed hand up and down and to the right and left of the object at which the patient is gazing, and asks him whether he sees the hand dis- tinctly and simultaneously with the object he looks at. If he does not, then the retina is blind on the side opposite to that on which the sight of the hand is lost. Hemianopsia has been observed in lesion of the cuneiform convolution of the occipital lobe, and also in lesion of the cerebrum, which implicates the optic tract or chiasm. Hemianjesthesia is sometimes attended by Hemianopsia. GENERAL SYMPTOMATOLOGY. 4^ 14. Auditory symptoms. Disorder of the auditory nerve is not often witnessed in cerebral disease. General ansemia is sometimes attended by a buzzing or humming noise, or sounds resembling the tinkling of bells. There is reason to infer that the temporal lobe is the central destina- tion of the auditory nerve. Deafness of one ear has been observed when the auditory path between the medulla and the superior temporal convolution of one side was involved in a lesion. 15. Disturbance of the function of the olfactory nerve is rarely noticed in cerebral disease. Hemianesthesia is sometimes accompanied by loss of smell on the affected side. Hysterical patients occasionally experience per- version or obliteration of the sense of smell. 16. It is difficult to recognize disorder of the sense of taste. The gustatory sense is sometimes abnormally acute or perverted in hysteria. Nothing definite is known concerning the central destination of the gusta- tory nerve. 17. Paralysis of the sensory portion of the fifth nerve, which is of rare occurrence, causes anaesthesia from the ver- tex to the lower jaw, and loss of sensibility of the mucous membrane of the nose, tongue and mouth on the same side. The most serious effect resulting from paralysis of the nerve is atrophy and ulceration of the cornea. Paralysis of the motor portion of the fifth nerve causes weakness of the masticatory muscles of one side. Eventually the temporal and zygomatic fossae become flattened from wasting of the fronto-temporal and masseter muscles. 18. A lesion in the path of the facial nerve above its nucleus, between it and its cortical destination, causes paralysis of the face on the opposite side. Paralysis of U MANUAL OF NERVOUS DISEASES. the face on the same side as the lesion happens when the facial is implicated in the vicinity of the pons varolii. It is usually observed that in hemiplegia, only the mus- cles of the lower half of the face are affected. This shows that the lesion has involved the central path of the facial. 19. Circulatory disturbances. Alterations of the pulse are not commonly observed in chronic affections of the brain. The pulse in acute meningitis is variable. It may be rapid, wiry and jerky, or abnormally slow and feeble, irregular or intermittent. The full, bounding pulse in cases of cerebral hemorrhage is often due to ven- tricular hypertrophy. 20. The tache cerebral is a test to determine the condi- tion of the cutaneous circulation which is frequently depressed in cerebral disease. On passing the finger somewhat firmly across the upper part of the inguinal region or the inner aspect of the thigh, a red streak appears after the removal of the finger, which but slowly fades w^hen the circulation is feeble. 21. By the term '' cerebral breathing" is understood a morbid alteration of the act of respiration, which is of bad omen in brain trouble. The breathing is noisy, nasal and interrupted. An aggravated kind of cerebral breath- ing is known as the "Cheyne-Stokes respiration." It consists of a series of respiratory movements that attain to a great rapidity and then gradually become exceed- ing slow. Spinal Symptoms. Sensory disturbances. Pain in the region of the verte- bral column is a rare symptom in chronic affections of the spinal cord; but violent rhachialgic pain coming on G ENER A L S YMP TO MA TO LOGY. 45 spontaneously or aggravated by movement of the body, occurs in spinal meningitis and intraspinal tumor. Gen- eral hy2)ercrstliesia is a marked symptom of irritation of the spinal cord. It is observed in spinal meningitis, tetanus, hydrophobia and hysteria. The reflex excita- bility is usually heightened in this condition. Tender- ness of the vertehrse usually limited to the cervical and upper dorsal regions independent of disease of the bones or spinal cord is probably of a hypersesthetic char- acter (points apophysaire). This is the essential symp- toms of "spinal irritation," but it is often associated with dorso-intercostal neuralgia. A dull constricting sensation encircling the waist frequently attending dis- ease of the spinal cord is called the "girdle" or "cincture" sensation. Motor Symptoms. Paraplegia is the typical form of paralysis in inflamma- tion of the spinal cord. In the vast majority of cases the inferior extremities are affected. The paralysis varies from complete loss of the muscular movements to incom- plete paralysis or paraparesis. In mild cases there is a shuffling gait, or the patient is able to walk only with the aid of crutches. Sometimes the paraplegia merely amounts to muscular weakness of the legs. The distribution of the paralysis varies with the seat of the disease in the cord. The lesion may affect the lumbar, the dorsal or the cerv- ical region, though in the greater number of cases the lesion is in the lumbar cord. In severe lesion of the cervical cord all four extremities are paralyzed. Sometimes the paralysis of one lower extremity is more complete than in the other, and may simulate hemiplegia. In very exceptional cases one lateral half of the spinal cord is 46 MANUAL OF NERVOUS DISEASES. involved. The motor paralysis in conformity with the anatomical arrangement of this organ is on the same side as the lesion, and the anaethesia on the other side. Impairment of the sphincters of the bladder and rectum occurs in transverse myelitis. Weakness of the bladder from this cause is recognized by imperfect evacuation of the urine. As the disease advances, the urine, on being retained, decomposes and becomes ammoniacal, which tends to develop cystitis and pyelitis. Rectal paralysis causes obstinate constipation and finally involuntary dis- charges. Weakness of the sexncd fnnction usually accompanies the paralysis of the sphincters. It is indicated by imper- fect erections tending to complete loss of the sexual power. Tests of reflex action. Alteration of the reflexes is a com- mon symjDtom in spinal disease. Reflexes are of two kinds, the superficial and the deep. The former are excited by irritating the cutaneous surface; the latter by exciting the tendons or fascia of muscles. Tickling or pinching the skin is the usual manner of eliciting the cutaneous reflexes. A more elegant method consists in stimulating the skin with the faradic current. 1. The plantar reflex is excited on tickling the sole of the foot. It causes a jerking movement of the limb, through the action of the gastrocnimii muscles. 2. The cremaster reflex is obtained on pinching the inner side of the thigh. This causes retraction of the testicle. 3. The gluteal reflex is induced on pinching the skin in the region of the buttock. 4. The epigastric reflex is excited on irritating the skin of the chest between the fifth and sixth intercostal spaces. It causes dimpling of the epigastrium. GENER A L S YMP TOM A TO LOG Y. 47 The most important of the deep reflexes are the patellar tendon reflex and the ankle clonus. 5. Patellar reflex (knee jerk). One of the methods of eliciting this reflex consists in letting the patient sit on a chair, one leg being crossed over the other so that it does not touch the floor. A light tap with the edge of the hand on the patellar ligament immediately below the knee cap causes the foot to jerk forward through the action of the rectus femoris muscle. Another method of inducing the knee jerk, only practiced on males, is to raise and support the thigh by passing one hand beneath it, just beyond the knee joint, and to grasp the knee of the other leg. The tap is then made at the proper point of the free leg. Experiments in healthy individuals show considerable differences in regard to the energy of the patellar reaction. 6. In exciting the ankle clonus the leg is slightly bent upon the thigh and supported by placing the hand under it near the knee joint. The toes are seized with the fin- gers and pulled forward, so as to stretch the tendon Achillis. On suddenly flexing the foot, while the fingers continue to press against the toes, a series of rythmical contractions of the calf muscles ensue. The ankle clonus is not as readily excited as the patellar reflex. Inhibition. There is good reason to infer the existence of an anatomical mechanism, probably in the spinal cord, which controls reflex action independent of the will. We know, that by an effort of the will, we often succeed in suppressing a strong inclination to laugh or to cry, and sometimes we are able to restrain a fit of sneezing or coughing. When infantile convulsions are checked by a warm mustard bath we have an analogous illustration J^ MA X U AL OF XER VOUS D IS EA S ES . of the controlling influence of an artificial impression. Brown-Seqnard put a stop to spinal spasm by forcible flexion of the big toe. In these examples it may be said that the reflex action which produced the spasm has been inhibited. Inhibition may therefore be supposed to take place when a center, which is the medium of reflex action looses its excitability on being acted upon by a nervous influence which forms a part of the same reflex mechan- ism. Perhaps many an anomalous phenomena in ner- vous and hysterical individuals is due to defective inhib- itory action. The subject of incoordination will be more conveniently considered in connection with locomotor ataxia. CHAPTER III. GENERAL THERAPEUTICS OF NERVOUS DISEASES. ReM. Whilst in surgical treatment, absolute rest is often of itself curative, the beneficial influence of relaxation from nervous strain and exhaustion is not as frequently insisted upon as it should be. The benefit derived from the tonic and bracing effects of mountain air or a sojourn at the seaside cannot be overrated. Many an overworked person, broken down in health, who constantly complains of languor, sleeplessness, dyspepsia and a host of other nervous ailments that had baffled the ordinary remedies has returned from one of these resorts completely restored. Probably the chief factor in this happy change was the release from unremitting attention to business and the worry it entails. The treatment introduced by Weir S. Mitchell in aggravated cases of functional derangement of the ner- vous system in females frequently meets with brilliant success. It chiefly consists in seclusion of the patient and in securing rest and quietude. Active exercise is replaced by electricity and massage. The diet is strictly controlled by the attending physician. Diet. Derangement of the digestive functions fre_ quently attends nervous disorder, and in turn a reduced 4 M9) 50 M A ^ U A L F X ER V O C S D I S E A S E S . tone of the nervo-muscular apparatus develops an enfeebled digestion. This vicious circle of morbid intlu- ences may causeembarrassment of diagnosis. Dyspeptic symptoms obstinate to treatment are often but the mani- festations of nervous depression. It can hardly be expected that anorexia, nausea and epigastric uneasiness brought on by anxiety, disappointment and other mental trouble, perhaps bad habits, will yield to regulation of diet and reputed anti-dyspeptic remedies. A starving dietary would surely augment the mischief. On the con- trary, sufficient substantial nourishment is called for, and the medical attendant will do well, who, under these cir- cumstances, succeeds in weaning his patient from the domineering caprice of a squeamish stomach. Above all, nervous patients should be warned against yielding to the seductive fascination of alcoholic stimulants, however much they may afford temporary relief. What may be called ''nervous dyspepsia" is very often but the obtrusive- ness of digestive symptoms among manifold complaints that arise in general deterioration of health from whatever cause. Opium. Among the internal remedies in the treatment of nervous diseases, none are as frequently employed as the narcotics. These substances relieve pain, promote sleep, arrest spasm, and often exert a beneficial influence on the course of many diseases. The therapeutical prop- erties of opium, especially its chief alkaloid, morphia, are not equaled in eflficacy by any other of the class of sedatives. Since the introduction of the hypodermic syringe, the desired promptness of action of morphia and its compeers can be obtained. GENERAL THERAPEUTICS. Bi Codeia is a good substitute for morphia, when the latter, owing to idiosyncrasy, cannot be tolerated. It is not so likely to derange the stomach or to confine the bowels as morphia, but is less reliable in its action, and must be given in relatively larger doses. As a general rule it cannot take the place of morphia, but very strange sus- ceptibilities are sometimes witnessed. I remember the ease of a young man who suffered from chronic ulcer of the stomach. His attacks of hematemesis were frequently attended by violent cardialgia. 'Hypodermics of morphia invariably brought on epileptiform convulsions, while codeia gave prompt relief. Belladonna. It must be said in favor of belladonna that it sometimes exerts a sedative effect when morphia fails. Owing to the antagonism of these powerful rem- edies they are often given in combination. The tincture of belladonna, or the extract, is often useful in neuralgia, gaslralgia, whooping cough and spasmodic affections. This remedy still retains some reputation in the treat- ment of epilepsy. The parvules of atropia of different strengths afford a reliable and convenient mode of pre- scribing this medicine. Extreme caution is advisable in the use of this powerful remedy. Hyosciamus. The hypnotic effects of this remedy sug- gest its use when opium is indicated, but it is far less certain. Hyosciamine in doses of gr. 1-150 has been found useful in tremor. Aconite. Remarkable cures of inveterate facial neural- gia are reported from aconitia. This dangerous alkaloid is given in doses of gr. 1-200. Stramonium leaves enter into the composition of cigar- ettes and pastiles for the relief of asthma. 5^ MA N UA L OF N ER VO US D/S EA SES . Calabar bean. Its alkaloid _p/j2/sosfi^r/ja has been chiefly employed in the treatment of tetanus. Canabis Inclica sometimes acts well as a hypnotic and in mild forms of neuralgia. Conium. This remedy is little used. Alienists ascribe to it the eflfect of subduing maniacal excitement. Chloral hydrate is one of the best hypnotics we possess, though it does not relieve pain like morphia. This remedy is often of signal service in acute alcoholism. Chloroform. This valuable anaesthetic is often our last resort in severe and protracted forms of spasmodic parox- ysms. The bromides form a class of remedies of great value. They lower reflex excitability and exert a general sooth- ing eff'ect on the nervous system. Bromide of potassium alone or in combination with other bromides is our sheet anchor in epilepsy. Large doses of this drug promote sleep. Alcohol in the form of whisky, brandy or wine is unsur- passed as a restorative in shock or sudden nervous pros- tration. These liquors cannot be replaced by any other remedies when reliable stimulants are indicated. Gelseminum sempervirens. The tincture or fluid extract of yellow jessamine is strongly recommended in neuralgia of the dental nerve. This remedy is said to quiet the " hydrocephalic cry" in meningitis. Aniipyrin, Phenacetin, Sulfonal. These newly intro- duced remedies possess undoubted analgesic qualities. Their excellent effects in nervous headache is especially praised. Sulfonal does good service in insomnia. GENERAL THERAPEUTICS. 53 Paraldehyde is well adapted to allay the mental excite- ment and worry of hysterical patients. It is also a hypnotic. Phosphorus is now much prescribed as a nervine tonic. Its reputation has yet to be established. Strychnia. This powerful excitant o'f the axial nerve center was formerly the most favorite remedy in all par- alytic affections. Its use has been in a great measure superseded by electricity. Subcutaneous injections act sometimes favorably in feebleness of the bladder and rectum and impairment of the sexual function. Iodide of potassium. Independent of the antisyphilitic action of this remedy, a considei*able influence in con- trolling tissue changes of a low inflammatory character may be claimed for it. The good effects not infrequently witnessed from its employment in cases where no history of syphilis exists, justifies such a favorable opinion. Musk, camphor, ether, aromatic spirit of ammonia, sweet spirits of nitre and valerian are frequently useful for the relief of nervous depression and various functional ailments. Among the empirical remedies most frequently used with advantage in the treatment of chronic nervous dis- eases, belong arsenic, nitrate of silver and preparations of zinc and ^old. Medical Electricity. The importance of electricity as an invaluable thera- peutical agent in the treatment of nervous diseases demands for it a larger space than has been assigned to the consideration of other classes of remedies. 64 MANUAL OF NERVOUS DISEASES. The electric currents in use in medical practice include the galvanic and faradic currents. Static electricity is as yet very little employed. (ralranum. (voltaism, constant current, battery cur- rent.) Galvanic electricity is generated by the contact of dissimilar metals which are submitted to chemical action. The simplest arrangement consists of the combi- nation of a plate of zinc and copper or of carbon immersed in a glass vessel containing dilute sulphuric acid. To each of the plates outside of the fluid, a wire is attached, and as soon as these wires are joined, a current of elec- tricity is established which continues to flow until the plates are oxidized. Such an arrangement is called a cell or an element. The combination of a number of cells consisting of an alternate series of dissimilar metals constitute a battery. The terminal of the wire connected with the copper plate, the last in the series, is the positive pole or the anode. That connected with the zinc plate at the other end of the series is the negative pole or the lathode. In explanation of the terms positive and negative, it should be understood that electricity inheres in all bodies. The tendency to develop electricity is called the potential of the body. The earth, being an unlimited reservoir of electricity, is taken as a standard in regard to the comparative potential of a body. Those bodies from which electricity flows to the earth we call posi- tive bodies, and bodies which draw electricity from the earth we call negative bodies. The former are said to be of a Jiigh potential, the latter of a low potential. The terms positive and negative merely express the difference of the potential; for all bodies are relatively positive and GENERAL THERAPEUTICS. 55 negative. When we say that a body is charged with positive or negative electricity, we imply the condition of positive or negative potential of a body. This may be made more clear if we compare two different metals to two tanks containing water at different levels. If the tanks be connected by a tube, the water at a high level in the one tank will flow into the second tank containing water at a lower level. If a third tank containing water at a still lower level be connected with the second tank, then the water between these two tanks will flow again. The water will cease to flow as soon as it has reached a common level in all the tanks. In a precisely analo- gous manner we must create a difference of potential between two points if we wish to have a flow of electricity, and likewise the current of electricity ceases when an equilibrium is established between the high and low potential. Within the galvanic cell positive electricity passes from the zinc plate to the copper or carbon plate^ and outside of the battery the current passes to the zinc in completing its circuit. It is due to the latter circum- stance that the terminal of the connecting wire attached to the zinc element is called the negative pole. Faradism. Faraday's discovery that a galvano-mag- netic current induces new currents in a neighboring conductor, has been utilized in the construction of an apparatus which renders such "induction currents'^ available for medical use. A portable faradic battery consists of one or two galvanic cells that generate the original current. A coil of wire wound around a wooden cylinder and having in its center a bundle of soft iron rods is connected at one end with the cell and at the. 56 MA N UAL OF NER V US DISEA S ES . other end with an automatic interrupter. This inter- rupter is an ingenious contrivance by which the " make" and "break" of the current is effected. It consists of a spring attached by its lower end to the coil. Its free extremity has the form of a hammer which impinges upon the iron core of the coil and is in contact with a screw that connects with one of the poles. As long as the current generated in the cell is not interrupted, this mechanism is at rest, but as soon as the iron core becomes magnetized it attracts the hammer and the circuit is broken. On quickly becoming de nagnetized, the ham- mer by force of its spring flies back to the S2rew, the circuit being thus again re-established. The successive closure and opening of the circuit generates the induction current in the coil. This current is called the primary <:urrent. A second coil consisting of thinner and longer wire surrounds the primary coil, but is not otherwise connected with the apparatus. The connecting wire (rheophore) to which the electrodes are attached, connect with the terminals of the second spiral. The current which develops in this second coil constitutes the second- ary current. This current is the one usually preferred in medical practice. The strength of the current is regulated by sliding the upper coil over the lower to the required distance, which is indicated by a graduated scale. Faradic batteries are now made in which the coils are immovable, the strength of the current being regulated by a draw tube. The play of the hammer can be con- trolled by the finger or by means of a stud, which every good battery should have. It should be remarked that the physiological effects of GENERAL THERAPEUTICS. 57 both the primary and secondary currents only become manifest with the break of the original current. Electro-motive force. The work which a definite quan- tity of electricity can perform is called its electro-motive force. This working capacity of a current is influenced by the resistance which the current meets in its passage. There are two such resistances — the one essential to the battery (fluid, connecting wires) called the "internal resistance," and the other, outside of the battery (the interposition of a part of the human body) called the "external resistance." Ohm laid down the following law for the determination of the strength of electric currents: The strength of a current is always ^proportionate to the electro-motive force divided by the resistance. This is mathe- matics lly represented by the formula C = r. C signifies the current, E the electro-motive force and R the resist- ance. If we suppose E = 5 and R = 100, then C = t^o = 2V. It is apparent that we cannot increase the strength of a current by merely multiplying the number of the elem^ts — since for each increase of electro-motive force we get a proportionate increase of resistance. For instance, if we use two elements, our formula becomes C =1X ^ 1 ~ 2V i. e., the same as for one, and obviously with a like result for any greater number of elements. We obtain a differ- ent result when an external resistance is interposed, which is always very great in comparison with the internal resistance. This occurs in practice when the human body forms a part of the circuit. In such a case, giving the same values to E and R as above, let us call Ri the external resistance 1000; we then have the equa- tion C = ^^^j and substituting values, C 58 iMA N UAL OF NER VO US DIS EA SES . If we now use two elements we get C = loo+VJcTrrrr^^ ik the strength of the current is nearly doubled, for the external resistance is the same for any number of ele- ments as it is for one. Practically, the minute additions of the internal resistance may be entirely neglected in the calculation of the current strength when the external resistance is relatively very great. Measurement. In medical practice we adopt the one- millionth part of an ampere as a unit of measure for the current strength, and call it a milliampere. The scale of galvanometers is now^ usually divided into milliamperes. Density. The strength of a current in relation to a transverse section of its conducting medium is caHed the density of the current. This means that the current strength is in proportion to the quantity of electricity which, in a given moment of time, passes through a sectional area of. the conducting medium. Suppose an electric current be conceived to consist of a bundle of parallel rays it is evident that the smaller the diameter of a bundle the more compact will be the rays, and the density of the rays will increase in proportion. The density of a current is therefore the strongest in the con- ducting wires, less strong in the electrodes, and least in the lines of distribution through the human body. Among the rays 0/ the current in its passage, the strongest is the straight one between the points of application, for it takes the shortest route and meets with the least resistance. All the other rays from pole to pole decrease in strength in proportion to the length of their circuitous course, and the cumulative resistance they encounter. If it is GENERAL THERAPEUTICS. 59 intended to excite a certain part of the body, the method of conducting the current must be such that its greatest density shall act upon the part. Fig. 13. ThJB diagram is intended to illustrate the diffusion of the cur- rent throughout the arm. It also illustrates the greatest density of the current in the immediate vicinity of both electrodes of equal size, which are placed over a nerve (ulnar). The inactive rays of the current are marked by dotted lines; the .shaded parts indicate the regions of greatest density. Polar action. A contraction is the visible effect of the current when acting upon a healthy nerve or muscle, and a contraction only develops at the moment when there is a make or a break of the current. But the energy and amplitude of contractions are also influenced by the par- ticular pole with which the closure and opening of the circuit is effected. This peculiarity of the electrical phenomena exhibited in normal neuro-muscnlar organs is called the " polar action." Examination with the galvanic current in varying the experiment with currents of different strengths exhibits the normal laws of polar action: a. With a we,al: current the first perceptible contraction occurs, when the circuit is closed with the kathode. This 60 MANUAL OF NEB VOUS DI S EASES. kathodal closing contraction is expressed by the letters K C C (sometimes C C C or Ka 8 Z, according to the German notation). h. A medium current excites a strong kathodal closure contraction (K C C^), also a moderate anodal closure con- trction (A C C), and a moderate anodal opening contrac- tion (A O C). c. A strong current excites a tetanic kathodal closure con- traction (K C C'*), a-lso a strong anodal closure contraction (A C C^), a strong anodal opening contraction (A C^) and a perceptible kathodal opening contr-^.ction (K C). It will be observed that according to the normal laws of polar action the closure contractions appear earlier than the opening contractions, and that there is a regular order of polar action in relation to the appearance of the contractions. The formula of normal polar action only holds good when muscles are indirectly acted upon by exciting their corresponding motor nerves with the gal- vanic current. The direct stimulation of muscles is only effected by closure currents. Electrotonus. Although when a current passes uninter- ruptedly through a motor nerve or muscle no visible effect is produced, experiment shows that a change occurs in the condition of the nerve during this apparent quies- cence. This change consists of an altered irritability of the nerve. Such a nerve is]said to be in a condition of electro- tonus. The irritability of the nerve is heightened at the point of contact of the kathode and in its immediate vicinity (katelectrotonus); it is lowered at the point of contact of the anode and in its vicinity (anelectrotonus). From this circumstance it is inferred that the kathode is the stimulating pole and the anode the sedative pole. GENERAL THERAPEUTICS. 61 The conducting power of organic tissues. The distribu- tion of the current in the human body is influenced by the inequality of the conducting power of the different tissues. The muscles and nerves are the best conductors. The epidermis opposes the greatest resistance to the passage of the current, but this resistance varies in differ- ent areas of the cutaneous surface, as seen by the follow- ing table according to the investigations of Erb: Temples 40"" Cheeks 50° Side of the neck 35° Shoulder-blade 30° Anterior surface of thigh 3° Anterior svirface of the upper arm 25° Popliteal space 26° Palm of the hand , 20° Effects of the current on the special senses. The faradic current barely affects the special senses, but they promptly react to the galvanic. On applying a weak current to the temple or cheek the sensation of a flash of light is experienced. When a closure or opening current is applied to the ear, a whistling, ringing or hissing noise is heard. Stimulation of the tongue causes a peculiar metallic taste in the mouth. The sense of smell does not appear to be influenced. Galvanization produces a peculiar stinging or burning sensation of the skin. Faradization causes a feeling of tingUng. Strong currents cause pain and spasmodic rigidity of muscles. Electro-diagnosis. Electric examination intends to determine the existence or non-existence of quantitative and qualitative changes of the excitability of nerves and muscles. Quantitative changes relate to energy and ampli- tude of contractions. A normal electric contraction 62 MANUAL OF NERVOUS DISEASES. develops at once and is brief and vigorous. Diminution of the electric reaction is indicated when a relatively strong current is required to excite a contraction, or when the contraction develops slowly and is prolonged. The strongest current fails to excite a contraction in complete loss of electric reaction. Morbid increase of the electric excitability is manifest when a weak current elicits an energetic contraction of great amplitude. Qualitative changes chiefly relate to the existence of abnormal polar reaction. A diseased nerve or muscle may react to a weak current, but the contractions manifest a reversal of the normal formula of polar action. Such an irregular order of the electric reaction indicates the existence of degenerative changes of motor nerves or muscles, and is therefore called the reaction of degeneration (R D). This condition is exhibited, for example, when the sequence of normal polar action is altered, so that A C appears earlier than K C C, or when K C is too promptly excited. It may also be found that the faradic contrac- tility of a muscle is diminished or abolished, while the muscle still responds to the galvanic current for a certain time, and even with increased energy. In severe cases of atrophic paralysis exhibiting R D a gradual diminu- tion of the galvanic muscular contractility occurs until it is finally abolished. It is remarkable that in favorable cases the voluntary power of the affected muscle is restored sooner than its electric excitability. The reason why a degenerated muscle reacts, at least feebly, to the galvanic current and not to the faradic, has not ^-et been explained. A partial reactioii of degeneration is some- times observed. The nerve in this condition retains its electric excitability and the muscular contractility is normal, but the direct galvanic excitability of the muscle GENERAL THERAPEUTICS 6S is increased and the normal sequence of polar action is altered. This form of degenerative reaction indicates anatomical changes in the muscles, but not in the nerve. It is often manifest in atrophic paralysis. Motor points. To facilitate electric examination it is very advantageous to be familiar with those regions on the surface of the body where nerves are accessible to electrodes. Stimulation of such "motor points" excite a number of muscles to which a nerve trunk or a large branch is distributed. By this indirect method of elec- trization deep muscles are reached by the current. The annexed figures, showing the motor points, are reproduced from Ziemssen and Erb. MOTOR POINTS M. frontalis Upper branch of facial nerve 31. orbic. palpeb. Nasal muscles M. ziKornatici M. orbic. oris Middle branch of facial nerve M. levator mcnti^ M. quad, menti > M. triang. menti) Hypoglossal nerve M. platysm niyoid Inferior branch of the facial nerve M. omohvoides Region of the cen- tral convolution Region of the thir.d frontal convolut- ion (Brocas) Upper branch of the facial nerve Trunk of facial nerve Inferior branch of facial nerve M. sterno cleido- rnastoides. Accessory nerve Phrenic nerve Supraclavicular point Brachial plexus (Erb's point), M. deltoid, biceps, brachial internus and supinator longus. FiJ. 14 Branch of the median nerve for the pronator teres Palmaris longus Flexor carpi ulnaris Flexor sublimis diRltorutn (middle and ring fingers) Ulnar nerve Flexor sublimis digitornra (index and little fingers; Deep branch of the ulnar nerve Palmaris brevis Abductor minimi digitorum Flexor brevis minimi digiti Lumbricalis (2, o and 4) Supinator longus — . Extensor carpi radialis ... longior Extensor carpi radialis - brevior Extensor communis ) digitorum ( Extensor indicis -- Extensor indicis and extensor — ossis metacarpi poUicis Extensor ossis meta- " carpi pollicis Extensor primi internodii -■ pollicis Flexor longus pollicis ' Dorsal interossii •-- Flexoricarpi'radialis ' — Flexor profundus digitorum , iM3i am '""3 .„ Flexor sublimis digitorum Flexor longus pollicis "t ' """ •■■-■■■v- " Abductor pollicis \ -- Oppouens pollicis • Flexor brevis pollicis * • \ ■■" Abductor pollicis "*=■ ■ C^L^"' Lumbricalis (Isr) Extensor car]>i ulnaris Extensor minimi digiti Extensorjiudicis Extensor secundi internodii pollicis Abductor minimi digiti Dorsal interosseus'.(4) (64 J Fk;. 10 GENERAL THERAPEUTICS. 65 Inferior gluteal nerve for glutius maximus Great sciatic nerve Long head of biceps Short head of biceps .*:/ Abductor magnus Semitendonosus Semimembranosus Posterior tibial nerve Peroneal nerve Gastrocuemeus (external head) Soleus Fig. 17 Gastrocn emeus (internal head) Anterior crural nerve Obdurator nerve Sartorius Abductor longus Branch of crural nerve to quadriceps extensor feinoris Crureus Branch of crural nerve to vastus externus Tensor faciarfemoris (branch of superior^^luteal nerve)! Tensor facial femoris (branch of craral nerve) Rectus femoris Vastus externus Vastus externus Fig. 18 Peroneus longus ' Tibialis anticus • I'LTuiical uerve ,^ Ga.strocnemeus "'"°"' E.xtL'rnal communis digitorum longus Pi-roneias brevis Soleus Flexor loDgus pollicis Extensor longus pollicis Branch of peroneal nerve for >. \ extensor brevis digitorum / ^ 'A— Extensor brevis digitorum Dorsal iuteross "l;; "'M^' Fi(. 10 Gastrocnemeus (internal head) Soleus— Flexor communis digitorum longus Posterior tibial nerve. — Abductor pollicis — — Abductor minimi diglti (66) Fig. 20 GENERAL THERAPEUTICS. 67 Methods of electric examination. In forming a correct judgment of the comparative reaction of symmetrical muscles it is necessary to choose a current of the same strength and electrodes of the same size. Symmetrical points of the two sides must be tested in every separate examination. The sponges should be well soaked in warm water (to which salt may be added), and the skin thoroughly moistened with the same solution. Inter- ruptions, when the galvanic battery is used, are made with a special interruptor. It consists of an electrode handle furnished with a spring which is connected with a stud. Pressure with the finger on the stud controls the make and break of the circuit. The strength of the faradic current is measured by the sliding scale or draAV- tube. The secondary current is preferred in examina- tions. In testing with the galvanic current the number of cells in use must be noted. The galvanometer is, how- ever, a more exact means of measurement. Small or " fine" electrodes are selected for exciting motor points and small muscles. In examining with the faradic current it should be noticed what minimum strength of the current is requisite to cause a contraction of each of the symmet- rical muscles. The suspected muscle may be as excit- able as its fellow, or require an increased current strength; or its electric contractility may be diminished in energy, or abolished. Examination with the galvanic current determines similar conditions of the muscular contrac- tility, and especially the signs of the reaction of degener- ation. Electrotherapy. Little of a positive character can be advanced in explanation of the modus opei'andi of elec- C8 MANUAL OF NERVOUS DISEASES. tricity as a therapeutical agent. Its reputation rests for the most part on the teachings of experience. We know that certain pathological conditions are modified under the influence of electricity in some undetermined man- ner. The peculiar stimulant effect of the current on nerve or muscle is of great value in paralytic affections. It is supposed that in cases where electricity exerts a beneficial influence on pathological changes, it is by a process of molecular or chemical action. When morbid exudations tend to be absorbed and removed through the effects of the current it maybe conceived that an osmotic process has been developed among the organic cells. The palliative influence of the current in hyperaesthesia, neu- ralgia and spasm is perhaps to be attributed to its anelectrctonic effect. Experiments tend to show that electric excitation may act beneficially by exciting reflex action. Methods of using the current. A stabile current means the application of electricity when no contraction is intended to be excited. The electrodes in this method are held immovable upon the part. By alabile current is understood a more active influence of the current. For this purpose one of the electrodes remains in contact with a part of the body and with the other the muscle is dabbed or stroked. Energetic contractions are caused by successive closures and openings of the circuit with the interrupter. An increase of the strength of the continuous current with- out adding to the number of cells is accomplished by occasional reversals of the poles during the sitting (Vol- taic alternatives). Stimulation of the skin is best done with the farad ic brush. GENERAL THERAPEUTICS. 69 Position of the electrodes. The following rules in regard to the position and size of the electrodes are of practical importance: 1. When it is desired to concentrate a current on a large structure near the surface, botk electrodes should be of a medium size and placed upon it near to each other, and be successive!}^ applied to all of its parts. This method is suited to large muscles, as the deltoid, the gluteus, vastus internus, etc. 2. When it is intended to send a current to an elon- gated structure, such as the spinal cord, it is advisable to select two very large electrodes, and to place them wide apart over the region of the affected organ so that the. rays of the current may include a part of it. 3. Deep seated structures may be reached by the cur- rent when two large electrodes are placed opposite each other so that some rays of the current may permeate the diseased part of the organ. This method is adopted for electrizing circumscribed lesion of the brain and diseased joints. 4. If it be desired to direct the current to a particular part by the polar method a small electrode is selected which is then called the " active electrode." The other electrode of a larger size, called the "indifferent electrode," is applied to a remote part, usually the nape of the neck or the knee cap. The direction method. As this method of electrization is advocated by eminent observers it is proper to refer to it here. A current is said to be descending when it passes from the center to the periphery, namely when the kathode is nearest to the muscle, and conversely, it is an ascending current when it passes from the periphery to 70 MANUAL OF NERVOUS DISEASES. the center, the anode being then nearest to the muscle. The majority of electricians prefer the polar method, which certainly has superior advantages. Fig. 21. Fig. 21 is intended to show the necessity of placing tlie two electrodes sufficiently apaitto allow the current to reach the organ (spinal cord) when it lies at a certain depth below tlie surface. F!g. 22 shows the greatest current density by the full lines. The dotted lines repre.^ent the inactive currents. This figure aL-o shows the greatest current density at the small active electrode whicli is indicated by the darker shading .of the lines. General galvanization is practiced for the purpose of influencing the nerve centers. The positive pole is suc- cessively passed from the vertex and forehead down the GENERAL THERAPEUTICS. 71 whole length of the vertebral column. The negative T)ole is applied to the epigastirum. A sitting should at least occupy fifteen minutes. General galvanization is recom- mended in the treatment of insomnia, neurasthenia and various functional affections of the nervous system. General faradization. The patient in this method is seated on a low chair, his feet resling on an electrode of suitable size which is connected with one of the poles of the faradic battery. With the other electrode, mounted with a large sponge, the operator electrizes the whole sur- face of the body from head to foot, care being taken to adjust the strength of the current to the varying sensi- tiveness of the different parts of the body. An applica- tion should occupy about twenty minutes. General faradization has a refreshing efft ct in muscular weakness. The electric hath is a mode of general faradization. One of the poles of a strong induction current is placed in the bathtub in which the patient is immersed to above his shoulders. The operator faradizes the body with the other pole, which should be mounted with a large sponge. The electric hand. This method is adopted for stimu- lating the face of children and timid persons. One sponge is held by the patient, the other by the operator. The latter applies the palm or fingers of his free hand to the well-dried skin of the patient. Dusting the face with toilet powder mitigates the unpleasantness of the appli- cation. Practical rides. An overdose of electricity should be avoided. There is no better way of becoming familiar with the different strengths of the current than to prac- tice on one's self. A good way of judging the intensity 12 MANUAL OF NERVOUS DISEASES. of the current is to apply one of the electrodes to the ball of the thumb. To prevent the pain which is caused in using a strong galvanic current, it is advisable to switch in the desired number of elements, a few at a time, and to exclude them in the same manner before removing the sponges. A firm steady pressure on the electrodes pro- duces less pain than holding them lightly. Dry sponges or the uncovered disks, and, better still, the electric brush should be used in anaesthesia. Wet sponges must always be used in electrizing motor nerves and muscles. Daily sittings are required where the cumulative effect of the stimulation is desired. The duration of a sitting varies according to circumstances from two to fifteen minutes. Batteries require constant care to keep them in good working order. In most instances when an induction apparatus loses its force it is due to rust which collects on the hammer or to some flaw in the conducting wires. The fluid requires frequent renewal. Friction^ massage, tapotement . The method of rubbing and kneeding the skin and subjacent muscles is much adopted in the treatment of nervous disorders. This procedure, technically called massage, takes up much time, and to carry it out effectually requires considerable expertness. Another method of practicing massage consists in ham- mering the muscles. For this purpose the inferior edges of the hands may be used after the manner of meat chop- pers. A more elegant and efficient way of practicing tapotement is to tap the part with India rubber balls or cylinders fastened to a wooden liandle. The percussion hammer is well adapted for use on superficial nerves and the small muscles of the face. CHAPTER IV. DISEASES OF THE NERYOUS SYSTEM. Diseases of Peripheral Nerves. NEURALGIA. Pathology. There are sufficient reasons to consider neuralgia an independent disease. Although pain is always due to a morbid condition of some part of the sen- sory apparatus, yet the pain of neuralgia cannot be referred to a known pathological change of the affected nerve. Probably the anatomical alteration is sometimes of the nature of a congestion or slight inflammation of the nerve sheath, some\>hat of the character of a neu- ritis. In the greater number of cases we can only con- ceive of the existence of a peculiar morbid sensibility of certain nerves which is intensified by a source of irrita- tion. Clinically neuralgia may be defined to imply the spontaneous occurrence of paroxysms of pain of great severity, limited to the course of a nerve and frequently associated with motor and vaso-motor symptoms. Etiology. In many cases of neuralgia we recognize abnormal influences and conditions that act as predis- posing or exciting causes. The predisposing causes include 1. Heredity. This is an important etiological factor as shown by the frequent occurrence of allied neu- (73) 7^ MA N UA L OF KER V DCS DIS EA SES . roses in members of the same family, such as hysteria, neurasthenia, epilepsy, etc. A neuropathic tendency dis- posing to the development of neuralgia may also be fairly presumed to exist in individuals free from hereditary influ- ence. 2. Age exerts a marked influence. Neuralgia usu- ally develops between the ages of twenty and forty, which includes the period of life when the general nervous sys- tem is most actively engaged. Children of a tender age and persons advanced in life rarely sufl'er from neuralgia, but elderly people are sometimes subject to a terrible form of this affection (epileptiform neuralgia.) 8. Ser. Females are more frequently attacked than men. Preg- nancy and the climacteric period especially dispose women to neuralgia. 3. Constitutional conditions. Gen- eral anaemia and the chlorotic diathesis often act as pre- disposing causes. The impoverished state of the blood and the consequent mal-nutrition lessen resistance to the obnoxious influences that favor the development of neuralgia. Among the exciting causes of neuralgia are included: 1, Cold. Neuralgic attacks are often traceable to the direct effects of exposure to draughts of cold air or living in damp cellars. 2. Traumatic Sind a nalagous causes, includ- ing injury to superficial nerves from contusion and lacer- ation, or irritation from a contiguous tumor, aneurism, necrosed bones and the contraction of cicatrices. 3. Malarial influences. The periodical type of neuralgia is usually but not always of malarial origin. 4. Toxic causes. The most frequent sources of neuralgia from these causes are chronic lead and arsenical poisoning. 5. Syphilis. The nocturnal pains in syphilis may be of a purely neuralgic character. 6. ^' Reflex neuralgia.''' The D IS EA SES OF THE NER VO US S YS T E M. 75 frequent connection of neuralgia with disease of remote organs, more especially with uterine and ovarian trouble? is a common observation. If this form of neuralgia as is supposed is of a reflex character, it is difficult to under- stand the connection. Finally neuralgia is often asso- ciated with diabetes mellitus, gout and pulmonary phthisis. General Symptomati logy of neuralgia. The essential charac- ers of neuralgia have already been described. The onset of an attack may be sudden, but premonitory symptoms are often noticed consisting of a sensation of pricking, furriness or coldness in the area to which the affected nerve is distributed. Usually the pain begins with twinges in the course of the nerv-e that soon assume great intensity with variable intermissions. The pain is of lancinating, darting, tearing or burning character. The paroxysms of pain greatly vary in violence and duration. There are patients who have only one attack or several at long intervals. Others suffer for a prolonged period with numerous attacks in rapid succession, always affecting a particular nerve or one of its branches. Painful points. The pain often affects with aggravated intensity certain points in the path of the nerve. These puncta dolorosa are recognized by passing the finger along the course of the nerve and exerting some pressure which causes a feeling of soreness even during the intermissions of the paroxysms. They are not always present, but usually they are found in parts where the painful nerves pass through bony canals or penetrate the fasciae of mus- cles. It is not unusual for the pain to radiate to other twigs of the same nerve. Symmetrical nerves or even 70 MA X UAL O F NER V US DISEA S ES . nerves in remote parts of the body are sometimes simul- taneously affected. Motor irritation. Symptoms of motor irritation fre- quently associated with neuralgia, consist of twitching of muscles or cramps when a mixed nerve is affected as in sciatica. But more frequently the motor disturbance is of a reflex nature. This is well examplified in the ''convulsive tic" of facial muscles in trigeminal neuralgia. Vaso-motor symptoms are especially often observed in neuralgia of the face and head. There is marked pallor of the face followed by redness of the skin and of the adjacent mucous membranes. The secretions of the lach- rymal and salivary glands are increased. The trophic changes of neuralgia consist of cutaneous eruptions in the area of the affected nerve, atrophy of the skin, especially of the fingers, and alteration of the color of the hair in regions corresponding to the path of the painful nerve. The general health in neuralgia does not seem to suffer, but in long standing cases an excitable condition of the nervous system develops which gives rise to a despondent state of the mind. General treatment of neuralgia, It is of prime import- ance in all cases of neuralgia to search for its possible cause. A morbid tendency whether constitutional or acquired frequently opposes the best directed efforts toward permanent cure. To guard against the recurrence of attacks, those prophylactic and therapeutical measures are indicnted that invigorate the general system and especially tend to improve the condition of the blood. Cases that admit of surgical interference promise satis- factory results. Thus foreign bodies and necrosed bones may DISEASES OF THE NER VOUS SYSTEM. 77 be removed, cicatrices split or excised and neuromatous tumors extirpated. Neuralgia occurring at regular periods, whether caused by malaria or other morbific influences are often successfully treated with quinia or arsenic. Neuralgic pain of syphilitic origin indicates specific treatment. Iron has a deserved reputation in all varieties of neuralgia occurring in anaemic individuals. Codliver oil and malt extract may also be given with advantage. Local treatment sometimes suffices in very mild cases. Good eff'ects are often derived from the various forms of sedative and stimulant applications. The cantharidal col- lodion is certainly preferable when in cases of this kind a strong counter-irritant eff'ect is desirable. This vesci- cant has the advantage that it can be applied with a brush to any part of the surface. Electricity is often of great service. Diff'erent methods of using the current may be adopted. It is a good method to apply the anode of a weak galvanic current to the whole extent of the aff'ected nerve, or to select the painful points. The strength of the current may be gradually increased. Variations of the current strength during a sitting, or interruptions should be avoided. In neuralgia of large nerve trunks the anode of a descending stable current should be applied either to the center of the nerve or to the corresponding region of the vertebral column, and the kathods to an indifferent peripheral point. Sometimes the interrupted current gives good results when applied Avith the faradic brush in the form of a counter-irritant. Duchenne saw good effects when the brush was applied at some distance from the painful part. 78 MAIS UAL OF NERVOUS DISEASES. Subcutaneous injections of morphia give such instan- taneous rehef even in the severest forms of neuralgia that patients are apt to demand a frequent repetition of the remedy. Nerve-stretching or neurectomy is the last resort in des- perate cases. The relief is sometimes permanent. Among the numerous empirical remedies in vogue for the cure of neuralgia, there are undoubtedly some that do not owe their reputation to mere coincidence. Arsenic is one of them and should have a fair trial in obstinate cases. Turpentine in large doses is an old remedy in neuralgia. Strychnia is sometimes useful. THE DIFFERENT FORMS OF NEURALGIA. Neuralgia of the Trigeminus. Etiology. This is the most frequent of all the forms of neuralgia. On taking a glance at the distribution of this nerve it is observed that its main divisions and branches pass through many openings of the cranial bones where they are readily subject to pressure and irritation from various causes. The mild type of facial neuralgia is usually caused by atmospheric or malarial influences. The "brow ache" is said to be very common in malarial districts. Draughts of cold air give rise to the so-called ''rheumatic" form of trigeminal neuralgia. Search should be made in neuralgia of the head for decayed or filled teeth or a crowded wisdom tooth. Affections of the eyes, ears and nose are well known to be often attended by facial neuralgia. In many cases of obscure origin, consti- tutional causes may be suspected. ' DISEASES OF THE NERVOUS SYSTEM. 79 Clinical History. The pain in severe cases of trigeminal neuralgia is extremely violent. Patients can hardly find words enough to express their suffering. Sometimes the slightest physical exertion, such as washing the face, talking, masticating, or a temporary mental excitement suffices to bring on an attack. Various sensations like a feeling of pulling or dragging the skin precede the pain. Some patients frantically rub the face with the hand, which seems to give them relief. The pain is not always confined to the part of the face where it commenced, but frequently shoots towards the occiput, and sometimes to the region of the shoulder and clavicle. Motor Disturbances, in the form of reflex spasmodic movements, are especially frequent in severe trigeminal neuralgia. The twitching of the facial muscles aff'ects the forehead, the eye and corner of the mouth and causes distortions of the face (tic doloreux). Vaso-motor symp- toms, which are quite common in severe cases, consist of strong pulsation of the temporal arteries and an increased secretion of the lachrymal and salivary glands. Neuralgia of the opthalmic branch is sometimes compli- cated with herpes zoster, which, if it aff'ect the eyeball, may have serious consequences. The most constant painful points in the distribution of the opthalmic branch are found in the regions of the supra-orbital notch, on the upper eyelid, and the parietal eminence. In the superior maxillary there is a focus of pain at the infraorbital foramen and another in the region of the malar bone. The most constant painful point in 80 MANUAL OF NERVOUS DISEASES the distribution of the inferior maxillary branch is at the mental foramen. Fig. 22. V^, V2, V A Region of the anterior. P Kegion of the posterior cer vical nerve. C iii The third cervical nerve So Supraorbital n. St Supratrochlear n. It Infratrcchlear n. 1 Lacrimal n. 3, First, Second and Third Branch of the Trigeminal Nerve (v). S m Subcuteneus malar n. at Auriculo-temporal n. b buccinalis. m Mental n. o ma and o mi Occipital ma- jor and minor nerves, cs Cervicalis superficialis. Diagnosis. A careless diagnosis may possibly confound trigeminal neuralgia with an affection of the skull, nose or jaw. As a point of distinction between the central and peri- pheral form of neuralgia of the head or face, it should be remembered that the distribution of the pain in the former is the more extensive. Prognosis. Recent cases, especially when the pain is confined to a small nerve twig, generally get well in a short time, but curative treatment is not encouraging in invet- erate cases occurring in persons advanced in life. DISEASES OF THE NERVOUS SYSTEM. 81 Treatment. A thorough examination of the possible local or constitutional cause of neuralgia should always be made. The teeth should be inspected. A crowded wisdom tooth or an old stump ma}^ require removal. Attention should also be directed to the condition of the upper nasal pas- sages in severe pain in the region of the frontal sinus. The neuralgia, from disease of the middle ear, requires local treatment. Large doses of quinia are indicated in the periodical type of neuralgia. The same remedy sometimes acts well in cases of irregular paroxysms. Arsenic often suc- ceeds ^\hen quinia fails. This remedy, usually given in the form of Fowler's solution, should have a fair trial in obstinate cases. The rheumatic form of neuralgia some- times yields promptly to a full dose of salicylate of soda. The fluid extract of gelseminum in doses from 10 to 20 drops every hour, is highly recommended in neuralgia of the dental nerve. The remedy is to be omitted if relief does not follow the third or fourth dose. Morphia, as may be expected, gives sometimes instantaneous relief in even the severest cases. Mild cases are often cured by one injection. Atropia injections are indicated in very obstinate cases. A syringe full of warm water injected in the region of the painful nerve is said to answer as well as a small dose of morphia. Phenacetine has lately established much reputation in facial neuralgia. Aeon- ilia has been known to give surprisingly good results in cases which had baffled other remedies. The dose is from 3-1^ to j-i-o grs. Narcotics may sometimes be avoided in mild cases by the use of sedative or irritating embrocations. A very good application consists of a mixture of chloroform, one 82 M A y C A L (}F X E R V U S D 1 S E A S E S . part to three of water. A piece of flannel is soaked with the mixture and applied to the painful part; the flannel should be covered with a thick cloth to prevent rapid evaporation. The external application of atropia is some- times successful. (See formula.) The veratria ointment well rubbed in until it produces a sensation of tingling is often of benefit. In very obstinate cases one is tempted to try many remedies that have occasionally been found of service. Among these may be mentioned croton chloral, nitrate of amyl, turpentine, phosphorus, strychnia, chloride of gold. The general treatment in weak, ana?mic persons includes rest, a generous diet, and the administration of iron, cod liver oil and malt extract. Section of the nerve has been frequently practised with success in supraorbital and infraorbital neuralgia. The risk of the operation is hardly to be considered in des- perate cases. Occipital Neuralgia. As branches of the upper cervical nerves distributed to the lower portion of the cheek and the supraclavicular region are often simultaneously involved with those that go to the occiput, it is usual to speak of cervico-occipital neuralgia. Etiology. A very frequent exciting cause of this form of neuralgia is exposure to drafts of cold air when the body is overheated. The neuralgia is not to be confounded with pain located in the same regions from caries of the vertebral bones. Clinical History. Occipital neuralgia is often bilateral. Usually the pain extends from the back of the head to DISEASES OF THE NERVOUS SYSTEM. S3 the vertex. Sometimes it radiates to the lower jaw and even to the arm. The worst pain, when both sides are affected, is felt between the occipital prominence and the mastoid process. The least movement of the head aggra- vates the pain. Paroxysms of great severity are almost unbearable if they are of unusual duration. Vaso-motor disturbances are not uncommon during the greatest violence of the attack. One of the pupils may be contracted, and the ear abnormally red and warm. The neuralgia is sometimes attended by stiffness of the neck and swelling of cervical glands. The most constant painful points are found in the nape of the neck where the occipitalis major emerges, and one in the course of the same nerve at the back of the head. Treatment. Local treatment often suffices in a mild case. The nape of the neck is to be frequently rubbed with an anodyne liniment, and surrounded by cotton, wool or oakum. Patients find much relief from supporting the head. In more severe cases, blistering the nape of the neck with the cantharidal collodion is preferable. A few doses of the salicylate of soda sometimes succeeds in checking the repetition of attacks. In protracted cases, very good results are sometimes obtained from a strong, constant current passed for ten minutes through the mastoid process. Violent paroxysms of pain require morphia. Brachial Neuralgia. Etiology. The cutaneous distribution of the ulnar, the median and radial nerves which collectively come from the brachial plexus, may either be affected with isolated or combined forms of neuralgia. The superficial situation 84 MA X UAL F NER VOUS DISEASES. of these nerves exposes them to direct injury and rheu- matic influences. Clinical History. Generally the pain in brachial neuralgia is widely distributed. Sometimes it is continuous or comes on in attacks of great violence. It is usually worse during the night. Movement of the limb aggravates the pain. Not only the arm but also the shoulder and back are often affected with severe shooting pains. Weir Mitchell describes a form of this neuralgia ( causal gia) resulting from gunshot wounds. The pain is of an intense burning character. Among the most constant painful points are 1. The radial point at the lower outer aspect of the arm. 2. A median cephalic point at the bend of the elbow. 3. A shoulder point corresponding to the emergence of the cutaneous branches of the circumflex. Adventitious symptoms of a vaso-motor or trophic character are sometimes observed. There is a peculiar shining atrophic condition of the fingers (Glossy fingers.) An instructive example came under my notice at the Baltimore City Hospital. A young girl presented herself complaining of violent pains of the left arm in the region of the distribution of the posterior, superior and inferior subcutaneous nerves. The arm was covered on this part with an eruption of large blebs. On the outer side of the bend of the elbow a few black spots were seen that proved to be the ends of rusty sewing needles. The girl confessed afterwards that she had designedly thrust the needles in for the purpose of being admitted into the hospital. Treatment. The arm should be kept in a sling. Mild cases often yield to sedative or stimulant liniments, but blistering is sometimes necessary. The use of the con- DISEASES OF THE NERVOUS SYSTEM. 85 stant current gives good results in obstinate cases. A full dose of salicylate of soda may be found of service in the rheumatic variety of the neuralgia. The paroxysmal violence of the pain can only be relieved by morphia. DoRso — Intercostal Neuralgia. The superficial branches of the seventh, eighth and ninth pairs of dorsal nerves that run in the direction of the intercostal spaces, are generally affected in this variety of neuralgia. Etiology. Intercostal neuralgia is more often met with in women than in men. It is especially common in fac- tory girls, seamstresses, milliners and nursing women. Females with uterine or ovarian trouble are very prone to suffer from it. The pain usually affects the left side of the chest and is often associated with spinal tenderness. It should be remembered that severe and obstinate side pain attends caries of the vertebrae, aneurism of the thoracic aorta and cancer of the mediastinum. Clinical History. The pain is felt along the distribu- tion of the intercostal nerves, but quite as frequently it is fixed at a point below the mamma or in the region of the axilla. Coughing, sneezing or even drawing a deep breath aggravates the pain. Herpes Zoster is often asso- ciated vfiih this form of neuralgia. The pain frequently persists after the disappearance of the eruption. Severe cases of intercostal neuralgia bear some resemblance to angina pectoris, but the pain is less severe though more con- tinuous, and all the other symptoms characteristic of the latter affection are absent. There is no sensation of constriction of the chest, no embarrassment of respiration nor tumultuous action of the heart. Painful points are SJ MAXUAL OF NERVOUS DISEASES. found in the regions where the nerves emerge from the intervertebral foramen, at the bend of the ribs and near the junction of the costal cartilages and the sternum. The course of intercostal neuralgia is frequently pro- tracted in nervous and anaemic females. Treatment. In recent and mild cases it will often suffice to apply a mustard poultice, and if the pain does not soon yield, blistering may become necessary. The use of the constant current is a good resource in obstinate cases. Speedy relief of the pain is obtained from morphia injec- tions. ^Iastouynia (Irritable Breast). This special form of intercostal neuralgia of the female breast occurs at the period of puberty, and generally in nervous and anaemic women, but it often develops at an advanced age. It is sometimes caused by erosion of the nipples during lactation, and is also liable to appear dur- ing pregnancy. Small nodules are often found in the breast. The breast is so extremely sensitive to the touch that even the pressure of the clothes becomes unbearable. The pain is either continuous or occurs in paroxysms. Treatmsnt is unsatisfactory. Many cases of mastodynia last for years and appear to baffle every remedy. Patients obtain some relief from a suitable bandage that supports the breast. Friction with chloroform liniment or bella- donna ointment, temporarily mitigates the pain. Elec- tricity is occasionally of service. The anode of a stabile constant current is applied to the mamma, and the kathode to the spine. The question of amputating the organ arises when the suffering is so great that it under- mines the general health. DISEASES OF THE NERVOUS SYSTEM. 87 LuMBAK Neuralgia. The branches of the lumbar plexus of nerves are rela- tively seldom affected with neuralgia. The implication of the anterior cutaneous branches of the crural nerve below Poupart's ligament, constitutes crural neuralgia. The pain is felt in the inner aspect of the thigh and extends to the calf and foot. Neuralgia of the obturator nerve deserves particular attention as it is usually symp- tomatic of strangulated hernia in the obturator foramen. Diagnosis. Lumbar neuralgia must be distinguished from afifections of the bones and joints in the painful regions. Lumbago is a rheumatic muscular pain and is bilateral. Treatment is conducted on the general principles that have been described. Sciatica. This is one of the most frequent forms of neuralgial The great length and extensive area of distribuiion of the sciatic nerve subjects it to injurious influences, and besides, the sacral plexus is often involved in intrapelvic disease. Etiology. Age and sex appear to exert some influence on the causation of sciatica. It is seen most frequently in the middle period of life and is moro common in the male than the female. It is also noteworthy that the right leg is oftener affected than the left. In most instances the neuralgia results from strain or the com- bined effects of cold and dampness. Certain vocations requiring a constant uncomfortable sitting posture may also give rise to the neuralgia. Among the special excit- SS MANUAL OF NERVOUS DISEASES. ing causes are to be mentioned the gravid uterus, forceps delivery, impacted feces, pelvic tumor or inflammation and psoas abscess. Clinical History. The pain usually begins in the region of sciatic notch and gradually extends to the buttock, the posterior surface of the thigh, the anterior aspect of the leg and finally to the calf and outer border of the foot. As a general rule the whole area of distribution of the great sciatic is affected. Paroxysms of violent pain which patients describe as of a burning and lightening character are preceded by a feeling of furriness and coldness of the limb. Very often the pain becomes continuous and is worse at night. Flexion of the limb is apt to bring on the pain, and hence the patient adopts a peculiar stitf gait. The concommitant symptoms include tremor and reflex spasms (f the calf muscles and a feeling of numbness and tingling of the skin. One of the tender points corresponds to the part of the trunk of the nerve between the great trochanter and the tuber ischii. There is a fibular point in the superficial course of the peronial nerve and another at the malleolus. Course. Recent mild cases of sciatica readily yield to judicious treatment, and even chronic cases if there be no irremovable cause, are frequently cured, but relapses are common. Some degree of weakness and stiffness of the limb often persists for weeks and months after recovery. Diagnosis. The distinction between sciatica and lum- bago is not always an easy matter. The pain in lumbago is more diffuse and generally confined to the buttock and is increased bv movement and pressure. A careful exami- nation will guard against' the error of confounding sciatica with hip-joint disease. The real cause of sciatica may DISEASES OF THE XERVOUS SYSTEM. 89 remain concealed for a long time if there exists an abdominal aneurism or intrapelvic disease. Treatment. Old standing cases of sciatica which resist ordinary treatment sometimes yield with astonishing rapidity when the true cause is discovered and treated accordingly. The most favorable of chronic cases are those in which the exciting cause is removable, such as habitual constipation, haemorrhoids, varicose veins and tumor. In sciatica of recent date it is of the first importance that the patient keep in bed. Warm applications are very grateful. A hot vapor-bath is especially of service in "rheumatic'' cases. Such a bath can readily be improvised by heating bricks, wrapping them in wet woolen cloths and placing them between the lower limbs and outside of them. The escape of the steam is pre- vented by a thick covering of blankets. Protracted cases often yield to blistering. A good plan is to cross the affected part of the nerve with small blisters about two inches apart. Sciatica is more frequently cur^d by the electric treat- ment than any other form of neuralgia. I use a gradually increasing constant current. The anode is allowed to rest quietly foriit least two minutes at a time on different parts over the path of the nerve, and the kathode is applied to the back. Painful spots are preferred for the anodic application. Internal remedies rarely give satisfaction. Quinia and salicylate of soda may occasionally be found of service. Strychnia has also been recommended. Turpentine in large doses is an old remedy in sciatica. If iodide of potassium is successful in an inveterate case of the neuralgia, it was probably of syphilitic origin. After 90 MANUAL OF NERVOUS DISEASES. every other remedy has failed, nerve-stretching is the last resort which although it may not give permanent relief, is nevertheless a justifiable procedure. Neuralgia of the Genitals. The external genital organs are but rarely subject to neuralgia. Spermatic neuralgia or "the irritable testi- cle" as it was formerly called, demands particular atten- tion. It is marked by violent paroxysms of pain, beginning in the testicle and extending to the spermatic cord. During an attack, the testicle retracts and is very sensitive. This is a most obstinate and harassing species of neuralgia, little amenable even to palliative treatment, and resisting narcotics and electricity. Castration appears to offer the only means of relief. Weir Mitchell has described " a neuralgia anno- peronialis" occurring among masturbators and smokers. Neuralgia of the region of the rectum is sometimes seen in persons much reduced in health, especially from malaria cachexia. Dr. Neftel of New York saw good results from the use of the constant current in such cases. COCCYGODYMA. This affection is characterized by severe pains in the coccygial region. It is aggravated when the patient sits or walks, and during defecation. This trouble generally occurs in women, and is probably caused by strain or injury in labor. It is a most intractable affection, and the removal of the coccyx has been resorted to with good success. Before deciding on such a measure, which is only advisable in a desperate case, a fair trial should be given to faradization. One of the electrodes is introduced into the rectum, and the other is applied to the sacrum- DISEASES OF THE NERVOUS SYSTEM. 91 Neuralgia of the Joints. It is well known that Sir Benjamin Brodie first directed attention to the occurrence of a painful affection of joints in hysterical women. Recently the subject has been studied by Esmarch, whose observations convinced him that cases of this kind in which generally the hip joint is affected, illustrate the existence of an '' articular neurosis." The painful joint is exempt from gross anatomical change. Weir Mitchell, in his interesting chapter on the " Mimicry of Disease," refers to the morbid influence of concentrated attention on a particular part of the body on account of some trivial hurt. Hysterical patients are especially prone to the development of a neuritic affection from such a cause. A case in point came under my observation. The patient, a young married woman fell against her side, which greatly alarmed her, and rendered her very anxious concerning the consequences. A few weeks later she took to her bed, in which she remained for eight months. I found her lying in the position which, I was informed, she had assumed from the beginning. The left leg was extended and slightly rotated inwards. This is the limb that gave her so much trouble after the fall. She described to me, with tears in her eyes, the unbearable suffering she had since undergone. She begged me not to touch the sore limb, as the pain it would cause was unendurable. The slightest movement, she said, the merest touch of the hand, would give her the most excruciating pain. Those about her had so much given away to her entreaties not to be disturbed that they neglected to attend to a very bad bed sore that had developed in the sacral region. Her mother had given up housekeeping so as to be constantly with her daughter. I observed no swelling about the knee or hip joint where the patient located the pain. She appeared to be somewhat emaciated, though her appetite was fairly good and she got sufficient sleep. An attempt to move the limb was out of question, as the patient vehemently protested against it, and would not listen to any reasoning or persuasion. I suspected the character of the affection, and stated my opinion to the attending physician Of course we could not come to any definite 9e MA X UA L F X ER VO US BIS EA S ES . decision until the limb was more thoroughly examined. The patient absolutely refused to take an anesthetic. We carried out a conspiracy, with the help of the mother and nurse, and removed her to a lounge amidst her loud wailing and protestations. After the bed sore was dressed, I succeeded in rotating the limb with considerable ease, and to flex the knee in spite of the cries and opposition of the patient. There was now no room for doubt that the leg was healthy, barring the neurosis of the joints. Galvinization constituted subsequently the chief treatment. Gradually the patient was induced by coaxing and occasional Arm language to allow her limb to be handled more freely, and to make a few steps with the assistance of her mother and nurse. By and by she learned to walk on crutches. When I paid her my last visit, I found her quite well and walking without any support. NEURITIS. EtiOlcgy. Inflammation of peripheral nerves is observed in injury from gunshot wounds, laceration and contusion. Nerves in the neighborhood of diseased vertebrae and joints may become involved. Neuritis also occurs as a rheumatic or a syphilitic affection, but often no cause can be assigned. Anatomical Changes. Generally the neurillema and nerve fibre are conjointly affected. The nerve appears swollen, its capillaries are enlarged and hemorrhagic spots are seen. Disintegration of the medullary sheath and nerve fibre develops in severe cases. Numerous cellular elements accumulate in the neurillema, which is grad- ually thickened by the formation of connective tissue, and may finally lead to destruction of the affected nerve. An ascending interstitial neuritis sometimes occurs which starts from the seat of the lesion. In mild cases regene- ration of the nerve takes place- Simultaneously with the degeneration of a motor nerve, nutritive changes of the corresponding muscles ensue that .causes atrophy DISEASES OF THE NERVOUS SYSTEM. 9S This atrophy is permanent if the nerve fibre has com- pletely degenerated. ac ac ac Fig. 24. Fig. 25. Fig. 24. Normal Medullary Nerve Fibre. (Ranvier.) Fig. 25. Alteration of Nerve Fibre After Section. ac Axis cylinder. S Strangulation of the medullary e Ranvier' s nodes. sheath, sch Sheath of Schwan. my Masses of myalines. my Masses of myeline. n Nucleus detached from the sheath of Schwan. 94 MA NUAL OF NER VO US D ISEA S ES . Clinical History. Considerable febrile excitement marks the onset of acute neuritis. Intense pain is felt in the course of the nerve and its distribution. The parts are exceedingly painful to the touch, and the swollen nerve can be felt through the skin. There is often a subjective sensation of numbness of the afiected part, but the motor disturbance that finally makes its appearance is of more importance. A form of atrophic paralysis is estab- lished after the subsidence of the acute symptoms. The muscles show the reaction of degeneration. There are mild cases which do not advance to this condition. Others take a tedious chronic course, with eventual loss of function of the part. There is a group of degenerative neuritis, of which the following are the most important. Multiple Neuritis. This form of neuritis is chiefly observed to affect motor nerves of the limbs. At a late stage of the inflam- mation this process extends to the finest nerve filaments that are distributed to the muscles. The nerve fibres are thickened and nodulated in different places (neuritis nodosa). The sarcolemma is increased and infiltrated with fat. This morbid alteration does not extend to the nerve roots. Further investigation will probably disclose the fact that multiple neuritis is the pathological con- dition underlying the atrophic paralysis of lead and arsenic poisoning. Symptoms of sensory disturbance occur at the begin- ning, consisting of tearing pain in the extremities, especially in the hands and feet and attended by parses- thetic sensations about the joints. Motor disturbances develop next, characterized by a flaccid condition of the DISEASES OF THE NERVOUS SYSTEM. 95 muscles, diminution and final loss of the electric reaction, as in all forms of peripheral paralysis. The neuritis in the first stage is marked by fever and violent pains in the limbs. Restoration may t&ke place, but in severe cases an atrophic paralysis develops. Alcoholic Neuritis. Chronic alcoholism may give rise to forms of paralysis which are now considered to be dependent on the develop- ment of multiple neuritis. The main clinical feature of the disease is atrophic paralysis of the inferior extrem- ities. In some cases additional symptoms appear that bear a close resemblance to sclerosis of the posterior columns of the spinal cord. The disease begins with violent tearing pains in the legs and sometimes in the arms. Gradually, an uncertainty of the gait is estab- lished. In well-marked cases there is also a paretic con- dition of the limbs. The affected muscles show wasting and abnormal electric reaction. There is early abolition of the patellar reflex. The cutaneous sensibility is impaired. It is evident from the character of these symp- toms that their resemblance to those of loco-motor ataxia is complete. If, however, atrophic paralysis coexists, then spinal disease is excluded. In the alcoholic affec- tion there is generally no immobility of the pupils; the girdle sensation is absent and there is no irritation of the bladder. Treatment. Causal treatment is of the first importance in traumatic neuritis. The antiseptic treatment is indi- cated in the case of infectious wounds. Primary acute neuritis call for measures to subdue the inflammation. If the arm is affected it should be supported in a sling. 90 MA X UAL OF NEB VO US D IS EA SES . A poultice of crushed ice is very grateful to the patient. Salicylate of soda may be given from the beginning, but to allay the severity of the pain, morphia is often required. The patient should not be allowed to leave the bed too early. The paralysis of chronic neuritis is best treated with electricity. The following method may be adopted : The kathode of a strong constant current is placed on the vertebral column in a position corresponding to the near- est part of the affected nerve. The anode is applied for five minutes daily to paralyzed muscles. The interrupted current is also useful. This treatment may be advantage- ously assisted by massage and warm baths. Neuromata. New growths, diff'ering in histological structure, develop in nerves as they do in other organs. True neuromata consist of newly-formed nerve tissue; false neuromata are fibromatous. The so-called "painful tubercle'' is usually of the latter species. It occurs in different parts of the body, and can often be felt as a small nodule under the skin. True neuromata sometimes develop in the stump of an amputated limb. The cause of these growths is unknowm. In some individuals a numerous crop of little nodules scattered over the whole body make their appearance. These multiple neuromata do not give rise to symptoms. Many cases of true neuromata are attended by a violent intractable pain. The only permanent cure is their extir- pation. Temporary relief is obtained from narcotics. CHAPTER V. PERIPHERAL PARALYSIS. Under the head of peripheral paralysis, in contradis- tinction to paralysis of cerebral or spinal origin, are included those individual forms of motor and sensory paralysis, which result from injurj^ or disease of peripheral nerves. The general character of peripheral paralysis may be summarized as follows: 1. Diminution or loss of -muscular power in conse- quence of interruption of the conducting motor path, limited to the affected nerve. 2. Impairment or abolition of sensation in injury or disease of mixed nerves. The disturbance of the cutane- ous sensibility is usually insignificant and is often absent. 3. Vaso-motor and trophic disturbances, especially atrophy of the paralyzed muscles, arrested growth of bones, affections of the joints and changes in the skin. The latter are indicated by dilatation of the superficial vessels, local elevation of the temperature, cyanosis and coldness of the surface. 4. Abnormal condition of the electric excitability. Etiology. In reference to the exciting causes, we distin- guish the traumatic, the rheumatic, the toxic and post- febrile forms of peripheral paralysis. The traumatic variety also includes the paralysis from prolonged com- 7 (97) 98 MA y UAL OF NERVOUS BIS EA S ES . pression of a nerve, as may occur in cases where the patient, in a state of intoxication, had been sleeping on a hard substance, with his arm bent behind his back. Tight bandaging and ill-constructed crutches may pro- duce a similar effect. Paralysis of one or both of the upper extremities is sometimes caused in new born infants during the operation of version. Rheumatic peripheral paralysis most frequently affects the face, and less frequently one of the limbs. These parts are especially exposed to rheumatic influences. The toxic forms of paralysis chiefly include lead palsy and arsenical paralysis. Among the post-febrile forms of peripheral paralysis, the one of greatest practical importance is diphtheric paralysis. Anatomical Changes. In the traumatic form of paralysis and probably also in severe cases of rheumatic origin, the anatomical changes are of the nature of an interstitial neuritis with a tendency to undergo the process of degen- eration. There are other forms of paralysis usually con- sidered to be of a peripheral character, whose pathology has not yet been satisfactorily determined. VARIETIES OF PERIPHERAL PARALYSIS ACCORDING TO THEIR DISTRIBUTION. Paralysis of the Motor Branch of the Trigeminus. This species of paralysis is very rarely of local origin. In partial paralysis of the masticatory muscles, the act of deglutition is difficult. In complete bilateral paralysis, mastication is impossible. The jaw hangs down and the muscles gradually atrophy. PERIPHERAL PARALYSIS. 99 Treatment. Galvanization deserves a trial, but if the paralysis is of central origin, it requires causal treatment. Facial Paralysis. Etiology. This is the commonest of all forms of peri- pheral paralysis. The causes of the paralysis in their order of frequency are: 1. Exposure to drafts of cold air, as when a person sits near an open window in a rail- road car on a cold, windy day. This is the rheumatic form of facial paralysis. 2. Disease of the ear, when the facial nerve is involved in its passage through the Fallopian canal. 3. Disease at the base of the brain where the nerve is implicated after its emergence from the brain. Facial paralysis is therefore frequently observed in intercranial syphilis, and is often associated with paralysis of some of the ocular muscles. 4. Swell- ing of the parotid gland or its removal in operations. 5. Forceps delivery. The infant is often unable to take the breast. In very mild cases, the paralysis may only be discovered when the child cries, which produces distor- tion of the face. Clinical History. Facial paralysis is easily recognized in consequence of the immobility of the muscles of expres- sion of one side of the face. On the paralyzed side no wrinkles are visible on the forehead when the patient attempts to frown. The eye on the affected side cannot be voluntarily closed. This permits the entrance of dust which may cause conjunctivitis. The labio-nasal fold is effaced; the ala nasi is flattened; the cheek " hangs " and flaps during inspiration, and bulges out during expiration. The mouth is drawn over to the healthy side; this becomes very apparent when the patient speaks, laughs or cries. He finds it difficult to whistle, blow or spit. The saliva 100 MANUAL OF NERVOUS DISEASES. escapes from the half-opened mouth. Morsels of food lodge between the gum and cheek, and mastication is rendered difficult on account of the flaccidity of the cheek. The tears run down the face, as the paralysis of Horner's muscle prevents their escape into the lachrymal canal. Speech is indistinct from imperfect movement of the lips. Immobility of the soft palate on the affected side is observed in so?iie cases, but the position and move- ments of the uvula vary too much in the healthy condition for this S3^mptom to be of any sigaiticance. Impairment of the sense of taste exists in cases in which the chorda tympani nerve is imj^licated. This nerve accompanies the facial for a short distance, and sends gustatory fibres to the lingualis. Dryness of- the mouth, due to diminished secretion of saliva, is depend- ent on the same cause. Disturbance of hearing occurs where the paralysis originates from aural disease. The abnormal electric reaction in facial paralysis is of much importance in regard to prognosis. Erb distin- guishes three different conditions of the electric excit- ability : 1. The mild form, which is the one most commonly met with. The electric reaction is perfectly normal. Recovery may be expected within two or three weeks. 2. The middle form. The electric reaction is dimin- ished, but not lost. At the expiration of about three weeks there is an increase of the galvanic excitability of the muscles. The anodal closure contraction (A C C) is greater than the kathodal closure contraction (K C C). Recovery usually ensues at the end of six weeks. 3. In the severe form, there is loss of the faradic and galvanic excitability of the nerve and loss of faradic excitability of the muscles. The reaction of degeneration PERIPHERAL PARALYSIS. 101 is complete, and the prognosis is unfavorable. Recovery, in cases which are at all cured, is very tedious. At a late stage there is often spasmodic contraction of the muscles inserted at the mouth when the patient smiles or laughs, or is engaged in animated conversation. Course and Prognosis. In the rheumatic variety of facial paralysis much depends, as already mentioned, on the result of the electrical examination in regard to prog- nosis. If the electric excitability remains normal at the end of three weeks, recovery w^ll speedily be established. Manifest reaction of degeneration offers little hope of curability. The paralysis from ear trouble disappears with the latter. In basal tumor, if not due to syphilis, it is absolutely incurable. The facial paralysis in infants after forceps delivery passes off' quickly. Diagnosis. Slight cases of facial paralysis are only recognizable during the acts of laughing and crying. The distortion of the mouth simulates spasm of the healthy side. In general, the symptoms of facial paralysis are so manifest that mistakes can hardly happen. Of greater importance is the discrimination between peripheral and central facial paralysis. The differential diagnosis must consider the etiology and concomitant symptoms of the individual case. External injury, compression, exposure or aural disturbance indicate the existence of peripheral paralysis. Imperfect closure of one eye points the same way. In the paralysis of cerebral origin there is seldom immobility of the muscles in the region of the forehead and the eye. Complication with paralj^sis of other cranial nerves, or especially the co-existence of hemiplegia, signifies a central lesion. The electric excit- ability is not usually abnormal in the latter form of paralysis. 10? MA X UA L F NERVO US D I SEAS ES. Treatment. The indications of causal treatment in rela- tion to affections of the parotid gland, otitis or syph- ilis require the first attention. In all other cases there is no remedy equal in efficacy to electricity, though uni- form or brilliant results must not be too confidently expected. In paralysis of recent date, it is recommended to apply a weak, stabile galvanic current to the auriculo- mastoid fossa for two or three minutes every other day. But the chief method at a later period is to place the anode in the same fossa, and gently stroke the paralyzed nerves and muscles with the kathode. Faradization of the muscles may also be of service in tedious cases. Injections of strychnia are disappointing. Paralysis of the Sterno-Cleido Mastoid. The head is inclined to the healthy side, and the chin is raised and directed towards the opposite side. Motion in the opposite direction is difficult. The deformity is temporarily rectified by passive movement of the head. This cannot be accomplished in spasmodic contraction of the muscle. Paralysis of the Trapezius. The shoulder sinks downwards and forwards, and the act of " shrugging the shoulder" is impaired. Raising the arm above the horizontal position is difficult. The normal condition of the scapula in relation to the verte- bral column is altered. Simultaneous paralysis of the sterno-cleido mastoid and the trapezius is often seen, as both muscles are supplied by external branches of the spinal accessory nerve. PERIPHERAL PARALYSIS. WS Paralysis of the Pectoralis — Major and Minor. Isolated paralysis of these muscles is extremely rare. The anterior thoracic nerve is distributed to these muscles. Abduction of the upper arm is impossible, and the hand cannot be placed on the shoulder of the opposite side. Paraiasis of the Rhomboidii and Levator Angul.^ Scapula. The shoulder-blade cannot be approximated to the ver- tebral column, nor elevated. This form of paralysis can only be recognized when the trapezius is also effected. Paralysis of the Latissimus Dorst {subscapular nerve) usually results from lifting heavy weights. The hand cannot be placed on the sacrum. There is no deformity observed when the body is at rest. Paralysis of the Outward and Inward Rotators of THE Humerus. Movements with the teres-major and sub-scapular muscles on the opposite side of the body are impaired. Rotation of the arm outward is abolished when the teres- minor and scapularis are paralyzed. This form of paral- ysis causes marked interference with the acts of writing and sewing. Paralysis of the Serratus Magnus. (Thoracic Longus Nerve.) It is observed, when the body is at rest, that the lower angle of the shoulder-blade is somewhat approximated to the vertebral column and slightly inclined upward and outward. The patient cannot raise the arm above the 104 MANUAL OF NERVOUS DISEA S ES . horizontal line, and the indentations of the muscle on the side of the chest do not become conspicuous. If the scapula is pushed forward, the patient is enabled to raise the arm, and if the arm is extended, the very character- istic symptom of paralysis of the serratus becomes apparent. We now observe the wing-like projection of the inner border of the scapula, so that a deep fossa is formed, in which the hand can readily touch the inner surface of the scapula. Paralysis of the Deltoid. ( Ci re u 771 flex Ne rve . ) The arm cannot be raised to the head, and the shoulder appears sunken. This form of paralysis can be easily distinguished from anchylosis of the shoulder by passive movement, which is impossible in the latter afifection. Paralysis of the Biceps and Brachialis Anticus. {Musculo-cutanens Nerve ) is rarely isolated. It interferes with tlexion of the fore- arm when in supination. In pronation, the flexion is assisted by the action of the supinator longus. Paralysis of the Muscles Innervated by the Mus- culo-spiral Nerve. Peripheral paralysis in the distribution of this nerve is of frequent occurrence from injury and exposure. This nerve is especially prone to be affected in chronic lead poisoning; in pressure from badly-fitting crutches and tight bandaging of the arm, and also from compression of the nerve, where it curves around the humerus. The latter causes produce a nnld form of paralysis. PERIPHERAL PARALYSIS. 105 Paralysis of the Triceps is unusual. It is recognized by inability to extend the arm; but in the experiment the arm must be raised so as to exclude the weight of the forearm. Paralysis of the Extensors of the Forearm causes the ''wrist drop." The hand hangs down in the flexed position and has lost its "grasp." Dorsal flexion of the hand is impossible. Its lateral movements are difficult. The fingers cannot be extended nor spread apart, but the extension of the terminal phalanges is found to be normal if the first phalanges are supported. Extension and abduction of the thumb 'is abolished. The flexed forearm can be supinated by the biceps, but if the forearm be extended and pronated it cannot be supinated. The characteristic prominence of the supinator lons^us is want- ing if the forearm is forcibly extended, whilst the patient tries to resist the attempt by fixing the semi-flexed fore- arm in the pronated position. The electric excitability of the paralyzed muscle is normal in the early stage and continues so in mild cases. The reaction of degeneration becomes manifest on the occurrence of atrophy. Impairment of the cutaneous sensibility is insignificant, but a feeling of numbness or creeping often ushers in the paralysis. Ulnar Paralysis. Isolated ulnar paralysis is relatively of unfrequent occurrence. It is chiefly caused by injury of the elbow, the wrist or the ball of the little finger. Implication of the flexor carpi-ulnaris interferes with complete flex- ion and lateral movement of the hand towards the ulnar side. Flexion of the last three fingers is imperfect. 106 MANUAL OF NERVOUS DISEASES, The movement of the little finger is totally abolished. Paralysis of the lumbricalis prevents the spreading of the fingers. Flexion of the primary phalanges as well as extension of the terminal phalanges, is impossible, in consequence of paralysis of the interossii. A very char- acteristic deformity of the hand develops, which is ren- dered more unsightly by the grooves of the atrophied interossii on the back of the hand. This peculiar position of the hand gives the appearance of the '' claw-like hand " (main en grifFe). Combined Paralysis of Muscles of the arm. Inj uries affecting the distribution of the different nerves proceeding from the brachial plexus may give rise to various combinations of paralysis of the upper extremity Total paralysis of the plexus is caused by severe contusion in the regions of the neck and shoulder. A form of com- bined paralysis is described by Erb involving the deltoid, the biceps, the brachialis anticus and the supinator longus. Duchenne reports similar cases of paralysis in new born infants, caused by shoulder delivery. The arm in such cases hangs down by the side; the forearm cannot be flexed, but the hand and fingers are not affected. Treatment of Paralysis of the Upper Extremity. It is only in rare instances that a causal treatment is possible. The chances of cure in traumatic cases are not favorable. Those of a rheumatic origin are more amenable to treatment. The mildness or severity of the paralysis is best judged by the condition of the electric excitability. The greatest reliance in improving the muscular power must be placed in electric treatment, and the more recent the case the better is the prospect of cure. A good method is to gal- PERIPHERAL PARALYSIS. 107 vanize Erb's motor point. Each muscle should also be stimulated by stroking or dabbing it with the kath- ode. If the test for the reaction of degeneration gives early anodal closure contractions, it is preferable to excite the muscle with the anode, while the kathode is placed on a distant part. Faradization proves useful in exciting reflex action. In all cases patience and perseverance in continuing the electric treatment is necessary if any benefit is to be achieved. The more obstinate the case the more persistent should be the treatment. Massage and the use of liniments should not be neglected. Peripheral Paralysis of Muscles of the Inferior Extremity. This form of paral3^sis occurs in injury of the thigh, disease of the vertebrae, compression from pelvic tumor and in psoas abscess. It is also to be observed that defective innervation of muscles inserted in the vertebral column interferes with walking, in consequence of the insecure equilibrium of the body. Paralysis of the crural nerve. The symptoms in this form of paralysis are due to the implication of the illio- psoas and the quadriceps extensor muscles. The thigh cannot be flexed on the pelvis, and the trunk cannot be raised from the recumbent position. Anaesthesia is some- times observed in the lower half of the anterior aspect of the thigh and along the course of the saphenus nerve. The characteristic symptoms of paralysis of the obtu- rator nerve is defective abduction of the thigh. The patient is therefore unable to cross one leg over the other. Paralysis of the gluteal nerves causes impaired abduction of the thigh and difficulty of rotating it inwards. The 108 MANUAL OF NERVOUS DISEASES. trunk sways from side to side in mounting and descend- ing steps. Paralysis in the region of the thigh results from injury and disease of the vertebrae, pelvic tumor, hard labor and rheumatic influences. Isolated paralysis of the differ- ent branches of the sciatic nerve may occur from any of these causes. Paralysis of the foot is the most common. In paralysis of the i^eroneal nerve there is inability of voluntary dorsal flexion of the foot. The tips of the toes and the outer edge of the foot first touch the ground in walking, as the abduction of these parts is abolished. A similar condition is characteristic of infantile spinal paralysis. Paralysis of the tibial nerve completely abolishes plantar flexion. It is impossible for the patient to rise on his toes. Secondary contraction of the calf muscles grad- ually develops talipes calcaneus. A claw-like appearance of the foot is caused by atrophy of the interossii. Paralysis of the trunk of the sciatic nerve causes, in addi- tion, paralysis and atrophy of the foot, and inability to flex the leg backward on the thigh. This is due to the impli- cation of the biceps, semi-membranous and semi-tendinous muscles. Walking is still possible if only one extremity is afl'ected, as the quadriceps, which usually escapes, stiffens the limb. Vaso-m'otor and trophic symptonis are quite frequent, as shown by the cyanosis^ coldness of the skin and atrophy of the muscles. Impairment of the electric excitability is manifest, as in all cases of peripheral paralysis. Treatment accords with the same principjes observed PERIPHERAL PARALYSIS. 109 in the management of peripheral paralysis of the upper extremity. Lead Paralysis. Chronic lead poisoning occurs among type-setters, type- founders, house painters, potters, workers in white-lead factories, and among all artisans who expose themselves to the introduction of small quantities of the metal or its salts. The paralysis usually makes it appearance subse- quent to attacks of colic. As lead palsy belongs to the class of atrophic paralysis, it may be inferred that the toxic action of the metal either produces degenerative changes in the gray sub- stance of the cord or analogous changes in peripheral motor fibres. Certainty in regard to this pathological question has not yet been obtained, but recent investiga- tions tend to show that the anatomical change of nerve fibres is the primary condition. Clinical History. Lead paralysis is a bilateral affection. In the large majority of cases the paralysis is lim- ited to the extensor muscles of the forearm, but the triceps and the supinator longus remain remarkably exempt. The conspicuous symptom is the "wrist drop." Occasionally the muscles of the upper arm are also implicated. Lead palsy of the lower extremities is rarely seen. Atrophy of the affected muscles develops in all severe cases, and the reaction of degeneration is observed. Tremor of the paralyzed part is sometimes seen in aggra- vated cases, and attended by anaesthesia. Treatment. Recent cases of lead paralysis are often promptly cured by the frequent use of warm sulphur baths and the employment of electricity as indicated in no MANUAL OF NERVOUS DISEASES. all forms of peripheral paralysis. Iodide of potassium is believed to promote the elimination of the lead poison from the system. Very aggravated cases, that manifest the reaction of degeneration and show much muscular atrophy, do not permit of a favorable prognosis. Arsenical Paralysis. This form of paralysis is less frequently met with than lead palsy. It succeeds the symptoms of acute arsenical poisoning. The paralysis affects, in the larger number of cases, the inferior extremities. Severe pain is felt in the limbs and sacrum, attended by anaesthesia. These S3'mptoms are characteristic of arsenical paralysis. Atrophy of the paralyzed muscles finally ensues. It is undetermined whether the anatomical change underlying the paralysis is a neuritis or myelitis. Recovery is some- times rapid and is hastened by electricity. Diphtheric Paralysis. The paralysis of diphtheria usually develops in the course of the third or fourth week after the termination of the primary disease. Paralysis of the soft palate is the first symptom that attracts attention. This is indi- cated by the nasal twang of the voice and difhculty of deglutition. The ocular muscles are sometimes impli- cated, causing ptosis, strabismus or mydriasis. A paretic condition of the lower extremities is occasionally observed. Sensory disturbances always accompany the paralysis, especially obtuseness of the mucous membrane of the lips, tongue and cheeks. But the most serious occurrences in diphtheric paralysis relate to irregularity of the heart's action and embarrassment of the respiration. Sudden death may happen from fatal syncope and asphyxia. PERIPHERAL PARALYSIS. Ill Disappearance of the paralysis usually takes place in the course of a few weeks if it is limited to the palate; even severe and protracted cases tend to recovery. The general treatment tends to improve the patient's strength, fur which quinia, iron and cod liver oil constitute the approved remedies. Electric treatment is of much benefit in acting favorably on the paralyzed muscles. Reflex Paralysis. By this term is meant a paralytic affection dependent on an irritation existing in a remote organ. The most common example of such a form of paralysis is the occur- rence of paraplegia in urinary disease. Intestinal and uterine troubles may also give rise to this type of paraly- sis. Leyden attributes the paralysis in such cases to an ascending or migrating neuritis which starts from the diseased part and secondarily affects the spinal cord. Treatment must be directed to the cure of the primary cause, but the paralysis may persist and require special treatment. CHAPTER VI. VARIETIES OF LOCAL SPASM. Spasm of the Muscles of the Eyeball. Tonic spasm of the internal rectus, which is the most frequent of the local spasms of the ocular muscles, is recognized by the presence of strabismus. It is often caused by long standing paralysis of the external rectus. Nystagmus is a bilateral affection. It consists of clonic spasm of the muscles of the eyeballs, and is especially noticeable when the patient looks at remote objects. The eyes are affected with oscillatory movements. Nystagmus is associated with various local affections of the eyes. It is also often seen in acute meningitis, and is a frequent symptom in multiple sclerosis of the brain. Spasm of the Masticatory Muscles. Trismus is a tonic spasm of the muscles of mastication. It is rarely seen as an isolated affection, but constitutes a prominent symptom of tetanus, and occurs in hysteria. The closure of the jaws is caused by the firm contraction of the masseter muscles (lockjaw). In the clonic spasm of the masticatory muscles the lower jaw is constantly moved in the vertical direction, and gives rise to chattering of the teeth. (112) LOCAL SPASM. 113 Both varieties of local spasm probably depend on reflex action, which may be excited either by an irritation in the jaw itself, such as decayed teeth, or by an affection in a remote organ. Treatment aims at the removal of the discoverable cause. Difficulty of feeding must be overcome by intro- ducing food through the nose by means of a small oesophageal tube. Galvanization is sometimes very ser- viceable. Hypodermic injections of morphia or atropia and the internal use of the bromides, arsenic and zinc may be tried in succession in obstinate cases. Facial Spasm (Convulsive Tic). In the absence of any recognizable cause of this practi- cally most important form of local spasm, we can only conjecture the existence of a hereditary or neuropathic tendency that predisposes to its development. Convuls- ive tic is sometimes caused by direct reflex action, as in neur£ilgia of the fifth nerve, or indirectly under the influ- ence of a source of irritation in a remote organ, as in uterine disease. Facial spasm has also been known to occur immediately after violent emotional disturbance. Perhaps in many cases the source of irritation is central. The acquired habit of grimaces, observed in children through imitation, is a tonic spasm of facial muscles. Clonic spasm of the face is^ usually a bilateral disease. It occurs periodically, and may be excited by the acts of mastication, talking or a mental impression. The move- ments produce contortion of the features. The contrac- tion in severe cases may also involve the tongue and the muscles of the neck. There are patients who constantly make the strangest grimaces, while in others they recur lU MANUAL OF NERVOUS DISEASES. at irregular periods. The affected muscles carry out normal movements during the intervals and are free from pain or other sensory disorders. The so-called *' tricks" are of the nature of clonic spasm. Partial spasm of the eyelids either causes constant winking (nictitating spasm); or the entire orbicularis pal- bebrarum may be affected with tonic and clonic spasm. The contractions cause firm closure of the eyes, that may last for minutes or hours (blepharospasm). The spas- modic paroxysms are as a rule bilateral. Very often the spasm is excited by affections of the eyes, or tic doloreux, but often no cause is discoverable. The involuntary grin (risus sardonicus) is due to convulsive movements of the muscles supplied by the malar and labial twigs of the facial nerve. Facial spasm is not easily remedied by treatment, unless the exciting cause of the reflex movements be removed. Resection of the supraorbital nerve is recommended if obstinate neuralgia of this nerve is at the bottom of the spasm. Favorable results from this operation are reported. Improvement of the sj^asm has been observed from the application of Paquelin's thermo-cautery to the cervical vertebrae. Electricity deserves a fair trial before resorting to severe measures. The anode of a stabile constant current is to be applied to the affected muscles and brought in contact with the tender points of the nerve, which should be searched for. In using the inter- rupted current it is recommended to begin TAith a weak strength and gradually to increase it. Some benefit is also claimed from the use of the bromide of potassium in large doses. LOCA L SPASM. 115 Lingual Spasm. This is rarely an independent affection. The tongue is commonly affected in epileptic and hystericfil spasms. When occurring as an isolated condition it interferes with speech and respiration. The tongue during the spasm is thrown backwards and up against the hard palate. Relief is afforded by pulling the tongue forward with a forceps. To allay the spasm it may become necessary to use chloroform. Spasm of the CEsophagus. Spasmodic stricture of the oesophagus is usually met with in hysterical women, and is^ often so persistent as to simulate organic disease. The so-called " globus hj^steri- cus" is supposed to be a spasmodic affection of this kind. The oesophageal tube can be passed with little difficulty in the hysterical disorder. An anaesthetic may be required to overcome the obstinacy of the spasm. Spasm of the Respiratory Muscles. Spasmodic attacks of the glottis occurring in children is usually described under the name of laryngismus stri- dulus, or " false croup." This affection often coexists with infantile convulsions. The exciting cause in many cases is difficult dentition or derangement of the digestive organs. Ricketty and weakly children are especially prone to attacks. The paroxysm comes on suddenly without any warn- ing. It consists of complete closure of the glottis. Res- piration is arrested and suffocation appears imminent. At the same time the fingers are pressed against the palm of the hand and the lower extremities are extended. 116 MANUAL OF NERVOUS DISEASES. Towards the termination of the spasm, which lasts but a few seconds, respiration is gradually reestablished, and relief of the glottis is announced by a sonorous, crowing inspiration, provided there is no occurrence of general con- vulsions. Death from asphyxia during one of the attacks often happens. It is seldom that the physician arrives in time to wit- ness the spasm. He usually finds the little patient in a warm mustard bath, which is probably as good as any- thing that can be done for the moment. Complicated Spasms of the Respiratory Muscles are seen only in hysteria. They consist of fits of laugh- ing and crying, a brassy cough, gurgling and squeaking sounds, snuffling, fluttering at the heart and extreme rapidity of the respiration. Spasm of the Diaphragm [Singultus). Ordinary hiccough is a sudden contraction of the dia- phragm. Persistent hiccough is often a hysterical symp- tom. It is sometimes exceedingly troublesome and even exhausting. The worst case of hiccough I have ever seen occurred in a young healthy man, who had been two days under treatment without receiving relief. It happened to him after having taken a hasty lunch at a railroad station. I found him sitting in an arm-chair in a reclin- ing position, and with both hands firmh^ grasping a stick to support himself. The hiccough was incessant and violent. The spasm was promptly checked by several ten-grain doses of musk. Hiccough is an ominous symp- tom in severe affections of the bowels, and in peritonitis. Persistent hiccough isusually arrested by morphia or a LOG A L SPASM. 117 few whiffs of chloroform. Galvanism is also useful. One pole is to be applied to the side of the neck and the other to the epigastrium. Spasm of the Muscles of the Neck. The mild form of " wry neck" is usually of rheumatic origin. The spasm is a tonic unilateral contraction of the sterno-cleido mastoid. The more severe variety of "torticollis spastica" is seen in disease of the cervical vertebra. Frequently several of the muscles of the neck are simultaneous!}^ aflfected. In unilateral spasm of the storno-cleido mastoid, the head is turned to the opposite side and the chin is raised. If the trapezius is similarly affected the head is turned backward towards the shoulder of the same side. In spasm of the sjjleniiis, whether isolated or combined with spasm of other muscles of the neck, a firm ridge is seen beneath the outer portion of the trapezius. Bilateral Clonic Spasm, in which the deep muscles of the neck are affected, usually occurs in children. It causes nodding or rotatory movements of the head, which may attain to great severity. General Treatment. All cases of chronic spasm of the mus- cles of the neck offer great difficulty to treatment. The greatest amount of relief is obtained from mechanical apparatus that supports the head, as the spasm usually ceases when the head is at rest. Electric treatment is occasionally of benefit Either current may prove useful by methods which experience in the special case may indicate. A resort to the red-hot iron to the back is 118 MA NUA L O F NER VO US DISEA SES. recommended by some observers. Internal remedies appear to be of little use. ^lorphia injections may become indispensable to afford the patient some respite from the painful or constant spasmodic contractions. Spasm of the Muscles of the Upper Extremity. Convulsive movements of the muscles of the upper extremity are usually seen in central disease and in hysteria. The tonic spasm of the arm in brachial neu- ralgia is a reflex action. Tonic spasm of the rhomhoidii causes a peculiar position of the scapula. Its inner border runs obliquely upward and outward, and its lower border approximates the ver- tebral column. The arm cannot be raised in the upright direction, which also is seen in paralysis of the serratus; but in the latter affection the scapula stands off from the spine. Tonic spasm of the pectoralis wajor, the deltoid and the latissimus dorsi and analogous isolated contractions of muscles of the back and shoulder are of rare occurrence. Their existence is recognized by the hindrance they offer to normal movement of the parts and the rigid condition of the affected muscles. The Flexors of the Hand and Fingers are frequently subject to tonic spasm. The hand is flexed towards the radial side and is rendered concave- In tonic spasm of the muscles of the fingers supplied by the ulnar nerve, the thumb is adducted and the little finger is strongly flexed. Treatment. All these isolated forms of spasm are best treated with the constant current. The rule is to apply LOCAL SPASM. 119 the anode of a stabile current to the spasmodic muscles and the kathode to an indifferent point. Saltatory Spasm. This is a peculiar form of reflex spasm affecting the lower extremities, but only when the patient attempts to stand or walk. The moment the soles touch the floor very energetic contractions begin in the muscles of the leg, which forces the patient to jump or to hop. This affection is occasionally seen in nervous and hysterical individuals. WRITERS' CRAMP AND ALLIED PROFESSIONAL NEUROSES. Among the disorders of co-ordination in persons follow- ing occupations that require the constant use of the hand and fingers, none is as frequently seen as "writers' cramp." There is no defect of the gross muscular power of the hand, but as soon as the patient begins to write, he loses the control of the associated muscular movements needed in using the pen. The right hand being the one usually employed is oftenest affected. No other cause is known than the constant use of the pen. Symptoms. The trouble generally develops gradually. At the beginning, writing is rendered difficult, and finally it becomes impossible. There are various ways in which the movements in using the pen are disturbed. A fre- quent variety of the affection consists of a spasmodic condition of the fingers as soon as the pen is seized. The pen is so firmly pressed by the fingers that it cannot follow the impulse of the writer. In another form the arm is quickly tired out and at last becomes powerless to con- 120 MANUAL OF NERVOUS DISEASES. duct the pen, or the limb is affected with a tremor so that the letters are distorted and the writing illegible. Occa- sionally improvement takes place after the patient has desisted for some time from using the pen, but in general he is finally compelled to relinquish the effort. Persons affected with writers' cramp are often subject to other functional disturbances of the nervous system. Treatment. Cessation of writing for weeks or months is absolutely necessary whatever plan of treatment be adopted. It is of no avail for the patient to learn to write with the other hand, for that will very soon be similarly affected with the cramp. Many contrivances have been devised for facilitating the act of writing. The one which appears to give much satisfaction is a sort of bracelet to which a penholder is attached, that supports the out- stretched fingers. In mild cases the patient may succeed in writing if he rests the whole arm upon a low desk. The judicious and persevering use of galvanism has given some good results. One of the methods is to apply the anode of a weak current to the muscles of the arm and fingers, and the kathode to the region of the cervical vertebra. Interruptions are to be avoided. The faradic current appears to do more harm than good. Brilliant cures have lately been reported from systematic massage treatment. No special rules can be laid down for the varied and complicated manipulations which are necessary to achieve success. To acquire the proper skill it is indespensable to be familiar with the nice and har- monious play of the muscles in the act of writing. Professional neuroses are also met wdth among piano- forte players, telegraph operators, type-writers, cigarette- rollers, tailors, shoemakers and engravers. LOCAL SPASM. /f/ Milkmaids' Cramp. In most cases both hands are affected with spasmodic contractions on attempting any kind of movement, but particularly that of prehension. The median and super- ficial radial nerves are involved. Treatment is the same as that of writers' cramp. CHAPTER VII. MINOR NEUROSES Headache. The clinical importance of headache is to be rated in accordance with its persistence and association with other symptoms. In all febrile affections and grave diseases of the brain, headache is a very frequent con- comitant. Severe and constant pain in the head attends cerebral meningitis, brain tumor and cerebral syphilis. Migraine and neuralgia of the trigeminus and disease of the upper cervical nerves must be distinguished from ordinary headache. Headache is also a common reflex symptom in a variety of morbid conditions. Gastric derangement and sluggish bowels are often accompanied by frontal headache. A distressing form of headache occurs in cerebral anaemia and neurasthenia. Rheumatic headache affects the scalp, usually the occipital region. Toxic influences such as alcoholism, chronic lead and nicotine poisoning, frequently give rise to headache. Physical overexertion and mental excitement consti- tute daily causes of headache. On excluding all these manifold sources of headache, there still remains a pecu- liar form of the malady which is usually called " nervous headache" or ''habitual headache." Its paroxysmal occurrence has been quaintly termed a "nerve storm." (122) MINOR NEUROSES. ITS There are people who are never without headache. Prob- ably in numerous cases this functional affection is due to a constitutional predisposition. The pathology of habitual headache can only be conjectured. It may be said that the brain substance is in an irritable condition. We know, however, that sensory filaments from the trigeminus are sent to the dura mater. Circulatory disturbances of the brain of the nature of congestion, arising under well-known circumstances, may become manifest as cephalalgia. Habitual headache greatly varies in intensity and fre- quency of occurrence in different individuals. Some patients can foretell by vague sensations that an attack is coming on. An attack may continue for half an hour or last a day or two. The headache may only amount to a dull, heavy feeling, diffused over the whole head, or the pain is limited to a particular spot. Patients often give graphic descriptions of the severity of the pain. They say, it feels as if the head were pressed in a vice ; or if it were crushed or split. During, and even some time after an attack, many of the patients manifest much irritability of temper ; they declare themselves unfit for physical or mental exertions. Habitual headache is hard to cure. There may be a particular exciting cause which the patient can perhaps avoid. Overworked and debilitated persons should seek rest or be sent to the country or the seaside. Tonics; especially iron, may often be prescribed with advantage. The coexistence of indigestion, which is usually accom- panied by sluggish bowels, may require attention. Patients often ascribe their headache to a particular arti- cle of diet, or think they suffer from dyspepsia, and then take too little nourishment. In general they are great m M A NUA L O F NER V US DfSEA S ES . €onsuniers of cathartic medicines. This is all wrong. If a mild aperient is indicated it is best to order small doses of Carlsbad salts or the fluid extract of cascara sagrada. The majority of patients have long ago come to the conclusion that nothing will help their headache, and are resigned to their fate. But they still continue to resort lo certain remedies, which they think do them eome good, or which really give them some relief. Remedies Avhich stand in much repute are cold applications to the head ; mustard plasters Vjchind the ears or on the tem- ples ; a hot footbath, strong green tea, etc. There is no lack of remedies from which to chooso. Quinia takes the first raidv, and next comes arsenic, in the form of Fowler's solution. Salicylate of soda in one large dose sometimes averts an attack. Guarano in powder form, 10 to 20 grains every two hours, is occa- sionally of service. The Eff. bromo-caftein is a very popular remedy. The inonobromate of camphor in pills, from 4 to 6 grains, is also much prescribed. Nervous persons may re<'eive benefit from frequently repeated mioses of aromatic spirit of ammonia or sweet spirits of nitre. Prompt relief is often obtained from phenacetin and antipyrin. Excellent results are now and then observed from a very weak constant current. For a min- ute or two the electrodes may be applied to the temples, or one over the forehead and the other to the nape of the neck. HEMICRANIA. (Migraine. Sick Head ache.) Etiology. By hemicrania is understood a peculiar form of headache, affecting only one side. The pain is gener- ally attended by vaso-motor disturbar.ces. ^^'omen are MINOR NEUROSES. 125 chiefly liable to this affection. Uusually it dates from the period of puberty, but genuine migraine also occurs in young children. The cause of this malady is obscure^ nor is it known with certainty Avhat part of the nervous system is primarily involved. Although the concomitant vaso-motor symptoms manifest disturbance of the cervical sympathetic, they may nevertheless be of a reflex char- acter, due to a central irritation. Heredity is probably always a predisposing cause. Hemicrania is especially common in nervous and hysterical women. Mental excitement is very liable to bring on an attack. CliniCil history. Paroxysms of migraine recur at irreg- ular periods, though in some women they coincide with the menstrual flow. A majority of the patients enjoy their usual health during the intervals, while others still continue to be troubled with various nervous complaints. The onset of an attack is often announced by shuddering, sighing and yawning; a feeling of heaviness and of pres- sure of the head; flickering before the eyes; noises in the ear, and a feeling of general weakness. The attack begins with a boring or thumping pain, first in the frontal, then in the temporal, region, and finally invades one-half of the head, in the majority of ca<^es the left side. The pain has not the intermittent character of neuralgia, but gradually increases in intensity. There are no painful points in the distribution of the trigeminus, but the scalp becomes ver\^ sensitive to the touch. At the height of the attack occur the disturbances of the special senses that had already appeared in a minor degree during the prodromal period. The ocular symp- toms are very prominent, consisting of shimmering before 126 MANUAL OF NERVOUS DISEASES. the eyes, flashes of light and temporary hemiopia (hemi- crania ophthahnica). The vaso-motor S3'mptoms deserve especial notice, as they support the theory of migraine being an affection of the sympathetic. During the acme of the attack, in a number of cases, one-half of the face shows decided pallor, the skin is cool, the temporal arteries are con- tracted, the pupils are dilated, and the flow of saliva is increased. Towards the close the spastic condition of the arteries relaxes, the affected side of the face reddens, and the skin becomes warm (hemicrania sympatico-tonica). In another form of migraine there is unilateral flushing of the face, the skin appears puffed, its temperature is raised, the pupils are contracted, the temporal arteries dilated, and sometimes there is one-sided sweating of the face (hemicrania sympatico-paralytica). Although the sympathetic nerve is certainly involved in many cases, it cannot be said that the difficulty of explaining the char- acter of the affection is thereby removed. The occurrence of pain has still to be accounted for. Attacks of migraine vary greatly in duration and severity in different persons. They may last an hour or a whole day. Nausea or vomiting frequently supervenes towards the termination, and is succeeded by nervous depression and a strong inclination to sleep. In view of the chronic course of migraine it is advis- able to be cautious in regard to promises of cure. Patients learn to submit to the periodical visitations of their sick headache. When an attack comes on they usually retire to their rooms, darken the windows, and refuse to be disturbed. MINOR NEUROSES. 127 Treatment. Relief is often obtained from cold applica- tions to the head. Morphia does not allay the pain as promptly as in neuralgia and is often ill borne, as are all the other narcotics. Phenacetine and snlfonal are some- times effective. A large dose of quinia at the commence- ment of the attack may succeed in arresting it. Powders of guarano in half-drachm doses are at times of benefit. Salicylate of soda is another remedy worthy of trial. This remedy is best taken in cafe noir. Two scruples may be given at once. I have seen some good effects from teaspoonful doses of the effervescent citrate of caffein every thirty minutes. Inhalation of nitrite of amyle has been suggested in the spastic form of migraine. NEURASTHENIA. Etiology. The late Dr. Beard of New York described, under the name of neurasthenia, a functional disorder of the nervous system, which he alleged to be extremely common among the adult male population of the United States. He says: "One reason why neurasthenia has been so long neglected is that the symptoms are in some instances so subtle and difficult of analysis and classifica- tion. One, who has never seen and carefully examined a large number of cases of this disease, would not believe it possible that it should manifest itself in so many dif- ferent ways." Nearly all the morbid phenomena which are said to characterize neurasthenia have usually been grouped among different affections, chiefly hysteria, spinal irrita- tion and hypochondriasis. It will hardly be disputed that many vague and ill-defined symptoms come fre- quently under notice which cannot be satisfactorily lfS8 MANUAL OF NERVOUS DISEASES. referred to those disorders of uncertain pathology and inconstancy of clinical features. Experience fully sus- tains what physiological teachings lead us to expect, that numerous and diversified disorders of the nervous system are directly traceable to the depressing influences of phy- sical overexertion and mental strain. Whatever other causes may be assumed to favor their occurrence, it is but fair to consider nervous exhaustion a fruitful source of manifold functional disturbances. The practical impor- tance of recognizing such a condition under the many disguises it may assume is undeniable. It is a curious instance of the change of meaning that words undergo, that the word ''nervous" was originally employed to imply the idea of vigorous, racy, forcible: usage has now assigned to it the very opposite meaning. We still speak of the "nervous style" of a writer, but a feeble, excitable person is characterized as being " nervous." Dr. Beard's happy choice of the word ''neurasthenia," which denotes nervous exhaustion or nervous debility, was at once taken, up and has gained currency among medical men. The adverse criticism which Dr. Beard encoun- tered in setting up a new disease was certainly unde- served, for neurasthenia has the same claims as an independent nervous affection as hysteria or spinal irrita- tion. But his assertion that neurasthenia is par excellence an American disease cannot be sustained, as it is found to be a widespread nervous affection since medical observers have become better acquainted with its characteristics. The greater number of neurasthenic patients are found in our large cities, the centers of culture and traffic, but also the places that incite to excesses. Men in the prime of life are its usual victims, and this fact is significant. MINOR NEUROSES. 129 The expenditure of nerve-force is enormous in the com- petition for wealth and position. The present state of society, especially in our country, holds out numerous and tempting promises not only to the resolute and those of a vigorous constitution, but also to those of a weaker fibre and stamina. There is, in consequence, a restless, dissatisfied spirit abroad that strives and strains for the attainment of the prizes of life. The unavoidable con- comitants of vexation and worry of those not favored by a robust nervous system gradually undermine the very roots of healthy existence. Irritability, feverish excite- ment and discontent unsettle the poise of the coordinate powers of life; then comes the shock of disappointment, the depressing consciousness of failure and the rebound from blasted expectations. These deleterious influences, varied as they are in different individuals, do the work silently until mental and physical disturbances make their appearance that are often difficult to trace to their original causes. Neurasthenia is said to be " the penalty we pay for our high-pressure civilization, and for the wear and tear of body and mind in the hot race for wealth and distinction." The latter clause comes certainly nearer to the truth. A predisposition to neurasthenia or an inherited ten- dency, as in allied affections, must be admitted to exist, for otherwise we could not conceive why among indi- viduals, who are exposed to the same order of influences, some should be affected while others go free. It has, for instance, not been observed that shipwrecked sailors, or soldiers undergoing the hardships of long marches, or professional or business men of a robust constitution who are constantly engaged in the pursuit of their labor- 9 130 MANUAL OF NERVOUS DISEASES. ious and tr^dng avocations, are picked out as victims of the disorder. If a certain proportion of these classes of persons become neurasthenic a predisposition must be presumed to have operated that tended to the develop- ment of this morbid condition. But neurasthenia, as has been shown, may be acquired by the influence of the exciting causes that heavily tax the integrity of the nervous system, diminish the capacity of properly per- forming its manifold and delicate' functions and bring about an " irritable weakness'' that lays the foundation of the functional disorder. It is hardly necessary to enumerate all the more special exciting causes that emi- nently tend to its development. Clinical History. The distinction of cerebral and spinal neurasthenia is based on the prominence of certain classes of symptoms in individual cases. Cerebral neurasthenia is generally observed among men who do much " head- work," or are engaged in positions of great responsibility, whose extensive and complicated business aff'airs make great demands on their constant attention. The literary man, for example, begins to find himself unequal to his task; he soon feels exhausted; the work before him becomes irksome and he is finally unable to bring him- self to carry on a sustained intellectual eff'ort. He com- plains of headache, vertigo, insomnia, an indifferent appetite, muscular weakness and a feeling of general debility. A merchant is worn out by unremitting atten- tion to business, anxiety concerning heavy ventures, per- haps financial embarrassment, and the like. His health breaks down; he becomes dyspeptic; he feels the necessity of rest, which he denies himself; he is subject to frequent attacks of fainting, his sight grows weak, and he has MINOR NEUROSES. ISl "swimming" of the head. One of these symptoms may be more obtrusive than the rest, which fixes his attention upon a particular organ as the seat of his trouble. A hypochondriac disposition is thus apt to show itself. A very singular form of psychical disturbance some- tijies develops in this class of patients. The disorder relates to a morbid fear, which the patient is unable to suppress. It may assume different forms, the most com- mon being agraphobia (fear of open places); claustra- phobia (fear of inclosed places); androphobia (fear of crowds of people) and mysophobia (fear of contamina- tion). I knew of a gentleman, who had been unfortunate in stock speculations, and whose morbid fear consisted in the dread of fatal accidents that might be due to his negligence. He tortured himself with the accusation of having caused the death of an intimate friend because on a cold winter day he did not close the door of the sick- room on his last visit. He picks up bits of fruit parings he finds on the pavement and throws them into the gut- ter lest some one might slip on them and break a limb. He stops in his walk to fasten a loose brick on the pave- ment, and hammers in nails which he finds sticking out in houses and fences which he passes. The man's intelli- gence is perfectly clear. The pathophobia in neurasthenia is not to be confounded with hypochondriasis. The former implies an unsubstan- tial dread; the fancied disease of the latter is founded on a real morbid sensation. Disturbances of the special senses are also quite fre- quent in neurasthenia. Asthenopia often exists, but hallucination of hearing is the most troublesome and distressing of this group of symptoms. A nursing 133 MA NUAL OF NER VOUS DIS EA SES . woman, who complained to me of a large number of neurasthenic disorders that had only lately begun to affect her, consulted me particularly concerning a distinct voice that terrified her almost continually with the com- mand to kill her child. She was perfect! \^ aware of the unreality of the voice, which was proved by her desire to avail herself of medical assistance. A peculiar species of headache, which may properly be called the "neurasthenic headache," is also a very har- assing and obstinate symptom. It is not precisely a pain, but a sensation as if the head were pressed upon by a heavy weight, or distended to bursting. Patients declare they will " go mad " if not relieved. Spinal neurasthenia gives rise to numerous symptoms. The most prominent and constant one is pain in the back and the lower extremities. The patient comjDlains of an unaccountable feeling of fatigue even if he is inactive. Micturition and defecation may cause much discomfort. The genital function is often impaired. There is an unpleasant feeling of coldness, numbness or formication of the limbs or trunk. Many neurasthenic patients suffer only from the minor disorders that have been described and get little sympathy. The more severe forms of the affection unfit patients for all physical and mental efltbrt. Diagnosis. Dr. Beard was undoubtedly correct when he laid stress on the difficulty of recognizing the existence of neurasthenia. Diagnosis may err in many ways. In the presence of a complexity of symptoms, that do not agree with the picture of a well-known individual disease, a particular symptom of prominence may be falsely singled out by the observer to which the rest are consid- MINOR NEUROSES. 1S3 ered subordinate. It may happen, for instance, that dyspeptic derangement is obtrusive, which suggests serious disease of some of the chylopoedic viscera, or the muscu- lar weakness and numbness of the lower extremities may suggest paraparesis. The diagnosis of neurasthenia cer- tainly requires caution, and often must be arrived at by exclusion. Prognosis. Neurasthenia is not a dangerous affection, but it takes a chronic course and is subject to exacerba- tions. The greater number of patients make a complete recovery, while others of a neuropathic tendency are never entirely cured. Treatment. It is of the first importance, in the treatment of neurasthenia, that the patient change the mode of life which led to his brain exhaustion or spinal irritability. He may require absolute rest and quiet, or be benefited by outdoor exercise that does not fatigue. The recuper- ative influence of mountain air, or a visit to the seaside, should be strongly recommended when the patient is much run down. All kinds of mental excitement should be avoided. He may require sufficient sleep, a substan- tial diet and a judicious course of tonic remedies. The nervous dyspepsia can be better overcome by assuring the patient of his ability to digest the ordinary dishes to which he has been used than to ply him constantly with stomachic remedies. In his case the indigestion is due to the want of a proper innervation of the muscular structure of the stomach, and probably the same fault affects the secreting apparatus. A minute direction in regard to the articles of diet to be selected only confirms him in his pusillanimity. m MANUAL OF NERVOUS DISEASES. Next in importance is the moral treatment, differing, however, from that followed in hysteria. The dread and apprehension of the neurasthenic patient is to be allayed by constant assurance of the curability of his disease, and confident expressions in regard to his progressive improvement at every visit. Severe nervous debility in women must be systematically treated, for which Weir Mitchell's method is excellently adapted. The refreshing and invigorating influence of electricity is much appreciated by neurasthenic patients. It is a constitutional treatment that should be persistently employed. The methods of application may be varied. General faradization and central galvanization are the most effective. In timid persons it is preferable to use the electric bath or the "electric hand." The restoration of the muscular vigor is also assisted by massage. Surf- baths and swimming are of analogous benefit. Symptomatic treatment requires a few remarks. Habitual constipation, which always attends nervous dyspepsia, is best overcome by a change of diet. Knead- ing of the abdominal walls is sometimes quite effective in exciting the peristaltic action of the bowels. Sexual weakness is benefited by douches to the back. Conti- nence should be advised. Wakefulness, which is a stand- ing complaint in neurasthenia, tempts to the abuse of morphia and chloral. Before even prescribing the less powerful hypnotics some other means may be found to secure sufficient sleep. A warm bath before bedtime or a wet cloth wrapped around the head is often effectual. Very weakly persons unused to alcohol frequently sleep well on a hot rum-punch, or a glass of ale. The bromide of potassium in large doses occasionally promotes sleep. MINOR NEURONES. 1S5 A resort to the following hypnotics offers much choice. They include sulfonal, .urethan, paraldehyde, canabis indica and phenacetiii-^ But in the end all these drugs disappoint. In fact, the amelioration of insomnia, and all the other symptoms of neurasthenia, will come with the general improvement of the patient. SPINAL IRRITATION. Etiology. Formerly, w'hen this disorder was thought to be of frequent occurrence, extravagant notions were entertained concerning its importance, as the common pathological factor of a legion of diseases. Spinal ten- derness is now known to attend many affections of which it constitutes an insignificant symptom. Moreover, the same symptom is so often observed in hysterical females that neurologists of the present day are inclined to dis- card " spinal irritation" as an independent disease. But, on the other hand, it is hardly permissible to label every obscure nervous disorder in females with the convenient title, hysteria. The physician in actual practice cannot ignore the fact that he has frequently to face a group of symjjtoms, which seem to stand in no other relation to each other than their co-existence with painful vertebrae. The circumstance that eccentric pains and an exalted sensibility constitute symptoms aFmost invariably asso- ciated with spinal tenderness tells strongly in favor of the assumption that spinal irritation is at least a malady of clinical importance. Excessive physical exertion trying to the spine is prob- ably, in many instances, the exciting cause. Anstiesays: "I believe the starting-point of the disorder will very often be found in some strain or blow to the back." 136 MANUAL OF NERVOUS DISEASES. Clinical History. Patients are often unaware of the exist- ence of tender vertebrae until they are firmly pressed upon. The painful points are usually limited to the cer- vical or upper dorsal region. In severe cases the whole vertebral column appears to be tender to the touch. Areas of hyperaesthesia about the neck and between the shoulders are also recognized. Neuralgiform pains of a shifting character are felt in different parts of the chest and abdominal walls. Their locality frequently corresponds to the distribution of the sensory fibres that proceed from the tender portions of the spinal column. A crampy condition of the muscles of the neck often gives rise to a distressing sensation of choking. There is sometimes a dry, harassing cough, attended by disturbed respiration and cardiac anxiety, which greatly alarms the patient. Insomnia is much complained of, and in aggravated cases the feeling of languor and depression causes the patient to seek the bed or lounge in the daytime. As the disorder is almost exclusively confined to the female, it is no wonder that the menstrual function is often irregular. It would be unprofitable to enumerate all the " functional symptoms" that, by a choice of phrase, might also be named hysteri- cal or neurasthenic. Although spinal irritation is a chronic disorder, exceed- ingly variable in the severity and number of its symp- toms, hard to deal with and prone to relapse, it nevertheless tends to recovery. Treatment. As spinal irritation often occurs in females who have undergone much hardship in life, both physical and mental, or subjected the nervous system to debili- tating infiuences, such remedial measures are to be rec- MINOR NEUROSES. 1S7 ommended that invigorate the general constitution. Symptomatic treatment is often called for to meet special disturbances. All observers are agreed that the alcoholic stimulant is of decided benefit in giving relief to the manifold ailments of this disorder, though its dangerous fascination is a great drawback to its employment as a remedy. Blistering of the tender vertebrae should be continued until the pain disappears. The hypera^sthesia often yields to stabile galvanization of the affected parts. CHAPTER VIII. DISEASES OF THE MEMBRANES OP THE SPINAL CORD. Preliminary Remarks. Ideopathic inflammation of the membranes of the spinal cord is usually attributed to the influence of cold. The disease is more frequently- due to direct injury of the vertebral column, or to exten- sion of the inflammatory process in the bones, to the meninges. Of greater practical importance is the asso- ciated inflammation of the cerebral and spinal pia mater, which constitutes the distinctive anatomical change of the infectious disease known as "epidemic cerebro- spinal meningitis." Implication of the spinal meninges is of subordinate importance in inflammatory disease of the substance of the cord (meningo-myelitis). Spinal meningitis may complicate tubercular cerebral menin- gitis. It sometimes develops in pyaemia, typhoid fever and the acute exanthemata. PACCHYMENINGITIS SPINALIS. Suppurative inflammation of the external surface of the dura mater often arises' in caries of the vertebral bones (pacchymeningitis externa). The inflammation often involves the inner surface of this membrane and gradually spreads to the pia mater (pacchymeningitis interna). As ( 138) MEMBRANES OF SPINAL CORD. 139 there are no peculiar symptoms that distinguish the dif- ferent forms of spinal meningitis, it will suffice to describe the primary acute inflammation of the spinal pia mater. SPINAL MENINGITIS. (Leptomeningitis Spinalis Acuta.) Anatomical Changes. The pia mater in the early stage of the disease is injected and thickened. As the disease advances, an effusion of coagulable lymph is thrown out, which is most abundant upon the posterior surface of the cord. Later, a sero-purulent or purulent exudation col- lects in different parts of the surface of the cord, and sometimes is found to cover the whole length of this organ. Clinical History. In many cases of spinal meningitis there is a combination of spinal and head symptoms, due to the simultaneous implication of the cerebral and spinal pia mater. The symptoms of spinal meningitis may also complicate acuter infectious diseases. The clinical charac- ter of a primary spinal meningitis is likewise varied or modified by symptoms dependent on inflammation or the disturbed circulation of the cord. By a careful analysis of the symptoms in complicated cases it will not be found difficult to distinguish those that refer to the spinal inflammation. They chiefly consist of severe pain in the baek and the inferior extremities, accompanied by stiffness of the trunk and the affected limbs. The least movement of the body starts and increases the pain and the muscular rigidity. This is the reason why the patient is found lying perfectly still on his back. He L'fi MA y UAL OF NER VO US D IS EA S ES . shuns every movement and even tries to repress coughing and sneezing. The voluntary immobility of the patient presents the appearance of loss of muscular power, but paralysis is not a symptom directly due to spinal menin- gitis. Hypersesthesia is often well marked and attended by increase of the reflex excitability. The patient dreads to be moved or to change his position in bed in fear of bringing on spasmodic movements. In severe cases he is annoj'ed by the opening and shutting of the door, and even by a footfall on the floor. The bladder is irritable and the bowels are confined. There is always more or less fever. The development of anaesthesia or paralysis indicates implication of the cord. Diagnosis. An uncomplicated case of acute spinal men- ingitis is chiefly recognized by the rather sudden onset of a febrile affection attended by rhachialgia, rigidity of the trunk, and pain and stiffness of the inferior extremities. When these symptoms develop in connection with those of cerebral disease, they are overshadowed by the far more serious import of the latter ; and the same is true when the appearance of paraplegia indicates implication of the substance of the spinal cord. It is of importance to recognize the grave character of spinal symj^toms aris- ing in pyaemia or typhoid fever when the cervical cord becomes involved. This occurrence is manifested by dis- turbance of the respiration, disordered action of the lieart and pupillary changes. Prognosis, Recovery may be expected in the primary form of acute spinal meningitis, due to exposure to cold, but the prognosis of pacchymeningitis and of that form of the disease accompanied by cerebral symptoms is exceedingly unfavorable. MEMBRANES OF SPINAL CORD. Ul Treatment. An active treatment is indicated in the primary form of the disease. The therapeutical meas- ures that tend to subdue the inflammation include wet cups in the painful regions of the vertebral column, fol- lowed by warm or cold poultices. A saline cathartic is often of much benefit, not only for moving the bowels, but also as a derivative. This may be kept up with advantage by small doses of calomel. The bladder demands attention. For the relief of the rhachialgia nothing can take the place of the judicious administration of morj^hia. Iodide of potassium is of benefit in the later stage or when the disease is protracted. HEMORRHAGE OF THE SPINAL MENINGES. (Spinal Apoplexy.) Injury of the vertebrae is the usual cause of extravasa- tion of blood from the venous plexus between the bones and the dura mater. Aneurisms have been known to burst into the spinal canal. The symptoms of spinal apoplexy develop suddenly and with great violence. The pain in the back is intense ; the patient falls over as if shot ; the lower extremities become powerless and the nervous prostration is extreme. After a variable time, if the patient recovers from the effects of the shock, the group of symptoms characteristic of spinal meningitis make their appearance. CHRONIC SPINAL LEPTOMENINGITIS. Since the* recent advances in the more precise path- ology of the spinal cord the existence of a primary form of chronic spinal meningitis has become exceedingly doubtfuL The possibility of the acute disease becoming 11,2 MA N UAL OF NER VO US D IS EA SES . chronic is not disputed, but according to observation it must be of very rare occurrence. Inflammatory adhesions of the pia and dura mater are often found in various affections of the spinal cord, but are of slight clinical importance. PACCHYMENINGITIS CERVICALIS HYPERTROPHICA. Etiology. This is a chronic disease of the cervical dura mater. It is met with in persons addicted to excessive use of alcohol, and is also attributed to exposure to cold and damp. The Anatomical Change consists of marked induration of the dura mater, the pia being only slightly aff'ected. The thickening of the membrane irritates and subsequently compresses the nerve roots. Finally the motor tract of the spinal cord is involved. Clinical History. The disease begins with severe neural- giform pains in the occiput, neck and arms. There is also a feeling of numbness in the upper extremities, on which occasionally an herpetic eruption makes it appear- ance. In the second stage an atrophic paralysis develops in the muscles of the forearm, which are supplied by the median and ulnar nerves. In some cases the muscles to which the musculo-spiral is distributed are also impli- cated. This gives rise to a peculiar deformity of the hand. The hand is strongly flexed, the fingers are on a line with the metacarpal bones and are flexed, and the thumb is bent upon the palm of the hand. If the change in the cord takes a downward direction the inferior extremities become also paralyzed and aucTsthetic, but there is no wasting of muscles. The additional symp- MEMBRANES OF SPINAL CORD. US toms include painful swelling of the small joints of the hand, dilatation of the pupils and troublesome hiccough. Ross reports two typical cases of the disease, one of which recovered. Joffroy recommends the thermo-cautery to the back of the neck. THROMBOSIS OF CEREBRAL SINUSES. Besides the inflammatory thrombosis of the cavernous and petrosal sinus occurring from extension of otitis to the dura mater another form of thrombosis is met with affecting the longitudinal sinus, which is seen in ill- nourished children and marasmic adults. The clinical history of these cases is not sufficiently pronounced to permit of a certain diagnosis. Either the symj)toms characteristic of meningitis are prominent or there is a low typhoid condition. CHAPTER IX. DISEASES OF THE SPIXAL COED. Diseases of the spinal cord may be divided into two large groups. The pathological change in the one is more or less diffused in the transverse direction of the cord, involving both the white and gray substance. This group includes the different forms of transverse myelitis. The anatomical change in the other group is confined to definite tracts of the cord. This remarkable limitation of the lesion gives rise to special sj^mptoms, that distin- guish the '' systemic diseases" of the spinal cord. They chiefly include locomotor ataxia, poliomyelitis anterior acuta, amyotrophic lateral sclerosis and pro- gressive muscular atrophy. The clinical peculiarities of this class of diseases are essentially due to the situation and not the nature of the lesion. We are thus enabled in cases which do not correspond to typical spinal affec- tions to form a diagnosis concerning the definite part of "the cord which is involved. The simultaneous or suc- cessive implication of different nerve tracts of the cord give rise to combined forms of spinal disease. This is usually dependent on the extension of the original lesion. (144) DISEASES OF THE SPINAL CORD. llfS The following figure reproduced from Young is an instructive diagram illustrating a number of functional disturbances of the spinal cord. C, Skin. 4, Lesion of the anterior gray T, Tendon. horn. M, Muscle. 5, Lesion of the antei-ior root 1, Lesion of the peripheral nerve. zone. 2, Lesion of the posterior root. 6, Transverse lesion of the spinal 3, Lesion of the posterior root cord. zone. 7, Local lesion of the cerebral hemisphere. The different nerve fibres of C and T terminate in the ganglion cell of the anterior gray cornua from which issues an efferent nerve, which connects the cell with the muscle M. The lesion 7 of the pyramidal tract in the hemisphere causes hemiplegia of the opposite side. The dotted lines indicate descending degeneration of the pyramidal tract. 10 U6 MANUAL OF NER VOUS DISEASES. Lesion of the peripheral nerve at 1 causes atrophic paralysis, loss of sensation and abolition of both kinds of reflexes, but no paralysis. Lesion of the posterior root nerve at 2 causes loss of sensation and abolition of both kinds of reflexes, but no paralysis (pacchymeningitis). Lesion of the posterior root zone at 3 causes loss of tendon reflex only (locomotor ataxia). Lesion of the anterior graj^ nerve at 4 causes atrophic j)aralysis, but no sensory disorder (poliomyelitis). Lesion of the anterior root at 5 causes the same symptoms. Transverse lesion of the spinal cord at 6 causes paralysis of the lower extremities with excess of both kinds of reflexes. ACUTE AND CHRONIC MYELITIS. Etiology. The usual causes of ideopathic myelitis are attributed to physical hardship, especially outdoor work during rough weather. It is much less certain that sexual excesses or violent emotion cause the disease. Individuals are affected in whom the existence of a pre- disposing or exciting cause cannot be ascertained. The most frequent causes are injuries to the vertebral column, such as fracture, dislocation, penetrating wounds, falls, and blows on the back. Another important factor in the causation of myelitis is compression of the cord in caries of vertebral bones. Secondary myelitis may result from suppurative spinal meningitis. There is also strong evi- dence that myelitis may be of syphilitic origin. Anatomical Changes. On inspecting the spinal cord in recent cases of myelitis no marked changes are seen. An expert may, however, recognize in some places an abnormal hardness or softening of the cord. The out- lines of the gray matter on cross sections appear less distinct than normal and the white substance is of a red- dish-gray color. Microscopic examination gives more satisfactory evi- dence of the effects of the inflammatory process. Staining DISEASES OF THE SPINAL CORD. W brings out a prominent difference between the healthy and diseased parts of the cord. The nerve fibres in the latter are reduced in number, some are atrophied and others have entirely disappeared; the axis cylinders are round or contracted and have lost their processes. A striking change is recognized in the neuroglia, consisting of increase of connective tissue, which replaces the destroyed nerve elements. The " spider cells" represent the many branched nucleii of the connective tissue cells. Com- pound granular corpuscles are seen in abundance between the meshes of the neuroglia, but are less numerous in old sclerosed parts. Marked changes are also found in the blood-vessels; they are dilated and congested, this condition gives rise to hsemorrhagic spots. The walls of the vessels have undergone " hyaline degeneration." These anatomical alterations usually occupy a transverse section of the cord and extend for a very short distance in the longitudinal direction of the organ. The only dif- ference in regard to the character of the anatomical changes of acute and chronic myelitis is the unimportant circumstance that the diseased part of the cord in the former is of less consistence. Clinically we speak of acute myelitis, when there is a rapid development of the symptoms. Clinical History. A description of the motor and sensory disorders, including abnormal reflex action and implica- tion of the bladder, the rectum and sexual functions, embraces the essential clinical history of all forms of transverse myelitis. The special symptoms observed in individual cases depend on the particular region of the cord which is the seat of the disease. us MANUAL OF NERVOUS DISEASES. Motor Disturbances. The initial motor symptoms indi- cate the development of paralysis. The patient complains of weakness and a sensation of fatigue in the lower extremities, and he has an unsteady gait. Gradually the weakness of the limbs increases until marked paraplegia is established. These symptoms take a different course when the upper region of the cord is affected. Signs of motor irritation are also observed in the early stage, consisting of the spontaneous occurrence of twitching and cramp in the paralyzed muscles. Paraplegia is the constant and conspicuous symptom of transverse myelitis, as the motor tract of each lateral column of the cord is involved. Sensory Disorders are not well marked in the early period of mild forms of myelitis. Some slight numbness and furriness of the lower extremities is often present. At a later stage the cutaneous sensibility in these parts is impaired and complete anaesthesia is finally estab- lished. This occurrence indicates implication of the gray posterior cornua and the posterior columns of the cord. Total anaesthesia of the paralyzed parts speedily ensues in traumatic myelitis. In lumbar myelitis the anaes- thesia is on a line with the umbilicus ; in myelitis of the lower dorsal region the anaesthesia is on a level with the lower part of the sternum ; in myelitis of the upper dorsal region the anaesthesia reaches the axilla, and in cervical myelitis the sensibility of the arms is impaired. The Reflexes. Both the cutaneous and tendon reflexes are morbidly affected, either in consequence of interrup- tion of the centripetal paths of the nerves or interfer- ence with the inhibitory fibres. In severe inflammation of the dorsal or cervical cord there is marked increase DISEASES OF THE SPINAL CORD. U9 of the reflexes. When the disease involves the lumbar enlargement the patellar and cremaster reflexes are abolished. Disorder- of the Bladder and the Rectum. Impairment of the functions of the bladder and the rectum is a very common symptom of myelitis. At the outset there is con- siderable vesical irritability. The evacuation of the bladder is attended by a straining effort, and there is often retention of the urine. At an advanced stage incontinence ensues, which frequently leads to cystitis. This is always a serious complication, as it threatens the development of pyelo-nephritis. Obstinate constipation of the bowels exists from the beginning, and as the paralysis increases the discharges pass away involun- tarily. The sexual function is weakened early in severe cases, and finally may be wholly lost. In the case of a young married man whom I attended the myelitis, which resulted from the kick of a vicious mule, had so far improved that the patient was again able to walk with the assistance of a cane, while his sexual powers still con- tinued to be entirely lost. Trophic Disturbances. The paralyzed limbs in disease of the dorsal and cervical cord do not waste. The muscles are, however, flabby from disuse. The electric reaction is normal. When myelitis affects the lumbar cord the muscles of the lower extremities atrophy and manifest the reaction of degeneration. Vaso-Motor Disturbances. The paralyzed limbs present a mottled appearance or are cyanotic. The surface is cool and oedema appears. 150 MANUAL OF NERVOUS DISEASES. Bed sores constitute serious complications in myelitis. They usually develop in the sacral region and inner side of tlie knees. The decubitus is chiefly due to pressure and the effect of irritating discharges from the bladder and rectum. Malignant decubitus is supposed to be due to trophic changes. Psychical Symptoms are absent during the whole course of myelitis. In rare cases the brain is involved from upward extension of the disease, which gives rise to bulbar symptoms. Changes of the Pirpils are observed in cervical myelitis. Sometimes optic neuritis is discovered by the ophthalmo- scope. Diagnosis. Transverse myelitis in which the diameter of the cord is implicated can hardly give rise to diagnostic difficulties. The essential symptoms are paraplegia, anaesthesia, implication of the sphincters of the bladder and rectum, impairment of the sexual function, absence of atrophy in lesion of the dorsal and cervical regions, but wasting of the paralyzed muscles and abnormal electric reaction in advanced cases of lumbar myelitis. It remains yet to consider the special symptoms presented when the disease attacks different segments of the cord. Cervical Myelitis. In myelitis of this region of the cord some or all of the muscles of both arms and legs are paralyzed. Atrophy of single muscles is occasionally observed, and in a late stage also anaesthesia. The tendon reflexes in the lower limbs are exaggerated and there is disturbance of the sphincters of the bladder and rectum. Pupillary changes are sometimes noticed. Dorsal Myelitis. The paraplegia is confined to the DISEASES OF THE SPINAL CORD. 151 inferior extremities, and eventually anaesthesia develops. There is no degenerative atrophy of the paralyzed mus- cles, but increase of the tendon reflexes. The bladder and rectum are involved. Lumbar Myelitis. There is motor and sensory paralysis of the legs, the upper extremities are free. The cuta- neous and tendon reflexes are diminished. Sometimes there is atrophy of the paralyzed muscles and reaction of degeneration. The functions of the bladder, the rectum and the sexual organ are impaired. Course and Prognosis. Chronic myelitis, which is not the continuation of the acute form, begins slowly and in an insidious manner. The vague parsesthetic sensations and rheumatoid pains in the limbs, the slight muscular weak- ness, the occasional vesical trouble and slight impairment of the sexual function may at the beginning cause little anxiety to the patient. Gradually the paresis increases, although the cutaneous sensibility be still intact until the paralysis is completely established. Chronic myelitis may remain stationary for years and even for a lifetime. Some improvement may occasionally be observed, but recoveries are extremely rare. A fatal termination is threatened on the occurrence of cystitis or the appearance of malignant bed sore. Treatment. The faintest suspicion of a history of syphilis indicates the prompt employment of the specific remedies. This causal treatment is of course to be abandoned if not followed by improvement after a reasonable time. Ergo- tine is recommended by Brown-Sequard. This remedy may be of service in the early stage. Russel Reynolds speaks favorably of the tinct. ferrichloride. Among the other internal remedies generally employed in myelitis are 152 MANUAL OF NERVOUS DISEASES. included the iodide of potassium, strychnia and nitrate of silver. Very little must be expected from other curative measures in confirmed myelitis. Electricity may be of considerable benefit, though it can as little restore degen- erated structure, as any other remedy. Galvanization promises most. The method recommended is to place two large electrodes on the vertebral column near the supposed seat of the disease in the cord, and to pass through it a stabile or slow labile current of medium strength. The position of the electrodes may be varied in different sittings. Stimulation of the paralyzed muscles with the constant and interrupted current is also to be practiced. The electric brush is adapted for the anaes- thesia. The bladder and rectum may be separately gal- vanized with suitable electrodes. A warm bath, which should never be over 98' F., is an excellent means of relieving many unpleasant sensations attending the paral- ysis. It often relieves tremor and twitching of the para- lyzed muscles. The warm mud baths of the Arkansas hot springs stand in much reputation for the treatment of paraplegia. Attention to the functions of the bladder and the rectum is required throughout the whole course of the disease. To prevent retention of urine nothing can replace the use of the catheter. Severe cystitis is treated with chlorate of potassium freely diluted, benzoic acid and liquor potassie. Bed sores are often prevented by cleanliness and the proper adjustment of the bedclothes so as to avoid the formation of folds and wrinkles. A water or air cushion may become necessary. The abrasions of the skin are DISEASES OF THE SPINAL CORD. 153 sometimes satisfactorily treated with a combination of castor oil and balsam of copaiba spread on a piece of thick linen cloth. Suppurating sores are best treated with iodoform liniment. Constipation should be overcome by an appropriate diet and enemata. The restlessness and insomnia of old paralytics may sometimes be best relieved by a hot rum punch at night. ACUTE ASCENDING PARALYSIS. Landry's Disease. This is a peculiar form of paralysis which was first described by Landry and has since been often seen by other observers. The etiology of the disease is obscure. It attacks apparently healthy persons and men more frequently than women. Clinical History. The development of the paralysis is always announced by premonitory symptoms. For the first few days the patient complains of headache, loss of appetite, a dragging sensation in the limbs, pain in the back and some fever. Quite suddenly one leg becomes paralyzed, then the other, next the trunk and lastly the hands and arms. Voluntary movement of the lower extremities is completely abolished, and the paralyzed limbs are flaccid. In some cases the reflexes and the electric excitability remain intact, but usually the tendon reactions are diminished or entirely abolished and the electric excitability is lost. The sensory disorders are insignificant. Anaesthesia is very seldom obseived. There is occasionally some ting- 15 Jt ^lA N UAL OF NER VO US D IS EA S ES . ling or numbness of the fingers. None of the cranial nerves are affected. The legs are sometimes oedematous and often covered with perspiration. The bladder and rectum are not implicated. A favorable turn of the symptoms after the patient has lingered from two to four weeks may lead to complete recovery. A fatal termination is imminent if the disease in its upward progress involves the medulla oblongata. Respiration becomes then difficult, the movements of the diaphragm are diminished, and before death ensues the paresis frequently affects the lips and soft palate. But patients have been known to rally even after the appear- ance of these formidable symptoms and to make a tedious recovery. In the absence of anatomical changes affecting the nervous system, it has been conjectured that the disease may be of an infectious origin. The character of the premonitory symptoms and the attending fever lend sup- port to this view. The Diagnosis rests on the development of a paralysis commencing in the feet and rapidly extending upwards. Primary multiple neuritis presents similar clinical pecu- liarities, but this affection is distinguished by marked sensory irritation, consisting of violent pain in the affected parts. These symptoms are absent in acute ascending paralysis. Treatment. The disease suggests the treatment of acute myelitis. In addition to the usual remedies recommended in that disease it may be of service in the early stage to apply wet cups along the vertebral column. DISEASES OF THE SPINAL CORD. 155 SPINAL PARALYSIS FROM GROWTHS AND CAVITIES IN THE CORD. Paraplegia is in rare instances caused by tumor of the spinal cord and more seldom still by an aneurism making its way into the spinal canal. These forms of "pressure paralysis" are accompanied by violent shooting pains and stiffness of the limbs and the usual symptoms characteristic of transverse myelitis. Unilateral paralysis develops when the tumor is confined to one side of the cord. Cavities found in the spinal cord arise from dilatation of the central canal (hydromyelia), or develop near it (syringo-myelia ) . It is impossible to diagnose the existence of a tumor or cavity of the cord during the life of the patient. These lesions give rise to varieties of myelitis according to their situation. Small cavities develop no symptoms. Unilateral Lesion of the Cord. Traumatism is the usual cause of this form of spinal paralysis. The peculiarity of the paralysis consists in this, that motor paralysis is confined to the side of the lesion, and anaesthesia to the opposite part of the body. Physiology furnishes an explanation of this phenomenon. CONCUSSION OF THE SPINAL CORD. Railway Spine. Although this is usually considered a surgical disease, yet symptoms of an essential nervous character may develop in the course of weeks or months after the imme- diate effects of the injury have passed off. Since the intro- duction of railroad travel, accidents affecting the spinal 156 MA N UA L F NER VOUS DISEASES. cord in consequence of concussion have* become frequent and have given rise to suits for damages. Erichsen in his little book on this subject proposed the name ''railway spine" to characterize spinal concussion in which there is absence of gross injury to the vertebrae, such as fracture, dislocation or hemorrhage. A knowledge of the finer changes taking place in the spinal cord from concussion, independent of a palpable lesion, is not claimed. The infer- ence that this organ is in a morbid condition is based on the appearance of a group of symptoms that are evidently spinal. Such an inference is strengthened by the anala- gous fact that no coarse lesion of the nervous system has been found in many cases of death occurring a few hours after concussion of the brain. Clinical History. The symptoms that develop or become troublesome by their persistence after the accident are chiefly subjective, and for this reason admit of different interpretations. They mainly consist of a general mus- cular weakness and painful sensations in diffent parts of the body. There is no actual paralysis, but many patients are quickly tired out from standing and walking. The gait is stiff, slow and dragging, and often requires the'aid of a stick or crutch. The pain is mostly felt in the back and limbs, and there is a sensation of constric- tion about the trunk. Numbness of the tips of the fingers is frequently complained of and on closer examination well-marked anaesthsia will be found in different areas of the skin. In some cases there is contraction of the field of vision. The tendon reflexes are diminished or may be entirely abolished. If cerebral symptoms are present they generally consist of headache, dizziness, attacks of DISEASES OF THE SPINAL CORD. 157 faintness, ringing in the ears, specks before the eyes and often nervous irritability and mental depression. Recovery or much improvement may be expected from treatment in favorable cases. The trouble is, however, usually protracted and tends to develop a serious spinal affection. The hope of having made a fortunate escape from the consequences of the concussion is disappointed. Paresis and anaesthesia of the legs and disturbance of the functions of the bladder and rectum and sexual organ render it apparent that the previous mild symptoms have culminated in the establishment of a grave spinal disease. The occurrence of difficulty of speech, insomnia, defective memory and general nervous prostration indi- cate cerebral complication. Though casual improve- ment may still take place it soon becomes clear that the patient is continually losing ground. Emaciation and marked weakness are manifest and the fatal termination is hastened by the occurrence of any incidental complica- tion. It may be fairly assumed that the concussion has finally given rise to grave lesion of the spinal cord and brain. The Diagnosis of spinal concussion should not be lightly made, for symptoms showing irritation of the spinal cord and functional motor disturbances may be due to a dif- ferent cause, or may be simulated. The circumstance that the initial symptoms are all subjective and partake of the hysterical or neurasthenic character render it incumbent to make a thorough examination. The judg- ment in regard to the early symptoms should take into consideration the influence of fright, the exaggeration of impressible individuals and a possible interested motive. 158 MANUAL OF NERVOUS DISEASES. Due weight must, however, be given to the condition of the reflexes and other physical signs of disease. The Treatment of the condition that persists after the shock has passed off consists of rest in bed, cold spong- ing, followed by friction of the back and galvanization of the vertebral column and of the limbs. General faradi- zation is also of benefit. The judicious administration of iodide of potassium, ergotine and strychnia may be found of service. CHAPTER X. SYSTEMIC DISEASES OF THE SPINAL COED. Loco-motor Ataxia. {Tabes Dorsalis.) Etiology. Loco-motor ataxia is a striking example of the class of systemic diseases of the spinal cord. It is a chronic disease, anatomically distinguished by degenera- tion of the posterior columns of the spinal cord and clinically marked by peculiar motor symptoms. The predisposing and exciting causes are usually referred to a hereditary tendency, physical and mental overexertion and sexual excesses; but the uncertainty in regard to these alleged etiological factors must be admitted. The disease appears with greater frequency in men than in women, and usually in the middle period of life. The fact has been ascertained as the result of recent investi- gations that a very large percentage of ataxic patients have had a history of syphilis. Fournier rates the proportion at 75 per cent; Erb as high as 90 per cent. Other observers give lower figures, but the probability of a connection between ataxia and syphilis is very strong. Secondary or tertiary symptoms are only occasionally observed in ataxic patients. The objection raised against the supposed relation existing between (159) wo MANUAL OF NERVOUS DISEASES. ataxia and syphilis is the circumstance that the ana- tomical changes in ataxia differ histologically from those characteristic of syphilitic degeneration. It is neverthe- less highly probable that loco-motor ataxia is somehow connected with a syphilitic influence. In female tabetic patients a history of syphilitic infection can be made out in nearly every case. Anatomical Changes. Inspection of the spinal cord in patients who have died in the advanced stage of loco- motor ataxia discovers considerable alteration of this organ. A streak of gray discoloration running along the whole length of the shrunken cord is seen through the pia mater. This membrane at the under surface is thickened. On a cross-section it is noticed that the smallness of the cord is due to atrophy of the posterior columns. These parts appear thin and flattened and are distinguished from other portions of the cord by their darker color. The posterior cornua and posterior nerve roots present sometimes a similar appearance. The microscope shows unequal distribution of the degeneration. In the lumbar cord the morbid change is well marked in the middle and posterior portion of the posterior columns. Nearly the whole of the posterior columns of the dorsal cord is degenerated. Goll's col- umn in the cervical cord is chiefly implicated, and also fibres of the posterior root zones that enter Burdach's column in the lumbar cord. Areas of degeneration are also seen in the gray matter of the posterior cornua, and many of the medullated fibres of Clarke's column have disappeared. The degeneration in advanced cases can be traced to peripheral nerves of the posterior nerve roots, especially in the trunk of the sciatic. It is note- ,S' rS TEM IC DISEAS ES SPINAL CORD. 161 worthy that every case of loco-motor ataxia presents the same anatomical change in the symmetrical nerve tracts of the spinal cord that subserve the same physiological functions. The pathological process in the diseased structure is a primary degenerative atrophy of the nerve elements and an increase of the connective tissue. The grayish color of the posterior columns is due to the loss of the medul- lary sheaths. A few fat granules and numerous corpora amylacea^ are also found in old cases. Clinical History. It is convenient in considering the clinical history of loco-motor ataxia to divide it into three stages, although there is great variation in the intensity of the symtoms, their order of occurrence and their combination. 1. The stage of sensory irritation. Usually the disease develops in an insidious? manner and this condition may continue for a considerable length of time before the more significant symptoms make their appearance. Patients begin to complain of wandering pains in the lower extremities, which they are apt to ascribe to rheu- matism. The arms and back are often similarly affected. But the most characteristic symptom at the early stage is the occurrence of darting, lancinating or lightning-like pains in the legs. These pains are of great intensity and recur at first at irregular periods, but as the disease advances they are almost continuous. Sometimes "stab- bing" pains are felt in the joints. A headache like migraine is also a common tabetic symptom. The "girdle sensation" is often well pronounced. The patient has the feeling as if a rope were tightly fastened around his trunk or abdomen, or there is a feeling as if the 102 M A N UAL OF N E R V U S DISEASES. calves of the legs or the insteps of the feet were tightly bandaged. The other sensory disturbances are less constant. Certain areas of the skin are found hypera^sthetic. The patient is especially very sensative to changes of tem- perature. Some degree of numbness in the tips of the fingers is often present. On examining a patient it may be found that at first he does not feel the prick of a pin, but a few minutes afterwards he feels pain at the point of contact. The tactile sensation is frequently abnormal. On being touched in one place he may declare that he felt two simultaneous impressions. It is only in the later stage of the disease that evident anaesthesia and anomalies of the muscular sense can be satisfactorily recognized. Disorders of the bladder and rectum, which are usually well marked in advanced cases, are often conspicuous at an early period, and the same maybe said of the sexual function. Ocular symptoms sometimes appear at an early stage. Immobility of the pupils is often noticed, especially the; " Argyle Robertson symptom," or the pupils are very much contracted. Paralysis of ocular muscles is not as fr(^quently observed at the beginning and may only be temporary. A diplopia may disappear and not return. Dimness of sight, contraction of the field of vision ter- minating in total blindness, also belong to the occasional initial symptoms. The latter complication of the disease is due to optic atrophy. In a small percentage of cases auditory symptoms develop consisting of tinnitus, deaf- ness and vertigo as in Menier's disease. 2. The ataxic stage. The appearance of the ataxic symp- toms may l)e considered the second stage of the disease. S Y S T E M IV DI S E A S E S S P J N AL CO U I) . /';? There is no paralysis, for the patient is able to offer great resistance to an attempt to bend the limb, but there is inco- ordination of movements. The mechanism which adjusts and controls the harmonious action of muscles in carrying out intended movements is impaired. The act of standing is insecure and uncertain, the gait is oscillating and totter- ing. In the act of rising from his seat the patient has much difficulty to gain a secure footing, which he tries to overcome by bracing himself Avith his hands. These irregularities of motion are of much importance and may be observed before the disease has made much progress. The patient himself may have noticed that his body sways when, for instance, he bathes himself in the morning. When mounting steps he is apt to stumble. He has a straddling gait, he places his feet wide apart to gain greater support ; in lifting them he raises them too high and they come down on the ground with a stamp. On making a quick turn, as in the military " face about," he loses his equilibrium. In standing he seeks for support by leaning against something, and in walking he needs a stick. There are many ways of testing the existence of inco-ordination. When the patient lies on his back and is told to touch the knee of one leg with the heel of the other foot he makes several attempts before he succeeds. When he is asked to throw one leg over the other he makes too wide a sweep with the raised leg. The impaired cutaneous sensibility and disorder of the muscular sense constitute the causes of "Romberg's symptom." If the patient closes his eyes whilst stand- ing his body begins to reel; he is unable to sustain his center of gravity, and if not supported he would fall over. It is interesting to observe the influence of sight 1(;4 MA .V UA L OF NER VOUS DIS EA S ES . in supplementing the loss of control over the movements of locomotion. The patient fixes his eyes on every step he takes. The upper extremities are much less affected. There is sometimes a want of precision in manipulations, especially in those that require nicety of execution. Patients experience much difficulty in buttoning a sleeve or threading a needle. Anaesthesia is frequently well marked; at least some of the different qualities of com- mon sensation are either blunted or entirely abolished. There is impairment of tactile and muscular sensibility. This explains the fact that patients cannot tell the position of their limbs when in bed or in the dark. A more constant sensory symptom is an abnormal feeling of the nature of numbness. Patients compare it to a feeling of furriness, especially experienced in the soles of the feet, as if they were standing on a soft cushion or on a bag filled with air. In the hands the sensation produces the impression of being covered with gloves. There is also a morbid sensitiveness to changes of temperature. The cutaneous reflexes, as a general rule, are normal^ but the aholition of the i^atellar tendon reaction is such a constanl'symptom of loco-motor ataxia that it constitutes one of the most important diagnostic signs of this dis- ease. Exceptional cases may be met with in which many of the tabetic symptoms are present, while the patellar reflex is not deficient. This circumstance does not diminish the gigniijcance of the absence of the knee jerk. On the other hand there are healthy individuals in whom the patellar tendon reflex can be but faintly elicited, which of itself would not be considered an abnormal condition. Trophic disorders are not conspicuous in ataxia. An S YS TEM [ C I) IS EASES SPINAL CORD. 165 eruption of pemphigus or herpes sometimes appears on the inferior extremities along the course of painful nerves. Occasionally perforating ulcer of the foot develops. Of greater interest is the occurrence of painful swelling of one of the large joints. The ^^ arthropathic iaheiiqve'" either affects the hip or the knee joint. Intercurrent attacks of gastralgia, nausea and vomiting — the cnsis gastrique — are observed in many cases of ataxia. Laryngeal crisis consists of the occurrence of severe dyspnoea and spasmodic cough. Violent lumbar pain, resembling an attack of nephritic colic, is less fre- quently observed. Periodical acceleration of the pulse is sometimes noticed during the course of the disease. Incoordination. The peculiar motor disturbance which is such a prominent symptom of loco-motor ataxia, brings up the consideration of the nature of coordination and the mechanism that subserves this physiological function. It is now generally understood that co-ordination is the machine-like execution of .movements by which different muscles are brought into harmonious action. The vol- untary impulse incites the special movements, but con- sciousness is not concerned with the action of the individual muscles. The exercise of the will is all that is necessary to set the muscles into action to carry out the purposed movement. The mode in which co-ordina- tion is established we may learn from the efforts of a child ^vhen it begins to walk, or when we atttempt new and complicated movements. We call into play our tactile sense and our sense of sight, and, above all, our past experiences of graduating our muscular energy in accomplishing a desired act. In other words, we make use of the " muscular sense" in co-ordinating our move- KUi M A N U A L O F NERVOUS DI S EASE S. ments. Gradually an organic connection is established between certain nervous elements, so that consciousness is no longer engaged in the movements after they have once been incited by the will. Although the existence of centers and conducting paths of co-ordination cannot be anatomically demonstrated, yet there is strong reason to infer that such exist in the spinal cord and are implicated by the lesion that gives rise to loco-motor ataxia. We have seen that an ataxic patient resorts again to the aid of the sense of sight to relieve, in a measure, the loss of co-ordination. 3. The Paralytic Stage. Numerous ataxic patients suc- cumb to some intercurrent disease, so that they are spared the wretched condition of helplessness which marks the paralytic stage.* As in all severe affections of the spinal cord that tend to a fatal termination, paraplegia sets in attended by bedsores and nephritic complications. Diagnosis. Loco-motor ataxia, when fully established, presents such clearly cut clinical features that diagnosis meets with no difficulty. At an early stage, when the neuralgiform pains in the inferior extremities constitute the most conspicuous symptom, diagnosis may be doubt- ful. It is well to remember that persistent or paroxysmal pain in both legs, especially if attended with eye symp- toms and vesical trouble, should always raise suspicion of serious spinal disease; and if the patellar reflex is much diminished, or absent, the diagnosis of loco-motor ataxia is certain. Prognosis. Experience confirms the bad prognosis, which may be a priori entertained of a disease marked by a progressive destroying lesion. Recoveries if they S Y S T E MIC DIS E A S E S S P I .V A L CORD. 167 ever occur, are extremely rare. Still the forecast need not be absolutely gloomy, for loco-motor ataxia some- times assumes a mild type, and, under favorable condi- tions, life may be prolonged. for many years. The course of the disease is very chronic, though occasionally serious symptoms develop rapidly. Much can be done for the relief of the patient in palliating the severity of the pain in the limbs and other symptoms as they arise, which sustains his hope and courage. Treatment. The early recognition of the disease affords the opportunity of adopting an appropriate treatment, with the expectation at least of effecting some improve- ment, if not arresting its advance. The patient should consider himself an invalid, and abandon any avocation that calls for much physical and mental exertion. An energetic anti-syphilitic treatment in the early stages is indicated if there should be the least suspicion of the venereal taint. P]nough would be gained in check- ing the advance of the disease, although the mercury and the iodide of potassium be ''found wanting" for the removal of the mischief that has already occurred. Different methods of electric treatment are recom- mended. An ascending constant current may be passed through the cord in the manner that has been mentioned for the treatment of chronic myelitis. Another method consists in brushing the skin of the back with a strong faradic current for five or ten minutes. Peripheral gal- vanization is often of benefit in allaying the pain in the limbs and the irritation of the bladder. The methods of electric treatment may be varied, but whichever is selected should be kept up for months. TJte Suspension Treatment. An estimate of the merits of ^ 7^ ^sj^'^f^- "^^^^^^^ '- ^VHz/j /t—J^/*^ ^4,,?*^^ U^-fy^y^ rJCU^ A168 AlANUAL OF NERVOUS BISWASES. ' . the suspension treatment in ataxia, recently introduced"' into practice by Charcot, can hardly yet be decided upon, although in many of the reported cases the improvement was incontestible. Further experiments will determine whether the benefit derived from this treatment is a per- manent one or not. Suspension is made by Sayre's well- known apparatus. It is advisable to commence with half-minute suspensions, and then according to the sus- ceptibility of the patient they may gradually be pro- longed to the maximum of four minutes every other day. Nerve-.itretching of the sciatic for the relief of the pains often produces a good effect, though usually it is transient. Internal remedies are indicated on the same general principles that call for their employment in the treatment of myelitis. The nitrate of silver is highly recommended. One-fourth of a grain in pill is the usual dose to begin ^, y j^with. It is given three times a day before meals. rP/^t^'^ Symptomatic treatment is often indicated, more par- ticularly for the mitigation of the pains in the limbs, for which hardly any other remedy but morphia will suffice. Vesical trouble also requires attention. ^ HEREDITARY ATAXIA. F"riedrich's Disease. This very rare form of ataxia occurs far more fre- quently in young females than in males. There is no initial stage of pain. It begins with ataxia of the inferior extremities and soon extends to the arms. The abolition of the tendon reflexes is observed in most cases. The cutaneous sensibility remains intact. There S YS TEM IC D IS E A S ES S P IN A L COR D. PJ9 is no vesical disturbance nor affection of sight. A peculiar defect of speech develops during the course of the disease, which appears to be due to inco-ordinate action of the lips and tongue. The disease runs a very chronic course and finally atrophic paralysis of the extremities is established. The anatomical change con- sists of disease of the posterior and lateral columns of the spinal cord. Treatment is unsuccessful. POLIOMYELITIS ANTERIOR ACUTA. (Infantile Spinal Paralysis.) Etiology. This disease was described by older writers under the name of "the essential paralysis of children." It occurs in early childhood between the ages of six months and four years. Healthy children are as likely to be attacked as those of a sickly constitution. Some observers conjecture that the disease is of an infectious nature. It is not identical with the forms of paralysis seen after attacks of diphtheria, scarlatina and measles. Anatomical Changes. The character of the anatomical change in recent cases appears to be an acute inflamma- tion of the anterior cornua of the spinal cord. In old cases the cornua are found in the condition of atrophic degeneration, implicating to some extent the white sub- stance in their vicinity. The degenerated cornua are transformed into a dense tissue from which many of the ganglion cells have disappeared. A secondary degenera- tion involves the anterior nerve roots, that correspond either to the cervical or lumbar cord, according as the upper or lower extremities had been affected with atrophic paralysis. 170 MA N UAL OF NER VO US DISEA SES . Clinical History. The disease in the majority of cases begins with a sudden onset of acute symptoms. A high grade of fever develops, accompanied with headache, delirium and stupor, which continues with brief intermis- sions for a few days or much longer. Sometimes the initial symptoms are of a mild character and brief duration. After their subsidence or, in some cases while apparently the child is in good health, the little patient is seen to have lost the use of one or both of the lower extremities or the paralysis is more extensive. The arms or some mus- cles of the trunk may at the beginning be involved but very soon the affection becomes limited to one leg or much less frequently to one arm. The paralysis in the leg is often confined to the muscles supplied by the peroneal nerve. The general health of the child does not seem to be aflfected and the paralysis usually improves up to a certain point and then becomes stationary and frequently permanent. There is marked flaccidity of the paralyzed muscles from the beginning. Gradually they atrophy and often to an extreme degree. The atrophy may be concealed by an abundant deposit of fat. Sensory disoi'ders are absent during the whole course of the disease. The functions of the bladder and the rec- tum are rarely afFected. Reflex action of the paralyzed muscles is much dimin- isiied or entirely abolished. The electric excitability shows marked changes in the course of the few weeks next succeeding the onset of the disease. The faradic reaction of nerves and muscles is rapidly lost and the reaction of degeneration is clearly manifest. For the next two or three months an increase SYSTEMIC DISEASES SPINAL CORD. 171 of the galvanic contractility of the muscles is sometimes observed, which then diminishes and is finally lost. The surface of the paralyzed limbs is cyanotic or mot- tled and the skin is flabby and cold. Shortening of the affected limb frequently results from arrested growth of the bones. The relaxed condition of the ligaments of the joints and the lack of muscular support allows of unusual passive motion of the paralyzed limb. The deformities which at a late period develop are partly produced by the predominant action of the antagonistic muscles and partly by the weight and position of the limb. In this manner the different forms of 'club foot" develop. In bad cases the stunted, withered limb is reduced to a use- less appendage of the body. DiagQOSis. Retarded development in small children may be confounded with some of the symptoms of spina, paralysis. These children are slow in learning to walk and exhibit much awkwardness in their movements dur- the period of their growth; but there is no history of acute symptoms, no real paralysis, nor muscular atrophy. The distinction from other forms of paralysis in chil- dren can easily be made if we remember that the essen- tial features of the spinal type are an acute onset, a flaccid paralysis joined with atrophy, loss of the reflex action, and the reaction of degeneration, with retained sensibility. The temporary paralysis of children described by Ken- nedy can be usually traced to exposure and is a mild affec- tion that disappears in the course of a few weeks. Prognosis. After the acute stage has passed off the prognosis is entirely favorable as regards danger to the life of the patient, but the complete restoration of the 172 M A N UA L F NERV O US Dl S EASES. motor function is very doubtful. If the paralysis does not continue to improve after the first few months, little further improvement must be expected. By a judicious and persevering course of treatment during the first years it may stili be possible, as experience has shown, to induce a noticeable change for the better in the paralyzed parts. Treatment. When called upon to treat the acute stage of the disease those therapeutical measures will be indi- cated that are usually employed to subdue febrile excite- ment and to quiet the nervous system. The recognition of the true state of the case at that period is difficult. Galvanization holds out the best prospect in the treat- ment of the paralysis. The most approved method is to place a large electrode on the vertebral column in the. region of the cervical cord if an arm is paralyzed, and to the upper dorsal region if a leg is affected. The other electrode is applied to the paralyzed nerves and muscles or dabbed over them. At first a constant current of medium strength is used, which is gradually increased in intensity. During the electrization the current may occasionally be reversed. Sometimes the kathode and then the anode should be slowly passed over the affected muscle. A sitting should last from two to five minutes and be repeated every other day or more frequently. Local faradization of the muscles is often of decided benefit. p]lectric treatment to be of any avail must be carried out with persistence. Some benefit is derived from passive exercise of the paralyzed limb, and this is best accomplished by massage. It is possible that this procedure may prevent or at least improve deformities of the limb. The good effects of S rs TEMIC D IS EA S ES SPINAL CO R D . 17S various liniments and embrocations, if they have any, are probably due to the vigorous friction that accom- panies their use. Good results are occasionally obtained from the use of brine baths during the Summer months. A brine bath may be improvised by dissolving a few pounds of sea salt in a tub of tepid water. An orthopedic apparatus will be often found necessary to facilitate walking. Internal remedies are of little use. It is recommended to give hypodermic injections of strychnia from oV to h grain until its physiological effects are produced. ACUTE AND CHRONIC POLIOMYELITIS IN ADULTS. A form of spinal atrophic paralysis identical in ana- tomical and c]inical characters with the disease occur- ring in children, as described in the foregoing section, has been repeatedly observed in adults. The acute symptoms are far less marked. At first the patient complains of muscular weakness in the lower extremities, and a few days later he is unable to walk. After a short time the arms are similarly affected and become also paralyzed. Extensive atrophy of the paralyzed muscles ensues, followed by loss of the electric excita- bility. In severe cases the degenerative reaction is man- ifest and the cutaneous reflexes are lost. In exceptional cases the muscles of the neck, the tongue, the lips and the pharynx are attacked. There are no sensory disturb- ances, and the functions of the bladder and rectum remain normal. After the complete development of the paralysis there is a halt in the disease for months. nJ^ MA iV UAL F XER V US D IS EA SES. Improvement gradually takes place, and the paralysis may finally disappear; oftener, however, recovery is" imperfect and the patient is more or less disabled for life. Further investigations are required to determine whether the symptoms which have been described are really dependent on a poliomyelitis. They certainly bear a close resemblance to those of multiple neuritis. SPASTIC SPINAL PARALYSIS. (Tabes Dorsal Spasmodique, Primary Lateral Sclerosis.) Although paresis of the lower extremities, increased muscular tension and exaggeration of the reflexes con- stitute a group of symptoms differing from other well- known forms of spinal disease, it cannot be said that the anatomical basis of this combination of symptoms has as yet been satisfactorily determined ; but they strongly point to implication of the lateral columns of the cord. Autopsies of cases that had presented the clinical char- acters of spasmodic paralysis do not always show evi- dences of disease of these columns. In amyotrophic lateral sclerosis there is a class of symptoms that include spasmodic paralysis of the inferior extremities, but they appear in association with muscular atrophy, and bulbar phenomena, dependent on extensive destruction of the pyramidal tract. Spasmodic forms of paralysis are met with in chronic hydrocephalus, transverse myelitis of the upper dorsal and cervical cord, tumor of the same regions of the cord, multiple sclerosis and hydromyelia. Etiology. The exciting cause of ordinary spastic spinal paralysis is unknown. It occurs more frequently in men S YS TEMIC T) IS EA S ES S PIN A L CO R D . 175 than in women, and usually develops about the middle period of life. Clinical History. The essential symptoms of spinal spas- tic paralysis consist of a more or less paretic condition of the lower extremities and exaggeration of the tendon reflexes, especially the patellar and the ankle clonus. In many cases there only exists a slight muscular weakness of the limbs, while in others the paralysis is pronounced and extensive. But the chief characteristic of the dis- ease relates to disturbance of motion that depends on stiffness and contracture of the muscles. When the reflex actions are excessive any passive movement of the inferior extremities, even their own weight, as when they hang free over the edge of the bed, brings on contractions. The rigidity of the flexors opposes the bending of the knees. Plantar flexion is sometimes so strong that the soles of the feet cannot be raised from the floor. At times the contractions are attended by such violent tremor that the limbs and the trunk are shaken. The exaggeration of the reflexes is especially conspic- uous when the patient attempts to walk. The muscu- lar tension is then so great that flexion of the limbs becomes very difficult, which causes the characteristic "spastic gait." In consequence of the stiff'ness of the legs the patient has much trouble to raise his feet; they seem to cling to the ground, and in bringing them for- ward the toes make a scraping noise. As the stiff'ened muscles oppose the elevation of the leg, the patient helps himself by rotating the pelvis, first on one side, then on the other. This produces a waddling gait. Sometimes the calf muscles contract so strongly that the patient stands on tiptoe and can only advance with a sort of no MA NUAL OF NER VO US D I SEA S ES . hopping movement. He appears to be walking on stilts. The tip of the foot catches on little inequalities of the ground; he constantly stumbles and is always in danger of falling. At last the gait is reduced to a mere drag- ging of the legs, and the body requires support to keep it erect. The patient, on becoming bedridden, finds it even impossible to sit up on account of stiffness of the legs. Sometimes late in the course of the disease the trunk and upper extremities become also involved. The spastic condition of the hand and fingers is then quite apparent. The cutaneous reflexes and electric excitability rarely show any alteration. Sensory disorders are absent. The functions of the bladder, the rectum and sexual organs remain normal. The Prognosis in all cases of confirmed spastic paralysis is unfavorable. The disease is always chronic, but unac- companied by pain. The Treatment is the same as that of chronic myelitis. AMYOTROPHIC LATERAL SCLEROSIS. For the first accurate description of this disease we are indebted to Charcot and loff^roy. A typical case pre- sents a group of well-defined symptoms. The distinctive anatomical changes include degeneration of the pyramidal tract of the lateral columns of the spinal cord, and degen- erative atroph}^ of the ganglion cells of the anterior cornua and certain nerve nuclei of the medulla. Etiology. The cause of the disease has been attributed to violent physical exertions, but nothing of a positive character is known concerning its etiology. The male sex is more frequently affected than the female. The S YSTE M IC n ISEAS ESS P IN AL CORD. 1 77 disease usually makes its appearance between the ages of thirty-five and forty-five j^ears. Anatomical Changes. A cross-section of the spinal cord, in advanced cases, shoAvs a simple degeneration of the whole pyramidal tract of the lateral columns of the cord, includ- ing both its crossed and uncrossed portions. The sclerosis also involves the ganglion cells of the anterior horns, the pons, the crura, internal capsule, and often some of the nerve nuclei in the floor of the fourth ventricle. Cases are also reported in which the degeneration had implicated ganglion cells of the central convolutions. The nerve nuclei in the medulla which are most prominently affected are the hypoglossus and the spinal accessory. The patho- logical change in some cases appears to involve the whole motor tract from the center to the periphery. The nerve fibres and cells of the diseased structures are atrophied and many of the nerve elements have disappeared. There is an increase of the connective tissue and slight alteration of the blood-vessels, but these are secondary changes. Destruction of the nerve tissues in the cord and the medulla are due to an identical pathological process. The same system of nerves is involved in every case. Clinical History. The encroachment of the disease is first noticed in one arm. The patient feels an unusual degree of fatigue in the limb. Soon after the oither arm is simi- larly affected and this paretic condition of the limbs gradually increases. Wasting of the muscles of the hand and fingers is the next symptom, commencing in the balls of the thumb and the little linger. This is suc- ceeded by atrophy of the interossii and extensors of the 12 i:S M A S U A L n f .\ E R V US D I S EA S ES . forearm. The Hexurs also become affected, Liit in a slighter degree. Among the muscles of the upper arm the triceps and the deltoid show, more wasting than the biceps and the muscles of the shoulder. In the course of a few months the atrophy also invades the inferior extremities, but to a less extent. The spastic symptoms are very prominent and as well marked as those described in the foregoing section. Although the dis- turbance of motion is influenced by muscular weakness, the chief difficulty of 'locomotion is due to spasmodic stiffness of the legs, brought on by excessive tendon reaction. The patellar tendon reflex is easily elicited and is very energetic. Ankle clonus is almost continually kept up by exaggerated reflex excitability of the calf muscles. On testing the reflex reactions in the upper extremities an equal increase of reflex excitability will be noticed. A slight tap on the end of the radius causes vigorous reflex contractions of the biceps and triceps. Spasmodic contractions of the hands and arms some- times develop spontaneously in the late stage of the ^disease. The sensibility continues unchanged and the cutane- ous reflexes show no marked alteration. ^Ficturition and •defecation remain normal. A new set of symptoms develop at a later period. Speech and deglutition become difficult. This constitutes ■the third and last stage of the disease. The tongue and lips are now attacked with atrophy. The articulation of words is indistinct and swallowing is much impeded. It is noticed that the tongue trem])ies and twitches and shows irregularities upon its surface. The- puckering of the mouth for the acts of suckintr, ])lowing and whistling is S YS TEMIC DISEA SESSPIJS^A L COUD. 119 nnicli impaired. Difficulty of deglutition interferes with the introduction of a sufficient quantity of food and the embarrassment of the respiration finally leads to a fatal termination. All the symptoms of amyotrophic lateral sclerosis depend on the disturbance of the physiological functions of the pans of the nervous system which are involved in the degenerative change. The paretic and spasmodic phenomena are due to the destructive lesion of the great motor tract in the lateral columns of the spinal cord, the muscular atrophy corresponds to the lesion of the ante- rior gray horns, and the bulbar symptoms accord with the implication of the nerve nuclei in the medulla. In explanation of the exaggerated reflex contractions, it may be fairly assumed that they depend either on irritation of reflex loops in the cord that are intact or on failure of inhibition. Diagnosis. Amyotrophic lateral scleroses i)resents an assemblage of symptoms which makes its distinction from allied diseases an easy matter. The co-existence of muscular atrophy, increase of the tendon reflexes, the bulbar symptoms, and the absence of sensory and vesical disturbance constitute reliable diagnostic points. The Prognosis must be considered as exceedingly unfa- vorable. The tendency of the disease to a fatal termina- tion has never yet been influenced by any method of treatment. PROGRESSIVE MUSCULAR ATROPHY. Wasting Palsy. Etiology. Individuals in the prime of life, who are actively engaged in occupations that call for hard physi- ISO MA N UA L F NER V US D fS EA S ES . cal exertions, are thought to be especially liable to wast- ing palsy, but often the exciting cause is unknown. Cases in which a hereditary tendency can be traced belong ta another class of muscular atrophy. The disease is some- times observed to follow S3'philis and acute infectious diseases, though probably the muscular atrophy in cases of this kind is not the genuine spinal disease. Anatomical Changes. We owe to Duchenne and Aran the first excellent description of progressive muscular atro- phy, but to Cruveilhier belongs the merit of having rec- ogaized the spinal origin of this disease. He located the morbid alteration in the anterior gray cornua of the spinal cord. Opinions were still divided in regard to the correctness of Cruveilhier's statement, for other eminent observers considered wasting palsy a disease of the muscles, until Lockhart, Clarke and Charcot succeeded in demonstrating the spinal origin of the disease. This view is now generally accepted. The gradual atrophy of the muscles which follows a regular type corresponds to degenerative changes of peripheral motor nerves, motor nerve roots and ganglion cells of the anterior gray cornua. There is a high degree of probability that progressive muscular atrophy, amyotrophic lateral scle- rosis and bulbar paralysis are of an identical patho- logical nature. The anatomical difference between these separate diseases rests solely on the circumstance that in each the lesion is localized in a definite portion of the cerebro-spinal axis. A peculiar form of muscular atrophy of a myopathic character will be considered later. The lesion in the spinal cord is most evident in the anterior gray cornua of the cervical region. Numer- .S' Y S T E M IC DISEASES-SPI N A L C ORD. 181 ous ganglion cells have disappeared and others are much atrophied. Fine connective tissue, studded with .spider cells, has replaced the neuroglia. The lateral columns are perfectly normal. Anterior nerve roots and nerve fibres corresponding to the degenerated portions of the anterior horns are also affected. Micro- scopical examination of the shrunken, pale muscles shows diminution and a waxy or fatty condition of the muscular fibres. The stria are, however, still retained. The interstitial connective tissue of the atrophied mus- cles is always increased and a deposit of fat is interposed between the remaining muscular fibres. In this condi- tion of the muscles the reaction of degeneration is manifest. Clinical History. The first sign of the insidious develop- ment of wasting palsy is atrophy of the small mus- cles of the hand, usually the hypothenar eminences. No other symptom at the beginning is experienced by the patient except difficulty in performing certain movements. The atrophy alters the position of the ball of the thumb and approximates it to the second metacarpal bones. Gradually a further deformity of the hand occurs from the wasting of the interossii and the lumbricalis muscles, such as is seen in ulnar paralysis. The next point of attack is the extensors of the forearm, or the atrophy jumps to the muscles of the shoulder. The arm grad- ually loses its natural contour as the dift'erent muscles become affected with atrophy, and finally appears thin and wasted. In the upper arm it is always the deltoid which first atrophies; then comes the biceps, the triceps holding out the longest. If the atrophy is much advanced in the upper extremities the arms hang dangling by the is: M A X UAL O F K E R V O U S 1) I S E A S E S . sides as if suspended by a string, and nothing appears to remain of the shoulders but the projecting acromion and coronoid processes. In their turn the muscles of the back,, the chest and abdomen become also more or less affected, those of the lower extremities being but rarely attacked. A curious configuration of the body is produced when there is an irregular wasting of the muscles, only a part of a large muscle being atrophied, while its next neighbor is intact. The bellies of the sound muscles strangely con- trast with the grooves left by the wasted muscles. Bones and tendons become prominent in situations where the volume of the muscles is diminished. Corresponding with the extent of the atrophy there is a functional weakness of the muscles which does not amount to true paralysis, though the patient is finally reduced to a pitiable state of helplessness. For a long time he is still capable of carrying out movements by calling into action supplementary muscles that yet retain their structural integrity. A striking instance of this phenomenon I observed in the case of a so-called "living skeleton." The trapezius was much atrophied so that the head often dropped forward, but he contrived to put it straight again by a violent jerk and retain it in position l.)y means of the deep muscles of the neck. On attempting to rise from his seat he had the trick of giving his body a sudden twist that brought him to his feet. Tn this case the lower extremities were much atrophied, and to some extent also the pectoralis major, the serratus and other muscles of the back. In addition to the atrophy and impaired functions of the muscles they are also affected by fibrillary twitching and tremor. These symptoms disappear when the S Y S T E M I C ' I) 1 S E A S E S- S I'f S A L C O R I>. IS-3 atrophy becumes complete. The muscular tremor can be easily excited by giving a slight blow to the bellies or tendons of the muscles. The electric exploration of the diseased muscles varies in results. In general it is found that the electro-muscu- lar contractility diminishes in proportion to the extent of the atroph^^ So long as there are some of the muscular fibres left contractions, though feeble, can be obtained. A con:ipletely atrophied muscle, or one which is mostly replaced by infiltrated fat, ceases to give responses to either current. Increased galvanic excitability is some- times observed, and, on the other hand, a decided dimi- nution of electric reaction is occasionally noticed in muscles before atrophy is perceptible. The tendon reflexes of the superior extremities are much diminished, in striking contrast to their increased reaction in amyotrophic lateral sclerosis. This difference is due to the circumstance that in the latter disease degeneration of the pyramidal tract occurs prior to the atrophy, which \» not the case in progressive muscular atrophy. When the lower extremities are involved there is absence of the patellar reflex. Trophic changes are infrequent and of little signifi- cance when they occur. If the atrophy is attended with much fatty in-filtration it may be difficult to recognize the wasting, but the atrophied muscles have a soft and pasty feeling and the electric excitability is diminished. The skin is sometimes cyanotic, thick and fissured, and the nails are brittle. In very few cases a relatively sudden development of the atrophy is preceded by vague rheumatic-like pains, but sensory disorders, as a general rule, are absent IS ; M A X U A L F X E R V US D I S EASES. throughout the whole course of the disease. The cuta- neous sensibiHty is preserved and the sphincters of the bladder and rectum are unaffected. The symptoms of bulbar paralysis make their appear- ance in protracted cases in consequence of the extension of the disease from the anterior cornua to the nerve nuclei of the medulla oblongata, that innervate the muscles of the tongue, the lips, the pharynx and the respiratory muscles. AVe have here the identical com- plication which more frequently and at an earlier date occurs in amyotrophic lateral sclerosis. Diagnosis. Errors of diagnosis can be easily avoided if the marked peculiarities of genuine progressive muscular atrophy be kept in view. They include the typical course of the disease; the appearance of the wasting, first in the small muscles of the hand; the gradual extension of the atrophy to other muscles ; the absence of sensory disorders and the immunity of the sphincters of the bladder and the rectum. Progressive muscular atrophy is excluded in diseases where the wasting is only a sub- ordinate symptom. It is distinguished from amyotrophic lateral sclerosis by the absence of spastic symptoms and the normal condition of the reflexes. The differential diagnosis from the myopathic form of muscular atrophy can easily be inferred from the description of the latter disease in the following section. Prognosis. Patients may survive for many years if the atrophy advances slowly and makes frequent pauses. Recovery even under the most favorable conditions is exceptional. The fatal termination is hastened when the respiratory and masticatory muscles licome affected. S Y S T E M I C D I S E A S E S- -S PINAL CORD. IS', Treatment. Electricity appears to be the only means of exciting some favorable influence on wasting palsy. Duchenne recommends to begin the treatment at once with strong faradic currents to the affected muscles. Galvan- ization of the spinal cord in the usual method should be combined with it. A systematic course of massage may assist in arresting the advance of the atrophy. PSEUDO-HYPERTROPHY OF MUSCLES. (Lypomatous-hypertropiiy of Muscles.) The myopathic class of muscular atrophy is distin- guished from the spinal form of the disease by the differ- ence that the anatomical changes in the former develop in the muscles, the nervous system being not involved. Myopathic atrophy occurs in the greater number of cases in the young members of the same family. I once saw three brothers who presented the typical form of the dis- ease. Boys are more disposed to the affection than girls. Nothing is noticed until the patient has begun to walk. The parents cannot understand why the child becomes unsteady on its feet and constantly stumbles in walking, although its limbs are straight and finely developed. The little patient makes a poor effort at mounting steps, falls over when slightly pushed and when down has much trouble to get up. The arms and hands appear perfectly normal, but the attitude in standing is odd and the walk is a mere waddling. In fact the nature of the child's disease can be recognized at a glance by observing the position of the body and the character of the gait. The shoulders and the upper part of the vertebral column incline backwards, the dorsal curvature is deeply arched, 18:1 M A X UAL OF N ER V U S DISE A S ES . the abdomen protrudes, the feet are kept wide apart and the patient cannot approximate them without the risk of falling. At a late period he cannot bring the heels to the ground whilst in the erect position, but bal- ances his body on the toes so that he easily loses his equilibrium when slightly pushed. The characteristic gait resembles the movements of a duck, the body oscil- lates from one side to the other. Dr. Ross remarks: " When the feet are kept widely apart the center of gravity must be carried at each step over the side of the active leg in order that the line of gravity may pass through the center of the arch of the foot planted on the ground. It is therefore necessary that at each step the body should be inclined well over the side of the active leg, and the patient aids himself in maintaining the center of gravity vertically above the ball of the foot on the ground by moving his arms about like a rope dancer." The series of movements which the patient adopts in raising himself from the floor when there is nothing near him to lay hold of is characteristic. He gets on all fours, plants his feet on the floor and props himself with his extended arms, then gradually straightens his legs so that his trunk raises and assumes an inclined position from the buttocks downwards. Having gained this posi- tion he next grasps one knee with the one hand, and while the other hand is firmly flxed on the floor, he stiffens the arm to support himself, and then quickly freeing the hand he grasps with it the other knee, and in this manner the trunk is brought into a vertico-horizontal position from the shoulder downwards. The last grand effort to gain the erect position he accomplishes by .S^ Y S T E M IC DI S E A S E S -S P I X A L C O R D . 187 thrusting the body forwards and climbing the thighs with his hands. On observing for the first time the precarious attitude and waddling gait of the patient, attention is attracted by the remarkable development of some of the muscles. The gastrocnimii especially have gained in volume. The gluteal muscles are also massive, and in older patients the thigh and the deltoid are sometimes increased in thickness. " This pseudo-hypertrophy " is caused by an increase of interstitial fat. The real cause of the feebleness is the atrophy of numerous muscles w^hich strangely contrast with the excessive volume of others. In many cases the thighs are thin and wasted, while the gastrocnimii are of an enormous size. The muscles of the upper extremities, with the exception of the deltoids, are more frequently atrophied than enlarged. Those of the shoulder and upper part of the body are occasionally attacked. Usually the distribution of the hypertrophy is such that the arms and upper part of the trunk appear emaciated in comparison with the development of the buttocks and the calves. ErVs juvenile form of hereditary muscular atrophy is also a disease of early youth. It usually attacks the female members of the same family. The atrophy begins in the shoulders and arms and gradually extends to the trunk and the inferior extremities. In all cases there is a remarkable regularity in the order in which the differ- ent muscles are attacked. The motor disturbance cor- responds to the extent and severity of the atrophy. There is no apparent increase in the volume of the affected muscles. The disease is very chronic, but sometimes a 18S MA N UAL F N ER VOUS DISEA S ES . sudden fatal termination takes place from asphyxia in consequence of atrophy of the diaphragm. Duchenne reports cases of atrophy in which the disease began in the facial muscles and then extended to other muscles of the body. In all the forms of myopathic atrophy no change occurs in the nervous system. There is no fibrillary twitching of the muscle and the reaction of degeneration is not manifest. Treatment has hitherto proved unavailing. BULBAR PARALYSIS. (Glosso-labto-larynge.\l Paralysis.) Etiology. The special disease of the medulla oblongata which Duchenne originally described under the name of glosso-labio-laryngeal paralysis, is caused by a degener- ative atrophy of the nuclei of nerves that arise on the floor of the fourth ventricle. To the group of symptoms resulting from this lesion that chiefly affects speech, deglutition and respiration, the term bulbar paralysis is now generally applied. No particular exciting cause of. the disease is known, but a history of s^'philis exists in many cases. Men between the ages of 40 and 70 years are chiefly affected. Clinical History. Bulbar paralysis always develops very insidiously. Slight premonitory symptoms, such as pain in the back and front of the neck, precede the impedi- ment of speech that first attracts the attention of the patient. He experiences difficulty to articulate certain consonants, usually r, s, 1, k, g and t. Among the vowels he pronounces i but poorly. This defect is mainly due to SYS TEMIC DISEASESSPINAL CORD. 189 disturbed innervation of the tongue, which interferes with the mobility of this organ. As the disease advances an analogous difficulty occurs in chewing and swallowing food. On examination the tongue is found atrophied, it is thin and flabby and grooves form upon its surface. At a later period the tongue can no longer be protruded. Morsels of food remain in the mouth, as they cannot be carried back by the tongue into the pharynx. A similar debility is observed to affect the lips. Read- ing aloud becomes quickly tiresome. The acts of whistling, bloAving and sucking are but imperfectly performed, and finally puckering of the mouth is impossible. When the paralysis of the orbicularis oris increases the patient is unable to pronounce the vowels o and u, and he finds it difficult to articulate the consonants p, f and b. The next trouble is due to the extension of the paraly- sis to the pharynx and larynx. Swallowing is interrupted and the voice becomes monotonous. Liquid food regur- gitates through the nose in consequence of the paralytic condition of the soft palate. Inability to modulate the voice may be the only sign of implication of the laryngeal muscles for a long time, but more serious symptoms develop in the course of the dis- ease. The voice becomes extremly feeble and hoarse, and the incomplete closure of the larynx permits the entrance of liquids and even solid food into the air passages. A very characteristic change in the expression of the face is observed if in addition to the paralytic condition of the lips the lower facial muscles are also implicated. The mouth stands wide open; the lower lip hangs down; the naso-labial fold is deepened, while the muscles of the 190 M A XUAL OF N E R V US 1)1 S E A S ES. upper part of the face and of the eyeballs are normal. There is a constant trickling of saliva over the chin so that the patient is seen constantly holding a pocket hand- kerchief to his mouth. Exceptionally the muscles of mastication are involved, which in addition to the paral- ysis of the tongue and lips, renders chewing extremely difficult. Morsels of food would drop out if the patient did not prevent it by pressing the palm of the hand against the mouth. At an advanced period it is not unusual to witness attacks of dyspnoea and fainting fits. These symptoms indicate implication of the pneumogastric nerve. When the disease has reached its height another symp- tom is occasionally added to the catalogue of troubles, dependent on the implication of the spinal accessory, and causing atrophy of the muscles of the neck. The patient in consequence experiences much difficulty to keep the head in the erect position. Reflex action of the paralyzed muscles is diminished, or entirely abolished. Tickling of the root of the tongue does not cause the patient to gag. It is a noteworthy circumstance that all the symptoms enumerated are exclusively motor. The cutaneous sensi- bility and the senses of taste and smell continue intact. Course and Termiaatlon. During the early stage of the disease there is nothing in the outer appearance of the patient indicating the beginning of a fatal affection. The paralysis invades in the order that has been stated, first the tongue, then the lips, then the soft palate and lastly the larynx. The general health of the patient does not seem to suffer until serious difficulty of deglutition develops. At a late period the patient presents a woeful jncture of S YS T E M I (' 1) I S E A S ES—S P / XA L C O R T) . 101 wretchedness. Speech is gone, the desperate attempts to swallow food are futile, the lips are thinned to trans- parency, the mouth constantly gapes, the saliva dribbles away, and amidst all this the intelligence is clear and only the motions of the eyes convey the expression of misery. Death may be postponed for three or five years. Complications. Bulbar paralysis stands in close relation to the allied affections of progressive muscular atrophy and amyotrophic lateral sclerosis. The degenerative atrophy of the nerve nuclei in the medulla and of the corresponding muscles is analagous to the lesion and its consequences that characterize the latter diseases. The best evidence of the degenerative process in the medulla is found in the nucleus of the hypoglossus nerve, more or less also in the vagus and the accessory and only sometimes in the nucleus of the facial and -of the glosso- pharyngeus. A similar anatomical change is observed in the nerves that start from these nuclei. The similarity between the nature of the pathologi- cal changes in bulbar paralysis and progressive mus- cular atrophy is complete. In both of these diseases the degenerative atrophy involves the motor and trophic nerve tracts and the corresponding muscles. The lesion in bulbar paralysis affects the nerve nuclei in the medulla, and in progressive muscular atrophy the lesion involves the ganglion cells of the anterior gray cornua. The difference implies only a difference in the localiza- tion of an identical lesion. It is now easy to understand why during the course of bulbar paralysis we often meet with atrophy of the extremities and conversely that toward the late period of progressive muscular atropliy li)3 MA N UA L OF NER VO US D IS EA SES . symptoms of bulbar paralysis not infrequently make their appearance. The complication of amyotrophic lateral sclerosis with bulbar paralysis has also been met with. The occur- rence of spastic symptoms in cases of this kind shows the extension of the primary disease in the medulla to the lateral columns of the spinal cord. Diagaosis. Symptoms of bulbar paralysis have been observed in cases which turned out to be multiple sclero- sis, obliteration of basal arteries or tumor of the medulla. In all such cases, however, there is a clinical history which markedly differs from the symptomatology and course of a typical case of primarv bulbar paralysis. It would be a serious mistake to confound with this dis- ease the aphonia, the choking sensation and excessive salivation suddenly occurring in a hysterical woman. Prognosis. Trousseau makes the remark in reference to the prognosis of bulbar paralysis : " I do not believe that a single case is on record in which the progress of this disease has been arrested for a single minute." Treatment. An effort should at least be made to check the advance of the disease. Duchenne and Kussmaul observed temporary improvement of the speech and deglutition from faradisation of the palate and tongue. Galvanization may possibly be of some service: the elec- trodes should be applied to the mastoid processes. Diffi- culty of swallowing may sometimes be relieved by applying the kathode to the side of the larynx and the anode to the nape of the neck. Excessive salivation is restrained by atropia. CHAPTER XL DISEASP]S OF THE MEMBRANES OF THE BRAIN. Diseases of the cerebral meninges are nearly always of a secondary nature, and more or less involve the sub- stance of the brain. Each of the membranes may be separately affected, but frequently the inflammatory pro- cess commencing in the dura mater extends to the pia. INTERNAL HEMORRHAGIC PACCHYMENINGITIS. (H.T':matoma of the Dura Mater.) Etiology. ILematoma of the dura mater is far more frequently met with on the dissecting-table than recog- nized during the life of the patient. It is sometimes found in connection with acute febrile diseases, as typhoid fever, smallpox pneumonia, and is often one of the post_ mortem appearances in the general paralysis of the insane, senile dementia and chronic alcoholism, l^sually the disease occurs among old people and more frequently in men than in women. Anatomical Changes. Hamiatoma is generally considered to originate in inflammation of the internal surface of the dura mater, which leads to the formation of a new mem- brane and extravasation of blood within its meshes. In old cases the connective tissue of which the mem- i;! ( I'.i:; ) m J/ ^4 X UAL F y EnVOUS D I SEAS ES . brane consists is much thickened and filled with blood. The new growth exerts much pressure on the underlying part of the brain. Its rupture gives rise to " meningeal apoplexy." The usual seat of the hsematoma is the parietal region. Clinical History. Symptoms referable to hemorrhagic pacchymeningitis are not characteristic though they are sometimes very serious. The difficulty of diagnosis is due to the variable location, size and recurrence of the hemorrhage. The disease gives rise to headache, vertigo, a slow pulse, vomiting and stupor: some- times hemiparesis or twitching of muscles of one side of the body is a conspicuous S3'mptom, or only on^ extremity is paralyzed and affected with convulsive movements. The paralysis, if the hemorrhage is copious, may become bilateral. Aphasia occurs in some cases. The disease may begin abruptly like an apoplectic attack. Drowsiness is often a prominent symptom in old people, and when conjoined with contracted or dilated pupils the possible existence of a ha?matoma is indicated. The course of the disease is very variable. In many cases improvement takes place; the paralysis and the other symptoms may even entirely disappear, but only to return at irregular intervals on the recurrence of the effusion. Death from coma suddenly ensues in aggra- vated cases. Diagnosis is impossible when haematoma occurs as a complication in affections distinguished by other promi- nent symptoms. The variable clinical features the disease assumes must at any rate embarrass its recogni- tion. The following diagnostic points are to be considered : DISEASES OF MEMBRANES OF BBAIX. 19o Chronic cerebral disease, alcoholism, sudden onset of severe cerebral symptoms, their improvement and recur- rence, unilateral spasms, hemiplegia or monoplegia. Treatment. It is impracticable to recommend any special line of treatment in a disease of this kind. The apoplectiform attacks would call for a cooling treatment and derivatives, and paralysis for the electric treatment, etc. DISEASES OF THE PIA MATER. The varieties of cerebral meningitis are distinguished partly by their etiology and partly by the particular seat of the inflammation. The pia mater is chiefly affected. We distinguish : 1. Tubercular meningitis. 2. Meningitis of the convexity. o. Epidemic cerebro-spinal meningitis. This being an acute infectious disease it cannot be properly classed among nervous diseases. TUBERCULAR MENINGITIS. (Acute Hydrocephalus.) Etiology. Tubercular meningitis is generally believed to be a secondary affection, but the focus of infection in remote parts of the body cannot always be found at the autopsy. In the larger number of cases the men- ingeal disease in adults takes place in the course of pul- monary tuberculosis. The influence of age is marked. Tubercular meningitis most frequently affects children. J / N UA L O F XER VOUS Dl S EA S ES . AnatomiCil Changes. Miliary tubercles develop in greatest abundance in the pia mater at the base of the brain, hence the disease is often characterized as " basilar men- ingitis." The greater number of tubercles are found along the course of the large blocd-vessels and furrows between the convolutions. They can easily be detected on stripping the hypersemic membrane from the brain. The inflammatory exudation chiefly consists of a sero-fibrinous effusion, which is sometimes cloudy from the presence of a scant amount of pus. Hemorrhagic spots are frequently found in the inflamed pia. Often the brain substance is also involved and shows deposit of tubercles and capillary haemorrhage. Flattening of the convolutions is seen when the exudation is large. A copious eff"u- sion, more or less of a sero-purulent appearance, is usually found in the ventricles, hence the disease was formerly termed "acute hydrocephalus." The pia mater of the spinal cord is often conjointly affected. This membrane being inflamed and sometimes studded with tubercles explains the combination of spinal and cerebral symptoms. Clinical History. It is convenient for description tu divide the clinical history of the disease into three stages. The first stage includes the prodroma due to cerebral irrita- tion. The second stage marks the .complete development of the disease, and the third stage is the stage of collapse corresponding to grave impairment of important nerve centers. But the sudden or slow development of the inflammatory exudation, the variable extent and severity of the cerebral implication, and the degree of compression exerted by the eflfusion constitute factors that greatly DISK A SES F MEMBRA NES O F BRAIN. 197 modify the symptomatology and course of the disease in individual cases. The onset of tubercular meningitis is occasionally tumultuous. In topers the disease not seldom begins as a delirium tremens. (Generally, however, the disease is preceded for a longer or shorter period by a precur- sory stage. For a week or two patients complain of headache, aversion to food, constipation, sleeplessness and a feeling of general illness. Vomiting is often a con- spicuous initial symptom. Tliis condition grows worse, the headache increases, delirium comes on, and soon the marked signs of a formidable brain trouble make their appearance. In children, who are more frequently the victims of tubercular meningitis than adults, the invasion presents some peculiarities. It often appears as if a previous attack of measles, hooping cough, or other affections to which children are prone, had hastened into activity the dormant process of tuberculosis. But apparently healthy children are often unexpectedly taken with the disease. There are families who lose their little ones, after they have arrived at a certain age, from "brain fever." An infant refuses the breast, sleep is disturbed, the tongue is coated, the bowels are constipated, and towards evening fever appears. The little patient has short spells of cry- ing, is exceedingly restless or is drowsy and often vomits without a palpable cause. Usually these symptoms are attributed by the mother or nurse to difficult dentition, indigestion, worms, or disordered bowels. An older child has headache, refuses food, is restless, abandons its play- things, and with remarkable frequency complains of pain in the chest and abdomen. In very young children it is 198 MA X UA L OF NER VO US D IS EA S ES . not iiniisiial for the disease to set in suddenl}^ with eleva- tion of the temperature and general convulsions. The second stage in adults may begin with a chill, but the most prominent and constant symptom, when the disease is completely established, is violent pain in the head. It persists, with short intermissions, as long as the patient is at all conscious. He breaks out in loud complaint of its severity, and even when overcome by the advancing drowsiness the contortions of the face express its continuance. (I once saw a little girl who in this stage constantly beat her forehead with the fist.) Very young children manifest the headache by the repe- tition of an abrupt shrill cry and by boring the head into the pillow or tossing it from side to side. Delirium is an early symptom iu adult patients. They sing, shout or whistle, throw off the bed covering and make attempts to escape from the room. Sometimes the delirium is low and less noisy, the muttering being unin- telligible and the patient picks the bedclothes. The most conspicuous motor symptoms are stiffness of the neck and retraction of the head due to implication of the upper region of tlie spinal cord. Various symptoms showing irritation of cranial nerves at the base of the brain make their appearance. There is twitching of the facial muscles, strabismus, rolling of the eyeballs and later ptosis and partial facial paralysis. The pupils show much irregularity, they may be unequal, contracted or dilated. Usually they are sluggish and finally do not respond to light. Spasmodic movements of the limbs are occasionally observed, but more frequently a rigid condi- tion of the inferior extremities exists. In children a boat-shaped appearance of the al)d()minal walls is DISEASES OF MEMBRANES OF BRAIN. J99 observed toward the close of the second stage. If the patient does not fall early into a state of unconsciousness there is generally well marked hyper?esthesia and intol- erance of light and sound. The temperature varies. It rarely rises above 103°, but at times there is an elevation reaching 105° to 106°, or the temperature may suddenly become subnormal. Remarkable changes of the pulse are noticed. In the early stage it often gets as low as 60 or 50 beats per minute, and later it becomes exceedingly rapid and feeble. The " tache cerebral " is well marked in small children. The respiration is often sighing and nasal. At the early stage before stupor comes on the breathing is acceler- ated, but toward the end it is hardly perceptible. Constipation of the bowels persists throughout the dis- ease. It has been noticed that the cough, dyspnoea and the profuse perspiration in phthisical patients cease on the development of meningitis, but the marasmus rapidly increases. The second stage of the disease averages about eight days. The third or final stage shows the signs of speedy dis- solution. Swallowing of food is now impossible. The breathing is irregular and occasionally assumes the character of the " Cheyne Stokes respiration." The pulse can hardly be counted, the extremities are cold, and the coma is profound. In children the fontanels are sunken and often death is ushered in by general convulsions and paralysis. Cases of recovery from tubercular meningitis are reported, but it has been asked — how about the diag- nosis ? Diagnosis. There are few diseases of infancy that offer greater difficulties to diagnosis than the prodromic period wo MA N UA L O F NER VOUS DISK A S ES . of tubercular meningitis. A decisive judgment in regard to the nature of the symptoms will often be held in sus- pense until positive evidences of cerebral trouble appear. It is advisable when diagnosis is doubtful not to disregard the symptoms of incipient pulmonary tuberculosis and to examine the chest. Scrofula and diseased joints are of similar import. Suspicion should always be awakened if a child begins to vomit without an assignable cause and shows great irregularity of the pulse. If the invasive stage of tubercular meningitis in adults is very protracted and accompanied by high fever it may suggest the devel- opment of typhoid fever. Here again, a cautious opinion must be formed until the disease declares itself. The •ophthalmoscope may come to the assistance of diagnosis if tubercles are found in the choroid. The differential •diagnosis between the tubercular and simple variety of meningitis chiefly rests on the question of etiology. It is sometimes surprising to find at the autopsy ver\^ insignificant changes, that seem insufficient to account for the gravity of the symptoms. Treatment. An infant should be provided with a healthy wet nurse when tuberculosis is hereditary on the mother's side. Superabundance of clothing and a hot sleeping- room are rather injurious to children disjDOsed to brain trouble. Tepid bathing and friction of the skin should be recommended, and, in fact, all the well-known prophy- lactic measures. Energetic treatment in tubercular meningitis is of doubtful benefit, but cold applications to the head are very serviceable when steadily kept up. Purgatives are indicated at the early stage. Calomel is best adapted for children. Iodide of potassium deserves a trial. These 1) ISEA S E S F M E M B R A N E S F B R A IN. 201 little patients can easily tolerate from two to three grain doses. Warm baths give temporary relief to the cere- bral excitement, but small doses of Dover's powder or a few drops of a morphia3 solution should not be withheld. Children under two years of age should never be blistered. In the stage of collapse stimulants are indicated, but they are of little avail. MENINGITIS OF THE CONVEXITY. Etiology, Simple meningitis of the convexity is very rarely an idiopathic disease. It is probable that sporadic cases may be examples of that variety of the disease which is known as the epidemic cerebro-spinal meningitis. In fact simple meningitis is so frequently found to be a secondary affection that many observers doubt its occurrence as a primary inflammation. In place of making the divisions of "traumatic meningitis," " metastatic meningitis," etc., an enumeration of the remote causes that give rise to purulent inflammation of the cerebral membranes will answer every practical pur- pose. Disease of the middle ear is a very frequent cause of secondary purulent meningitis. In caries of the petrous portion of the temporal bone, which is usually due to otitis media, the extension of the disease into the cranial cavity is easily accounted for. Irruption into the interior of the skull may take place, or the inflammation proceeds from the mastoid cells, or it creeps along the sheath of the nerves. Suppurative phlebetis of a venous sinus may ensue when the dura mater is implicated. Persons with running ears are in constant danger of such a com- plication. The meningitis occurring in cases of this kind W2 MAXUAL OF NERVOUS DISEASES. begins suddenly and with violent symptoms. Disease of the upper portion of the nasal cavity may possibly also develop meningitis. Injury to the skull is one of the most frequent causes of purulent meningitis, and calls for surgical treatment. The bursting of an intracranial abscess invariably develops meningitis. All other cases of cerebral meningitis which are not traceable to a direct or palpable cause are proba- bly due to the transmission of an infectious agent from a remote organ. "Metastatic meningitis" sometimes devel- ops in the course of pneumonia, t\"phoid fever, erysipelas, articular rheimiatism, empysemia, and very rarely in pyaemia. The anatomical changes in secondary meningitis are as a general rule limited to the convexity of the brain. The pia mater is injected and infiltrated with pus. Thick greenish-yellow pus is often found in the subarachnoid spaces and along the course of the meningeal blood-ves- sels. The arachnoid presents in places an opaque appearance. Spots of softening are often observed in the substance of the brain where the pia is adherent to the cortex. Clinical History. Tt so often happens that the symptoms of secondary meningitis are mixed up with tliose of the primary affection that the latter attracts the first atten- tion. In traumatic meningitis the symptoms of compres- sion predominate. The base of the brain is involved, as Hutchinson has pointed out in cases where hemiplegia exists. In a case of meningitis of the convexity, which appears to be primary the symptoms resemble in nearly everv feature those of the tubercular varietv. D IS EA SES OF MEMB R A NES OF BRAIN. 203 A precursory stage in meningitis of the convexity is either not well marked or entirely absent. There may be an initial chill, but usually the invasion of the disease is announced by violent headache and febrile excitement. The pain in the head is intense and dominates the atten- tion of the patient. It may be limited to a fixed spot or be diffused over the whole head. There is often consid- erable elevation of the temperature, but it is generally varying. The patient is restless and irritable, he shuns the light and is annoyed by loud sounds; the eyes glisten; the pupils in the beginning are usually contracted; a circumscribed flush is seen in the face; the respiratiori is somewhat hurried or irregular; speech is slow and at times incoherent; an active or low delirium soon sets in; stupor develops, and finally a deep coma is established. Stiffness of the neck and retraction of the head may supervene. Remarkable variations of the pulse are observed. It may be excedingly rapid at times, but quite as often it is very slow, irregular and intermittent. Symptoms corresponding with implication of cranial nerves as in tubercular meningitis are noticed in individ- ual cases, especially disturbances of the motor oculi. Twitching of muscles and paralysis of the hemiplegic type may likewise occur. The course of the disease is often rapid, death taking place in two or three days, either preceded by coma or convulsions. Sometimes the fatal termination is post- poned beyond a week. Recovery is exceptional. Cerebral meningitis occurring in persons of an advanced age presents certain peculiarities. The symptoms develop insidiously; there is but slight headache, the m J/^ -V UAL F KEB VOUS D ISEA S ES . fever is moderate, delirium comes early and is often quickly succeeded by coma. In other cases there is merely mental confusion, a vacant expression of the face, tremor and rapid sinking of the vital powers. The very dangerous cephalic symptoms sometimes met with in acute articular rheumatism resemble those of meningitis, though the post mortem appearances are not decisive. Diagnosis. It is a ditficult point of differential diagnosis to discriminate between meningitis and encephalitis. Practically it is of no moment, for the brain is more or less involved in all cases of cerebral meningitis. Diag- nosis may be embarrassed when cej^halic symptoms in severe cases of typhoid fever, pneumonia or general tuberculosis are exceptionally prominent. Careful anal- ysis of the symptoms will usually overcome the diffi- culty. Those indicating the existence of meningitis include violent and persistent headache, the early onset of cerebral excitement, delirium, stupor, rigidity of the neck, ocular paralysis and the gravity which the disease quickly assumes. Treatment. There is a great temptation in encountering the grave symptoms that characterize all forms of cere- bral meningitis to adopt an energetic plan of treatment. Formerly it was the rule to practice venesection, now we are content to appl}^ leeches to the head. More reliance is to be placed on the application of cold to the head. The ice helmet or irrigator answers this purpose far better than bladders filled with ice. In addition a woolen cloth wrung out in warm water may be wrapped around the lower limbs. In desperate cases it is recommended DISEASE S F M E M B R . I X ES OF BRA I X . Mo to shave the scalp and to raise a blister. I have never seen a good effect from it. Iodide of potassium in fre- quent doses is indicated. The bowels are best kept open by small doses of calomel. Morphia injections may become necessary to allay extreme cerebral excitement. CHAPTER XII. LOCALIZATIOX OF CEREBRAL DISEASES. The diseases which chiefly produce focal lesions of the brain are cerebral hemorrhage, softening from occlusion of cerebral arteries and cerebral tumor. The symptoms to which these diseases give rise do not depend on the nature of the pathological change, but on its locality. It makes no difference what the character of the lesion may be, which for example destroys any part of the pyramidal tract in the brain, it is always followed by hemiplegia. In an analogous way, whatever may be the nature of irritation or interruption that implicates an excitable area of the cortex, it will either cause a monospasm or monoplegia. Aphasia develops when a part of the speech mechanism in the brain is involved by any kind of lesion. The following brief summary of the pathological diagnosis of cerebral diseases includes the results of clinical obser- vations and experiment. Lesion of the central convolutions, produces hemiplegia of the opposite side of the body. Implication of separate parts of this region gives rise to corresponding forms of partial hemiplegia. We are thus enabled to localize dis- ease in this region. It will be recollected, that the center of movement for the leg is in the upper part of the central convolution or in the paracentral lobule ; for the movements of the arm in the middle third of the anterior ( -joc. ) LOCALIZA TIO N—CEREB RAL DIS EA S ES. 207 ascending convolutions ; for the movements of the facial muscles in the lower third of these convolutions and that for the tongue somewhat lower. Disease affecting any of these parts causes either isolated monoplegia or a com- bined form of monoplegia in conformity with the posi- tion and extent of the lesion. The commonest form of such a combined paralysis is that of the arm and face. The simultaneous paralysis of the leg and face has never been seen, for the reason that the intermediate arm cen- ter would not escape in a lesion affecting the other two centers. If a cortical lesion of these centers causes irritation, then we have either " monospasm" (muscular twitching, tremor), or simultaneous spasm of the muscles of the face, arm and leg. It has been demonstrated that these motor centers are involved in cases of unilateral epileptic convul- sions associated with hemiplegia of the same parts. Disease of the second and third frontal convolutions cause no marked disturbance of function, but mental symptoms develop if these regions in both hemispheres are affected. Lesion of the third or inferior frontal convolution of the left hemisphere gives rise to the interesting phenomena of aphasia. Parietal convolutions. It is uncertain whether cortical lesion of the parietal lobe, exclusive of the ascending parietal convolution, gives rise to any symptom. Impair- ment of the cutaneous and muscular sense has been observed in a few cases. Temporal lobe. There exists satisfactory evidence, tliat extensive disease of the superior convolution of the tem- peral lobe gives rise to the aphasic symptom of " word deafness." 208 MA X UAL OF N E R VO US D I SEA SES . Occipital lohc. Experiments and pathological invest!" gations leave no room for doubt that the occipital lobe contains a center of vision. Destruction of the occipital lobe does not cause paralysis. Centrum ovale. Lesion of the centrum ovale may exist without causing any symptoms. This immunity is due to the circumstance that a sufficient number of nerve fibres remain intact to conduct innervation. If paralysis occurs, it cannot be distinguished from ordinary hemi- plegia. Island of Reil. The island is not infrequently involved in extensive disorganization of neighboring parts. Aphasia has been observed in exclusive lesion of the island. Thalamii.^ Opticus. Although the thalamus is very fre- quently involved in cerebral hemorrhage and occlusion of cerebral arteries there is considerable discrepancy among observers in regard to the symptoms peculiar to lesion of this basal ganglia. Cases are reported in which old standing lesions of this ganglia had remained entirely latent. In the great majority of instances the ordinary type of hemiplegia existed and was sometimes accom- panied by hemian?psthesia. Hemiplegia occurring in lesion of the thalamus is probably due to a co- existent lesion of the internal capsule or of the corpus striatum. The occasional occurrence of hemiannow generally conceded that hemiplegia in lesion of the corpus striatum, is invari- ably dependent on implication of the internal capsule. Cases are reported in which an old focal lesion existed in the strialed body, that had not given rise to hemiplegia. In such cases the internal capsule was evidently not involved. Disturbance of sensation rarely accom2:)anies hemi- plegia in disease of the corpus striatum, but the following exceptional forms of paralysis have been observed in lesionof this ganglia: 1. Hemianaesthesia of the same side as the hemiplegia, but disappearing at an early date. The sensory paralysis in such a case is only an indirect symptom. 2. The hemiaucTsthesia like the hemiplegia is a perma- nent symptom. 3. Hemian£esthesia alone permanent or complicated with cross paralysis of special senses. The anaesthesia affects the same side as the hemiplegia when these forms of paralysis co-exist. The cutaneous sensibiUty in such cases is impaired or entirely abolished on the affected side from head to foot, and is attended by impairment of sensibility of the corresponding mucous membranes and of the muscular sense. The most prom- inent symptom in regard to the implication of the special senses is cross amblyopia or amaurosis. LOCALIZA TION—CEREBRA L DISEASES. 211 Pathological diagnosis in all cases of destructive disease of the corpus striatum, which are marked by the typical form of hemiplegia and attended by disturbances of sen- sibility, locates a lesion that involves the region of the posterior division of the internal capsule. Charcot has drawn attention to the appearance of vaso-motor symptoms in hemiplegia due to disease of the corpus striatum. These are the occurrence of oedema and changes of temperature in the ])aralyzed limbs, besides some other symptoms relating to the sym- pathetic nerve. Although the intracerebral path of this nerve is undetermined, it is known that it passes the crura cerebri and must therefore occupy a part of the internal capsule. Post-hemiplegic chorea is not due to lesion of fibres of the internal capsule, as it was formerly supposed, but to a lesion involving certain fibres that come from the thala- mus optici. Corpora Quadrigemina. These basal ganglia are sup- plied by arterial branches which are also distributed to adjacent parts of the cerebrum. This accounts for the meagre report of cases of hemorrhage in which this lesion was solely located in the corpora quadri- gemina. The information concerning the special symp- toms manifested in lesion of these bodies is gathered from the effects of tumors. Apart from the symptoms common to all cerebral tumors, it appears that lesion of a part or of all the corpora causes visual disturbances chiefly affecting branches of the motor oculi. In another class of cases symptoms of incoordination were prominent. 202 MA X UAL F NER VOUS Dl S EA S ES . The Cerebellum, Hemorrhage and embolism of the cere- beUum are of very rare occurrence. A clinical distinction between cerebellar and cerebral apoplexy is not practic- able. The extravasation of blood into the cerebellum is always marked by violent symptoms. The hemorrhage affecting one of its hemispheres usually bursts into the fourth ventricle, involving the medulla and the pons. Histories of total destruction of the lateral half of the cerebellum from softening show complete latency, but symptoms of much significance are often witnessed from the presence of tumor, usually tuberculous, in the vermi- form process and the crura cerebelli. The characteristic symptoms of lesion of the worm include a reeling sway- ing gait, vertigo and vomiting. Accessory symptoms, such as amblyopia, amaurosis, epileptiform convulsions and severe pain in the head are incidental to all cerebral tumors. Certain remarkable forced movements are observed in lesion of the middle peduncle of the cerebellum (ad pon- tem). These phenomena consist of lateral deviation of the head and eyes and rotatory movements of the body. As these symptoms have not been observed in focal lesion of other parts of the brain, they may be considered diagnostic of disease of the cerebellum. Pons Varolii. Hemorrhage of the pons is of rare occurrence and is not easily distinguished from hemor- rhage of other parts of the brain. Speedy death is exceedingly common on account of the proximity uf the medulla to which the extravasation usually spreads. Marked stertor and irregularity of the heart's action are witnessed from the outset. Deviation of the eyes and rotation of the head, which are always grave LOCAL//. A no y~ C E R E B It AL DI S E A S ES. 213 syiiiptoins in cerebral apoplexy, also occur in hemor- rliage of the pons. The pupils are sometimes so extremely contracted, that in connection with the coma, opium poisoning is simulated. Symptoms of motor irritation quite often develop in pons lesions. They consist of partial spasm or epileptiform convulsions. In large hemorrhage of the pons there is usually a general relaxation of the whole muscular system. The most reliable evidence of the existence of a pons lesion, whether it be a hemorrhage, embolism or tumor, is a peculiar form of paralysis (alternate paralysis). It differs from typical cerebral hemiplegia in this, that the paralysis affects the upper and lovyer extremities of one side of the body, opposite to that of the lesion and the face on the same side as the lesion. In this form of paralysis there is sometimes implication of the hypoglossus. The abdu- cens and the trigeminus are less frequently involved. If ordinary hemiplegia exists as is seen in lesion of the basal ganglion, the diagnosis of a pons affection is impos- sible. Crura Cerebri. In hemorrhage or embolism of either the thalamus opticus or the inferior extremity of the corpus striatum, one of the crura is sometimes indirectly involved. This complication arises from the circum- stance that these parts are supplied by branches of the posterior cerebral artery. But in a focal lesion confined to one of the cerebral peduncles a very char- acteristic form of paralysis is seen. The hemiplegia affects the extremities on the side opposite to the lesion, and the motor oculi of the same side as the lesion. All the ocular muscles to which branches of this nerve are distributed are paralyzed, and, in consequence, divergent 214 MA X UA L F XER VO US DISEA S ES . strabismus and diplopia develop. The facial and hypo- glossal are usnalh^ involved on the same side as the extremities are. Anaesthesia is also noticed, always on the side opposite to the lesion, but it is a subordinate symptom. If a lesion of the crura does not produce the alternate form of paralysis, as stated, but only the usual form of a cross paralysis, it cannot be diagnosed. Medulla Oblongata. The causes that give rise to focal lesions in different parts of the brain seldom affect the medulla oblongata. Hemorrhage of this organ, which is extremely rare, usually causes instantaneous death. If the patient survives the onset symptoms arise that can- not be discriminated from those presented by ventric- ular hemorrhage or a large clot in the pons. Cases of inflammatory softening of the medulla are described under the head of " apoplectic " or " acute bulbar paralysis," which is marked by a group of symptoms greatly resembling those of the chronic degenerative disease of the medulla known as " labio-glosso-laryngeal paralysis." The latter is an entirely different affection. The most prominent symptoms of the former include cross hemiplegia or paraplegia and very grave disturb- ance of the respiration and circulation. APHASIA. Anomaly of speech was the first symptom that led the way in the search for the " localization of the functions of the brain." Although it would be misleading to speak of a '^center of speech," for the faculty of language requires the action of a complicated mechanism, yet pathological investigations and experiment leave no room for doubt LOCAL IZA TIO N-CEREBRA L D ISEA SES. 215 tliat definite parts of the cerebrum stand in intimate relation to the function of speech. Aphasic disturbances of speech are manifested in many different ways, and various forms of the disorder are often observed in the same individual. In complete loss of the memory of language, the patient may know very well what he wishes to express, and correctly answer questions by gesticulations, but the words have escaped him. He may understand the meaning of the word that is spoken to him, or he may not. He may repeat a word or short sentence he has heard spoken, but he cannot of himself express a thought. Sometimes an aphasic patient uses one or several words, whether they have a meaning or none, as the only vehicle of his thoughts. I once attended a hemiplegic woman who made invariable use of the senseless word "ninny" and none other, whenever she desired to ask for something or intended to answer a question, although she understood spoken and written language. Other aphasics command a limited vocabu- lary, and are foiled when desiring to express a long or complicated sentence. It is an interesting fact that certain aphasics are able to speak with great facility under the momentary influence of strong emotional excitement. Graves reports the case of an aphasic patient who only knew the initial letters of words and had to consult the dictionary for the rest. Such forms of partial aphasia are very common. An aphasic person may forget his own name or those of his wife and chil- dren. In all these instances of aphasia the fault is on the intellectual side. Another important form of aphasia relates to the fault on the motor side. There are 216 MA N UAL OF NER VO US D I SEA SES . aphasic patients who have a complete knowledge of words that correctly express their ideas and perfectly understand what is spoken to them, but they have lost the capacity for the movements by which language is articu- lated, although the muscles engaged in speech are sound and not paralyzed. A third chief variety of aphasia consists in the use of wrong words. The patient is not aware of this defect, and Avill often show his vexation at not being understood. The question arises, what part of the brain is involved in aphasia ? It is now universally believed, on the strength of reliable statistics, that in the vast majority of cases of aphasia the lesion is located in the left hemis- phere. Of 260 cases of aphasia, Seguin found the lesion in the left hemisphere in 243; in the right in 17: a proportion of 14.3 to 1. In Lohmayer's table, out of 53 cases of aphasia there are 34 in which the third or inferior frontal convolution of the left hemisphere was diseased. This is the convolution in which Broca lirst discovered the aphasic lesion. The island of Reil comes next in frequency as the seat of the lesion. Other por- tions of the left hemisphere which are less often involved are the superior temporal convolution bordering on the fissure of Sylvius and the corpus striatum of the left hemisphere. Kussmanl classifies aphasic symptoms under the fol- lowing heads: 1. Ataxic (or motor) aphasia. There is incapacity of motor innervation of words. Patients have lost the power either totally or partially of coordinating the move- ments for articulate speech. They fully understand L OCA LIZA TiO N-CEREB RAL DIS EA S ES. 217 the language spoken to them. The gross muscular power of the organ engaged in articulation is retained, but the ability to associate the movements required in uttering words is lost. 2. Amnesic aphasia. (This is the sensory aphasia of Wernike.) There is incapacity for the recollection of words as aggregate acoustic sounds. The idea is pres- ent, but the word is wanting, although articulation is at the service of the word. 3. Word dumbness^ or the inability with good hearing and sufficiently preserved intelligence to understand words. This defect is also called "word deafness." 4. Paraphasia. There is an inability to properly con- nect word images and correspondin g conceptions. Instead of words expressing the idea intended to be conveyed, they are misplaced, or confused word images present themselves to the aphasic. Aphasic disturbances in individual cases may range from slight defects of speech to its entire abolition. In ataxic or motor aphasia, the mental images of words are intact. The stock of auditory representatives of words is retained. There is in this form of aphasia no actual loss of muscular power of the organ of speech, but the revival of the motor images of speech, that formerly readily responded with corresponding articulation is imperfect or abolished. The patient has lost the gift of adequately adjusting the associated movements for the formation of words. Many of us in the healthy condition have often experienced an analagous difficulty in states of mental excitement^to find words to express our thoughts, which under ordinarv circumstances would flow freely. It S18 MA X UA L OF XER VO US DIS EA SES . appears as if the resource on which we abvays confi- dently rely for supplying us with words had for the moment failed us. Mental images of words in amnesic aphakia cannot be recalled, or only to a partial extent. The general intelli- gence is clear, and the corresponding function for the articulation of words may be perfectly intact, but lan- guage, either vocal or written, has lost its meaning. The conceptions as they arise in consciousness do not excite memory of the corresponding words, or the words that are heard fail to evoke the mental images they represent. The patient hears the words, he is not deaf, but he does not understand what the Avords signify. Word dumbness often occurs as the only indication of aphasia. A patient may fail, for example, to recall the name of his father or his own child, but perfectly under- stands who is meant when he hears the name spoken. In paraphasia there is an interruption of the associa- tion of an idea and its corresponding word. A patient ma}^ ask for a spoon, when he means a knife, and persist that he is correct. Sometimes this use of wrong words renders his conversation unintelligible. Agraphia. Air. via. Incapacity to convey thoughts in writing, as well as in speech, is more or less observed in amnesic aphasia. It is clear that words, which cannot be recalled, can as little be communicated in writing. The agraphia in some patients is modified in so far, that they can correctly copy the writing of others. Alexia is usually also present. The written characters convey no meaning to the patient. Finally it has been noticed that in aphasia there is sometimes a loss of the language of LOCA L IZA TIOX^CEREB RA L DISEA SES. 219 gesticulation and pantomime. Patients wrongly indicate by their gestures the intention they wish to express. Topography of the Skull in Relation to the Surface of the Brain. FR Fissure of Rolando. 8^ Fissure of Sylvius. PI, P2 Upper and lower parietal convolutions. Cerebellum. Frontal lobe. Parietal ridge. Coronal suture. Fronto-Sphenoidal fissure. Lambdoidal sutui'e. Cb F R, R C,C FS LS AC and PC Anterior and poste- rior central convolutions. Occipital lobe. T Temporal lobe, fi First frontal. f.^ Second frontal, f;. Third frontal convolutions, tv Transverse vertical line. FB Angle of frontal bone. SS Squamous suture. The area corresponding to the first, second and third frontal convolutions is bounded anteriorly by a trans- verse line ending at the angle of the frontal bone, behind by the coronal suture and below by the fronto-sphenoidal fissure. The area corresponding to the anterior and posterior central convolutions is bounded in front by the coronal S^O MA N UA L OF NEIi VOUS DIS EA S ES . suture, behind by a parallel line intersecting the parietal ridge and below the t^quamous suture. The superior por- tion of the central convolutions is above the parietal ridge, its inferior portion is below the ridge. The supra- marginal convolution corresponds to the region of the parietal eminence. The area of the temporal lobe is bounded above by the squamous suture. The occipital lobe is bounded in front bv the lambdoidal suture. CHAPTER XIII. DISEASES OF THE BRAIN. Cerebral Hyper.emta. (Congestion of the hrain.) Etiology. Circulatory disturbances of the brain used to play an important role in the pathology of various cephalic symptoms for which no other cause could be assigned. It is not easy to understand under what cir- cumstances arterial hyperaemia can occur, except it be from simple hypertrophy of the left ventricle of the heart. Full-blooded or rather " plethoric " people are popularly thought to be peculiarly liable to severe head affections. If by the latter be meant cerebral haemorrhage or cerebral embolism and it can hardly mean anything else, then morbid anatomy is at fault. Symptoms like headache, dizziness, throbbing of the carotids and a flushed face are often enough seen after a debauch or a heavy meal or in states of great mental excitement. It would not be hazarding too much to surmise that such causes tend to lessen arterial tension which induces increased blood pressure. The condition thus induced is probably meant by the phrase " a rush of blood to the head." Passive congestion of the brain is better understood. It is invariably a secondary affection resulting from imped- iment to the return of blood from the brain. This con- ( 1^21 ) 222 MA N UA L OF NE RVO US D IS EA S ES . dition occurs in cardiac and pulmonary diseases, which obstruct the venous circuhition. The face in well-marked cases has a purplish tinge and the lips are of a bluish color. The head feels heavy and full, the breathing is oppressed, there is a feeling of languor and the patient is indisposed to physical and mental exertion. Now, a brain that carries too much venous blood is a badly nour- ished and actually an anai^mic brain, and the symptoms correspond with this condition. Treatment. Persons who are liable to attacks of active congestion of the brain should be warned of the causes that bring them on. In the majority of cases it suffices to act briskly on the bowels and to apply leeches to the head. A course of aperient medicine, for which the bit- ter waters are well adapted, is often of much benefit. The treatment of venous hyperaemia of the brain is chiefly that of the primary disease. The symptoms may be temporarily relieved by gentle aperients, cold to the head and w^arm footbaths. Formerly it was the fashion to practice abstraction of blood in these cases, and no doubt it often gave prompt relief. One is sometimes tempted to take up this practice again under certain cir- cumstances. Some years ago I attended a young woman who suffered from constant violent headache, flushed face and heavy breathing, that depended on valvular obstruction of the heart. Nothing else gave her any relief but venesection, which, of course, could not be safely repeated as often as she demanded it. CEREBRAL ANiEMIA. Etiology. The sudden development of extreme cerebral anaemia is witnessed in profuse hemorrhages, failure of DISEASES OF THE BRAIX, 223 the heart's action and profound mental impressions. It is manifested by great pallor of the face, loss of conscious- ness, slow and sighing respiration, a feeble pulse, dilata- tion of the pupils, blackness before the eyes, sometimes vomiting and general convulsions. The gradual estab- lishment of cerebral anaemia is seen in chronic diseases, chlorosis, general anaemia, prolonged lactation and debil- itating discharges. Clinical History. The symptoms of chronic cerebral anaemia consist of various functional nervous disorders. Headache, vertigo and nausea are its constant attend- ants. Patients show mental irritability and complain of languor and weakness. They are liable to fainting fits. One of the most unpleasant symptoms is a feeling of drowziness. Hallucinations of sight and hearing some- times develop in aggravated cases. Many of the ailments attributed to neurasthenia are really the effects of cere- bral anaemia. The Treatment when general anaemia exists is obvious. Attention must be particularly directed to the special cause that underlies the head symptoms. A disregard of the causal indications render all the reputed nervines and sedatives of no avail. CEREBRAL HEMORRHAGE. (Apoplexy.) Etiology. Disease of the coats of the cerebral blood- vessels is the chief cause of cerebral hemorrhage. The degenerative change far more frequently consists of an arterio-sclerosis than atheroma. In consequence of the thinning of the vascular walls, miliary aneurisms develop which on rupture permit the effusion of blood. The ^•2Jf MANUAL OF NERVOUS DISEASES. formation of these minute dilatations of cerebral arteries is favored by the absence of the adventitia. Charcot and Bouchard found miliary aneurisms in every one of the seventy-seven cases of cerebral hemorrhage they had examined. Increase of blood pressure will certainly facil- itate the rupture of the aneurisms, but arterial tension alone without disease of the walls of the vessels is insuf- ficient to cause the rupture. There are many exciting causes which in consequence of increased blood pressure lead to cerebral hemorrhage. It is a matter of experience that apoplectic attacks are often seen after strong physical efforts. Even relatively slight exertions, such as cough- ing, sneezing and especially straining at stool may burst a diseased vessel of the brain. The indulgence in alcoholic stimulants and the use of the cold plunge-bath may be followed by the same consequences, ^[ental excitement has sometimes a similar effect. Cerebral hemorrhage is also often observed to occur in hypertrophy of the heart, especially in that form of car- diac trouble which develops in Bright's disease. In those cases characterized by the existence of the granular con- tracted kidney, the accompanying arterio-sclerosis facili- tates the rupture of cerebral blood-vessels under the influence of the exaggerated action of the heart. In 55 cases of cerebral hemorrhage cited by Charcot, hyper- trophy of the heart was found in 22. The kidneys were afif'ected in 32^ per cent of 49 cases. Extravasation of blood in the brain has been met with in scurvy, pernicious ana?mia and leukaemia. Capillary hemorrhage of the brain occurs in cases of pernicious infectious diseases, smallpox, pya-mia, etc. This acci- DISEASES OF THE BRAIN. 225 dent is insignificant in comparison with the grave nature of these diseases. Alcoholism, syphilis and gout must also be considered as occasional etiological factors of apoplexy. Age has a decided influence on the occurrence of cere- bral hemorrhage. Persons under forty years are rarely attacked. Sex has a similar important bearing. The proportion of men who are subject to cerebral apoplexy far exceeds that of women. A predisposition to cerebral hemorrhage must be admitted in the sense that certain families show a hered- itary tendancy to arterial degeneration. The wide-spread belief that thick-set, short-necked men of a florid com- plexion are prone to be affected w^ith cerebral hemorrhage does not accord with experience. Anatomical Changes. Certain parts of the brain are more often subject to hemorrhage than others. Those parts in the vascular districts supphed by the middle cerebral artery are especially frequent situations of blood clots. They include in the order of frequency, the caudate and lenticular nuclei, the thalamus optici, the internal cap- sule and centrum ovale. Hemorrhage of the convolu- tions, the pons and cerebellum is much less frequent. The crura cerebri and the medulla are very rarely affected. The blood sometimes makes its way into a ventricle or escapes to the surface of the brain. It always tears up the brain tissue and then forms into a clot. The blood clots are of various sizes in different cases ; they may not exceed the size of a pea or be as large as a man's fist. Very large hemorrhages flatten the convolu- tions. 15 ^26 M ANU AL OF NERVO US D I S EA S ES . A recent clot presents the appearance of a dark, pitchy mass, which is composed of the effused blood and the debris of the destroyed brain tissue. The contiguous portion of the brain is infiltrated with blood and is soft- ened. The edges of the cavity where the clot lodges are ragged and irregular. The clot itself undergoes certain changes. It is gradually absorbed and the surrounding parts tend to resume their normal condition. New con- nective tissue develops in the cavity which gradually forms a cyst containing an ochre colored fluid. Such an apoplectic cyst is often found in old cases of cere- bral hemorrhage. Sometimes the fluid contents of the cvst are absorbed, so that nothing remains but a cicatrix of a rusty color, from the intermixture of blood pigment. Clinical History. A person is said to be threatened with apoplexy when certain symptoms or " w^arnings" make their appearance. Such premonitory symptoms are iden- tical with those ascribed to cerebral congestion. It is probable they are observed in cases where the hemorr- hage begins with a slow escape of blood. The onset of the apoplectic attack may be protracted if only a small twig of an artery ruptures. But cerebral hemorrhage that develops slowly is often fatal. The patient begins to feel dizzv and nauseous, his gait is. unsteady, or his body inclines to one side; his mind becomes confused, his speech is thick, he feels drowsy and finally the stupor is succeeded by profound coma. Sometimes the apoplectic condition is absent and hemiplegia, whether complete or partial, is the first sign of the hemorrhage. The compression exerted by the clot in such a case is supposed to be insignificant. At autop- sies in cases of this description clots of no larger size DISEASES OF THE BRAIN. 221 than a hazel-nut were found. In case II of " Andral'e Observations" the hemorrhage occurred without an apoplectic attack. The seat of the clot was in the optic thalamus, of the size of a large cherry. Rosenstein reports a case in which neither unconsciousness nor paralysis occurred, but only motor aphasia. A coagulum of blood of the size of a hazel-nut occupied the white sub- stance of the third left frontal convolution. Ingravescent apoplexy is a form of cerebral hemorrhage characterized by the peculiarity that fatal coma develops for hours or several days subsequent to the appearance of hemiplegia and head symptoms. In cases published by Broadbent, the hemorrhage had begun in different parts of the brain and later either burst into the ventricle or broke through the pia. Delayed apoplexy differs from the foregoing in the circum- stance that the symptoms develop gradually. There is headache, dizziness, nausea, delirium ; one arm or one leg or the whole of one side is paralyzed and finally uncon- sciousness sets in. The hemorrhage in such cases accu- mulates slowly until the amount of the effused blood brings on coma. In severe attacks of cerebral hemorrhage there are no premonitory symptoms, the patient is suddenly and unexpectedly thrown into a condition of profound unconsciousness and utter insensibility. In popular language he has a " stroke of apoplexy." The patient may sometimes have just time enough to lie down or sink into a chair before he becomes completely comatose. He presents then the following appearance : The face is flushed, the eyes are watery, the pulse is full, but often slow, the respiration is noisy or stertorious, the mouth is Q28 MA X UAL OF NER V US DISEA S ES . drawn in with each inspiration and the cheeks bulge out with every expiration. Many patients in this condition rapidly sink. The temperature is seldom altered, but immediately before the fatal termination it may quickly rise or fall. In very bad cases there is sometimes lateral deviation of the eyes and rotation of the head in the same direction. There is no characteristic change of the pupils. They may be normal, contracted or dilated. Whilst the patient is in the comatose condition there is complete relaxation of the muscles. Examination of the urine after an ordinary apoplectic attack frequently detects traces of albumen and sugar. Quite often there is retention of urine. Many patients never recover from the initial symptoms of cerebral hemorrhage. In this condition all the vital functions begin to fail. The stertor is replaced by rat- tling in the throat, the saliva runs down the chin, the respiration becomes exceedingly shallow, the body feels cool, the pulse is very slow and feeble or extremely rapid, the eyes are sunk deeply into their sockets, the cornea is opaque, the face is pallid and the cheeks are fallen in. Death may happen within an hour or the patient may linger for a day or two. A more favorable termination is however witnessed in a large proportion of cases. Consciousness gradually returns, the patient gives signs of the clearing of the intelligence, he opens his eyes, looks around, changes his position and soon recognizes those that surround him. The amount of damage done to the brain after the subsi- dence of the shock can now be judged by the severity of the hemiplegia. The distinction between direct and indirect symptoms DISEASES OF THE B H A I N . 229 of cerebral hemorrhage is of practical importance. Hemiplegia is eminently the symptom which • represents the direct effect of the focal lesion, but it may be an indirect symptom if the pyramidal tract is only second- arily implicated. The coma, which often quickly disappears in favorable cases, is evidently a cortical symptom, and is the result of shock or compression. As it occurs wherever the clot may be situated in the brain, the impaired consciousness must be considered in the light of an indirect symptom. But coma may have the significance of a direct symptom, when the lesion affects the prefrontal lobe. It may be stated in general terms that those symptoms are of a direct character that denote permanent disturbance of special function's of the brain. Those are of an indirect character which are transitory and subordinate. We know from experience the tempo- rary nature of certain symptoms that attend cerebral hemorrhage, but often we are only able to determine their true character by the future course of the individual case. Under the head of indirect symptoms are usually included: disturbance of speech; early rigidity, transitory aphasia; changes of the urinary secretion; deviation of the eyes and myopia. The facial paralysis in hemiplegia is quite often an indirect symptom. Hemiplegia is the clinical evidence of injury or indirect implication of the pyramidal tract iir any part of its course in the brain. As the lesion in cerebral hemorrhage in the large proportion of cases involves the central gan- glia and adjacent parts, it is obvious that the internal capsule being almost invariably involved necessarily gives rise to hemiplegia of the side opposite to the lesion. The paralysis of the extremities is the most important 230 MA N UAL OF XER VOUS D IS EA SES . feature of hemiplegia. In some cases there is total paralysis of the arm and leg. In others there may only exist a slight hemiparesis. A variable degree of improve- ment of the paralysis takes place in numerous cases. It sometimes appears so early and well marked that prob- ably the paralysis to a great extent was an indirect symptom. But usually the improvement is only partial. It begins as a general rule in the inferior extremity. Many patients are again able to walk with the weak leg, whilst the arm is still useless. Paralysis of the face is usually not a prominent symptom in cerebral hemiplegia. It is confined to the muscles supplied by the lower division of the facial nerve, and may be so slight that it is only recognized when the patient smiles or shows his teeth. In impairment of the hypoglossus, the tip of the tongue inclines towards the paralyzed side. The soft palate is sometimes affected. It hangs lower down, and is also directed towards the paralyzed side. The tendon reflexes in nearly all cases of hemiplegia are exaggerated on the affected side. Vigorous contrac- tions are excited when the tendons and bones of the arm and the leg are tapped. On the other hand the cutaneous reflexes are always diminished on the hemiplegic side. Sensation is rarely impaired. Hemianesthesia in connection with hemiplegia is observed in lesion of the inferior third of the internal capsule. Contraction of the paralyzed muscles is often seen in the late stage of hemiplegia. This "late rigidity" affects the upper extremity more than the lower. The fingers are fixed in the position they assume when at rest; the upper-arm is adducted by the pectorales major and the forearm is in pronation. Moderate contraction of the DISEASES OF THE BRAIN. 231 calf muscles of the leg is occasionally observed. It is held that the muscular rigidity in hemiplegia is due to secondary degeneration of the pyramidal tract. "Asso- ciated movements" constitute occasionally interesting phenomena of hemiplegia. It is observed that move- ments of the paralyzed mut^cle^; are excited when volun- tary movements are carried out by the healthy side. Post-hemiplegic chorea is a rare symptom of cerebral hemorrhage. Vaso-motor symptoms are observed soon after the apoplectic attack. The paralyzed limbs are warmer and redder than those of the healthy side. Congestion and even effusion of blood into the lung, pleura, endocardium and kidneys has been found in fatal cases. By the trophic symptoms in hemiplegia are under- stood the development of malignant bed sores and painful joint disease. Atrophy of the paralyzed muscles is noticed in old standing cases of hemiplegia, but it is not of the degen- erative sort. The faradic reaction of the muscles is normal. Impairment of the mental capacity in hemiplegia patients is sometimes very evident. It may escape notice, when they engage in ordinary affairs of life, but they are often incapable of sustained intellectual efforts. The mental weakness is usually recognized by forgetfulness of recent events and the undue display of emotional excite- ment. Old paralytics are frequently seen to weep or whimper without any apparent provocation. Bastian gives the limit of four weeks, beyond which time little improvement of the paralysis may be expected. The general health is often fairly good, and many hemi- 232 MA XL' A L F NEB VO US D I SEA SES. plegic patients grow even corpulent. Later on, when they become bedridden and marasmus develops, they are apt to succumb to slight intercurrent affections. Diagnosis. The differential diagnosis between cerebral hemorrhage and cerebral embolism will be discussed in connection with the latter disease. Although cerebral apoplexy presents the striking phenomenon of sudden loss of consciousness, which in the majority of cases ren- ders diagnosis easy, yet the recognition of the true state of the case may remain uncertain in instances of very rapid death, say within half an hour or less. Cerebral hemorrhage does not usually kill instantly. Such a mode of death, preceded by coma, is more likely to be due to meningeal hemorrhage from a traumatic cause, the rupture of an aneurism or sudden failure of the heart's action in valvular disease. The most embarrassing cases however are those in which persons of whose previous his- tory nothing is known are found in a state of coma resem- bling that of cerebral hemorrhage. Suppose a man deeply comatose is picked up in the street by a policeman, or a stranger at a hotel is found in a complete state of stupor, from which he cannot be roused, it would be hazardous to express a positive opinion concerning the true condition of such a patient. If in an instance of this kind the patient is advanced in years, if the artery at the wrist is rigid, or the signs of cardiac or renal disease are evident, there is great probability that the loss of consciousness is either the effect of cerebral hemorrhage or embolism. Still this does not exclude the possibility of injury to the head, deep intoxication, opium poisoning, ur^emic or epileptic stupor or meningitis. It has often happened that the extreme prostration presented by a drunken man DISEASES OF THE BRAIN. 233 has induced compassionate people to ply him with brandy, and contrariwise a man with a clot in his brain has sometimes been arrested by the police on the charge of drunkenness. If paralysis co-exists the difficulty of diag- nosis vanishes at once, for whatever may have been the mode of onset, there is some lesion of the brain in the case. Very confusing complications occasionally arise that tend to lead diagnosis astray, as illustrated in the history of the following case: A man profoundly coma- tose was sent from the police station, where he had been placed in a cell the previous night, to the hospital. The house surgeon was informed that the man was seen in a deep state of intoxication, led about by a companion, and that he had a heavy fall on the curbstone. As he was still unconscious in the morning and could not be roused he was brought to the hospital in a patrol wagon. There was a strong smell of liquor about the man. The house surgeon on examination discovered no injury, and con- cluded that from all appearances more time would be required for the effects of intoxication to pass off. The man died three hours afterwards. At the autopsy an enormous meningeal hemorrhage and a linear fracture of the skull were found. Undoubtedly the fracture which caused the hemorrhage resulted from the fall during the state of intoxication. Prognosis. Whether a patient who is down with cerebral apoplexy will come out of it or not depends on the mild- ness or gravity of the onset, or rather upon the quantity or localization of the hemorrhage. If the coma be not profound and the insensibility incomplete; if there is little or no stertor and the pulse and temperature keep within normal limits, the pati-ent in all probability will recover .?S4 MA N UA L OF ^'ER VO US BISEA S ES . from the coma. The case is unpromising if the uncon- sciousness is profound; if there is marked and persistent stertor, shallow breathing, a retarded or irregular pulse, or a sudden rise or sinking of the temperature. A cautious prognosis must be given in regard to the future improve- ment of the paralysis, for it cannot be determined before- hand how much of the hemiplegia is a direct or an indirect symptom. The chances whether a patient who safely got over one attack of cerebral apoplexy will have another are much against him if his arteries are diseased or his heart or kidneys are affected. Treatment. The routine practice of venesection in every case of cerebral hemorrhage is now generally abandoned, and for good reasons. Numerous patients recover from the shock for whom nothing has been done in the way of active treatment. There are, nevertheless, exceptional cases in which benefit may be expected from blood-letting, though it requires much tact and judgment to select them. The following symptoms in a young individual may indicate abstraction of blood : a cyanotic appearance of the face, a hot head, injected eyes, a vigorous pulse and a labored respiration. Leeches on the temples or on the mastoid processes may suffice in elderly persons. Active purgation from the effects of a few drops of croton oil mixed with a little syrup or a stimulant enema deserve a trial when the coma is very prolonged. An opposite treatment is advisable when there is great pallor of the face, a low temperature, a feeble pulse, slow and shallow respiration and widely dilated pupils. Patients in this condition are in danger of sinking rapidly, though often nothing can be done to prevent it. Wine, brandy, ether, musk and camphor should be steadily administered DIS EA S ES OF THE BRA I N. 235 against the threatened collapse. Should the patient be unable to swallow, which is usually the case, some of these remedies may be given with the hypodermic syringe. The failing respiration may be excited by dashing cold water on the face and bare chest; the skin may be rubbed with dry mustard or sinapisms be applied to the insides of the arms and thighs. It suffices in ordinary cases of cerebral hemorrhage to place the patient in a comfortable position, to raise the head and shoulders and to keep off all disturbances from bystanders. An icebag should be applied to the head. Formerly a great variety of remedies were employed with the object of promoting the absorption of the clot. The futility of meddling wdth the clot is now better under- stood. Confidence in the recuperative powers of nature to restore in some measure the damage done to the brain is fully justified by the improvement of the paralysis which is often witnessed. Much can be done to prevent or retard the renewal of the hemorrhage, with which the patient is always threatened, by measures that invigorate the general system. Patients should be advised to abstain from heavy meals, and from physical strains and mental overwork. The paralysis is often of such long duration that the physician should not neglect to continue an appropriate treatment, which prevents the recurrence of an apoplectic attack. A judicious symptomatic treatment after the shock has passed off relieves a number of dis- tressing symptoms that more or less affect paralytic patients. Troublesome headache is sometimes promptly relieved by a blister behind the ears or nape of the neck. Insomnia may require chloral and bromide of potassium or an occasional small dose of morphia. Sometimes a S36 M A X UAL OF XER VO US DfSEA SES . nightly rum punch does better in old paralytics, but large and often-repeated quantities of alcohol do mischief. At the end of about four weeks, after all the initial symptoms have subsided, a systematic course of elec- tric treatment is the only therapeutic measure from which improvement of the paralysis can be expected, although it would be difficult to decide, in favorable cases, what share the electricity had in the improvement. A feeble galvanic current should be cautiously passed trans- versely through the head for about two minutes in a position corresponding to the hemorrhagic focus. Strok- ing the paralyzed muscles with the kathode of the galvanic current is also advisable. HEMIPLEGIA IN CHILDHOOD. There is much uncertainty in regard to the primary cause of cerebral hemiplegia in children. The post- mortem appearances that are observed after the disease has existed for a considerable time show the effects of a pathological process that led to loss of substance of the brain (porencephalia). The degeneration of brain tissue implicates the motor tract. Probably the origin of the morbid change varies in different cases. It may have been hemorrhage, thrombosis, embolism or a congenital defect. Strum pel describes the disease under the name of ''the acute encephalitis of children," and considers it analogous to the acute poliomyelitis of the same class of patients. The disease attacks children between one and six years of age, wht) had previously been in good health. It is sometimes seen to follow exanthematous diseases. Clinical History. The hemiplegia in some cases is pre- ceded by grave cerebral symptoms, fever, nausea, vomit- DISEASES OF THE BRAIN. 237 ing, stupor and general convulsions. After the subsidence of these symptoms the little patient is seen to be para- lyzed on one side. The hemiplegia gradually improves, but complete restoration is unusual. The arm is always more affected than the leg, but both limbs are arrested in their growth. The reflexes are exaggerated, contractures develop and the paralyzed muscles atrophy. Sensory disturbances are absent. Symptoms of motor irritation are observed in old standing cases, resembling hemichorea and athetosis. In some cases there is a relaxed condition of the metacarpal articulations that permits the fingers to be placed in positions at right angles with the back of the hand. Epileptiform convulsions develop at a late period. Sometimes impairment of the intelligence occurs, especially on the side of the moral instinct. Treatment. During the acute stage, when the diagnosis is of course uncertain, the object of treatment is the mitigation of the cerebral excitement. Leeches may be applied to the temples or mastoid process, followed by cold to the head and a calomel purge. After the hemi- plegia has become stationary, there is little to be expected from therapeutical measures. Improvement has been claimed in some cases from the iodide of potassium. Electricity and massage may possibly be of benefit. CEREBRAL EMBOLISM AND THROMBOSIS. (Softening of the Brain from Occlusion of Cerebral Arteries.) Etiology. The usual sources of embolism are thrombi of the left auricle, concretions of the arch of the aorta, and very frequently particles of matter that detach from fibrinous masses on the valves of the left ventricle of the 238 MA N UAL OF NER V US D IS EA S ES . heart dating from a previou;^ endocarditis. The eniboU on being washed away by the circulation, are carried to cerebral arteries and occlude them. Thrombi originate in diseased blood-vessels. If they develop in the cerebral arteries they directly produce occlusion. In the latter situation they often crumble and become thus another source of embolism. The blood-vessels in which the thrombi originate are either affected with arterio-sclerosis atheroma or syphilitic endarteritis. Sluggishness of the circulation, which favors the stagnation of blood, is an important factor in the development of thrombosis. If the collateral circulation is established which replaces the arterial blood cut off by embolism in a cer- tain vascular territory of the brain no harm results, but if this does not occur it must necessarily happen that the part of the brain deprived of its blood supply softens and breaks down. Emboli are more frequently arrested in the large basal ganglia and the internal capsule than in other parts of the brain. This is due to the circum- stance that those regions of the brain are supplied by branches of the middle cerebral artery, which sparingly anastomose. The left middle cerebral artery is rather more frequently affected than the right. The process of softening in cerebral embolism takes the same course as embolism of the lung, spleen and kidney, but no infarcti are formed. It begins with ana'mia of the area of the brain that has been occluded, which is soon followed by disintegration of the affected brain tissue until it is reduced to a pulpy mass. A focus of softening may present a reddish appearance from the intermixture of blood of neighboring vessels, or it is of a white or yellowish color. A recent spot of softening, when DISEASES OF THE BRAIN. 239 examined with the microscope, is seen to consist of the debris of the destroyed nerve elements and vestiges of neuroglia and vessels. Changes analogous to those tak- ing place in the blood clot of cerebral hemorrhage are observed in the dead brain tissue so that it is diffi- cult to make the distinction in old cases. The disinte- grated mass is absorbed and replaced by cicatrical tissue, which hardens and atrophies the convolutions. Deep depressions are found when the softening occurs on the surface of the brain. Clinical History. An apoplectic attack is often the first intimation of the occurrence of cerebral embolism in indi- viduals whose general health had previously appeared to be good. The loss of consciousness may be as complete and come on as suddenly as in cerebral hemorrhage, though it is more frequently ushered in by general con- vulsions, delirium or vomiting. But the onset may be slow and the coma incomplete. Patients can be roused for a moment, they look about and may answer ques- tions, but soon fall back again into the former dazed condition. This difference in the severity of the onset probably depends on the size of the artery that is occluded. The onset in thrombosis is usually slow and made up of frequent attacks of vertigo, faintness and mental weak- ness. This condition is generally seen in elderly people who have previously shown evidences of failing health or in those who have exhibited signs of premature senile decay. A deterioration of the physical and intellectual powers may have been noticed for weeks or months before the final breakdown. There is often much headache, dizziness, unsteadiness of gait, a tendency of the ])ody to 240 MA X UA L OF XER VO US DIS EA SES . lean to one side, now and then a marked incoherence of speech, or rather a misplacement of words, a feeble mem- ory, and sensations of numbness and formication in some of the limbs. These prodromic symptoms may never develop into an apoplectic seizure, l)ut there is a history of occasional paresis of the face, weakness of an arm or of a leg, mental impairment and finally senile dementia. The spots of softening found in the brain in cases of this kind result from thrombosis of atheromatous arteries. Heubrier observed obliterated cerebral arteries from thrombosis in syphilitic young persons. The abrupt development of the apoplectic coma in cerebral embolism and thrombosis does not admit of an easy explanation, and the same applies to the rather frequent occurrence of epileptiform spasms. Probably these symptoms depend on the sudden obstruction of a large arterial branch. A fatal termination may as quickly follow the onset as it does in cerebral hemor- rhage, but patients have often been seen to continue for days in an apparent precarious condition of unconscious- ness and still recover. The chronic course of softening requires no separate description, as there is a history of hemiplegia and acces- sory symptoms analogous to those of cerebral hemor- rhage. Diagnosis. However difficult and often impossible it may be to make the distinction between the clinical his- tory of softening and hemorrhage of the brain, there are certain considerations and points of differential diagnosis that tend to turn the balance in favor of the one or the other. The apoplectic condition is frequently as well pronounced in cerebral embolism as in hemor- D I S EA S ES OF THE BR A IN. 21^1 rhage, but its prolonged duration is of less serious import in softening. 2. A severe onset, accompanied by a flushed face and strong pulsation of the carotids, indi- cates hemorrhage rather than embolism. 3. Coma is more likely to be due to embolism than hemorrhage if the patient be a young person, especially if there is a history of syphilis or inflammatory rheumatism. 4. Mental disturbance is more common in occlusion than in clot. 5. A hemiplegia which disappears in a few days can hardly be due to hemorrhage, for it is far more prob- able that a paralysis in such a case resulted from embolism that passed off" as soon as the collateral circu- lation was established. 6. Thrombosis may be inferred to exist in syphilitic patients and in senile softening when the physical and mental deterioration slowly develops. Prognosis. Although patients often recover from the immediate effects of cerebral embolism, they are liable to its recurrence, as the one attack shows the existence of diseased blood-vessels. Even if no other attack follows they enter upon the stage of chronic softening, which may last for years, but tends to a fatal termination. Treatment. If it were possible to determine with certainty in a case of cerebral apoplexy the existence of embolism or thrombosis, eff'orts might be made, b}^ means of stimu- lants to restore the circulation in the affected part of the brain. But it involves a great risk to ply the patient with brandy when a hemorrhage may possibly be going on. Beyond good nursing and paying attention to the secre- tions, but little can be done, after the subsidence of the initial symptoms. The special treatment of the paralysis is the same as that detailed in the previous section on hemiplegia. 2Jf2 MA N UA L OF KER VO US D IS EA SES . CEREBRAL TUMORS. Etiology. Intracranial tumors are of the same histo- logical structure as neoplasms in other parts of the body, and their cause is as little known. Adventitious growths develop in persons who have shown no signs of impaired health. Men in the middle period of life are oftener affected than women. The solitary tubercle is the tumor usually found in children. Varieties of Cerebral Tumor. 1. Glioma. This tumor consists of a hyperplastic growth of the connective tissue of the brain, variable in size, of a grayish or reddish color, seldom sharply defined and often very vascular, so as to give rise to hemorrhage. Gliomata usually occur in the medullary substance, and often also in the central ganglia. 2. Sarcoma. The various forms of sarcoma generally develop in the dura mater and periosteum of the skull, most frequently at the base, where, in consequence of the irritation and compression exerted on the parts in that region of the brain, very marked symptoms arise. Total blindness of one eye in connection with paralysis of ocular muscles occurs in sarcoma and glioma of the orbit. 3. Tubercle. Solitary and multiple tubercle invade different parts of the brain, but more frequently the cortex, the cerebellum and the pons. These tumors are usually of the size of a cherry, but sometimes as large as a hen's egg. Before the discovery of the tuliercle bacilli it was difficult to distinguish tubercular masses from gummata. DISEASES OF THE BRATN. 2 4. Carcinoma. Primary cancer of the brain occurs, but usually it is secondary, developing in association with malignant growths in the breast, lung and pleura. Tumors of the brain of rare occurrence include lipoma, cystic growths, hydatids and psamoma. Clinical History. A tumor, wherever situated within the cranium and independent of its histological character, gives rise to general symptoms, chiefly due to the degree and amount of compression or irritation it exerts in its immediate vicinity or remote parts of the brain. General symptoms. Nearly all the cephalic symptoms of brain tumor are the clinical manifestations of crowding and flattening of the convolutions, abnormal tension of the dura mater and circulatory disturbance. The greater the size of the tumor the more pronounced and nuliierous are these symptoms. Besides, intracranial pressure of the venous trunks causes ventricular eff'usion. 1. Headache is the earliest and most constant symp- tom. The pain is generally very severe and marked by exacerbations. There is no uniform relation between the seat of the pain and the particular location of the tumor, but in persistent occipital headache the growth has often been found in the posterior fossa. Patients evince the violence and persistency of the pain by groans and corru- gation of the brows even when in a dazed condition. They are sometimes seen to grasp the head with the hands and run to and fro in a frantic manner. Sleep is difficult to procure. 2. Vertigo stands next in prominence as an early symp- tom. The dizziness is sometimes so aggravated that patients stagger and reel as if they were drunk. 2U MA X U A L O F N ERVOUS DISE A SES. 3. Cerebral vomiting is a very troublesome and intract- able symptom, and is apt to come on as soon as the patient rises from bed. 4. Remarkable slowness of the pulse is frequently noticed. Passive congestion of the cerebral venous trunks sometimes brings on sudden faintness or a momentary attack resembling apoplexy. 5. A marked symptom in severe cases is mental perturbation, which is exhibited in the expression of the face. The patient appears stupefied, he is slow in answering questions and forgets what he has been saying or doing a moment before. 6. Epileptiform convulsions occurring in brain tumors may be grouped among the general symptoms, but frequently the spasms are due to a tumor in the excitable motor areas of the cortex. Partial spasm affecting facial muscles or an arm also indicates the existence of such a definite focal lesion. 7. There are few cases of cerebral tumor which do not develop optic neuritis. This is a symptom of pressure exerted by the growth wherever located in the brain. It is therefore important to make an ophthalmoscopic exam- ination when a cerebral tumor is suspected to exist. Choked disk is now generally supposed to be caused by the cerebro-spinal fluid being forced into the lymph- sheath of the optic nerve. Sight may be unaffected for a long time, as the atrophy of the disk is often a late pro- cess. Amblyopia tending to amaurosis is however in some cases an early symptom of cerebral tumor, and the oculist may be the first to discover the true cause of the disturbed vision. DISEASES OF THE BRAIN. 245 Focal symptoms of cerebral tumor. A brain tumor may during its whole coarse excite no other but general symp- toms. Such is the history in cases where the tumor is lodged in the centrum ovale or in one of the basal gan- glia. It is also a peculiarity of cerebral tumor that symptoms which indicated implication of definite parts of the brain may disappear. A monoplegia, or even a hemiplegia, may pass away and not return. Such an occurrence is explicable on the supposition that a change in the tumor reduced its volume, and thus the pressure was removed from the particular part that had caused the paralysis. Aphasia in tumor of the left hemisphere may in this manner be only a temporary symptom. Partial spasm of paralyzed limbs, which is rather com- mon in brain tumor, may disappear under analogous circumstances. It is in tumors at the base of the brain that special focal symptoms always make their appearance. A tumor in this situation affects more or less the cranial nerves where they emerge from the brain. The paralysis of these nerves shows the peripheral type. The nerves which are subject to the paralysis include the different branches of the motor oculi, the trochlearis, the abducens, the facial, the hypoglossal and the trigeminus. Each of these nerves may be separately affected or several of them are simultaneously paralyzed. A large proportion of cases of paralysis of one or more of these cranial nerves, where the existence of a brain tumor is suspected, result from syphilitic gummata. To describe the special symptoms significant of tumor in other parts of the brain would merely repeat what has already been stated in regard to the pathological diag- ^J^ii MA N UAL OF NER VOUS DISEASES, nosis of cerebral lesions. An exception might be made in reference to cerebellar tumor, which is more common in children than adults. The general symptoms are sometimes violent, especially the constancy of the pain in the occipital region and the incessancy of vomiting. Stiffness of the neck is often well marked. Choked disk is nearly always present. Besides, there is not unfre- quently unsteadiness of the gait, amblyopia, anosmia and deafness. Course. At autopsies tumors of the brain have been found that had remained entirely dormant, but such instances are rare exceptions. Sometimes a cerebral tumor abruptly develops symptoms indicating a serious brain trouble. Usually the onset is slow, and the disease runs a chronic course lasting for months or years. The general health is gradually undermined by constant suffering and wakefulness. Towards the close amelio- ration is brought about by the decline of the mental activities and the deepening of the stupor. A fatal termination sometimes rapidly ensues from a succession of epileptiform convulsions. Diagnosis. The continuous and progressive course of cerebral symptoms, in which a severe headache that appears to baffle all remedies constitutes a prominent feature, would suggest the existence of a cerebral tumor- Such a diagnosis is greatly strengthened if epileptiform convulsions also occur, and is nearly brought to a cer- tainty if choked disk is discovered. A cerebral abscess may come near to presenting a similar set of symptoms, but this disease can often be traced to a traumatic or some other palpable cause. Its duration is shorter and choked disk is much less frequently found than in tumor. DISEASES OF THE BRAIN. 247 The implication of cranial nerves is as likely to be due to syphilitic degeneration as to a sarcoma at the base of the cranium. The differential diagnosis would meet here with difficulties, though the association with more of the general symptoms, and especially the presence of choked disk, would tend to decide in favor of tumor. Multiple sclerosis may possibly imitate brain tumor, but the for- mer is the more chronic disease and manifests other symptoms which are not common to cerebral tumor. In very rare instances a chronic hydrocephalus, the result of a circumscribed meningitis, has been found that dur- ing life had counterfited a brain tumor. In children, who are frequently subject to headache and convulsions, the probable existence of an isolated or multiple tuber- cule should be taken into consideration. The diagnosis in regard to the character of a cerebral tumor is sometimes possible, but far more frequently it is impracticable. A predisposition to tubercular infection in children would influence diagnosis in favor of a tuber- cular tumor. A history of syphilis would do the same for a gumma. The existence of cancer in a remote part of the body suggests malignant tumor of the brain. Cerebral aneurism, which seldom causes choked disk, is marked by paroxysms of violent headache and frequent attacks of vomiting. Prognosis. All intracranial tumors, irrespective of their histological nature, tend to a fatal termination. Excep- tion must be made in regard to syphihtic gummata. A guarded opinion is advisable as to the duration of the disease, though two years is about the utmost limit. Death may happen at any moment, either from hemor- rhage or epileptiform convulsions. 21,8 MA X U A L OF X E R V OUS DISEA S ES . Treatment. If anything is to be expected from treatment in cerebral tumor it is the iodide of potassium that holds out some prospect of success. This remedy is not only the most proper and efficacious one in gummatous intil- tration, but growths of a different nature may sometimes be influenced by its effects. In explanation of the ben- efit sometimes derived from the remedy, it is supposed that tumors often give rise to symptoms not so much dependent upon their size and location as upon the inflam- matory softening and oedema they produce. There remains still much scope for s3niiptomatic treat- ment. Anodynes for the relief of pain are indispensable. The bromides exert some control over the convulsive paroxysms. Alcoholic stimulants, tea and coffee should be strictly prohibited. ACUTE AND CHRONIC ABSCESS OF THE BRAIN. (Encephalitis, j Etiology. I. 'Traumatism of the skull is one of the chief causes of cerebral abscess. Complicated fractures that destroy brain tissue and permit the ingress of infectious materials invariably give rise to collections of pus within the cranium. It is equally a iviatter of experience that cerebral abscesses may develop from contusion and lacer- ation of the scalp, although the skull is uninjured. Cases of this kind usually come first under the notice of the general practitioner, for the extension of the inflamma- tion through the bones is often a late process. 2. Disease of the petrous portion of the temporal bone originating from inflammation of the middle ear is next in the order of frequency a cause of cerebral abscees. Children and DISEASES OF THE BRAIN. 3^9 youths who have runninor ears are in constant danger of being either suddenly attacked with acute cerebral abscess or meningitis. The abscess in this class of cases is situated in the parietal lobe, or in one of the hemispheres of the cerebellum, and is usually associated with suppur- ative phlebitis of a sinus. 3. The metastatic abscess is generally multiple and of small size. It develops dur- ing the course of pyaemia and is of subordinate clinical importance. Abscesses of this character sometimes form in purulent bronchitis. There still remains a class of cerebral abscess for which no cause can be assigned. Anatomical Changes. A cerebral abscess may merely pre- sent the appearance of a small spot of softening. If there is only one it is generally of a large size. The greater part of a hemisphere is sometimes found transformed into a collection of pus. The pus is of a greenish-yellow color or reddish from -the mixture of blood globules. It may be odorless or offensive and consist of the remnants of destroyed nerve tissue. The cavity in which it is lodged presents irregular walls. The surrounding parenchyma of the brain, to a greater or less distance, is softened and infiltrated with an abundance of granular corpuscles. A large abscess near the surface of the brain may sometimes be recognized by fl actuation. When centrally located it not unfrequently bursts into a ventricle. A cerebral abscess of old date is usually found encap- sulated. The cyst-wall is formed of fibro-cellular tissue. Its inner layer consists of a smooth pyogenic membrane. The contents of a chronic abscess often resemble a thick- ened cheesy substance. Clinical History. An acute cerebral abscess, whether directly caused by an injury or any other cause, which S50 MA NUAL F NER V OUS DI S EA SES . after a period of latency suddenly kindles into activity, gives rise to symptoms that cannot be distinguished from those of acute meningitis. There is a high grade of febrile excitement preceded by a chill or rigor, a violent or deep, dull pain of the head, delirium and finally stupor and coma. Rarely does an acute cerebral abscess run into the chronic stage. Precisely the same group of symptoms of a fatal tendency attends the class of encap- sulated abscess, which either rupture into a ventricle or escape to the surface of the brain. The clinical history of chronic abscess is marked by a course of symptoms of much less severity. There are often attacks of violent headache, probably brought on by incidental exciting causes that disturb the cerebral circu- lation, and is attended by the irregular occurrence of chills. Nausea is sometimes a troublesome symptoi^i that often terminates in vomiting. The general symptoms in many cases may amount to a feeling of ill health, nervous weakness and a gradual emaciation. But the persistence of pain in the head, the recurrence of febrile disturbance, occasional delirium, the sudden attack of convulsions and a deepening stupor tell the gravity of the underlying disease. The focal symptoms vary with the location of the abscess- An abscess rarely occupies the basal region of the brain and hence the cranial nerves in that situation are seldom affected. A large abscess in the frontal lobe may give rise to no special symptoms at all if it does not involve the central convolutions. But an abscess in the latter region of the brain is very likely to cause monoplegia or hemiplegia, often attended by epileptiform spasms. The appearance of paralysis affecting the motor oculi, the DISEASES OF THE BRAIN . 251 hypoglossiis or facial nerve, shows the encroachment of the abscess toward the base of the brain. Hemianospia if sought for will probably be discovered if the abscess occupies the frontal fossa. Paraphasia has been observed in abscess of the temporal lobe. The duration of chronic cerebral abscess varies. Recov- ery is of exceptional occurrence. The fatal termination may slowly ensue from aggravation of the general symp- toms. It rapidly takes place when changes in the abscess develop the symptoms of acute meningitis. Diagnosis. Cerebral abscess admits of being diagnosed with considerable certainty when cephalic symptoms of a general character are traceable to a previous injury to the skull, or are associated with disease of the ear or the upper nasal cavity. The differential diagnosis between cerebral abscess and tumor is not always easy. The etiol- ogy of the individual case affords the most reliable information. Choked disk is far less common in abscess than tumor. Febrile excitement, especially repeated chills, speak in favor of abscess. The sudden occurrence of violent head symptoms that indicates a very grave brain trouble suggest abscess. Treatment. Since the introduction of systematic anti-sep- tic treatment, surgeons are emboldened to trephine the skull to evacuate an abscess. Whenever such an opera- tion is feasible it holds out the only prospect of relief. But a procedure of this kind is often impracticable in view of the difficulty of locating the abscess with sufficient precision, or to reach it with safety to the patient- Nothing else is left when an operation is not justifiable than symptomatic treatment. Leeches and cold to the head serve to calm the cerebral excitement. The chief S.5£ MA X UA L OF XEB V US DISEA S ES . remedies to allay the headache and spasms are morphia and chloroform inhalations. CEREBRAL SYPHILIS. Etiology. Syphilis involves the nervous system at a late period, usually when the outward evidences of the con- stitutional disease have disappeared. It is prohably owing to an exciting cause or predisposition to nervous affections that leads to the development of cerebral syphilis. Anatomical Changes. Two varieties of gummy tumors are recognized, though they frequently occur in combination. 1. The circumscribed syphilitic tumor consists of a dense cheesy mass of a yellowish color. Histologically it is a granular tissue more or less vascular. The gumma generally originates in the dura mater and sometimes in the substance of the brain. In the latter situation it is difficult to distinguish svphilitic granulations from tuber- cles. 2. The second variety consists of a soft grayish mass, irregular in outline and blending with the surround- ing healthy tissue. It is made up of granular ceils and is very vascular. This syphilitic infiltration is sometimes transformed into fine cicatrical tissue. Much importance attaches to the specific changes which the walls of cerebral blood-vessels undergo. Branches of the middle cerebral and posterior cerebral arteries are particularly prone to be attacked. The vascular walls become opaque and gradual Iv assume a whitish color. Spots of a dense consistence form in jDortions of the vessels and gradually- change them into a uniform cartilaginous hardness. This change begins as an endarteritis and finally causes obliteration of the vessels througli the for- DIS EASES OF THE BRAl N. 353 mation of thrombi which arrest the circulation in certain areas of the brain. The diseased arteries on yielding to the blood pressure niay rupture and produce hemorrhage. Clinical History. Precursory symptoms, though not char- acteristic of the specific causation, often make their appearance during a considerable lei. gth of time before the complete development of the grave forms of cerebral syphilis. The cephalic symptoms of this order include headache, vertigo, insomnia, neuralgiform pains of the head and face (worse at night) and occasionally slight mental impairment. The occurrence of paralysis affect- ing cranial nerves is of greater diagnostic significance. Some of the ocular muscles are especially prone to be involved. Ptosis has become notorious as a sign of syphilis. The facial nerve is quite often paralyzed and next in frequency, the sixth. The onset of cerebral syphilis is often announced by a sudden epileptiform seizure or an apoplectiform attack, followed by hemiplegia. In other cases the initial symp- tom is a marked somnolence or a peculiar obtuseness of the intelligence. Severe implication of the higher nerve centers are fre- quently witnessed during the whole course of the disease and may at any time lead to a fatal termination. It is remarkable, however, how often the grave symptoms of cerebral syphilis disappear without being succeeded by serious consequences, especially if a prompt and energetic treatment be adopted. One of the marked types of cerebral syphilis presents a group of symptoms characteristic of brain tumor. It is not necessary to go over the same ground again in refer- ence to this subject. General and focal symptoms, as has 25 Jf MA N UA L OF NERVOUS DISEASES. already been mentioned, characterize a brain tumor irre- spective of its etiology and histological structure. The only point in this connection which is of practical impor- tance is the circumstance that the favorite situation of a gummatous tumor is the basilar region of the brain, where the cranial nerves are exceedingly prone to be involved. Another type of cerebral syphilis simulates the clinical features of the "general paresis of the insane," though the pathological changes are not extensive. Occasionally syphilis of the brain appears under the guise of multiple sclerosis. Diagnosis. The chief reliance in diagnosis of cerebral syphilis rests on the previous history of the patient. An accurate search for the objective symptoms of the vene- real disease is all the more necessary as its characteristic signs, when the nervous system is affected, are usually not apparent. None of the cerebral symptoms dependent on syphilis are reliable guides of diagnosis. More infor- mation is furnished by the order of occurrence of the several symptoms, their peculiar grouping, the presence of isolated forms of paralysis and their irregular combi- nations. It is not usual to encounter the sequence and assemblage of symptoms peculiar to cerebral syphilis in ordinary gross lesions of the brain. The age of the patient is of some diagnostic importance. An apoplectic attack or hemiplegia in a young person, if embolism, due to valvular disease of the heart, can be excluded, is more likely owing to syphilitic endarteritis than to ordinary cerebral hemorrhage. Prognosis and Treatment. Of all the grave affections of the nervous system those of a syphilitic origin afford rela- tively the most favorable prognosis. Permanent destroy- DISEASES OF THE BRAIN. 255 ing lesions, due to the effects of the venereal poison, are of course as little amenable to curative treatment as those from any other cause. But even in very unpromis- ing cases some measure of improvement is often attain- able if the specific treatment is followed up with prompt- ness and perseverance. The only questiori that can arise in relation to the treatment refers to the choice of the anti-syphilitic remedies, n:5ercury or iodide of potassium. Mercurial inunction is decidedly the quickest and safest way to bring the system under the influence of the spe- cific, though this method is better adapted for hospital than private practice. The continuation of the inunction must be governed by the efl'ects that follow. The potass, iod. is advantageously employed at the same time. This remedy alone often suffices, but it must be given in large doses and for a long time. Hutchinson's plan of using the mercury with chalk is a good one when inunction is objectionable. CHAPTER XIV. MULTIPLE SCLEROSIS OF THE BRAIX AM) SPINAL ( ORD. (Disseminated Sclerosis. Sclerose ex-plaque.; Etiology. Multiple sclerosis was formerly confounded with different forms of disease effecting the nervous system. We are indebted to the French school of neu- rologists for an accurate description of its symptoms. A hereditary influence is evident in some cases. The disease is most frequently seen in young persons between the ages of 20 and 35 years, but it has also been observed in children under 10 years. It occurs oftener in the female than the male sex. The isupposed exciting causes are exposure, physical over- exertion and emotional disturbances. Clinical History. In consequence of the very gradual development of the disease, no conspicuous symptoms make their appearance in the early stage, but a very marked group of symptoms characterizes typical cases. A peculiar tremor constitutes the most prominent symptom. It is owing to thi«' symptom that the disease was formerly confounded with paralysis agitans. But the trembling in sclerosis is only excited when the patient (2.%) M VLTIPL E S C L EROS IS. 257 attempts to carry out a movement. As soon as he relinquishes the effort, the trembling ceases. The tremor in paralysis agitans is of a more limited sweep, and is continuous whether the patient is at rest, or in motion. In sclerosis no tremor is observed, as long as the patient is quiet. When he rises frojii his seat, or moves a limb the trembling begins. When grasping a glass of water to bring it to the lips, the arm shakes violently, the hand takes a wide excursion and the water is spilt. If the glass reaches the mouth, it clatters against the teeth, A singular defect of speech, analogous to the tremor is another conspicuous symptom of sclerosis. Words are pronounced in a hesitating, drawling manner, a pause being made between each word or syllable, as in scanning. The voice is monotonous and a tremulous movement of the lips and tongue is observed during speech. Nystagmus is noticed in about half the cases. The eyelids oscillate in a lateral direction, especially when the patient is intent on looking at a remote object. The normal muscular power is often well preserved for a long time, but paresis of the limbs is sometimes an early symptom and may terminate in complete paralysis. A spastic condition of the muscles is a far more constant and conspicuous symptom. This motor disturbance is chiefly due to exaggeration of the tendon reflexes. It causes stiffness of the limbs, and when associated with considerable paresis that peculiar gait is witnessed which is characteristic of spastic spinal paralysis. At a late stage, walking is quite impossible. Permanent contract- ures develop in the lower extremities, so that in well marked cases, the heels touch the nates, and the thighs are firmly flexed on the trunk. 17 258 MA X UAL OF NER VO US DIS EA S ES . Disorders of sensibility are insignificant or entirely absent. Sometimes there is slight bluntness of the skin, but anaesthesia is of the rarest occurrence. The cuta- neous reflexes are normal. Ocular symptoms are only occasionally present. A serious complication is the development of optic neuritis terminating in atrophy of the disk. The functions of the bladder, the rectum and sexual organs are not disturbed in a typical case. Cerebral symptoms sometimes arise during the course of the disease. Patients begin to exhibit mental weak- ness, and often break out into fits of sobbing without an assignable cause. Headache and vertigo are frequently complained of in the early stage. Anatomical Changes. According to Leyden, the patho- logical process of multiple sclerosis is of the nature of an interstitial chronic myelitis, which at first affects the neuroglia and afterwards involves the nerve elements. Rindfleisch believes that the anatomical change begins in the blood-vessels and secondarily implicates the ner- vous tissue. Tire nodules are recognized as hard yellow- ish patches scattered through different portions of the brain and cord, and chiefly occupy the surface of these structures. They are found in great abundance in the spinal cord and pons, and are less numerous in the medulla, the cerebellum and the central ganglia. The nod- ules, when examined with the microscope, are seen to consist of reticulated connective tissue in which a few nerve fibres are still visible. The coats of the blood- vessels are thickened. The neuroglia is changed into a dense fibrous tissue which surrounds and compresses the MULTIPLE SCLEROSIS. 250 remaining nerve fibres, but their axis cylinders are pre- served for a long time. Atypical cases of Sclerosis. A certain number of cases come under notice which deviate in their symptoma- tology from the typical form of sclerosis. It has often happened that patients presented symptoms, that gave no intimation of the existence of sclerosis, but which post-mortem examination showed to have been due to this pathological condition. The reason of this anomaly is the localization of the sclerosed patches in special parts of the nerve centers, which would naturally give prominence to corresponding symptoms. It will suffice to give a brief summary of these atypical cases of the disease. 1. Cases resembling loco-motor ataxia, in which the nodules invade the posterior columns of the cord. 2. Apoplectiform attacks followed by hemiplegia, and epileptiform convulsions. In these cases the nodules pre- ponderate in the brain. 3. The symptoms of chronic transverse myelitis, includ- ing paraplegia, anaesthesia and implication of the sphinc- ters of the bladder and rectum. Here the patches involve the thickness of the cord. 4. Nodules situated in the lateral columns of the cord give rise to spastic spinal paralysis. Multiple sclerosis in combination with muscular atrophy indicates the extension of the lesion to the anterior gray cornua and the picture of amyotrophic lateral sclerosis is presented. Implication of the medulla oblongata gives rise to symp- toms of bulbar paralysis. Diagnosis. A typical case of multiple sclerosis offers no difficulty to diagnosis, if the peculiar combination of 260 MANUAL OF NERVOUS DISEASES. symptoms characteristic of the disease is borne in mind. Atypical cases are certainly embarrassing, but the very medley of symptoms showing functunal disturbance of different parts of the nervous system is suggestive of multiple sclerosis. Prognosis. The only encouraging features in the prog- nosis of multiple sclerosis are the occasional pauses and periods of improvement during the course of the disease. There are no reliable reports of recovery. Treatment. Therapeutics must be contented with efforts to improve some of the symptoms. Temporary benefit may be expected from electrical treatment. Remedies which are useful in chronic myelitis are indicated. PARALYSIS AGITANS. (Shaking Palsy.) Etiology. Paralysis agitans is a disorder of advanced life, although it is occasionally seen in young people. A hereditary influence is not very evident. Persons, who have passed through much hardship in life are consid- ered especially liable to be affected. An affection resem- bling paralysis agitans is sometimes seen to develop after injuries and acute febrile diseases. Clinical History. The essential symptoms of paralysis agitans include tremor and stiffness of muscles. Tremor is the earlier symptom. It usually begins in one hand and gradually becomes general. The patient is, at the commencement, able to control the shaking by a strong voluntary effort or by leaning his body against a support. Mental excitement increases the trembling, but active exertion appears to diminish it. The tremor ceases during PABA L YS IS A G IT A XS . 261 sleep. It may for a considerable length of time be con- fined to one arm or one side of the body, and when gen- eral it is always most apparent in the hands. On closely observing the involuntary movements of the hand, it is noticed that the thumb closes on the fingers (as in spin- ning wool or rolling pills.) The head is the least afi'ected, and often not at all. Speech is slow and jerky. Stiff'ness of the muscles is a very conspicuous symptom, and is the chief cause of the motor weakness. A fixidness of the facial muscles gives a stolid expression to the features. There is a perceptible interference with the act of swallowing, which is probably caused by muscular rigidity rather than by the tremor. The fixed condition of the muscles in advanced cases, causes much difficulty in standing and walking, although the gross-muscular power is little impaired. The patient requires assistance to raise himself from the recumbent position. He is unable in bed to turn from one side to the other. He has to make an extra effort to rise from his seat, though when he is once on his legs he may still manage to walk well enough : but as the disease progresses he needs the aid of a stick to steady himself. At every step the body sags forward, and the patient is unable without help to regain the perpendicular, he is therefore compelled to quicken his gait more and more in order to avoid falling forward upon the face. He is thus forced into a run, which he cannot stop until he meets with some object that offers him a support. If he is still able to keep at a walk he makes the impression of continually seeking his center of gravity. This phenomenon is called "propul- sion." Sometimes the patient has a tendency to run backward (retropulsion.) Such individuals are usually 262 M A X UA L OF XER V US BIS EA S ES . seen to walk with the arms crossed behind the back; the object being to counterbalance the sagging forward of the body. In well-marked cases of paralysis agitans a peculiar alteration in the attitude of the body develops which is typical of the disease, and by which it can be recognized in those exceptional cases where the trembling is insigni- ficant or entirely absent. The stiffness has not only invaded the trunk, but also the muscles of the neck and some of the flexors and extensors of the arms and lingers. The head strongly bends forward, the trunk is inclined in the same direction; the upper arms are closely held to the side of the chest, the forearms are somewhat flexed so that the elbows stand off from the body, and the position of the fingers resemble that assuUiCd in holding ii pen. In rigidity of the lower extremities the legs are slightly flexed on the trunk, the knees are turned inwards and the heels are somewhat raised. In the con- dition of advanced muscular stiffness, the patient moves as if all the joints had lost their mobility. ir. the commencement of the disease, patients some- times complain of rheumatic-like pains especially in the shoulder. A subjective feeling of internal heat, is more common, though the thermometer shows no elevation of temperature. Frequently a profuse perspiration breaks out. Other incidental symptoms may develop during the course of the disease. Paralysis agitans often comes to a standstill, so that it may last for many years, but recov- eries are exceptional. Pathology. As paralysis agitans usually occurs in aged persons, it has been conjectured that senile decay may be the true cause of the disease. But post-mortem CHOREA. 263 examinations show no distinctive changes of the nervo- muscular apparatus. Probably the finer anatomical changes that exist escape our methods of investigation. Diagnosis. The recognition of a typical case of paral- ysis agitans is easy. In the foregoing section the dis- tinction from the tremor of multiple sclerosis has been pointed out. Senile trembling is less marked and of more limited extent than the tremor of paralysis agitans, and is not attended by muscular stiffness and paresis. Treatment. It would be unprofitable to enumerate the various remedies that have been tried in this disease. In the early stage it may be possible to control the tremor. The prolonged employment of the subcarbonate of iron in large doses appeared to have been useful in a case reported by Dr. Elliotson. Charcot saw benefit from hyosciamine. Reynolds observed mitigation of the tremor from the wearing of a Pulvermacher chain. Beneficial effects are claimed for arsenic. Galvanism is sometimes of service in mild cases. CHOREA. (St. Vitus' Daxce.) Etiology. Chorea is most frequently observed to attack children between the periods of the second dentition and puberty. It predominates in the female sex. A direct hereditary transmission cannot be shown to exist, but it may be assumed that a constitutional susceptibility predisposes to its development. Psychical disturbances, especially fright, act as exciting causes in many cases. A similar mental influence operates in those singular cases resulting from imitation. Chorea often appears during the pregnancy of primipara?. The disease is prob- 2G4 M A X UA L F X ERVO U S DIS EA SES . ably of a reflex character when induced by intestinal irritation, especially from worms. A causal relation appears to exist between chorea and rheumatism; or at least chorea sometimes co-exists with valvular disease of the heart which had been preceded by slight rheumatic symptoms. Clinical History. The initial symptoms of chorea are usually misunderstood by parents and teachers. The affected children are often chided and even punished for having contracted certain objectionable habits and for indulging in silly behavior. These little patients let things drop from their hands, make all kinds of grimaces, continually shrug their shoulders, scribble when required to write and exhibit a constant restlessness. Very soon, however, these irregular movements and contortions are observed to be involuntary and to become general and aggravated as the disease advances. Volitional move- ments always start the jerks, but they also come on spontaneously. The motor disturbance may make long pauses when the patient is quiet, but in many cases they are continuous or appear in rapid succession. In severe cases, the whole body wriggles and assumes, with short respites, grotesque attitudes. Xearly every voluntary muscle may show incoordinate movements. If the facial muscles are afi'ected, the brow wrinkles and the mouth is distorted. There is occasional winking of the eye-lids. The pupils are usually dilated. The tongue is suddenly thrust forward and as suddenly withdrawn. Speech becomes affected, swallowing is interrupted, strange sounds are produced by spasmodic action of the laryn- geal muscles and the respiration is often irregular. CHOREA. 265 The choreic movements generally begin in the upper limbs and are there most prominent. The arms are flexed, extended, twisted and thrown about in every possible direction. The lower extremities are much less afl'ected, but now and then one leg is thrown forward or sideways, or the knees suddenly bend as if the patient was about to fall. In some cases the trunk is also involved, so that the body leans for a moment to one side or is doubled up. When the disorder is of a violent character it renders the patient completely helpless. He is unable to keep on his feet, and must be fed and dressed. The constant friction of the elbows and the knees against hard sub- stances produces abraisons of the skin. The tossing and jerking may be so violent that the patient has to be fast- ened down in bed. There is, however, every conceiv- able grade of intensity of the disease. Some patients when they are quiet and attention is not directed to their move- ments appear to be but slightly affected. Choreic move- ments cease during sleep. In hemichorea, as the name imports, the motor disturbance is unilateral. It is remarkable that choreic patients never complain of fatigue caused by the incessant jactitations. Increase of sensibility is sometimes noticed at the outset of the disorder, and later in its course a slight paresis and mental obtuseness may be observed in a few cases. Endocardiac murmur in connection with chorea is not always a sign of heart disease for the murmur may be merely a choreic symptom. The reflexes rarely show any alteration. The temperature is not elevated however severe the muscular contractions may be. 266 MA N UAL OF NER VO US DISEASES, The termination is variable. Mild cases may subside in four or six weeks. The average duration of an attack is about three months, but sometimes the disorder is pro- tracted for a year or more. Pathology. Post-mortem examinations have thus far led no satisfactory explanation of the nature of chorea. There is hardly a doubt that some motor center is involved, but which part of the nervous system is affected, or what the character of the pathological condition may be is undetermined. Chorea must therefore be provisionally considered to come under the category of the neuroses. Foyers of softening, probably due to capillary embolism are occasionally found in the basal ganglia, but it is far from certain that these anatomical changes have any relation with true chorea. A cerebral origin of the disease may be inferred from the occurrence of hemichorea and mental weakness. Diagnosis. It is hardly possible to mistake chorea for any other affection. Choreic movements are entirely unlike the tremor of paralysis agitans. mercurial, satur- nine or alcoholic trembling. The Prognosis is favorable, but relapses often occur, and in very severe cases the general health seriously suf- fers. Treatment. Choreic children should not be allowed to attend school. Any unnecessary allusion to the affec- tion in the hearing of the patient ought to be avoided. The child should be guarded against doing injury to itself. Mild cases require little medicine. Bromide of potassium in rather large doses is decidedly of benefit. An anaemia should be improved by iron. A palpa- CHOREA. 267 ble intestinal irritation requires appropriate treatment. Arsenic is the approved remedy in acute and protracted cases. Five drops of Fowler's solution may be given three times a day. The arsenic is sometimes advantage- ously combined with a bromide. Da Costa found hyoscya- mine in doses of gr. t^o of much benefit in the insomnia caused by unremitting choreic movements. Valerianate of zinc and nitrate of silver are also recommended. Narcotics according to general experience are not suit- able in chorea. Electric treatment very often disappoints. Chorea in pregnancy usually subsides after delivery. Cases are reported in which artificial delivery was neces- saij. As an appendix to the subject of chorea a class of cases may be fittingly mentioned characterized by irresistible impulsive movements. The "dancing mania" "tarant- ism " and "electric chorea," which prevailed from time to time in Europe in an epidemic form belong to this cate- gory. Motor disorders of an analogous nature, exhibit- ing quasi-involuntary movements are occasionally brought under notice. These morbid phenomena totally differ from chorea. They probably belong to the category of hysterical, maniacal or epileptic paroxysms; or per- haps are allied to the phenomena of trance, ecstasy, etc. The following brief notes of a case, which I had oppor- tunity to observe may exemplify the characters of these strange phenomena. A girl nine years of age had suffered for the past two years as her mother told me, from '"nervous- attacks." The child in the midst of play would suddenly begin to make a noise like some animal, and then contort its body, throw about the arms in a wild manner, kick the furni- St8 MANUAL OF NER V OUS D IS EA S ES . ture, jump in a leap-frog fashion, scratch the walls, tear its clothes and perform many other striinge antics. When I saw the child dming one of these attacks, there was a constant discharge of saliva and dribbling of the urine; the pupils were dilated, but consciousness was intact. Any attempt to prevent the child from going through her maneuvres only increased their violence and duration. After their subsidence the child resumed its normal con- dition. ATHETOSIS. Dr. Hammond described under the name of athetosis very peculiar involuntary movements entirely differing from chorea. The affection is almost exclusively confined to children. There is an idiopathic form of athetosis of rare occurrence, which appears to be congenital and may be attended by mental weakness. Athetosis is some- times a post hemiplegic symptom and may be associated with epilepsy. The characteristic movements are most conspicuous in the hand and fingers as illustrated in figures 28 and 29. The fingers are never at rest. They are constantly either flexed, extended or intertwined in the most curious man- ner. The singular positions they assume is due to an irregular elongation from continued stretching of the articular ligaments. The arms and inferior extremities are less affected, but the toes sometimes are involved in movements analogous to those of the fingers. If the facial muscles participate in the movements, they are twisted and contorted. The head is thrown forward, backward and sideways, if the muscles of the neck are implicated. ATHETOSIS. 269 Xo anatomical changes are observed in idiopathic athetosis. Probably the source of irritation is in the brain. Improvements of the movements is sometimes obtained from galvanism, the bromides, or Fowler's solution. Fig 29. TETANY. Etiology. Tetany is characterized by intermittent tonic tonic spasms of certain groups of muscles. The. disease occurs in children and young adults. Trousseau found •270 MA NUAL O F XER V OUS DISEAS ES . tetany rather frequent in young nursing women. In many cases, a rheumatic influence is probably the excit- ing cause. A co-existent diarrhoea has also been observed. The disorder sometimes appears in an epidemic form among girls at school. Tetany has been known to follow the removal of the thyroid gland. Clinical History. Certain precursory symptoms make their appearance. Pain is felt in the arms and a sensa- tion of coldness and tingling in the fingers. After a few hours the seizure begins in the fingers, they become stiff and the hands the arms and inferior extremities in succession are affected with contractions. Spasm of the flexors predominate. The fingers approximate, the term- inal phalanges are extended, the metocarpel ends are flexed, the thumb is strongly abducted and the palm is hollowed. This position of the hand resembles the peculiar form which it is made to assume by the accouch- eur, when he introduces the hand into the vagina. In severe cases, the upper arm is pressed against the chesty the elbow is slightly flexed and the forearms are crossed over the epigastrium. In attacks of the inferior extremi- ties, the toes are bent, and the feet are in the position of talipes equinus. The rest of the voluntary muscles are not often involved. The muscles in the condition of tonic contraction feel very hard and stiff, and even after an attack they do not completely relax. Certain characteristic phenomena are observed during the intervals. The peripheral nerves are found very sensitive to electric excitation, violent con- tractions being evoked by weak currents. Mechanical stimulation of the muscles show an analogous excita- TETANY. 21 1 bility. Thus, the facial muscles can be made to contract by stroking them with the hand. Trousseau discovered that in many cases energetic contractions can be excited by pressure of the arm in the regions of the median nerve and the brachial artery. As long as "Trousseau's sign" exists the recurrence of the paroxysms may be expected. The frequency of contractions vary in individual cases. Sometimes there is a long pause between them, and in others they are nearly continuous. An attack generally lasts about two weeks. Prognosis is always favorable. No anatomical lesion has yet been detected to account for the disorder. Diagnosis. A careful consideration of the symptoms which have been described as characteristic of tetany can hardly fail to render diagnosis easy. As tetany bears considerable resemblance to the very rare disorder called " arthogryposis" a few notes will be added here to point out the peculiarities of the latter disease. Art]iO(jryposis usually occurs in children, and may be attended by febrile symptoms throughout its whole course. Its essential symptoms consist of tonic spasms of one or of all four extremities. The arms are bent and the fingers flexed so as to assume fixed positions. The legs are either rigidly extended or drawn up to the body. Recovery in mild cases may take place in a few weeks, but a fatal termination usually happens in aggravated cases. The autopsy shows no dis- tinctive lesion. Treatment. The spasms in tetany are sometimes promptly relieved by applying the anode of the galvanic current to the different nerve trunks distributed to the affected muscles and the kathode to the sternum. Another method consists in passing the current through the spinal cord. The treatment is materially assisted by cold spong- ^72 MA N UA L F XER V US D IS EA S ES . ing of the back and friction. The bromides, belladona and arsenic give no satisfactory results. THOMSEN'S DISEASE. (Congenital Myotonia.) This disease was first described by Dr. Thomsen, a German physician, who suffered from it in. his own per- son and observed it in several members of his family. A strong hereditary tendency existed in the not numerous cases that have come under notice. The characteristic symptom of the affection is the occurrence of spasmodic rigidity of voluntary muscles when they are called into action after intervals of rest. The muscles of the inferior extremities are always affected. When the patient attempts to walk he succeeds for a little while, but very soon the muscles of the limbs get stiff, so that he must come to a halt. After a short time of rest the muscles relax, but the longer the muscles have rested the greater will be the difficulty of walking. No outward -change in the condition of the muscles is observed; they rather appear to be very well developed. Erb's recent investigations show that the individual muscular fibers are rounded, having lost their, normal polygonal appearance, and that the interstitial tissue is increased. He also noticed that the myotonic reaction outlasts the direct electrical excitation of the muscles. The reflexes and the sensations are normal. No addi- tional symptoms exist. Myotonia is a life-long disease. It baffles all therapeutical measures. CHAPTER XV. EPILEPSY. Deflnition. The peculiarity of epilepsy consists in an inexplicable tendency of certain nerve centers to mani- fest, without an at^signable cause, at irregular periods, a condition of excitement that gives rise to a typical form of generalconvulsions in individuals who, although they may have been subject to such attacks during a lifetime, show no distinctive lesion of the nervous system on post mortem examination. According to our present knowl- edge we must characterize epilepsy as a purely functional neurosis. Convulsive paroxysms occurring in the course of various diseases are symptomatic, and are therefore distinguished by the terms "epileptiform" or "epileptoid." Etiology. Although the essential cause of epilepsy is unknown, we are acquainted with certain conditions and circumstances which act as predisposing causes. A hereditary influence can be traced in a large propor- tion of cases. The descent is more frequently on the mother's side. Often the transmission is not direct, but there exists a family tendency, which favors the develop- ment of the disease. This tendency is shown by the fact that members of the same family are prone to be affected with allied nervous affections. It may be insanity, dypso- mania, hysteria, neuralgia, etc. Independent of a hered- itary predisposition, it may be fairly assumed that there 18 I -'73 ) 27 J^ MANUAL OF NERVOUS DISEASES. are individuals of a neurapathic constitution in whom this condition is manifested by the development of epi- lepsy. Alcoholism in the parent is believed to predispose to this disease in the offspring. Genuine epilepsy is not caused by syphilis. Among the exciting causes of epilepsy are understood those influences which tend to develop the disease in per- sons who are predisposed to it. The most important is sudden terror or fright. Continued worr}^ of mind, anx- iety and disquietude may act in a similar manner. In some cases the occurrence of the first attack has been preceded by declining health, ansemia, sexual excesses, sunstroke or an acute febrile disease. If epileptic spasms occur after injuries to the head from a blow, fall or cut, they do not imply true epilepsy. In these traumatic forms of epilepsy, there is nearly always a cortical lesion, and the convulsive movements are usually unilateral. (Jacksonian epilepsy.) That form of epilepsy caused by wounds of superficial nerves, from splinters of glass or other foreign substances is the so-called " reflex epilepsy." In cases of this kind it is highly probable that patients manifest a strong tendency to neurotic affections. Reflex epilepsy can be artificially produced in rabbits, as Brown Sequard has demonstrated, by injuring the medulla oblongata or the spinal cord. Epileptic attacks are excited in these animals by irrita- ting certain parts of the skin — " the epileptogenous zone." It is remarkable, that the progeny of the animals so operated upon are sometimes subject to spontaneous epileptic convulsions. Clinical History. An epileptic seizure is sometimes pre- ceded for hours or days by premonitory symptoms, chiefly EPILEPSY. 275 consisting of headache, vertigo, restlessness and psychical disturbance. In the greater number of cases the " warn- ing " is experienced immediately before the attack sets in. Such premonitory symptoms, called aura^, consist of sensory motor, vaso-motor and mental disturbances. 1. The epigastric aura. This is one of the most frequent of premonitory symptoms. It is described by patients as a distressing sensation in the pit of the stomach, attended by nausea and precordial anxiety. 2. An aura of great frequency is a peculiar sensation beginning in the legs or arms, or in the region of the heart and suddenly " going to the head." o. The aur?e referred to the special senses relate to optical disturbances, as flashes of light, colored rings, sudden blindness ; or spectral illusions, such as horrible faces, reptiles, but also enchanting scenes and pleasant visions. Hallucinations of hearing are less common. Some epileptics smell foul odors or have a metallic taste in the mouth, before an jittack. 4. Motor aur« are of various kinds. An attack may be ushered in by " dragging in the face," a '^ slap on the head," a choking sensation, or a strain, as if going to stool. 5. The aura of a vaso-motor nature refers to a sudden feeling of chilliness, flashes of heat in the face or pallor^ sweating or violent palpitations of the heart. 6. The most frequent psychical aura is a feeling of alarm and anxiety. The patient looks startled, fright- ened or amazed. Sometimes he is in a dreamy state, the past events of his life, crowding upon his memory. These premonitory symptoms in individual cases are often variously combined. Sometimes they last long S76 MA X UA L OF NER VOUS DISEASES . enough to apprize the patient of the coming attack, l)ut as a rule the convulsions immediately follow. It is usual in describing the epileptic paroxysm to make the division of: 1. Epilepsia gravior or grand mal; 2. Epilepsia mitior, or petit mal; 3. Epileptoid condi- tions. 1. Epilepsia Gravior. An epileptic attack whether preceded by an aura or not invariably begins abruptly. Many patients utter a peculiar cry at the onset, — " the epileptic cry" — although they are already unconscious, and suddenly fall headlong to the ground. Consciousness and sensibility are completely abolished and tonic spasm of brief duration seizes the whole body. The head is strongly extended, the pupils dilated, the conjunctiva insensible, the jaws firmly closed; the tongue is frequently bitten and bloody froth accumulates at the mouth. Pallor of the face is well marked at the beginning. The back is arched as in aposthotenos, the arms are firmly flexed and the inferior extremities are rigidly extended. The respira- tory muscles are involved, the breathing is arrested and the color of the face is bluish or dusky. This stage lasts from 15 to 30 seconds and is followed ' b\M he stage of clonic spasms. The face in this stage assumes a hideous appearance. All the features are contorted; the eyes roll wildly in their orbits, the tongue is thrust out and convulsively retracted, the head beats upon the ground, and the arms, the trunk and the legs are violently convulsed. Some- times the contents of the bladder and the rectum are evacuated and seminal emissions take place. The pulse and temperature remain normal, but during the venous stasis, the heart is tumultuous and the carotids throb. EPILEPSY. 'm Ecchymotic spots appear in the conjunctivae and upon the skin in the region of the neck. This stage lasts from 1 to 10 minutes. The third stage is characterized by the disappearance of the cyanosis and the gradual return to a natural respira- tion. The patient is still unconscious, but he begins to change the position of his body, he opens his eyes, looks about in a kind of a dazed condition and then soon passes into a slumber which may last a few hours. Some patients recover quickly, so as to be able to attend to their usual occupation in less than half an hour. Gen- erally complete recovery from an attack is delayed much longer. For a day or two patients suffer from headache, lassitude and an irritable mental disposition. A large quantity of urine is often passed immediately after a seizure, which contains traces of albumen. 2. Petit mal. The mild forms of epilepsy may begin with or without an aura, and be variously manifested. Sometimes the petit mal merely amounts to a moment- ary confusion of mind, attended or not by slight twitch- ing of facial muscles or contraction of the hands, which quickly subsides. Such a minor attack may stop a patient in the midst of a conversation, or while engaged in his usual occupation. Sometimes it is merely a fit of dizziness or faintness which rapidly passes off "and leaves the patient unaware that anything unusual has hap- pened to him. In others the whole attack may only con- sist of a sudden contortion of the face, or fixidness of the eyes, or a scream, or a reeling of the body. The patient knows nothing of it, and those who happen to witness these phenomena, may think them rather odd, but usually attach no importance to them. Very strange acts are f>18 MA N UAL OF NER VO US DISEASES. sometimes unconsciously performed by patients during minor attacks of epilepsy. Trousseau relates the case of a judge, who in open court would leave his seat and answer a call of nature in a corner of the room, then return to his place, entirely oblivious of what he had done. These " faints or spells " as these incomplete seizures are popularly called, rarely excite much alarm in the friends of the patient. The medico-legal bearing of such cases is sometimes very important. One of my patients often fell into the hands of the police for exposing his person in the public streets. He was at times afflicted with grand mal. 3. The Epileptoid condition. The s3^mptoms under this head have not been unapth^ called the " equiva- lents of epilepsy." They consist of aberrations of con- sciousness either of a paroxysmal and transient nature or succeed to a typical or rudimentary fit of epilepsy. Various psychical disturbances may immediately follow an attack which shows the intimate connection between them. But the nature of the mental derangement occur- ring independently of an attack would not be easily recognized if the individual were not known to be sub- ject to epilepsy. Aggressive and even violent criminal acts may thus be committed in the epileptoid condition. Such a form of transient insanity is recognized by alienists. The diagnosis would harldy remain doubtful, if in addition to the brutal, ferocious, unprovoked act devoid of all known motive and which after its commission appears inexplicable and abhorrent to the accused, there is evidence that he had previous attacks of epilepsy. In children and very young persons, the epileptoid condition is commonly exhibited by unaccountable behavior, vicious EPILEPSY. 279 propensities and especially a remarkable tendency to incendiarism. Course of the disease. Nocturnal epilepsy is a peculiar- ity of some importance, as the existence of the disease may be concealed for a long time if the attacks only occur during sleep. This condition may be suspected if patients continually suffer from sore tongue or frequently wet the bed. There is no uniformity in regard to the fre- quency of attacks. Some have only one or two during the year, others have them every month or daily. A similar dif- ference obtains in regard to the severity of the seizures. Many patients have none but the grand mal; some have also minor attacks; and in another class, the very mildest form of the disease or the epileptoid condition predom- inates. Genuine epilepsy develops in youth, rarely after thirty. The general health and the intellectual faculties may- remain unimpaired through a life-long existence of the disease. When mental deterioration occurs, the memory is the first to suffer, which ultimately terminates in hopeless dementia. In very rare cases, the seizures become violent and recur in rapid succession. This "status epilepticus " is a very dangerous condition and usually ends in death. Various influences favor the recurrence of attacks. The baneful effects of alcoholism, venereal excesses, physical overwork and mental excite- ment are undeniable. On the other hand a peaceful life^ moderation and genial surroundings exert a beneficial influence in reducing the repetition of the seizures. Epi- leptic girls sometimes improve, when they arrive at the menstrual period: more frequently this epoch develops S80 M A XUA L OF XER VO US D I SEA SES. the disease. That marriage exerts a favorable infiuence oil epilepsy, is not sustained by experience. Pathology. Anatomical changes of the cerebral meninges and blood-vessels are not unfrequently found in long standing cases of epilepsy, but such morbid appearances are of a secondary character and are not uniformly present. Atrophy of the hemispheres is sometimes seen in subjects who died of epileptic dementia. Induration of the pes-hippocampi minor is more frequently seen than any other sort of lesion in epilepsy, but it is not a constant lesion. In the absence of a distinctive anatom- ical change that might give a clue to the nature of the disease we may perhaps come nearer a solution of the problem, if the starting point of the epileptic paroxysm could be determined. It was for a long time supposed, that the medulla oblongata, which is the general reflex center, is the region where the epileptic commotion originates. Nothnagel in more recent times, thought that he had found a ''convulsive center" in the pons. The cortical origin of epilepsy finds at present most favor among neurologists. This view certainly agrees best with clinical facts. In the first place, the loss of conscious- ness, which is one of the essential symptoms of the epileptic attack, is a psychical phenomenon, and there- fore a cortical disturbance. And again, some of the aurae are of a purely mental nature. In the second place, the spasmodic movements which are epileptic phenomena of equal importance occur in lesions of the cortex. " Cor- tical epilepsy " artificially produced in animals attacks the muscles in the same order which is observed in the epileptic seizure in man. This whole subject has been admirably discussed by Hughlings Jackson. But the EPILEPSY. '^St nature of that morbid irritation which spontaneously initiates the convulsive paroxysm of epilepsy is still a mystery. Diagnosis. It is very unusual to mistake a case of epilepsy. Although the epileptiform convulsions in cere- bral tumor, abscess and syphilis greatly resemble those of true epilepsy, yet the intermediate clinical history of organic brain disease decides the differential diagnosis. " Jacksonian epilepsy " is generally unilateral and always depends on a cortical lesion. Hysterical convulsions as already pointed out are never confounded with epilepsy, by the experienced physician. In ur?emic spasms there is permanent albuminuria. Treatment. In the rare cases of '' reflex epilepsy " .per- manent benefit may follow surgical procedures. Trephin- ing of the skull in superficial tumor or abscess has achieved some brillant cures. In genuine epilepsy no indications for causal treatment exist. There is no doubt that the frequency of attacks is lessened, if the patient observes a proper diet and regimen and practices regular habits of life. Alcoholic stimulants are decidedly inju- rious, even coffee and tea are better avoided. Indigest- ible food, heavy meals and in fact excesses of all kinds favor the occurrence of the attacks. A strict vegetable diet has many advocates. Among the remedies employed in the treatment of epilepsy, there are certainly none which equal in efficacy the several bromides. The bromide of potassium is the one usually preferred. It should be given in large doses and continued for months and even much longer, if it be found of service. One drachm a day is the usual dose to begin with, but may be increased to the maximum dose 2Se MANUAL OF NERVOUS DISEASES. of 2\ dr. a day if the attacks are severe and frequent. Smaller doses suffice should improvement follow. The remedy should be much diluted in water to prevent irri- tation of the stomach, and for the same reason it is advis- able to gi 7e the daily quantity in divided doses. The other bromides, the sodic, the amnionic and lithic may be advantageously combined with the bromide of potassium. One part of each of the sodic and amnionic with two parts of the bromide of potassium form a good combina- tion. The bromide of sodium agrees better with delicate stomachs. The bromide of lithia contains the largest percentage of bromine, but is not superior to the other bromides'. The quantity of these medicines must be diminished or wholly omitted for a time if brominism appears. Its symptoms are an eruption of acne, tremor, dyspepsia, impotence, cardiac weakness and dejection. Belladonna enjoyed formerly a high reputation in Epilepsy, but is far inferior to the bromides. It is given in pills of the extract or in the form of atropia in equivalent doses of gr. yk three times a day. Dr. Gowers recommends a combination of belladonna with one of the bromides. The oxide of zinc is an old remedy for fits. From 2 to 8 grains combined with gr. \ of belladonna extract and 15 grains of valerian root powder, three times a day, is a favorite prescription with good observers after failure of the bromide treatment. Borax has lately been much lauded in doses from 10 to 15 grains three times daily. It is needless to do more than allude to other remedies that are recommended for epilepsy, such as nitrate of silver, arsenic, indigo and preparations of copper, as they MtN lERE'S DISEASE. 283 are rarely of benefit. Electricity does not appear to exert any influence in epilepsy. Various popular measures are in use to prevent an attack when the patient has a ''warning," such as slapping the palms of the hands, a brisk walk, and stuffing the mouth with salt. Nothing should be done during the attack except to guard the patient against injury. If the tongue is caught between the teeth, a gentle effort should be made to release it. MENIERE'S DISEASE. Aural Vertigo. Etiology. Chronic disease of the ear, affecting the labyrinth and semi-circular canals is supposed to be the cause of the peculiar disease to which attention was first drawn by Meniere. It is sometimes attended by otorrhoea and deafness. Clinical History. The chief symptoms of the disease are tinnitus aurium and excessive vertigo. It begins with shrill voices heard in one or both of the ears, accompanied by dizziness, nausea and vomiting. Later, the paroxysms occur frequently, at short intervals, and finally the vertigo is so continuous and severe that the patient has to keep to his bed. During the exacerbations of the vertigo? the patient has a sensation as if his body were whirled about in every possible direction, and with such a force that he clutches at surrounding objects to prevent falling to the ground. Towards the end of the attack a very distressing feeling of nausea comes on, the face is pallid and cold, and the body is covered with perspiration. After having progressed for several years complete deafness ensues, and with its appearance all the other S84 MANUAL OF NERVOUS DISEASES. symptoms cease. Meniere's disease may be confounded with epilepsy and disease of the cerebellum. Treatment. Special treatment of the ear, when called for is of primary importance. Quinia appears to give always relief. From 10 to 15 grains should be given daily. Politzer reports remarkable results from hypodermic injections of pilocarpin. HYSTERIA. Etiology. The multifarious and bizarre phenomena, which cannot be referred to a definite pathological change, but which bear a stamp and present a physiognomy that the experienced physician recognizes at a glance lend to hysteria the character of a singular disorder but one of great clinical importance. Symptoms, capricious, erratic and anomalous, ranging from a mild group of functional nervous disturbances up to an apparent formidable impli- cation of important nerve centers, and frequently disappearing suddenly ^without leaving a trace behind, show that no tangible morbid condition affects a par- ticular organ or tissue. The fact that hysterical mani- festations are eminently excited by psychical influences strongly supports the view that the nervous system, and especially the higher centers are aff'ected with a peculiar irritability or with defective inhibitory power. Hysterical persons certainly exhibit an impressible disposition which is either hereditar}^ or acquired. This neuropathic condition greatly preponderates in the female sex. It is not difficult to understand why the delicacy of the nervous apparatus in women readily reacts in an undue manner to exciting causes that hardly aff'ect the stronger sex. Hysterical symptoms in girls frequently HYSTERIA. mo make their first appearance at the period of pubes- cence. Of a similar influence is the recurrence of the menstrual molimen. Uterine and ovarian troubles, chlorosis and £in«mia often lay the foundation of a life- long hysteria. But the prominence formerly attributed to disturbances of the sexual organs in the female as exciting causes of hysteria is not sustained by experience. That boys are not unfrequently affected with hysterical' symptoms cannot be disputed. Even men under the mfluence of shock or strong emotional excitement some- times go through a paroxysm of genuine hysteria. A tendency to the development of hysteria must be assigned to the injurious effects of mental strain, especially of a depressing nature. To this category of exciting causes belong deep anxiety, concealed sorrow, disappointment and harsh treatment. It is alleged, that the frivolities and artificial excitement in which females in affluent circumstances indulge augment the number of hysterical patients. But women m humble walks of life are certainly not exempt. A deleterious influence must also be attributed to the ill-directed training of little girls who give intimation of a precocious disposition, or betray odd or morbid susceptibilities. Very remarkable and puzzling are the histories of hysterical individuals, who nurse and pet without a sinister motive some spurious ailment, that subjects them to a miserable state of existence and actual deterioration of health in order to keep up the role they assume. It would be difficult to account for such phenomena were it not for the fact, that they represent phases of hysteria. Probably some of this class of hysterical persons might be brought to confess that the undue anxiety and slavish ministration spent 283 MANUAL OF NERVOUS DISEASES. upon them, has fostered their n:iorbid craving for sym- pathy and their desire to become the objects of interest and solicitude. The hysterical element is also strongly developed in cases where a slight hurt or insignificant accident con- centrates attention upon a particular part of the body. It is usually a large joint or the spine where the hysterical neurosis locates. It would be an error to suppose that hysteria is con- fined to anaemic, feeble and broken down w^omen. The exhibition of decided hysterical symptoms in women otherwise healthy and vigorous is a matter of common experience. Clinical History. Considering the diversity of hysterical symptoms even in the same patient it would be a questionable undertaking to give a description of a typical case of the disorder. But the recurrence of a uniform order of symptoms or a particular one in the same patient is quite often observed. Hysterical convulsions. Not every hysterical female is subject to convulsions, though an attack is prone to develop under the influence of strong mental excitement. In some cases there is a brief prodromic stage char- acterized by a feeling of lassitude, epigastric uneasiness, a choking sensation, fluttering in the region of the heart and vague pains in different parts of the body. Some- times these symptoms stop short and terminate in a fit of spasmodic crying or laughter. The convulsive movements in hysteria are of a tumultuous character. The limbs are either wildly thrown about, or the arms and hands are contorted and twisted. The facial muscles are not affected, but the patient HYSTERIA. 287 makes all kinds of grimaces, expressive of anger, fright or terror. There is sometimes unconsciousness but the mind is usually unimpaired. The pupils are normal. In another class of cases, tonic contractions are prominent. The arms are bent, the fingers semiflexed, and the inferior extremities extended. An attack often consists of partial spasm of a limb or some group of muscles. Laryngeal spasm interferes with breathing. Sometimes the respiration is remarkably rapid, and the heart beats violently. Spasm of the pharynx and of the oesophagus is believed to give rise to "globus hystericus," which patients compare to a ball rising or sticking in the throat. Spasm of the diaphragm causes incessant hiccough, often accompanied by severe pain in the pit of the stomach. Hysterical cough has a harsh, brassy sound, unattended by expectoration. The loud move- ment of gases in the intestines causes the annoying " borborygmae." A great variety of other forms of hys- terical spasm occur ^hich hardly need mention. A case comes now and then under notice in which the hysterical and epileptic elements seem to be blended. French authors give frightful pictures of " hystero- epilepsy." They are seldom witnessed in this country. A genuine hysterical fit is easily distinguished from epilepsy. There is seldom complete coma in hysteria, no initial cry, the pupils are not dilated, the face is not cyanotic, there is no biting of the tongue, and the spas- modic contractions have not the rhythmical jerk of epilepsy. Besides, the duration of hysterical convulsions is indefinite. Psychical characteristics of hysterical individuals. It is especially in the sphere of emotional life, the sensibilities, ^^88 MANUAL OF NERVOUS DISEASES. the mood, temper and disposition, that the peculiarities of the hysterical element become manifest. The unbalanced state of the emotions is exhibited in sudden transitions from gayety to sadness. There is a passiveness to the play of fancy and whim; singular likes and dislikes arise; sometimes an unaccountable apathy and stolid indiffer- ence or an overcharged enthusiasm and a highly wrought pathetic sentimentality is exhibited. There may be a morbid desire to create interest and to attract sympathy. Slight impressions produce exaggerated effects. The inclin- ations and the will seem to be perverted, as shown in uncontrollable obstinacy and waywardness. Hysterical individuals who are more or less affected in this manner are an enigma to their friends and acquaintances, and des- pots in their families. But hysterical females can render themselves very agreeable if they like. There is some- times a line languor in the expression of their eyes and a supplicating tone of the voice, which novelists are fond of depicting. Hysterical individuals are usually of a bright intelligence. They are often well aware of the oddities and fancies that frequently possess them, but they ingeniously explain them away by a high-colored description of their manifold complaints. Hysterical paralysis. The paralysis in hysteria is gener- ally of the paraplegic type, but hemiplegia is not rare. Most frequently the paralysis suddenly develops after a mental shock or a strong emotional disturbance. A peculiarity of hysterical paralysis is the ability of the patient to move the limbs well enough when in bed or reclining, but when requested to rise she immediately sinks to the floor. One is tempted to suggest that the patient might easily get up and walk by an effort of HYSTERIA. 289 the will, but this command of the will is just what is wanting. The paralysis is evidently of cerebral origin. Another peculiarity of hysterical paralysis when only one limb is affected is the characteristic gait. The paralyzed limb does not describe an arc when carried forward, but the patient makes a long stride with the sound limb and the other is dragged along. Hysterical aphonia is often observed. The paralysis of the vocal cords comes on suddenly. Its existence is revealed by the laryngoscope. The reflex excitability of the pharynx is sometimes lowered and the glottis cannot be completely closed. In other hysterical individuals, usually in young girls, the alteration of the voice con- sists in the utterance of shrill, harsh sounds. Hysterical dysphagia probably depends on spasm rather than on paralysis of the oesophagus. The tube can be passed after a brief trial. Contracture of groups of muscles is sometimes an iso- lated hysterical symptom, or it is associated with paral- ysis. Most frequently one arm or the hand is affected. The arm is rigidly contracted and the fingers are inter- twined in a curious manner. Hysterical contractures are readily relieved by morphia injections or chloroform mhalations. Hysterical aniesthesia. One of the most remarkable symptoms of hysteria is complete hemianaesthesia gen- erally of the left side. The loss of sensibility is accurately defined by the median line of the body. All the qualities of common sensation are abolished. The patient does not feel the nearness of a lighted can- dle, nor the prick of a needle. This analgesia explains S90 M A X UA L OF NER VO US D IS EA SES . the mutihitions of the body, which hysterical individ- uals have been known to practice with the purpose of eliciting sympathy or for a sinister motive. In another class of hysterical patients, the ana?sthesia is confined to limited areas of the skin, affecting also the neighboring mucous membranes. Disturbances of the special senses are often associated with anaesthesia ; — amblyopia, amaurosis, achromatopsia and narrowness of the field of vision. There may be impairment of hearing, of taste and smell on the affected side. A very singular form of paralysis of the muscular sense has been described by Duchenne. The patient is unable to tell the position of a limb when her eyes are closed. Hypersesthesia is a very frequent accompaniment of hysteria. It is often associated with spasmodic contrac- tions. Touch or pressure in many parts of the body elicits pain. The head, the shoulders, the chest and the abdominal walls appear to be highly sensitive, which suggests to the patient the existence of some serious inter- nal disease. Usually the patient exaggerates this sensi- tiveness, as is discovered when her attention is distracted. Whether neuralgia, which may be present, is hyster- ical or independent of the disorder is difficult to decide. Intercostal pain is the most constant form of hysterical neuralgia and ovarialgia is sometimes intense. A species of pain peculiar to hysteria is the so-called "clavus hystericus." It is usually limited to a small spot along the sagital suture. Hypersesthesia of special sense exists when the patient complains of painful sensitiveness to light or of acute hearing. A perversion of the gustatory sense in hysterical girls explains their relish for unsavory substances and their dislike to ordinary articles of food. HYSTElilA. 291 Hypnotism. Hypnotic phenomena which can be artifi- cially produced in a certain class of people occasionally occur spontaneously in hysterical individuals. The very obscure nature of these phenomena surrounds them with much mystery. Since Braide's investigations in hypno- tism medical men have begun to overcome their aver- sion to a subject which had been so much mixed up wdth charlatanry and deception. A variety of strange conditions of the nervous system are induced b}^ dif- ferent methods, such as stroking the head with the hand, requesting the person to count numbers, to look con- tinually at a bright object, and the like. A condition of lethargy is produced in which the subject is semi- conscious and exhibits a remarkable contractile irrita- bility. A faint blow upon a nerve causes a spasmodic contraction of the corresponding muscle. Charcot in his cases of this description observed a cataleptic condition in which he could fix the limbs and position of the body in every conceivable way. Of greater interest are the cases of "suggestion." The hypnotized person under this influence is affected with hallucinations in which he assumes attitudes and goes through movements in corre- spondence with the special suggestion. By a change of the manipulations the hypnotized person passes into a state of somnambulism. He is half conscious, describes visions and does whatever he is bid. A number of nervous disorders affecting different organs remain to be mentioned. Frequent attacks of palpitation are very alarming to hysterical patients. They can usually be traced to a previous mental excitement. The pulse is occasionally exceedingly rapid without an apparent cause. Attacks resembling angina pectoris S93 MANUAL OF XERVOUS DISEASES. have been repeatedly noticed. ''Hysterical hsemoptisis" and "hysterical hsematemesis" belong also to this cate- gory of anomalous symptoms; and, stranger still, blood escapes into the skin (the so-called "stigmata"). These spontaneous hemorrhages cause great apprehension, though leading to no serious consequences. Digestive disturbances are often well marked. " Nervous dyspepsia'' is extremely obstinate, and seems to baffle all remedies. " The phantom tumor" is merely a partial distension of the abdominal walls, and if very extensive may simulate pregnancy. Ischuria is a very remarkable hysterical symptom. Days pass by and no urine i^ discharged, though there is no retention. Sometimes violent vomiting -comes on, and examination of the contents of the stomach discovers the presence of urea. It is highly probable that many cases of obstinate dysmenorrhoea are of a hysterical origin. Course of the Disease. It will be observed from the fore- going enumeration and description of the medley of symptoms recognized as hysteria, that the clinical history of this affection must include a host of other disorders, dependent as they are on an unstable and vulnerable nervous system. For the same reason it cannot be pre- dicted what different ailments will arise during the course of the disease. Experience has taught that whilst hyster- ical symptoms may entirely disappear for an indefinite period, an exciting cause, usually some emotional dis- turbance, rekindles the morbid tendency. It may hap- pen that none of the more severe forms of the disorder are present in some patients, but they are continually harassed by some of its minor ailments. We see hysteri- cal women who are never satisfied with their state of HYSTERIA. S93 health; they are always invalids. Some special com- plaint may predominate. It may be nervous dyspepsia, dyspnoea, palpitation or a worrying pain in some part of the body. On the other hand, it is peculiar to hysteria that severe symptoms, such as paralysis, contractures, hemiansesthesia or convulsive paroxysms, disappear sud- denly and spontaneously. Diagnosis. Hysteria presents a physiognomy of symp- toms that betrays their true character. Their very puzzling nature, that does not conforjn to the etiology, clinical history and course of well-known individual diseases, is significant. Hysterical paralysis as pointed out differs from ordinary forms of paraplegia and hemi- plegia dependent on gross nervous lesions. It should however be recollected that hysterical people are subject, like other mortals, to diseases which bear no relation to their nervous trouble. Treatment. A protest must be entered against the cruel indifference with which the ever returning ills and ailments of the hysterical are generally regarded. The physician who shares this error is certainly blamable. Banter and ridicule are entirely out of place. Hysteria is not a dangerous malady, it does not kill, but it is a most distressing affliction. To deal with it successfully requires a tact on the part of the physician, w^hich not every one has at command. If he succeeds in gaining the confidence of the patient, which is best accomplished by unaffected sympathy combined with firmness he will have a comparatively easy task before him. Moral therapeutics therefore takes the first rank in the treatment of hysteria. Seeing that mental excitement is often the vera causa of the most severe forms of the disorder, e04 MAX UAL OF XERVOCS DISEASES. such prophylactic measures should be recommended that guard against the influences which develop and keep up hysterical manifestations. In the management of invet- erate cases it may become necessary to change the sur- roundings of the patient and to secure rest by seclusion in which a rational treatment can be systematically carried out. Some of the popular measures for cutting short a hys- terical fit are often quite effectual, but stuffing the mouth with salt or throwing a pailful of water over the head of the patient should not have the sanction of the physician. It will suffice to splash some cold water in the face, or if the patient is ver\^ violent to irrigate the head for a few minutes at a time. Severe measures are at any rate not called for in a disorder which ceases of its own accord and is unattended with danger. What may be called '•habitual hysterical fits" are best controlled by stern reproof. Firm pressure in the region of the hyperses- thetic ovary sometimes succeeds in checking an attack. Hysterical paralysis yields better to moral treatment, when conducted with tact and perseverance, than to any other measure. The patient is to be persuaded to make at least some effort to overcome her muscular weakness. An intelligent nurse can be of far more assistance than any one of the family of the patient. As soon as the patient has gained some confidence in her ability to help herself, improvement will soon follow. This treatment can be advantageously aided by electricity, massage and cold douches to the spine. Hysterical aphonia is often successfully treated by electricity. The electrodes of a galvanic current are to HYSTERIA. 295 be placed to the sides of the neck, or Mackenzie's elec- trode is introduced into the larynx. Gynecologists claim good results in hysteria from the treatment of uterine disturbances. It may readily be admitted that benefit has been derived from correcting a displaced uterus, or from the relief of ovarian trouble, but in numerous cases such treatment has utterly failed to cure the hysteria. The employment of remedies against the multitude of nervous disorders in pronounced hysteria is a thankless task. But even under the unpromising condition of hav- ing to deal with a constitutional diathesis, the physician can be of great service to his patient if he succeeds in inspiring confidence in his eff'ort to aftbrd relief. The effects of moral therapeutics is sometimes seen in the "cures" from some highly advertised "infallible remedy," or the passes and manipulations of the "electro- magnetizer." In cases associated with anaemia or a decline of the general health a tonic and an invigorating treatment is indicated. Cold baths and douches and general galvani- zation will often be found of service. Among the " anti-hysterical " remedies it is only vale- rian that sustains some sort of reputation, because it is not quite as offensive as assafoetida. The bromides are sometimes very useful. Narcotics should be sparingly given, or better not at all if not urgently called for. Paraldehyde from 5ss to 5i is occasionally quite effective in calming hysterical excitement. Hemiana^sthesia is best treated with the faradic brush. 296 MAXCAL OF NERVOUS DISEASES. HYPOCHONDRIASIS. Etiology. Hypochondriasis chiefly affects men, but typical examj^les of the malady are occasionally observed in women. It is always a chronic affection, though it never endangers life. Apparently there seems to he an affinity between hypochondriasis and melancholia, inas- much as the alteration common to both is characterized by a depressed mental condition, but it would be errone- ous to class hypochondriasis with insanity, for the intelli- gence remains clear in the former, and it is only an excessive anxiety and apprehension manifested by the hypochondriac in regard to his ill-defined symptoms which develop his fanciful notions. Clinical history. The essential clinical feature of hypo- chondriasis is a morbid disposition to fix the attention on slight ailments, which are magnified and falsely inter- preted by the patient. The anomalous sensations of which he constantly complains are undoubtedly real; they absorb his thoughts, leave him no rest, and render him sad and peevish. Besides these indistinct sensations, which probably originate in the abdominal viscera, there are other symptoms of a more palpable nature. They chiefly consist of an uneasiness felt in the epigastric region, a burning sensation about the umbilicus, flatu- lence, disordered bowels, palpitations, flushes of heat in the face and frontal headache. Each of these morbid sensations, as they more or less bother the patient, is a source of alarm to him. He watches, studies and bewails them. By and by he locates them in a particular organ or some part of the body, and becomes convinced that he is the victim of a serious disease. The shifting character HYPOCHONDRIASIS. 297 of the vague feelings is probably the reason why hypo- chondriacs imagine they are successively affected by a variety of diseases. Now it is the stomach, then the liver, next the heart, the lungs, the bowels, the bladder, the rectum or spinal marrow. This change in the situ- ation of the fancied disorder is often suggested by the names of diseases about which these patients hear or read. They continually change their medical advisers and are voracious consumers of drugs. Some are in fear of losing their sexual power, and if ever they have had syphilis or imagine they had it, become confirmed syphilophobes. Treatment. Although hypochondriac people are exceed- ingly fond of taking medicines and sometimes declare they are benefited, yet they never acknowledge a cure- There is no use to direct treatment against any special symptom, for ten others will take its place. Attention should nevertheless be paid to the digestive organs, which are frequently disordered. Vegetable tonics, such as calisaya bark, cascarilla, columbo and gentian, with the addition of a mineral acid, answer very well. As torpidity of the bowels is a standing complaint of these patients, it is advisable to prescribe an occasional pill of aloes and nux vomica, or the compound liquorice powder if hemor- rhoids exist. An active life, devoted to a regular occu- pation which involves considerable physical exertion, is often of greater service than all medication. Good results are occasionally obtained from "moral therapeutics." An effort may be made to wean the patient from his gloomy thoughts and brooding over his ailments. Accord- ing to circumstances, he may be urged to enter a political career, or take an interest in a popular philanthropic S9S MA N UAL OF NER VO US D IS EA SES . cause, attend to vestry meetings, engage in a scientific pursuit, or cultivate one of the fine arts. Extensive traveling, which breaks in upon the monotonous routine of life, is sometimes beneficial. Such strategy has in some instances proved successful. Griesinger relates the case of a young woman who fancied that her intestines protruded through the partly opened abdominal walls. Her physician did not dispute this, but told her that it is not unusual for the abdominal muscles, when they are Aveak, to permit the intestines to come to the surface. He ordered an api>aratus to support the parts, and had the satisfaction by these means not only to cure her of her f^lse idea, but also relieved the constipation of the bowels, from which she had suff'ered for a long period. CHAPTER XVI. PARETIC DEMENTIA. (General Paresis of the Insane.) It is of great practical importance to the general physician to be familiar with the peculiarities of this disease, which, under the disguise of mental weakness and alteration of the moral tone, affects individuals in the prime of life, and tends to progressive deterioration of both body and mind. Outside of the profession the fully established disease is called by the ominous name of "softening of the brain." Etiology. Paretic dementia makes the heaviest inroads among those classes of society where the feverish activity of modern civilization is conspicuous. The disease attacks men between the ages of thirty and forty years. Women are much less liable to be affected. A hereditary ten- dency if at all existing is not evident. Of greater etio- logical importance is the connection of a history of syphilis with a large proportion of cases. It is a signifi- cant fact that the disease mostly occurs in men living in large cities. Its victims constitute a high percentage of the inmates of our insane asylums. Clinical History. Certain periods may be distinguished in the course of paretic dementia which mark its several stages, but the order of occurrence of the essential symp- toms in numerous cases is too variable to permit of such ( 290 ) SOO MA X UAL OF N EEVOUS DISEA S'ES . a strict division of its clinical history. The simultaneous and successive pathological changes of important nerve centers give rise to psychical, motor and sensory disturb- ances that observe no uniformity of development. Never- theless a typical case presents ample diagnostic points. The disease always begins with a precursory stage. Prodromic symptoms develop so insidiously that often no satisfactory information can be obtained in regard to the time when they lirst attracted notice. The condition of impaired mental capacity is chiefly manifested by a com- mencing failure of the memor}^ and laxity of the moral sense. This alteration is a puzzle to the family and associates of the patient. He exhibits an unusual levity? neglects his business, becomes fond of spirituous liquors, visits disreputable houses and gives various indications of changed habits. He mislays valuable papers, is inattentive to important appointments, gives orders to his assistants which he forgets and thus disarranges his affairs. Delinquencies of which he is guilty at this period are partly due to his thoughtlessness and partly to his moral debasement. He may for this reason com- mit a theft or forge a check with little compunction. The sedate paterfamilias shocks by his loose language and rakish demeanor. The promising young man violates the ordinaryirules of propriety and decorum. He enters a course of alcoholic and sexual excess. If he is reproached for his conduct he takes little pain to set himself right, or offers some unplausable reason in extenuation. The paretic dement is generally intolerant of contra- diction, flies into a passion about trifles, but shows a remarkable equanimity at the miscarriage of his affairs. PARETIC DEMENTIA. 301 He engages in foolish and ruinous enterprises, spends his money lavishly, and readily enters into objectionable matrimonial alliances. It would be difficult to prove that such a person is insane, but he is certainly fast drifting into it. Symptoms of a different order frequently make their appearance during this period. The patient is troubled with headache, dizziness, momentary confusion of the mind and a feeling of general illness. He becomes alarmed concerning the state of his health and is vaguely conscious of some deterioration of his former mental capacity. He is depressed, emotional, or a true melancholia develops. The physician, who is consulted at this stage would probably misinterpret the symptoms, if the family, who know more about the condition of the patient did not give the proper information. The development of very marked psychical and somatic symptoms may be considered the second stage. A close examination might have noticed before this a peculiar defect of speech, but this symptom is now more apparent. A tremulous movement of the lips and tongue attends the utterance of words, as if they had to overcome an impediment: the words come out with an explosion. The brow corrugates, the zygomatic muscles are fixed, the nostrils alternately contract and dilate. Very char- acteristic are the patient's blunders in pronouncing diffi- cult words, as "artrallirary" for artillery, "cletircal" for electrical. He makes use of wrong words. His hand- writing has also deteriorated. It is coarse and does not keep to the line, single letters and whole syllables are omitted. A similar incoordination affects his hands and fingers, especially noticeable in mechanical employments. 302 MA K UAL OF XEB VO US DISEASES. If the patient is an artist, he has lost nicety and deli- cacy of touch. There is an unsteadiness of the gait. The patient throws his limbs too Avide apart. Dancing, skat- ing, swimming and the like accomplishments are awk- wardly performed, or no longer practicable. If the patient is tested in reckoning or in drawing up accounts his lapses and glaring mistakes are of diagnostic value. Pupillary changes or paralysis of external ocular muscles constitute significant initial symptoms. They are rarely absent in advanced cases. Inequality of the pupils or reflex immobility (Argyle Robertson pupil) and ptosis are often observed. If in connection wath the symptoms that have been described, there is loss of the patellar reflex, migraine, and neuralgia of the extremities, the co-existence of loco- motor ataxia may be suspected. As the mental alienation progresses, there is a devel- op n:ient of expansive delusions and extravagant pro- jects corresponding to fancies of exaltation and grandeur. This character of the delusions is not peculiar to general paresis, but is observed in this disease with great fre- quency and distinguished by an absurdity that overleaps all bounds of the possible. The monomaniac may fancy that he is a king, an apostle, or a millionaire : he acts the assumed role and maintains his pretensions against all comers. But the paralytic dement declares that he is King of all Kings, the possessor of all the gold mines in the world, Napoleon, or God Himself — all in one breath. He is never struck by the bare incongruity of these fic- tions, personates them but indifferently and is easily per- suaded to drop them — though only to take up others PARETIC DEMENTIA. SOS just as senseless and ridiculous. Even when melancholia tinges the delusions, they partake of the absurd. Such a patient may say that he only measures an inch in height, that he is three-cornered and died yesterday. The delusions of the female paretic turn upon matters con- genial to her sex. She boasts of possessing thousands of silk dresses, is confined with twins every day and the like. The paretic dement not only braggs of his enormous w^ealth and high distinction, but also of his muscular strength and fabulous sexual power. He can lift the roof off the building with the greatest ease ; he has married the finest women in town and his genital is two feet long. Erotic delusions are particularly common in male patients. The subjective feeling of an exuberance of health and well-being is another of the marked features of the disease. If the paretic dement is asked how he feels — he answers "first-rate," " never felt better in his life," he is 'all right." Generally he is good-humored and cheerful and appears to be one of the happiest mortals. Some are, however, ill-natured and occasionally combative. The position in life and education of the patient modifies the delusions. A driver of a furniture wagon, whom I examined before his admission into the hospital, told me that his credit at the Savings Bank would keep him and his family for ten life-times, and then related with great gusto, how he "used up" a man with whom he had had a quarrel. This tendency to give revolting details of imaginary encounters has often been noticed in the paretic dement. The extravagant projects of patients frequently involve delusions of ludicrous and impossible schemes of amassing untold wealth. 304 JIAXUAL OF NERVOUS DISEASES. Paroxysmal attacks of mania and epileptoid and apoplectiform seizures constitute notable features of the disease. The maniacal paroxysms generally develop at a late period, and sometimes even at an early date. In very rare cases, they are nearly continuous and may prove fatal from nervous exhaustion, but usually they resemble acute delirium. The mental excitement in many cases is that of simple mania, of a violent, outrageous and malevolent character. Patients sing, shout and are destructive. They are filthy, constantly spit and besmear themselves with their excrements. In their imbecile fury they make desperate assaults, and are considered the most trouble- some inmates of asylums. Their brutality is sometimes exhibited in outbreaks after release from their confine- ment. They use violent and abusive language and threaten those who had a hand in their incarceration with cruel penalties. A maniacal paroxysm may last for hours or days and is succeeded by a brief stupor. Epileptoid attacks^ appear towards the termination of the disease. Usually the spasms are unilateral and rarely present the violence of a true epileptic fit. A patient often remains in this condition for days and recovers from it. Consciousness is not always impaired. Apoplectiform attacks like the epileptoid seizures occur towards the close of the disease, though in some cases they are witnessed at an early period. The sudden loss of consciousness may happen whilst the patient is engaged in conversation. The head is hot and the face flushed like in cerebral hyperemia. But apoplexy from cere- bral hemorrhage may also occur and prove fatal. I once attended a man who had apparently improved after hav- PARETIC D EMEN TIA. 305 ing exhibited unmistakable symptoms of paretic demen- tia. He became a frequent visitor of restaurants and club-rooms, from which places he was several times carried home in a condition of congestive apoplexy. He died eighteen hours after the last seizure during which time he did not recover his consciousness. Although patients usually get over these episodical attacks of mania and epileptoid and apo23lectiform seizures, they constantly lose ground after each attack. Before the last stage of the disease is reached, very remarkable remissions of prominent symptoms are occasionally witnessed. Improvement may be so evident, that the family of the patient conclude to remove him from the asylum under the impression that complete recovery has taken place. Such a patient may again ])e capable of attending to ordinary affairs and enjoy the liberty and comforts of home. But experience has taught that relapses are common, and that these invalids are not only liable to give way when undertaking the man- agement of complicated transactions, but are apt to become involved in enterprises that may sink a fortune. The downward tendency of the disease is marked by progressive obscuration of the intelligence and continued increase of the paretic condition, until the patient is reduced to an utter wreck of body and mind. When this third and last stage is reached he may be carried off in a few months by the " galloping" form of the disease. The fatal termination is sometimes postponed for two or three years. Death is often hastened by the development of malignant decubitus. Anatomical Changes. Very marked post-mortem appear- ances are found in subjects, who have died in the 20 S06 MA NUAL OF NER VO US D IS EA S ES . advanced stage of the disease. Symmetrical parts of the brain and spinal cord are involved in a degenerative process, that probably originated in a low inflammation. The sknll in many places is thickened. Bony plates are sometimes found in the adherent dura mater. Hemor- rhagic pacchymeningitis quite often exists. Some por- tions of the brain are entirely atrophied, leaving gaps between the unaffected parts. Cortical areas are slightly softened or indurated. The ganglion cells in these regions show marked degeneration. A cystic formation is very frequently noticed, consisting of minute cavities, which are due to dilatation of perivascular spaces in the gray and white substance. The basilar portion of the brain is affected to a much less extent than the convexity, but the pons and the medulla show partial atrophy. The axis cylinders of the nerve fibres are coarse and dis- tended. Very decided changes are constantly found in the neuroglia, from slight increase of connective tissue to complete sclerosis. The blood-vessels of the affected parts are twisted and tortuous. The adventitia and the mus- cular coat have undergone degeneration. To this condi- tion of the vessels must be attributed the venous stasis and thrombic coagulations in the substance of the brain. Nuclear or " free bodies" are seen in the lymph spaces, some of which are transformed into spider cells. Analogous changes are found in the spinal cord. The adhesions of the arachnoid and dura mater to the subjacent parts of the cord present the appearance of a meningo-myelitis. A fascicular degeneration often involves the posterior columns as in loco-motor ataxia. Sometimes the sclerosis is diffuse and has implicated the cells of the anterior cornua, PARETIC DEMENTIA. 307 The gross changes in the brain and the spinal cord explain the general nature of the symptoms, but what can be said in regard to those cases of the disease, in which no such morbid alterations are found. It has been suggested, that disturbance of the cerebral circulation initiated by vaso-motor influences which leave no traces, originates the symptoms, and that the degeneration of important nerve-centers takes place in the more advanced cases of the disease. Diagnosis. In the matter of diagnosis the great practical importance of recognizing the early signs of the disease is evident. Alteration of the mental condition, espe- cially on the moral side is significant. It is not usual for a man of settled habits of life to change them. The evidences of such a change vary in different individuals, but they all indicate the complication of an enfeebled memory, shallow reasoning, moral laxity and weakness of the will. Palpable errors in reckoning, a deteriorated hand-writing, tremulous lips in the act of speaking and pupillary changes are valuable diagnostic points. Of much importance are the episodical paroxysms of mania and the epileptoid and apoplectiform attacks. Usually the diagnosis of a typical case of paretic dementia causes no embarrassment. Uncertainty will be felt in cases resembling ordinary mania, brain tumor, cerebral syphilis and especially atypical examples of multiple sclerosis. Tlie Prognosis is exceedingly unfavorable. Cases of recov- ery do occur, but hundreds of demented paralytics die yearly in our hospitals. Treatment. Therapeutics holds out but faint hopes in a disease dependent on destroying lesions of important SOS MANUAL OF NERVOUS DISEASES. nerve centers. In the early stage it may be possible to arrest the disease in some cases, and the effects of iodide of potassium should at least be fairly tested. Alcoholic stimulants and sexual excesses should be strictly pro- hibited. Above all, it is the bounden duty of the attend- ing physician to apprise the family or friends of the patient of the true state of the case, and of the risk he runs of raising scandal and effecting his pecuniary ruin, if the proper precautions be not taken. There should be no hesitation to recommend the seclusion and care of an asylum as soon as the disease is recognized. The prompt and systematic treatment at an early period in such an establishment offers the best chance of benefit- ing the patient. BIBLIOGRAPHY. Arndt. Die Neurastlienie. Bastian. On Paralysis from brain disease. Beard. jSJervous Exhaustion. Rroadbent. Transactions. Charcot. Diseases of the brain and spinal cord. Dalton. Topographical anatomy of the brain. DowsK. On Neuralgia. EcKEK. Die Gehirnwindungen des Menschen. Ekb. Electrotherapie. EscHEVERRiA. Epilepsy. Ferrier. Functions of the brain. Flechsig. Die Lietungsbahnen in Gehirn and Riickenmarks des Menschen Gowers. Diseases of the brain and spinal cord. Epilepsy. Hammond. On nervous system. Hamilton. On nervous diseases. Jackson, H. Clinical and physiological researches of the nervous system. Jacobi. Hysteria and brain tumor. LiDDEL. Apoplexy and cerebral affections. MiTCHEL S. Weir. Lectures on diseases of the nervous system, especially in women. Meynert. Strieker's Histology. MuNK. Verhandlungen der physiologischen Gesselschaft zu Berlin. Nothnagel. Gehirnkrankheiten. PuTZEL. Functional nervous diseases. Rannev. The applied anatomy of the nervous system. RocKWELT-. Electricity. Rosenthal. Diseases of the nervous system. ( m ) 310 MA N UAL OF NER VO US D IS EA SES . Ross. Nervous diseases. Seguin. Spinal paralysis. Seligmuller. Nervenkrankheiten. Spitzka. Manual of insanity. Starr. Cortical lesions of the brain. Am. Jour. Med. Sci. Strumpel. Text-book of medicine. Trosseau. Clinical medicine. TuKE. Influence of the mind on the body. Vulpian. L'appareil vaso — moteur. Webber. Nervous diseases. Wernicke. Lehrbuch der Gehirnkrankheiten. Wood, H. C. Nervous diseases. ZiEMSSEN. Encyclopedia of practical medicine, vol. xiv. FORMULAE Hypodermics. Tablets of morphia gr. i to \ and of atropia gr. T2 to eV are now conveniently employed for hypodermic injections. They readily dissolve in water. Magendie's solution of morphia containing one grain in 30 minims is also well adapted for hypo- dermic use. The cerebral effect of morphia is antagonized by combining it with atropia. Tablets containing the proper proportions of these remedies are now offered for sale by reliable druggists. The following formulae are recommended : ^ Morphias Sulphatis - - - gr. vi Atropine Sulphatis - - - ^t. I Aquae Destillatte - - - 5 ss M Sig. Inject 10 M. or more according to circum- stances. ^ btrychnue ... - gr. 1 Aquae Destillatae - - - 5 ss M Sig. Inject from 5 to 10 minims. ^ Codeiae gr. iv Aquae DestillatcC - - - - 5 ss M Sig. Inject M xxx Headaclie. ^ Antipyrini - - - - - 9 ij Insomnia. Ft. in capsulas no. iv Sig. one every 3 hours or one &t bedtime, or (311) 312 MANUAL OF NERVOUS DISEASES. HeadaClie. 9^ Autipyrini 5 ii InsOMia. Syr. Aurantite cort. - - - 5 ss Aquse Aurantifc flor. ad - - 5 ij M Sig. A dessert spoonful every one or two hours until three to six doses are taken. Tinct. Cannabis Indic?e - gtt. XV Chloral Hydratis gr. X Potass. Bromid. gr. XX Elix. Smpl. .... 5i M Sig. Take before going to bed. Heiiucrania. Tinct. Cannabis [ndicfe - gtt. X Eth. Sulph. ■ gtt. xxiv M Sig. Take in a tablespoonful of water. V^ Urethani gr. viii Confect. Rosa^ - - - - gr. xv M Ft. massa et. in pil. No. xxiv div. Sig. From one to three pills. Insomnia. 9= Paraldehydi - - - - oi'i Alcohol is .... - ^^iss Spir. Lavandul. Comp. - - '^\\ Syr. Smplicis - - - ad ^iv M Sig. One dessertspoonful every hour until sleep is produced. 9; Sulfonali gr xx— xxx Sig. Take in black coffee or in syr. aurant. Insomnia. T^ Camphor Monobromatis - - 9 i Make into 10 pills covered with gelatine. Sig. Take one or two pills every two hours. FORMULAE. 3U Headache. V^ Caffein Citratis ... 5 gg iDSOmnia. Syr. Limonis - - - - S ss Aqu?e - - - - ad g ii M Sig. One teaspoonful every three hours. 9^ Efferv. Brorao-CafFeini Sig. One teaspoonful in a wineglassful of water every hour or two. 9 Guaranie gr. x— xx Pulv. i\romat - - . - - gr. v Sig. Take every 2 hours until relieved. Hemicrania. ^ Phenacetini - - - - gr. iii CafFein Citratis ... gr. iss Sacch. Lacti - - - - gr. v M Sig. Take every two hours until the head- ache is relieved. ^ Tinct. Opii Deodorat - - - gtt. xxx Tinct. Digitalis - - - - gtt. x M Cerehral Congestion ^ Pulv. Opii - - - - gr. i Quinifp . - - - gr. iii M Make into two pills. Cerebral Anxmia. 1^ Ext. fl. Conii - - - M xx Sig. At one dose to be followed by from five to ten minims every hour until the excitement is subdued. Mai. iacal Excitement. 9 Chloral. Hydratis Potass. Bromidi - - aa 5 ^^ ^ (One full dose acts better than frequent small doses.) 314 MA N UA L O F KEB V OUS DI S EA SES . Headaclie, ^ Ammonii Chioridi - - - 3 iii InSOinia. Morphia- Acet. - - - gr. i Caffein. Citratis - - - - 5 ss Spirt. Ammonite Aromat - 5 i Elix. Guarana? - - - - '!^ iv Aqua- Roste - - - - 5 i^' ^^ Sig. One dessertspoonful every quarter hour until relieved. Bilious headache after debauch. Debout's Pills. ^ Quinine Sulphatis - - - 5 i Pulv. Digitalis - - - - gr. viii Make into twenty pills. Sig. One every four hours. Neuralgia. ^ Quiniae Sulphatis - - - 5 i Morphise Sulphatis - - - gr. ii Ft. massa in pill No. xxx div. Sig. One pill thrice daily and gradually in- creased until nine are taken. J^ Quiniae Sulphatis - - - 5 i Morphiae Sulphatis Acid Arseniosi - - - aa gr. iss Ft. massa in pill No. xxx div. Sig. Taken as the foregoing. ^ Fl. Ext. Gelsemini " " Black Cohosh - aa ."^ i M Sig. Four drops every hour. The dose should be diminished if drooping of the eyelids is noticed. ^ Exalgina' ----- gr. vtox Taken in capsule. FORMULJE. 315 Borson's Pills. Neuralgia. 9= PuIv. Moschi - - - gr. x Pulv. Digitalis - - - - gr. v Opii - - - - - - gr. iv Make into ten pills. Sig. One every four hours. 9; Acomiuii {Duquesnill) - - ^Y.^^io\ Glyeerina? Alcoholi - - - - aa 3 i Aqua Mentlue pip q. s. ad 5 ii M Sig. One teaspoonful two or three times a day. Facial Neuralgia. (i Phenacetini - - - - gr. x In capsule. Sig. P^very hour until relieved. 1^ Antipyrini gr. lxxv Aqua^ Destillata? - - - - ,3 ijss Spts. Lavandulae Comp. - - 5 iJi Syr. Limonis - - - q. s. ad 5 iv M Sig. One dessert-spoonful three times a day. V^ Crofcon Chlorali - - - 3 i Glycerinje Syr. Aurantise - - - - aa 3 i M Sig. One teaspoonful per dose. 9; 01 Terebinthin^e - - - - 5 ii — Jii Mucilage Accacise - - - q. s. Ft. Emulsio et adde Syr. Zingeher - - - - ,^ i Aquani ad ^ iv M Sig. One tablespoonful every four to six hours. . . Sciatica. 31G MANUAL OF NERVOUS DISEASES. Neuralgia. R Strychnia^ - - - - gr. «s Aqute - - - - - - 5 ss M Sig. Eight drops in a dessert-spoonful of water three times a dav. Sciatica. 5fe Ext. Nux Vomicio - - - gr. i Manme 9 i Ft. massa et in pil. No. viii div. Sig. One pill three times a day. 9? Ammon. Chloridi - - - 5 ^j Ext. Fl. Glycyrrhiz?e - - - 5 ss Syr. Auranti?e - - - - 5 i Aqu?e - - - - - ad g vi M Sig. One tablespoonful three times a day. Epilepsy. 9= Potass. Bromidi - - - 5 ss Sig. In a wineglassful of water. J^ Potass. Bromidi - - - gr. xv Sod;e Bromidi Ammoniae Bromidi - - aa gr. v M Sig. In a tablespoonful of water. J^ Potass. Bromidi - - - - 9 i Tinct. Digitalis - - - gr. v — x Elix. Simplicis - - - - 5SS M ^ Potass. Bromidi - - - - 9i Sol. Fowleri - - - - gtt. iii M 9; Potass. Bromidi - - - - 9 i Tinct. Belladonna' - - - gtt. x M Sig. Three times a day. 9^ Sodas Boracis - - - - gr. xv — xxx Glycerinae - - - - gtt. v Aqupe Menth. pip. - - - 5 ss M Sig. Three times a day. FORMULA. 317 Nervine V^ Spirt. Aetheris Comp. Stimulants. Tinct. Valeriana? Ammon. - aa 5 i M Sig. One teaspoonful with a tablespoonful of water. Hysteria. ^ Spirt. Ammon. Aromat. - - 5 i Syr. Aurantia* - - - - 5 ii M Sig. One dessert spoonful every hour. Nervousness. ^ Spirt. Vini Gallici - - - ,^ ss Tinct. Opii Deodorat. - - gtt. xv — xxx M Nervous Shock. ^ Aetheris Chlor. - - - 5 i Pulv. Acaci?e - - - - 5 ss Aqure 5 iv M Sig. One tablespoonful every two hours. Hysteria. i* Spirt. Lavandulae Comp. Tinct. Cardamom. Comp. - aa 5ss Syr. Aurantia' - - - - 5 i ^^ Sig. One dessert spoonful in a vvineglassful of water. Restorative. J^ Cauiphont- .... g^-. xxiv Sapo-medicat - - - - q. s M et divid in pillulas - - viii Sig. One three times a day. 9= Camphor^e - - - - gr. xxiv Aetheris Sulph. - - - - 5 ss M Sig. Twenty drops in a wineglassful of water every half hour. 318 MA N UAL OF NERVOUS DISEASES. Nervine ^ Ext. Quebracho - - - .5 j StiMlantS. Sig. Twentj' to thirty drops three times a day. Hysterical Asthma. StiMlant ^ Linimentum Chloroformi - 51" and Sedative Tinct. lodini Applications. Tinct. Aconitii - - - aa 5 ii Tinct. opii .... ggs M 9; Methyl Chloridi pulv. - - -Si Sig. Apply with a brush, or a pledget of lint to tin painful part. 1^ Menthol . - - ■ gr. iiss Cocaini Muriatis - - gr. viiss Chloral Hydratis gr. iv Vaselini - 5 ii^s ^I Sig. Apply to painful part and cover with a strip of court-plaster. Supraorbital Neuralgia. V^ Carbonis Bisulphidi - - - o i^' Pulv. Camphora:* q. s. ad solut. satur. Sig. Apply with a brush to the painful parts. Lxunho-ahdonii nal Neuralgia. T^ 01. Terebinthinfi- Chloroformi - 5 viii ss Tinct. opii - aa 5 ii ^I Sci-xtica. Vc Ext. Hyosciami Ext. Balladonna? aa 5i Glycerinre - - 5i M Irritable Testicle. 9^ Methyl chloridi Sig. For a spray to the vertel^ral column. Spinal Irritation. (Huchard.) FORMULjE. 319 Stimulant V^ Atropifo Sulphatis - - - gr- v and Sedative Aquae DestiU. - - - 5 iii M Applications. pig. Soak a compress with some of the sohition and apply for an hour. Neuralgia ( Trousseau). ^ Ext. Belladonn?e - - - - 5 i Tinct. opii . - . - § i Glycerine^ - - - - - § iii M Sig. A piece of Unt wet with this mixture is applied to the neuralgic nerve. Cover the part with oil silk. 9; Veratrise - - - - - gr. xxiv Glycerinae - - - - - 3 ii Spir. Rectific - - - - 5 vi M 9; Collodii Cantharid. - - - 5 iv Sig. Paint the skin. liscellanBons. 9 Magnesire Sulphatis - - - 5 iv Acidi Sulphurici dil. - - 5 i Ferri Sulphatis - - - - gr. xv Syr. Aurantife . - - - ,^ ss Aqua? Mentha? pip. - - - 5 vii M Sig. Two tablespoonfuls twice daily. Tonic Aperient. 9 Ergotin (Beaujou) - - - o ss Ft. pilhilas no. x. Sig. One ter. in die. 9 Strychnia? - - - - - gr. i Tinct. Ferri Chloridi - - ,5 ^s Tinct Colomb?e - - - "Hi Aqua? - - - - - ad g iv M Sig. One teaspoonful three times a day. Nervous Dyspepsia. 320 MANUAL OF NERVOUS DISEASES. MiSCellaneCUS. ^ Tinct. Digitalis - - - - o iss Ext. Fl. Ergoti - - - - 5 "SS Syr. Aurantijc - - - - .3 ss M Sig. One teaspoonfnl every eight hours. Essential Vertigo. T^ Auro-Chloridi - - - - gr. i Ext. Gentiani - - - - gr. xv Ft. massa et in pill, No. xxx div. Sig. One three times a day. Loco-motor Ataxia. ^ Acid Arseniosi - - - - gr. i Mass. Ferri Carhonatis - - 3 i Quinise S\ilpli. - - - - 3 s.s Ft. massa et in pill. No. xl div. Sig. One pill three times a day. Nervous Dyspepsia. 1^ Hydrarg. Chloridi Corrosivi - gr. i Glycerinje ,3 i Tinct. Cinchon. Comp. - - ^ ii Spirt. 01. Menthte pip. - - - M xxiv M Sig. One teaspoonfnl in a wineglassful of water ter. in die. Vertigo 'jfthe aged. Meglin's Pili.s. 9; Ext. Hyosciami Zinc Oxidi - - - - aa 9ii M Divide into forty pills. Sig. Eegin with one pill and increase by one pill every other day. Tic doloreux. FORMULAE. _i Miscellaneous. Fournier's pu,l.s. ^ Zinci Valerianae - - . - gr. v Ext. Opii ..... gr.'iss Ext. Hyopciami - . . . gj.. {[^^ Confect. Ros;e - . . - q. s. Divide into six pills, big. One pill every three hours until three are taken, then omit the pills, and take them again in the same way the next day. Neuralgia. Prof. S. Groj^s' Pills. 9^ Quinia? Snlph. . - . - Q ii Morphine Sul ph. - - . gj.. i Strychnine ----- gr. 2^ Acid Arseniosi - - . - gr. i Ext. Aconitii - - - . gr. x Divide into twenty pills. Sig. Take one pill three or four times a day. Neiwalqia. Br0WX-Se(«ITARD'S PfLLS. 9^ Ext. BelladonnjL- - - . or. l- " Stramonii - - . or. " Cannabis Iii(li(7ie - - . gr, '' Aconitii - . . . " Opii - - - - . " Hyosciami - - - gr. '' Conii ar. i Pulv. Glycyrrhiza^ - - - q. s. Make into one pill. Sig. Take from three to four pills a day. Brown Sequard has observed no great constitutional disturbance from the use of these pills ( ?) „ Inveterate Neuralgia. ffr. i gr. I GENERAL INDEX. A Abscess of brain 248 Abernethy 39 A C C 00 Aconite in nervous diseases . . 51 Aconitia in neuralgia 81 Acute hydrocephalus 195 Agoraphobia 131 Agraphia 218 Akinesis 33 Alexia 218 Allochirea 29 Amyotrophic lateral sclerosis . 17<) Anwmia, cerebral 222 Anaesthesia 29 " in hysteria 289 Analgesia 29 Analgia 29 Andropliobia 131 Anelectrotonus 60 Angular Gyrus 4 Ankle Clonus 47 Anode 54 Anstie 135 A C 60 Apoplexy 223 " delayed 227 ingravescent 227 " meningeal 194 " in paretic dementia .304 Aphasia 214 " amnesic 217 " ataxic 210 Aphonia, hysterical 289 Aran igQ "Argyle Robertson symptom" 162, 302 Arkansas Hot Springs 152 Arsenic in neuralgia 78 Arthogryposis 271 Ascending current 69 " paralysis 153 Ataxia, loco-motor 159 '* hereditary ] 68 \ Athetosis 268 Atrophy, hereditary 187 ' ' progressive muscular . 1 79 Auditory symptoms in nerv- ous diseases 43 Aur;e, epileptic 275 Aural vertigo 283 B Basilar meningitis 190 Bastian 231 Beard, George 127-132 Belladonna in nervous diseases 51 Bibliography 309 Blepharospasm 114 Borborygnic'v in hj^steria 287 ( :!'23 ) 32Jf GENERAL IXDEX Bouchard 224 Brachial neuralgia 83 Brain, circulation of 26 Breast, irritable 86 " amputation, in masto- dynia 86 Brow ache 78 Brodie, Sir Benj 91 BrownSequard 48, 151, 274 Bulbar paralysis 188 Burdach's column 23 C Calabar bean in nerv. dis 52 Capsule, internal 17 Castration for irritable testicle 90 Causalgia 84 C C C 60 Central convolutions, lesion of 206 Cephalalgia 122 Cerebellum, nerve tracts of. . . 20 Cerebral abscess 248 " anaemia 221 " breathing 44 " embolism 237 '' hemorrhage 223 " hypertemia 221 " - localization 206 " syphilis 252 " tumor 242 " " varieties of. . . .252 Cerebro - spinal conducting paths 23 Charcot. .. 168, 176, 180, 209, 211, 224, 263 "Cheyne-.Stokes" breathing. . 44 "Choked disk" 41 " " in cerebral tumor 244 Chorea " electric "Cincture sensation" Circulation of brain Clarke Clarke's column Claustraphobia " Clavus hystericus'" Clonus, ankle Clubfoot in infantile paralj'sis Coccygodenia Codeia in nervous diseases. . . . Coma Combined paralysis of arm. . . . Concussion of spinal cord Conducting power of tissues . . I Convolutions, lateral " of frontal lobe. I " occipital ; " median I " parietal j " temporal i Convulsions i " epileptiform ! " hysterical " infantile i "Convulsive tic" ' Contracture I " hysterical [ Corona radiata I Cortex, the " " excitable are is of. Corticle centers I Cramp. . 263 267 45 26 180 24 131 290 47 171 90 51 38 106 155 61 1 2 6 6 '2S6 "39 113 32 289 17 9 14 14 milkmaids' " writers' "Crisis gastrique" in ataxia "Croup, false" Crural nerve, paralysis of . . 121 119 165 115 109 GEXEEAL INDEX Crusta •„ 20 Cniveilhier 90 Cuneus 8 Da Costa 267 " Dancing ma.nia" 267 Degeneration, reaction of 61 Delirium 37 Dementia, paretic 299 Density of electrical currents. 58 Descending current 69 Diagnosis, electro 61 Diet in nervous diseases 49 Diaphragm, spasm of 116 Direction method in electriza- tion 69 Diseases of the brain 221 " " pia mater 195 " " peripheral nerves. 73 " *' membranes of brain 193 " " spinal cord 144 " systemic, of cord .... 159 Disseminated sclerosis 256 Dorso-intercostal neuralgia ... 85 Duchenne . .77, 106, 180, 188, 192 Dura mater, hiematoma of. . . . 193 Duret 209 Dyspepsia, nervous 50, 292 Dysphagia, hysterical 289 Dysmenorrhfea in hysteria . . . 292 Electricity, medical 53 '■ in treatment of neuralgia 76 Electrical examination 67 Ellectric bath 71 Electric chorea 267 hand 271 Electrotonus 60 Electro-motive force 57 Electro-diagnosis 61 Electro-therapy 67 Electrization, general rules for 71 Elliotson 263 Embolism, cerebral 237 Encejihalitis 248 Endocardiac murmur in chorea 265 Epilepsy 273 cortical 280 " hystero- 287 Jacksonian 39, 274 reflex 274 Epileptic aurie 275 Epileptogenous zone 274 Epileptoid condition 278 '' attacks in paretic dementia 304 Equivalents of epilepsy 278 Erb 61, 62, 106, 159, 187, 272 " juvenile hereditary atro- phy of 187 Erythromelalgia 31 Erichsen 156 Esmarck. 91 Essential paralysis of children 169 Eyeball, spasm of muscle; of. 112 F Facial spasm 113 Faradism 55 Faradic brush 58 Faradization, general 71 Ferrier 10, 11, 14 Fissures, lateral, of brain .... 1 326 G E NE RAL I S D E X . Fissures, inferior, of brain .... 8 " median, " .... 6 Flechsig 24 Formatio reticularis 25 Formuli^. . 311 Fournier 159 Friederich's disease 168 Friteh 10 Friction (massage) 72 Gait, spastic 175 " in shaking palsy 261 Galvanism in nervous diseases 54 Galvanization, general 70 Ganglion cells, spinal 25 Gastric symptoms in nerv. dis. 50 Genu of internal capsule 17 Girdle sensation ... .45, 161 "Globus hystericus' 115, 287 Glosso-labio- laryngeal paral- ysis 188 Glossy fingers 84 Gluteal nerve, paralysis of . . . . 107 GoU's column 23 '' Grand mal " 276 Griesinger 298 Gyru.s fornicatus 6 " hippocampi 7 " rectus 8 H Hematoma of dura mater. ... 193 Hammond, Wm. H 268 Headache 36, 122 Hemiplegia 32 " of children 236 Hemiaucesthesia 36 Hemicrania 1 24 Hemiparesis. 35 Hemianopsia.' 42 ' ' test for 42 Hemorrhage, cerebral 223 " of spinal meninges . 141 Hereditary ataxia 168 " atrophy of Erl>. . .187 Herpes Zoster in neuralgia . 79, 85 Hiccough 116 Hitzig 10, 13 Horsley 14 Hot springs of Arkansas 152 Hutchinson, Johnathan 202 Hydromyelia 155 Hydrocephalus, acute 195 Hyosciamus in nerv. dis 51 Hyperalgia 28 Hyperalgesia 28 Hyperaesthesia 28 hysterical 290 Hyperkinesis 32 Hj'per trophy, pseudo 185 " lipomatous 185 Hypenemia, cerebral. 221 Hypnotism 291 Hypochondriasis 296 Hysteria 284 " Hj'stericus, globus" 287 " clavus" 290 Hysterical paralysis 288, 293 " aphonia 289 ' ' ana'sthesia 289 dysphagia 289 '* ha-moptisis 292 " hypenesthesia 290 " hiomatemesis 292 " dysmenorrhtea . . . .292 Hystero-epilepsy 287 GENERAL INDEX 327 I Incoordination in ataxia 165 " i n' p a r e t i c dementia 301 Induction current 55 Inhibition 47 Insomnia 37 Infantile spinal paralysis 169 Irritable breast 86 testicle 90 Ischuria in hvsteria 292 Lypomatous-hypertrophy .... 185 " Living skeleton" 182 Localization, cerebral 206 Loco-motor ataxia 159 Local spasm 112 Lockhart-Clarke 180 Lockjaw 112 Lohmayer 216 M Jacksonian Epilepsy 274 Joffroy 143, 176 Juvenile hereditary atrophy . .187 K 60 KaSZ Kathode 54 KCC 60 Katelectrotonus 60 Kennedy 172 Knee jerk 47 Kussmaul 192, 216 Labile current 68 Landry's disease 152 Laryngeal crisis in ataxia. . . . 165 Laryngismus stridulus 115 Lateral sclerosis, primary. . . . 174 *' " amyotrophic. 176 Lead paralysis 109 Leptomeningitis 139 " chronic spinal.. 141 Leyden Ill, 258 Lingual spasm 115 " Main en griflfe" 106 Mania in paretic dementia. . . .304 Masticatory muscles, spasm of. 112 Mastodynia 86 Massage 74 Measurement of electricity ... 58 Medulla, fibres and nuclei. ... 21 , Meniere's disease 37, 283 ^^iMelancholia in paretic de- mentia 303 Meningitis, basilar 195 I " of convexity . . . .201 metastatic 201 j " spinal 139 j " tubercular 195 Meynert 20 Migraine 124 Milk-maid's cramp 121 Mitchell, ^Yeir 31, 49, 84, 90, 91, 134 Monoplegia 33 Moral treatment in hypochon- driasis 29 < Motor symptoms in nervous diseases 45 Motor points 63 Multiple sclerosis 256 Muscle, pseudo hypertrophy of ,.185 3es GENERAL INDEX Muscle, lypomatous hyper- trophy of 185 Muscular atrophy, progressive. 179 Muscular sense ....'. 30 Munk 14 Myelia 155 Myelitis 146 " cervical 150 " dorsal 150 " lumbar 151 " microscopic appear- ance in 1 47 " transverse 150 Myotonia, congenital 272 Mysopholjia 131 N Neftel '. . 80 Neck, v\ry 117 Nerve fibres in bram, system of 15 " associative 15 " " commissural 16 " " radiating 17 *' stretching 78 Nervousness 40 Nervous dyspepsia 292 Neurasthenia 127 Neurectomy 78 Neuralgia 10 Neuromata 96 Neuritis 92 " alcoholic 95 " interstitial 92 " multiple . . . . 94 ' ' nodosa 94 " optic 41 " pathology of 92 Neuralgia, general considera- tion of 73 Neuralgia, crural 87 " anno-peronialis. . . 90 " different forms of. 78 " diagnosis of 80 " brachial 83 " epileptiform 74 " exciting causes of. 74 " dorso-intercostal. . 85 " general treatment. 76 " lumbar 87 " obturator 87 " of the genitals 90 " of the joints 91 '* prognosis of 80 occipital 82 predisposing causes of 73 reflex 74 symptomatology of. 75 sciatic 87 spermatic 90 trigeminal 78 vaso-motor symp- toms S3 Neuroses, professional 119 Nictitating spasm 114 Nothnagel 208, 280 Nystagmus 112 " in multiple sclerosis. 257 Obturator nerve, paralysis of.. 107 CEsophagus, spasm of 113 Ohm's law 57 Opium in nervous diseases.. . . 50 Pacchy meningitis spinalis. ... 138 " cervical is . . 142 G E NE RAL IND E X 3r?9 Paecliy meningitis, internal hemorrhagic 193 Painful tubercle 96 Palsy, wasting 179 " shaking 260 Paresthesia 30 Paralgia 30 Paraldehyde in hysteria 295 Paralysis 83 " alternate-crossed. 33, 213 " atrophic 34 " arsenical 110 " acute ascending 153 " agitans 260 " bulbar 188 " combined, of arm. . .106 " diphtheric 110 facial 99 ' ' functional 34 lead 109 " musculo spiral 104 " of ocular muscles. ... 41 '■' of motor branch of trigeminus 98 " of sterno cleido mas- toid 102 " of pectoralis 103 " of latissimus dorsi. . . 103 " of rotators of hume- rus 103 " of serratus magnus . .103 of deltoid 104 " of biceps and l)rac- liialis anticus 104 " of leg muscles 107 ' ' of crural nerve 1 07 ' ' of obturator nerve . . . 1 07 " of gluteal nerve 107 " of peroneal nerve. . .108 Paralysis of tibial nerve 108 " of sciatic nerve 108 " peripheral 97 in hysteria 288 reflex Ill " of rhomboidii and levator scapuhe. . 103 " spinal, from growths. 155 " spastic 34 " of trapezius 102 " essential, of children. 169 Paraplegia 34, 45 Paresis 32 Paresthesia 30 Paraphasia 217 Paretic Dementia 299 Pathophobia 131 Perimeter < 42 Peripheral nerves, diseases of. . 73 Peripheral paralysis 97 Peroneal nerve, paralysis of. . 108 "Petit mal" 277 "Phantom tumor " 292 Pia mater, diseases of 195 Physostigma in nerv. dis 52 Polyesthesia 29 Polar action of electricity .... 59 "Points apophysaire" 45 Points, painful 75 Poliomyelitis anterior 1 69 " in adults 173 Potential, electric 54 Propulsion in shaking palsy. .261 Primary lateral sclerosis 174 Progressive muscular atrophy. 179 Primar}^ current 56 Psuedo-hypertrophy 185 Psychical blindness 15 ' ' deafness 15 S30 G E X E RAL I iV D E X Psycho-motor centers 15 Puncta dolorosa 75 Pupil in nerv. dis 40 " Argj'Ie-Robertson 42 " '' " in pa- retic dementia 302 Pyramidal tract 18 R Railwaj^ spine 155 Reaction of degeneration (32 Reflex action 46 '" tests for 46 " cremaster 46 " epigastric 46 " epilepsy 274 " plantar 46 " gluteal 46 ' ' patellar 47 "' movements in neuralgia 79 " in ataxia 164 Reil, island of 1 Respiratory muscles, spasm of 115 Rest in nerv. dis 49 Retropulsion in shaking palsy 261 Reynolds, Russell 151, 263 R. D 62 "Risus sardonicus" 114 Rindfleisch 258 Rolando, Assure of 1 " gelatin oils substance of 24 Rolandic region 4 Romberg's symptom in ataxia. .163 Ross 143, 186 Rules for the application of electricity^ 71 S Sayre, Dr 168 Sclerosis of the brain 256 " disseminated 256 " primary lateral 174 " amyotrophic lateral . . 176 Sclerose en-plaque 256 Sciatic nerve, paralysis of ... . 108 Sciatica 87 " diiferential diagnosis. . 88 " rheumatic 89 Secondary current 56 Seguin 216 Sensory crossway 24 Sensory paths of spinal cord. . 26 Sexual function, impairment of in nervous diseases. ... 46 Shaefer 14 Shaking palsy 260 Sick headache 124 Singultus 116 Softening of the brain. . . 237, 299 Somnolence 38 Spasm 32 " local 112 " saltatory 119 '* of masticatory muscles. 112 " facial 113 " nictitating 114 " lingual 115 ' ' of esophagus 115 " of respiratory muscles. .115 ' ' diaphragm 115 " of muscles of neck 115 " bilateral clonic 117 " of muscles of arm 118 " carpo-pedal 38 Spastic spinal paralysis .... 174 GENERAL INDEX 331 Spastic gait 175 (Spermatic neuralgia 90 Special senses, effect of elec- tricity on 61 .Sphincters, affection of 46 Spider cells, in myelitis 147 Spinal cord, concussion of . ... 155 " paralysis, infantile. ... 169 " symptoms in nervous diseases 144 '' irritation 45,135 ** paralysis, spastic 174 '* apoplexy 141 " leptomeningitis, chronicl41 '' meninges, hemorrhage . of 141 •' meningitis 139 ' ' pacchy meningitis 1 38 * • paralysis, from growths in cord 155 Springs, Arkansas hot 152 Stabile current 68 Stigmata in hysteria '292 Stramonium in nerv. dis 51 Striimpel 236 Strychnia in neuralgia 78 St. Vitus' dance 263 Suspension in ataxia 167 Symbols of polar action .... 59, 60 Symptomatology of nerv. dis. . 28 Sylvius, fissure of 1 Syphilis and ataxia. . 159 ' ' of brain 252 System of nerve fibres in brain 15 Systemic diseases 144 Syringo-myelia 155 T Tabes dorsalis 159 " dorsal spasmodique . . . . 174 \ Tache cerebral 44 j Tapotement 74 t Tarantism 267 I Talipes calcaneus 108 Tegementum 20 Tendon Reflex in ataxia 164 Testicle, irritable 90 Tetany 269 Theories of motor phenomena. 13 Therapeutics of nerv. dis 49 Thomsen's disease 272 Thrombosis cerebral 237 " of cerebral sinuses. 143 Tibial nerve, paralysis of 108 Tic convulsive 113 Tic doloreux 79 : "Torticollis spastica" 117 Tremor 32 Trophic cells . 26 " disturbances 32 " changes in neuralgia.. 76 Trigeminus, neuralgia of 78 Trousseau 192,269,278 Trousseau's sign in Tetany. . .271 Tubercle, painful 96 Tubercular meningitis 195 Tumor, phantom, in hysteria. 292 Turk 24 Turk's cohimn. 23 Ulnar paralysis 105 Uncus 7 Unilateral lesion of the cord. .155 Vaso-motor centers 31 " " disturbances 30 Vertigo 36 33S G EXE U A L IX D EX . Vertigo, aural 283 " essential 36 Vomiting, cerebral 38 A'oltaic alternatives 68 W Wasting palsy 179 Word deafness ! . 217 Vrrist drop 105 " "in lead paralysis. . 109 Writer's cramp 119 Wry neck 117 Young 145 Ziemssen 62 Zone, motor 11 ERRATA. Page 26 — 4th line from top, for " nerves" read cornua. Page 180 — *' Lockhart Clarke" (one'name). Page 209— 3d line from top, for " heniianospia" read lieuiianopsia. Page 310 — 7th line from top, for " Tros.';eau"jead Trousseau. UNIVERSITY OF CALIFORNIA LIBRARY / Los Angeles This book is DUE on the last date stamped below. Form L9-30m-7,'56(C824s4)444 UNIVERSITY Of CALIPu... AT L03 ANGELES LIBRARY