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
Len<icirai y
Nucleu'^
Horn of \^n^v^
( laustruin
Sphenoidal Horn of
Lat. Ventricle
Post-cerebral Arteries
8. — Vertic'o-transvekse Section of the Brain, Posterior to
THE Tlbercu'la Mammillari.a, Antkhor to the
Peduncle. (Charcot.)
OUTL /.V ES F A NA TO M Y.
19
On comparing the number of fibres that come from the
hemisphere and pass to the internal capsule, with the
small size of the cms cerebri, the difference in mass is
Fig.
9. — Diagram of a Horizontal Section of the Brain Below
THE Level of the Cokpus Callosum. (Wernike.)
/ Island of Reil.
t h Thalamus optici.
n I Lenticular nucleus.
n c Head of the caudate nucleus.
N c' Extremity of the caudate
nucleus.
C I Anterior limb of the internal
capsule.
<7 /■ ' Posterior limb of the internal
capsule.
apparent. Some of those fibres in their passage down-
wards must therefore be interrupted, or lost in parts
at the base of the brain. A portion of the fibres occupy-
G, f Gyrus fornicatus.
S P Anterior horn of the lateral
ventricle.
T Corpus Calossum.
E C External capsule.
(7 I Claustrum.
V Ventricle.
G h Gyrus hii^pocampi.
so MAXUAL OF NERVOUS DISEASES.
ing the anterior limb of the internal capsule enter the
corpus striatum. This basal ganglia, the optic thalamus
and the corpora quadrigemina may be considered as
"intermediary stations" where the entering nerve fibres,
and those that proceed from them are modified in their
function. The exact functions of these basal ganglia are
however not well understood. The rest of the fibers of
the anterior limb of the interior capsule constitute the
pyramidal tract. It occupies the middle third of the
foot of the crus cerebri. The outer third of the crus is
composed of fibres that come from the corpus striatum,
and its inner third consists of fibres that pass to the
optic thalamus, the corpora quadrigemina and posterior
part of the hemisphere.
According to the investigations of Meynert, there is an
anatomical distinction between the inferior part of the
crus cerebri, which he calls the crusta, and its upper
part the tegementum. The fibres of the crusta consist of
the pyramidal tract, and those of the tegementum con-
sist of fibres that come from the spinal cord and pass to
the mesocephalon.
Nerve-tracts of the Cerebellum.
The connection of the cerebellum with adjoining parts
consists of fasciculi of afferent and efiferent nerves that
form the three peduncles of that organ. Although little
has been accurately determined in regard to the fmictions
of the cerebellum, its influence on the cerebrum, the
spinal cord and intermediate nervous structures must be
considerable as shown by the numerous nerve paths that
connect it with these parts.
U TL IKES OF AKATO M Y.
21
Nerve-nuclei and Nerve-fibres of the Medulla.
The components of the complex structure -of the
medulla oblongata that merit particular attention, include
PyKr
Fk;. 10. — Lateral View or the
SEEN FROM THE SURFACE OF ':
Py Pyramidal tract,
Py, Kr Decussation of pyra-
mids.
O Olivarj' body.
Os Superior olivary body.
5 Motor,
5' Middle sensory,
5" Inferior sensory nucleus
of the trigeminus.
6 Nucleus of abducens.
G f Genu facialis.
7 Nucleus facialis.
Right Half of the Medulla,
'HE Section. (After Erb.)
8 Posterior median acoustic
nucleus.
9 Glos.^o pharyngeal nucleus.
10 Nucleus of vagus.
11 Spinal accessory nucleus.
12 Hypoglossal nucleus
Kz Nucleus of the funiculis
gracilis.
R5 Trigeminus roots, these of
the Re Abducens and R^
Facialis.
2^2
MA N U AL OF N E li VOU S DI SEA S E S .
the collections of gray masses from which the roots of
some of the cranial nerves on the floor of the fourth
Fig. 11. — Diagram of
01 Olivary body.
V Anterior,
S Lateral andH Posterior spinal
funiculi.
a Pyramido-anterior tract.
d Pyramido-lateral tract.
Py Pyramidal tract.
b Remainder of anterior col-
umn.
c Remainder of lateral column.
e, e Cerebello-lateraltract.
S H
THE Chief Tbacts of the Medulla.
(After Erb.)
g Funiculus cuneatus, and
g
f Funiculis gracilis, and
nucleus of the same.
nucleus of the same.
P, c i Internal fasciculus of
the peduncle cerebelli.
P, c, e external fasciculus of
the same.
Cq, F Tract from corpus quad.
to formato retic.
Cq, O The same to olivary
body.
Thl tract from the tlialamus
opticus. The formatis
f reticularis is piesented
by shading in the center
of the figure.
UTL 1 NES OF A NA TOM Y. 23
ventricle arise, and also tlie different nerve tracts in their
relationship to the spinal cord. The annexed diagrams
are intended to show the positions of the nuclei and
tracts.
Cerebro-Spixal Conducting Paths.
At the lower end of the medulla, the larger portion of
the pyramidal tract crosses and enters the lateral col-
umns of the spinal cord. This part of the tract is called
the crossed pyramidal tract. A small portion which does
not cross borders upon the anterior fissure of the cord,
and is called ^/?e direct pyramidal tract (Tiirk's column).
Both the crossed and the direct pyramidal tracts undergo
secondary descending degeneration in lesions, affecting
the internal capsule. The direct cerebellar tract consists
of fibres at the periphery of the lateral column. In its
upward passage it lies on the surface of the restiform
l)ody and enters the inferior peduncle of the cerebellum.
This cerebello-spinal conducting path is subject to second-
ary ascending degeneration. GolVs column borders upon
the median fissure of the posterior spinal column. In
passing upwards from the lumbar region of the cord it
enters the medulla and connects by arcuate fibres with the
inferior peduncle of the cerebellum. Loss of sensibility has
not been noticed in disease of GoU's column. The outer
portion of the posterior column of the spinal cord is known
as Burdach^s column. It consists of fibres that enter the
cord by the posterior nerve roots. This column con-
tains a sensory conducting tract, and joins the fibres
which constitute the posterior third of the hinder limb of
f^ MA X CA L OF XEB VO US DIS EA SES .
the internal capsule.. This region of the capsule is in
the immediate vicinity of what is called the '' sensory
crossway," where fibres of special and common sensation
meet. For the more precise information in regard to
some of these distinct nerve paths, we are indebted to the
admit able investigations of Flechsig. Tiirk had previously
made the observation that lesions affecting certain parts
of the brain stood in relation to secondary degeneration
of definite tracts of nerve fibres. Flechsig subsequently
discovered that these and other bundles of nerve fibres
in the brain and spinal cord acquire their medullary
sheaths at different stages of embryonic development.
By this method of research he succeeded in determining
the existence of distinct cerebro-spinal tracts of nerve
fibres.
Additional structural peculiarities of the spinal cord
remain to be mentioned. The regions of the antero-
lateral depression of the cord where the anterior nerve
roots are situated are called the anterior root zones. The
posterior root zones are in the regions of the posterio-
lateral groove of the cord where the posterior nerve roots
originate. The gray matter at the tips of the posterior
cornua is called the gelatinous substance of Rolando. Near
and along the junction of the anterior and posterior
cornua a peculiar vesicular appearance of the central gray
substance of the cord is observed which bears the name
U T L IXES F A NA TO MY. 2t
of Clarl-e^s column. The format io reticularis is an inter-
lacement of fibres between the anterior root zones.
Fig. 12. Transverse Section of the
Half of the Dorsal Region.
C, Anterior commissure. G,
d c' Filjres which pass from a r,
the vesicular column
of Clarke (v c) to the a r',
direct cerebellar tract.
a, Anterior grey horn.
P, Posterior grey horn.
P t, Pyramidal tract of the lat
eral column.
T, Column of Tlirk.
d c, Direct cerebellar tract.
V c,
f r,
pr,
Spinal Cord in the Upper
(After Flechsig.)
GoU's column.
Internal portion of the
Anterior root-zone.
External portion of the
Anterior root-zone.
Columns of Clarke.
Reticular formation of the
spinal cord.
Burdach's column,
p r", Posterior root zones
Spinal Ganglion Cells
Nerve cells varying in size and number occupy differ-
ent regions of the central gray matter of the spinal cord.
They are especially numerous in the cervical and lumbar
S6 M A X U A L F XERVO U S D I S E A S E S .
segments. Groups of very large cells are found in the
anterior cornua. Cells of smaller size and less in number
are found in the gelatinous substance and the posterior
nerves. Clarke's column contains but few cellular ele-
ments. All the cells in the cord are surrounded by a line
network of nerve fibres and interstitial tissue (neuroglia).
The spinal ganglion cells perform the function of motor,
sensory and reflex centers. There is also strong evidence
that the cells of the anterior nerves exert a trophic influ-
ence on the muscular organs with which they are con-
nected.
Sensory Conducting Paths of the Spinal Cord.
Our knowledge in regard to distinct sensory tracts in
the cord is still very imperfect. We only know that all
sensory impressions enter the posterior nerve roots and
are transmitted to the posterior cornua. The sensory
fibres of the cord on their entrance immediately cross
over to the opposite side.
Circulation of the Brain.
It is of pathological importance to consider briefly the
peculiarities of the cerebral circulation. The brain
receives its blood from two sources — from the verte-
bral arteries and the internal carotids. Each carotid
divides into two large branches — the anterior cerebral and
the middle cerebral arteries. It is the distribution of the
latter which is of special interest. This artery enters the
fissure of Sylvius and sends branches to the lenticular
nucleus and adjacent parts of the brain, including por-
tions of the caudate body of the corpus striatum, the
optic thalamus and the internal capsule. Some of the
branches are also distributed to the greater part of the
O U TL rXES F A XA TO M Y . 27
central convolutions, the supranmrginal and angular con-
volutions, and partly to the inferior frontal convolution.
Although the middle and anterior cerebral arteries have a
common origin, yet their ramifications do not freely
anastomose. They are terminal arteries. It is due to
this circumstance that in occlusion of branches of the
middle cerebral artery, collateral circulation often fails to
be established. Hemorrhage in the lenticular fascular
district is verv common.
CHAPTER IT.
OEXERAL SYMPTOMATOLOGY OF DISEASES
OF THE XERYOUS SYSTEM.
SENSORY DISTURBANCES.
1. Hyperalgia. Pain is the most common of all the
varieties of morbid sensibility. The mind locates the
seat of pain with great precision, when the source of irri-
tation affects an external part of the body, but often fails
to do so when internal parenchymatous organs are
involved. It is well known that extensive and destruct-
ive disease of the brain, lung and liver does not give rise
to pain if the enveloping membranes of these structures
are not implicated. The character of the pain is often
significant of the part which is affected. For example,
neuralgic pain is paroxysmal, lancinating, darting, etc.
The pain in inflammation of serous membranes is sharp,
piercing, stabbing. The pain in irritation of mucous
membranes resembles the sensation of smarting, burning
or soreness. Muscular pain consists of an indescribable
feeling of restlessness and fatigue. Pain in the joints is
of a deep-seated, boring, gnawing nature.
2. Hyperesthesia (hyperalgesia). Morbid increase of
the cutaneous sensibility is recognized by the circum-
stance that in this condition of the nervous system ordi-
(28)
GENER A L S YMP TO MA TO L OGY. 29
nary exciting causes give rise to unusually painful feelings
and heighten the reflex excitability. Hyperaesthesia may
be limited to circumscribed areas of the skin. General
hyperassthesia is probably due to an irritable condition
of the spinal cord. It is a prominent symptom in teta-
nus, hydrophobia, spinal meningitis, strychnia poisoning
and hysteria.
3. ^?^^s^/^es^a (analgesia). All cases of anaesthesia must
of course depend on interruption, either central or peri-
pheral, of sensory conduction. Loss of the cutaneous
sensibility does not constitute the only form of anaesthesia.
The different qualities of common sensation may be
wholly or separately abolished. Tactile sensibility is
simply tested by touching the skin with a blunt instru-
ment. The sensation of pain is conveniently determined
by a prick of the skin with a needle. The experiment
to ascertain whether a patient is able to localize an
impression, or to tell whether the contact has been made
in one or several placed at the same time, may be made
with the points of a compass while the patient has his
eyes closed. The appreciation of differences in tem-
perature is tested by the application of warm and cold
substances to the skin. Polysesthesia is a rare form of
partial anaesthesia. The patient feels two, three or five
impressions, though only one impact is made.
4. Allochirea denotes a perversion of sensibility, the
patient being uncertain which side of the body is touched,
although the cutaneous sensibility is normal.
5. Analgia means that morbid condition of common
sensibility in which no pain can be elicited. It is
observed in the hypnotic state and hysteria. A tardy
30 MA N UA L OF NER VO US D I SEA S ES.
tninsinission of sensory impression may be the only sign
of partial anaesthesia.
6. Impairment of the ^'muscrdar sense^^ is ascertained
to exist when the patient is unable to appreciate palpable
differences of weight. To exclude the tactile sensibility
during the test the weights should he suspended from
the limb. An easy way of determining the condition of
the muscular sense of the upper extremities is to request
the patient to touch the tip of his nose with a finger ; if
defective the finger will miss its mark. Muscular con-
tractility is best determined by faradization.
7. Paresthesia. Certain morbid sensations which
patients compare to a feeling of tingling, creeping, numb-
ness or formication are usually called paraesthetic. The
sensation as if the limb were "asleep," or stuck with
^'pins and needles," flushes of heat in the face, or a feel-
ing of chilliness in some part of the body relate to the
same class of sensory disorders.
8. Faralgia. By this term is understood an anoma-
lous sensation that partakes more of the feeling of con-
striction than pain. A distressing sensation of this
character, which patients locate in the region of the
heart, is often called (precordial anxiety). This symptom
is frequentl}' complained of by nervous and hysterical
individuals. Tobacco smokers are also troubled with it.
It occurs with greatest intensity in angina pectoris.
VASO-MOTOR DISTURBANCES.
Irregularities of the vaso-motor system of nerves are
often associated with disease of nerve centers. Among
the two varieties of vaso-motor nerves — the vaso-con-
strictors and the vaso-dilators — the former is of greater
GENERAL SYMPTOMATOLOGY. 31
pathological importance. Experiments have determined
the existence of vaso-motor centers in the medulla oblon-
gata and the spinal cord. The vaso-motor fibres pass
into the lateral columns of the spinal cord, emerge from
there with the anterior nerve roots, and collect in the
trunk of the sympathetic nerve and plexus.
Irritation of the vaso-motor nerves causes constric-
tion of the blood vessels. Paralysis of these nerves causes
dilatation of the vessels.
The external effects of vaso-motor disturbance are
chiefly seen in the skin. Spasmodic constriction of the
blood vessels produces pallor or cyanosis of the skin. It
sometime causes a sensation of creeping and coldnes of
the hands, with which nervous and hysterical persons are
often troubled. The more severe effects of vaso-motor
spasm are seen in malignant decubitus — Reynaud's dis-
ease, circumscribed gangrene of the extremities and the
eruption of dark bullae in different parts of the skin.
Paralysis of vaso-motor nerves gives rise to redness of
the skin and the sensation of heat in the affected part.
This condition is often observed in hysteria and neu-
rasthenia, and also occurs as an independent affection.
Weir Mitchell has described an analogous condition as
erythromelalgia. The redness and subjective feeling of heat
in this condition may be persistent or occur at irregular
periods. It is attended by palpitation of the heart, strong
pulsation of the arteries, anxiety, ringing in the ears and
sweating. A milder affection of this kind consists of a red
or mottled appearance of the palms of the hands and soles
of the feet, a distressing sensation of heat in these parts,
slight swelling and profuse perspiration.
3e M A y UAL OF XER V OUS Dl S EA S ES .
Trophic disturbances. Certain nntritive changes are now
supposed to be caused by an independent set of trophic
nerves. Examples of such trophic disorders are the
"glossy skin," the falling out of the hair, stunted nails
and perforating ulcer of the foot.
Motor Disturbances
The subjects under this head include the two impor-
tant groups of convulsive and paralytic affections.
CONVULSION, SPASM. (hYPERKINESIS).
Convulsion denotes an involuntary muscular contrac-
tion. The synonymous term spasm is often used to
express convulsive movements of a single muscle or a
group of muscles. We speak of general convulsions
when the head, the trunk and the extremities are simul-
taneously affected, as in epilepsy. A difference in the
character of convulsive movements underlies the distinc-
tion of clonic and tonic spasm. In clonic spasm there is
alternate contraction and relaxation of a muscle. Tonic
spasm is distinguished by the rapid recurrence of the
contractions, so that the affected muscle appears to be in
a fixed condition. The muscle in spasm is always
shortened. Cramp means a painful contraction. All
forms of convulsive movements are caused by motor irri-
tation in some part of the nervous system.
Contracture signifies the persistent contraction of a
muscle, which fixes the limb either in a flexed or an
extended position.
Tremor consists of very slight contractions of numerous
bundles of muscular fibres. The movements in tremor
are of a very limited sweep.
Fibrillary contractions consist of a waving motion of
small fasciculi of muscular fibres.
GENERAL SYMPTOMATOLOGY. 33
Paralysis (Akinesis).
Any lesion or morbid influence which interrupts the
conduction of motor impulses causes paralysis. Immo-
bility of muscles from any other cause is not paralysis.
The term paresis is used to signify incomplete paralysis.
The classification of paralysis, viewed anatomically,
includes 1, cerebral; 2, spinal and 3 peripheral paralysis.
The division of the different forms of paralysis in accord-
ance with their area of distribution and combination
with special morbid conditions, is of great clinical impor-
tance, and will be briefly considered in this place.
1. Hemiplegia. This form of paralysis is typical of
cerebral disease. It occurs when any part of the motor
tract above the spinal cord is interrupted. The paralysis
affects the lateral half of the body, namely, the face, and
the upper and lower extremity of the side opposite to that
of the lesion in the cerebrum. This distribution of the
paralysis necessarily results from the crossing of the
motor tract in the anterior pyramids.
2. Alternate or crossed, paralysis is a form of hemiplegia
in which the arm and leg of the side of the body opposite
to that of the lesion in the brain is paralyzed, while the
face or an ocular muscle of the same side as the lesion is
also involved.
3. Monoplegia. This is a form of cerebral paralysis
which either involves one side of the face, or one arm, or
one leg; or simultaneously, the face and tongue, or one side
of the face and one arm. Such a partial hemiplegia
occurs when a cerebral lesion affects a part of the motor
tract in the brain, where its fibres are yet too divergent to
become collectively involved.
3
SJf MANUAL OF NERVOUS DISEASES.
4. Paraplegia is tj^pical of tranverse disease of the
spinal cord. The paralysis affects symmetrical parts of
the body; most frequently the two inferior extremities.
5. Atrophic paralysis. The loss of motor power in this
form of paralysis is associated with atrophy of the
affected muscles. When the lesion is situated above the
spinal cord there is hemiplegia, but rarely atrophy.
Atrophic paralysis in central lesion of the nervous sys-
tem occurs in disease of the ganglion cells of the anterior
cornua of the spinal cord.
It has bf^en inferred from development of atrophic par-
alysis in disease of the anterior cornua, that its ganglion
cells exert an influence on the nutrition of the corre-
sponding muscles with which they are connected.
6. Spastic paralysis. This form of paralysis is distin-
guished by a rigid condition of the affected muscles.
The muscles are not atrophied, and offer resistance to
passive motion. There is usually exaggeration of the
tendon reflexes. The cause of the rigidity of the muscles
is either a direct central irritation or reflex action.
7. Functional paralysis. By this term is understood
a group of paralyses, whose pathology is obscure. It
includes, reflex, hysterical and alcoholic paralysis, and
also those paralytic affections that occur as sequella? to
infectious fevers.
Besides the essential points of distinction between the
different forms of paralyses, there are certain accessory
symptoms which assist differential diagnosis. These
refer to sensory and vaso-motor disturbances, and altera-
tion of reflex and electric reaction which will be described
in their proper places.
GENERAL SYMPTOMATOLOGY. 35
The following explanation has been proffered to
account for the exemption of certain groups of muscles,
which for anatomical reasons would be expected to become
also involved in hemiplegia. The muscles of the neck,
the tongue, the eyes and the trunk are rarely found par-
alyzed. Those of the jaw^s, the pharynx and larynx
always escape. This exemption or relative immunity is
due to the circumstance that all these muscles act in
pairs, from which it may be inferred that they are inner-
vated by both sides of the brain.
The recognition of liemijplegia when the patient is
unconscious is not always an easy matter. The following
hints will assist the diagnosis. On observing the appear-
ance of the face, it will be noticed that the cheek "hangs,"
that it bulges during expiration and flaps during inspira-
tion. The mouth is drawn to one side and often saliva
escapes from the half-opened lip«. On raising a paralyzed
arm and then suddenly releasing it the limb falls down
like a dead weight. Sometimes the head and eyes are
turned to one side. Hemiparesis is recognized with
greater difficulty, even when the consciousness of the
patient is clear. Much information may be gained by
noting the position of the limbs and the range of their
voluntary movements. The grasp of one of the hands
is feeble in comparison with that of the othe^- One cor-
ner of the mouth is slightly drawn when the patient
laughs or cries. In the act of walking his body leans
towards one side. In place of finding the paralyzed limb
in a flaccid condition and passively movable in every
possible direction, which is usually the case, it sometimes
happens that the arm is stiff and tightly pressed against
the chest, and the hands and fingers are forcibly flexed.
^6' 31 A XUAL OF XE RVO US DISEASES.
Occasionally the leg maintains an extended position.
This "early rigidity" is characteristic of hemiplegia, but
it soon disappears.
Hemianscsthesia. This is a far less common symptom
in brain lesions than hemiplegia. The special senses in
severe cases may be more or less simultaneously affected.
In complete loss of the cutaneous sensibility, there is
often obtuseness of the contiguous mucous membranes.
The lesion in central hemiansesthesia is located either in
the posterior or inferior third of the internal capsule, or
in the vicinity of the optic thalamus or lenticular nucleus.
Cephalic Symptoms.
This group of symptons includes headache, vertigo,
delirium, insomnia, somnolence, stupor and coma. Occa-
sionally the following adventitious symptoms are quite
prominent in brain disease: gastric derangement, nausea
and vomiting, disorder of the special senses and epilepti-
form convulsions.
1. Headache is a symptom attending a great variety
of morbid conditions, but is usually of little diagnostic
importance. Very violent and persistent pain in the
head is, however, an early and constant symptom of
meningitis, cerebral tumor, cerebral syphilis and cerebral
abscess. Infants manifest severe headache by a peculiar
abrupt cry, and boring of the head into the pillow.
2. Vertigo, like headache, is due to different causes. In
numerous cases it merely amounts to a slight sensation of
dizziness. Sometimes it is an obstinate and troublesome
symptom a^.d calls for special treatment (essential ver-
tigo.) The patient in severe cases has the sensation of
" swimming" in the head, or as if external objects con-
G EXER A L S Y M P T MATOLO G Y . 37
stantly moved around him. Anaemic persons and inva-
lids after fever are liable to vertiginous attacks on suddenly
assuming the erect position. Vertigo attended by a
momentary confusion of the mind constitutes one of the
minor forms of epilepsy. Gastric disorders, aflfections of
the eye and the ear, alcoholism and masturbation fre-
quently give rise to vertigo. Associated with deafness,
nausea and vomiting, it constitutes a very prominent
symptom in Meniere's disease. A reeling gait resembling
the effects of severe vertigo is a characteristic sign of
cerebellar disease. In regard to the nature of vertigo, it
appears to indicate an abnormal condition of the con-
sciousness in relation to the position of the body. There
is a disturbance of the sense of equilibrium.
3. Delirium. The diagnostic value of delirium is not of
a high order. It is a symptom arising under influences of
various and opposite pathological conditions. Delirium
may assume all conceivable grades of mental excite-
ment, from transient periods of wandering to maniacal
frenzy. It may present all the features of insanity; but
the incoherence of language and the morbid mental con-
dition pass off with the affection that gave rise to the
disturbance. In certain nervous diseases, however, much
significance attaches to the peculiarity of the psychical
derangement. The hallucinations in delirium tremens
are repulsive and frightful to the patient. The demented
paralytic revels in delusions of grandeur and exaltation.
4. Insomnid. Sleep is often much disturbed in func-
tional nervous disorders. An excited or ill-nourished
brain is incompatible with the conditions of rest and
quiet. Wakefulness is frequent!}^ an initial symptom of
insanity, and is a very common feature of chronic alco-
93320
38 MA N UAL OF NER V OUS D IS EA SES .
holism. Insomnia, accompanied by severe headache,
is often a marked symptom of cerebral syphilis. Short
snatches of sleep disturbed by unpleasant dreams more
commonly result from orastric or intestinal irritation than
from cerebral trouble.
5. Somnolence. A disposition to sleep at unusual hours
is observed in cerebral ansemia and chlorosis. Great
drowsiness may be a premonitory symptom of ursemic
convulsions. Brain disease in children is often ushered in
by prolonged and deep sleep. The so-called " inward
fits" in infants come on during sleep. The child grinds
its teeth, turns the eyes upwards, presses the fingers
tightly on the palm of the hand and flexes the toes
downwards (carpo-pedal spasm). These symptoms usu-
ally pass off without any serious consequences, but some-
times the little patient awakes with a start and cries
incessantly, or has an attack of convulsions.
6. Stupor, Coma. Consciousness may be disturbed in
different degrees. A bewildered or dazed condition of
the mind is often occasioned by powerful mental excite-
ment. Coma is usually ushered in by stupor, from wliich
the patient can still be roused. In profound coma there
is a total abolition of the perceptive powers. Loss of con-
sciousness and utter insensibilit}^ constitute the essential
symptoms of cerebral apoplexy. The usual mode of
death in cerebral disease is by coma.
7. Gastric symptoms attending brain affections are
probably of a reflex character, affecting the pneumo-
gastric nerve. "Cerebral vomiting" is recognized by the
absence of a palpable cause of gastric irritation. This
symptom is so frequently present in children threatened
with serious brain trouble that due weight must be given
G EJS^ERA L S Y MP TO 21 A TOLO G Y. S9
to its appearance. Brain lesions occasionally give rise
to gastric disturbances of such great severity and persist-
ence so as to mask the real cause for a considerable
length of time. Abernethy relates the case of a young
woman whom he treated for what he thought to be some
serious stomach affection. At the autopsy he found a
large abscess of the brain: the stomach was perfectly
healthy.
8. Epileptiform convulsions. All grave diseases of the
brain tend to develop spasmodic seizures. Cortical
lesions are especially prone to give rise to epileptiform
convulsions (Jacksonian Epilepsy.) Unilateral convul-
sive movements or when one side is more affected than
the other are usually dependent upon gross lesion
of the cerebrum. Epileptiform attacks frequently occur
in tumor, abscess and syphilis of the brain, and less
frequently in meningeal and cerebral hemorrhage and
embolism.
9. Infantile convulsions. Children of a tender age are
exceedingly prone to spasmodic attacks, though in the
greater number of cases they take a favorable termina-
tion. The unstable condition of the nervous system in
the very young offers but slight resistance to trifling
exciting causes, and in consequence reacts in an excessive
manner. Many children are readily thrown into spasms
by difficult dentition, and gastric or intestinal derange-
ment from the presence of indigestible food or worms. It
is a matter of daily experience that acute diseases
occurring in early childhood are often ushered in by gen-
eral convulsions. Sometimes it is difficult to foretell
whether the sudden onset of the spasms indicates the
establishment of some formidable disease (meningitis,
40 J/ .4 .V U A L F XER V O US DIS EA S ES .
pneumonia, scarlatina, etc.), or is merely the temporary
effect of a source of reflex irritation, or perhaps the fore-
runner of epiiej^sy.
10. Nervousness. This vague expression much in vogue
in popular pathology has not yet been admitted into
medical nomenclature. It is nevertheless true that
patients often complain of numerous and anamolous
symptoms which cannot be fairly labeled with the names
of well-known nervous affections. A fruitful source of
such undefinable ailments is undoubtedly dependent on
an enfeebled condition of the general nervous system,
however brought on. Such patients often exhibit a con-
stitutional tendency to become readily excited, depressed
or emotional. Among the special causes may be men-
tioned fi*equent loss of small quantities of blood, debili-
tating discharges, excesses of every kind, prolonged
mental depression and the incipient stage of many chronic
diseases. Conditions of this nature often underlie ner-
vous dyspepsia, insomnia, the hysterical or hypochondric
disposition and neurasthenia.
11. Ocular symjDtoms. The clinical significance of
pupillary changes can only be adequately appreciated if
the reflex mechanism regulating the movements of the
iris be properly understood. The size of the pupil in
health is determined by the quantity of light which enters
the eye, and by the act of accommodation. The pupils
contract when exposed to light, and dilate in the dark.
They contract when looking at near objects, they dilate
when looking at distant objects. As long as there exists
but the feeblest sensibility to light, the pupillary reaction
occurs, whether the light falls upon one or both eyes.
Contraction of the pupil is in direct proportion to the
GENERAL SYMPTOMATOLOGY. 4I
quantity of light impinging on the retina. The stimulus
of light acting upon the retina is transmitted by the optic
path to its cortical center and excites on reflex action
the branches of the motor oculi that connect >vith 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^/<t'Ji^A^t^ /CC^/t^A^^^ *^>*^ ^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 hemian<Tsthesia in connec-
tion with a lesion of the thalamus, may be due to the
implication of the posterior inferior portion of the internal
capsule which contains sensory paths. Xothnagel, in an
exhaustive analysis of published cases of lesion of the
thalamus, comes to the conclusion, that a focal lesion of
this basal ganglia never gives rise to motor paralysis.
LOCALIZATl O X—C EREB R A L I J 1 S EASES. 209
The symptoms most frequently observed are post-hemi-
plegic chorea, athetosis and tremor of the paralyzed
limbs. Visual disturbances, especially hemianospia,
have also been observed. There exists a connection
between the pulvinar (posterior extremity of the thal-
amus opticus) and the optic tract. It should also be
mentioned that temporal and nasal hemianopsia are
often diagnostic of a lesion in the frontal fossa, impli-
cating the optic tract.
Corpus Striatum. Destruction of the Corpus Striatum
from hemorrhage or softening gives rise to the most com-
mon form of hemiplegia. The exceeding frequency of
lesion of this central ganglia is chiefly due to its vascular
and friable texture. The caudate and lenticular nucleus
of the striated body has been divided by Duret into differ-
ent vascular districts, which, according to Charcot, may
be separately involved and thus give rise to modified forms
of hemiplegia. In all of them the internal capsule is
more or less implicated. The lesion in the ordinary form
of hemiplegia is situated in the central portion of the cor-
pus striatum. The lesion in the severe form of hemiple-
gia affects the region of the corpus striatum where the
internal capsule runs between the caudate and lenticular
nuclei, or between the thalamus opticus and the lenticu-
lar nuclei. In the latter region the lesion may cause
either a permanent hemianff'sthesia alone, or the combin-
ation of hemiplegia and hemianpesthesia.
The diagnosis of a lesion of the corpus striatum is
probably correct in the large majority of cases of hemi-
plegia, when the paralysis affects the arm, leg and face
with temporary paralysis of the hypoglossus, no other
:.'10 M A y CAL OF X ERVOUS DfS E A S E S .
crarial nerve being affected. The jDaralvsis of the face
and tongue which usually attends hemiplegia in lesion
of the corpus striatum shows the close proximity of the
central paths of the facial and hypolgossus nerves to
the motor fibres of the internal capsule, wdiich are dis-
tributed to the extremities. It is->now 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.
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