American Series of Medical Text-Books INTRODUCTORY. It has been increasingly recognized of late that there are defects in the teaching of medicine which may be done away with, to the advan- tage of the medical student. In past years, when medical text-books were extremely high in price and students as a rule extremely poor, there was a reasonable cause for the adoption of a method of teaching j almost wholly by didactic lectures. Few young men, however, are pre- pared by preliminary education or experience to understand or profit by the oftentimes rapidly enunciated oracular statements of their professors. Numbers of students annually enter medical colleges direct from the farm or from mercantile employment, to whom such lectures are almost incomprehensible. As a consequence of the prevailing system of education, medical text-books, so called, have been amplified to a degree far greater than necessary, and oftentimes lack that concise systematic treatment of a subject which characterizes similar books in other branches of knowl- edge. Such books are not well adapted for practical use by students. If a different system in the teaching of medicine is to be introduced, it will be necessary that new and condensed systematic text-books be prepared, in which a definite number of pages can be assigned the student to prepare himself, by careful reading and study, for such recitation as may be expected of him. To meet the growing demand for such text-books as this change in methods of teaching requires, we have in preparation, by authors of experience as professors in medical schools, a series which will, when completed, cover the entire range of medical teaching, and which we | desire to submit for the consideration of all who are interested. We believe the books of this series will excel, in many ways, the more bulky text-books heretofore offered. r AMERICAN SERIES OF MEDICAL TEXT-BOOKS. 2 VOLUMES ISSUED TO DATE. THE MEDICAL STUDENT'S MANUAL OF CHEMISTRY. BY R. A. WITTHAUS, A.M., M.D., Professor of Chemistry and Physics in the University of the City of New York, and of Chemistry and Toxicology in the University of Vermont, etc.. etc. SYNOPSIS OF CONTENTS. Part I.—Introduction.—General Properties of Matter.—Physical Characters of Chemical Interest.—Chemical Combination. Part II.—Special Chemistry.—Typical Elements. — Acidulous Elements.— Amphoteric Elements.—Basylous Elements.—Acyclic Hydrocarbons.—Cyclic Hydrocarbons. —Compounds of Unknown Constitution. Part III.—Chemical Technics. Appendix A.—Orthography and Pronunciation. Appendix B.—Tables. Index. One volume post-octavo, of 508 pages, illustrated with 62 woodcuts and handsomely bound in red parchment-muslin. Third edition. Price, $3.75. A MANUAL OF DISEASES OF THE EAR. BY ALBERT H. BUCK, M.D., Clinical Professor of Diseases of the Ear in the College of Physicians and Surgeons, New York. SYNOPSIS OF CONTENTS. Chapters I.-XV. viz.: General Diagnosis.—General Pathology.—Diseases of the Auricle.—Diseases of the External Auditory Canal.—Methods of Examining the Middle Ear- Diseases of the Middle Ear.—Acute and Subacute Catarrhal Inflammation of the Middle Ear. —Chronic Catarrhal Inflammation of the Middle Ear.—Acute Purulent Inflammation of the Middle Ear.—Chronic Purulent Inflammation of the Middle Ear.—Fractures of the Temporal Bone.—Miscellaneous Conditions of the Drum Membrane, Ossicles, and Tympanic Cavity.— Syphilitic and Tubercular Disease of the Deeper Parts of the Ear.—Different Forms of Aural Disease in which the Labyrinth is believed to be Involved.—Anatomical and Physiological Sketch of the Ear. General Index. One volume, post-octavo, of 420 pages, illustrated with 117 wood-engravings to elucidate the text. Bound in red parchment-muslin. Price, $2.50. Other Volumes at Back of Book. NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of Edward B. Schlesinger, M.D. NERVOUS DISEASES. DANA. Fig. 210.—Composite Photograph Showing Relations of Cranial Surface to thi Fissures and Convolutions (Alec Fraser). TEXT-BOOK OF NERVOUS DISEASES BEING A COMPENDIUM FOR THE USE OF Students and Practitioners of Medicine BY Charles L. Dana, A.M., M.D. Professor of Nervous and Mental Diseases in the New York Fost-Graduate Medical School, and in Dartmouth Medical College; Visiting Physi- cian to Bellevue Hospital; Neurologist to the Montefiore Home; ex-President of the American Neu- rological Association, etc. Secont) Edition, WITH TWO HUNDRED AND TEN ILLUSTRATIONS. NEW YORK WILLIAM WOOD & COMPANY 1893 Copyrighted, 1893, By WILLIAM WOOD A: COMPANY ELECTROTYPED AND PRINTED BY THE PUBLISHERS' PRINTING COMPANY 132-136 WEST 14TH STREET NEW YdRK PREFACE. It is the object of the author in this treatise to present tht> science of neurology in a concise yet as far as possible complete form. Each subject has been taken, all the available facts re- garding it ascertained, the writer's own experience collated, and with the data thus gathered the chapters have been written. The labor involved in such a task has been very great, but I am encouraged to believe that the result will be a useful one; for the work does not compare or compete with the large treatises which are already in the field nor with the smaller introductory text-books. I have tried to furnish a book which will be suit- able for the student and practitioner and not valueless to the specialist. The extreme importance of a knowledge of anatomy has led me to pay especial attention to furnishing in a condensed form the most recent accessions to our knowledge of this subject. Starting with the facts that can be gained in ordinary anatomi- cal works, the student can, I believe, acquire a good idea of modern neuro-anatomy with the help of the anatomical chapters given here. In the classification of nervous diseases and the description of their pathology, I have tried to apply the modern knowledge of general pathology as modified by bacteriology. This I have done conservatively, yet not less than in my opinion is absolutely demanded. A good deal of havoc will be wrought eventually in our conception of the nature of nervous diseases by the newer pathological doctrines; 1 have made as little change as was con- sonant with undeniable facts. The limits placed upon me have made it impossible to furnish a bibliography or to give due credit to every original investiga- IV PREFACE. tor. Full references to literature are to be found in the works of Hirt, Erb, Seeligmtiller, Ross, and Gowers. In many topics I have been much helped by valuable mono- graphs of my American colleagues. While a part of these are credited to their proper source in the text, 1 feel that I ought to refer here to some of the articles that have been of special service to me. They include monographs on Spinal and Brain Tumors by Mills and Lloyd; on Cerebral Palsies of Children by B. Sachs; on Muscular Dystrophies and Writers' Cramp by Gr. W. Jacoby and by M. Lewis; on Aphasia, Cerebral and Spinal Localizations by M. Allen Starr; on Cranial Temperatures and on Neuras- thenia by L. C. Gray; on Degenerative Neuritis by W. H. Les- zynsky; on Poliomyelitis by Wharton Sinkler; on Craniometry and Cranial Deformities by F. Peterson and by E. D. Fisher; on Angioneurotic GDdema by Jos. Collins; on Brain Tumors by P. C. Knapp, and on Sclerosis of the Cord by J. J. Putnam. I am indebted to Tourette's recent treatise on hysteria, to that of Fere on epilepsy, and to the annual volumes of Bourneville on these subjects. The masterly lectures of Charcot and the treatises of Ross, Gowers, Hammond, Hamilton, and Putzel have necessarily been freely used. In the anatomical part I have used the works of Edinger, to whose courtesy I am particularly indebted, the treatise of Obersteiner, and many monographs by Golgi, Marchi, Cajal, His, Waldeyer, and others. My own work in teaching anatomy and pathology has enabled me to do more than present a compilation. I must finally express my thanks to my publisher, Mr. W. H. S. Wood, for his patience and helpful generosity in my efforts to make my work a production that would be creditable to Ameri- can neurology. To the Student. As a special text-book the present work will be used by two classes of readers, one consisting of those who simply consult it for reference in connection with their cases, the other composed of students who desire to ground themselves systematically in a knowledge of neurology. To this latter class I venture some advice as to the method they should pursue. Neurology is a PREFACE. V difficult branch of medicine to master, nor is there any royal road to it. Still, it can be made comparatively easy if its study is undertaken in a proper and systematic way. In using the present work, the student should first refresh his general knowledge of nervous anatomy as furnished in ordinary text-books. He should then go carefully over the anatomical descriptions here given of the general structure of the nervous system and of that of the nerves, spinal cord, and brain. A thor- ough knowledge of anatomy and physiology makes clinical neu- rology comparatively easy, and in fact reduces much of it simply to a matter of logical deduction. The student should next master the general facts of nervous pathology, symptomatology, and etiology, for he will find com- mon laws underlying apparently the most varying phenomena. Finally, he must begin to study the special diseases. The num- ber of these is very great; in the present work I have described 176. Many of these are rare, and it would be wrong for the student to burden his memory with the details about them. He need know only of their existence and general physiognomy. There are, however, according to my enumeration, about 65 ner- vous diseases which are either very common or extremely im- portant, and it is these that the student should master and make part of his working knowledge. Since the distribution and names of the common and rare diseases may be a useful guide, I append here a table and a list: Peripheral. Spinal Cord. Brain. Functional. Totals. Common and im-portant nervous 31 56 13 27 12 16 10 11 65 111 87 40 28 21 17G The common or important peripheral nervous diseases are: General.—Neuritis, multiple neuritis, degeneration, neuralgia, paresthesia (5). Cranial Nerves.—Anosmia, optic neuritis, optic atrophy, pto- sis, ophthalmoplegia, abducens palsy, headache, migraine, tri- geminal neuralgia, facial spasm, facial palsy, tinnitus, vertigo, ageusia, wry-neck (16). vi PREFACE. Spinal Nerves.—Cervical neuralgia, hiccough, brachial pal- sies, single and combined, brachial neuralgia, intercostal neu- ralgia, herpes zoster, lumbar neuralgia, sciatica, leg palsies (10). Spinal Cord.—Spina bifida, hemorrhage, pachymeningitis, leptomeningitis, poliomyelitis, transverse myelitis, acute and chronic, secondary degenerations, locomotor ataxia, the pro- gressive muscular atrophies, bulbar palsy, muscular dystrophies, spinal irritation (13). Brain.—Malformations, hyperemia, pachymeningitis, lep- tomeningitis, simple, tubercular, and epidemic, abscess, hemor- rhage, embolism, thrombosis, children's palsies, syphilis (12). Functional.—Epilepsy, hysteria, the tics, chorea, tetanus, neurasthenia, spermatorrhoea, exophthalmic goitre, occupation neuroses, paralysis agitans (10). PREFACE TO THE SECOND EDITION. The kind reception of my work has been a source of great pleasure to me and has done much to recompense me for the labor and care expended upon it. The unfavorable criticisms which have been made have not been numerous and, I confess, not unjust. In treating of the pathology of myelitis, encephalitis, and of tubercular and alcoholic meningitis, so called, I have taken the ground that the older views of the nature of these diseases were misleading, and that the primary trouble was usually some de- structive process or toxemic condition rather than an inflamma- tion; also that a toxemia underlies many of the degenerative diseases such as tabes dorsalis and progressive muscular atrophy. My classification of the functional neuroses is also based upon somewhat similar views regarding degeneration and toxemia, using the latter term in its widest sense. I believe that already there appears a tendency to accept these doctrines and to look upon nervous diseases from the point of view of which the es- sential feature is that one should regard the pathogenic factor rather than the anatomical lesion underlying it. In the present edition I have corrected some minor errors in the text, have en- larged the index, and have added a supplementaryc hapter on neu- rological therapeutics. To write with full satisfaction on this topic one needs space and an opportunity to go into detail. This I did not have in the body of my work as originally planned. I trust that the present chapter will be found a useful supplement. I am much indebted to Dr. Joseph Collins for assistance in revising this edition. New York, June 25th, 1893. TATTLE OF CONTENTS. PART I. General Description of the Nervous System, its Anatomy and Diseases. chapter i. PAGE General Anatomy of the Nervous System, . 1 CHAPTER II. General Description of Diseases of the Ner- vous System. Method of studying,.........I5 General symptomatology and technical terms, ... 16 CHAPTER III. Diagnosis and Methods of Examination. Physiognomy and stigmata,.......23 Disorders of motility,.........27 Disorders of sensation,........ 34 CHAPTER IV. The Causes and Pathology of Nervous Diseases. Etiology,...........40 Pathology,...........43 CHAPTER V. Treatment, Hygiene, Prophylaxis. Oeneral hygiene, diet, exercise,.......47 Hydrotherapy,..........49 €limate,............52 Electrotherapy,..........53 X CONTENTS. PART II. Anatomy and Diseases of the Cerebro-Spinal Nerves. CHAPTER VI. General Diseases Affecting the Cerebro-Spinal Nerves. PAOE. Hyperemia, anemia,.........64 Degeneration,..........65 Inflammation,..........68 Of single nerves,.........69 Multiple neuritis,.........70 Functional disorders,.........80 Neuralgia,..........81 Paresthesic neurosis,........84 Acro-neuroses,..........85 Tumors of nerves,..........89 CHAPTER VII. Anatomy of the Cranial Nerves, . . 92 CHAPTER VIII. Diseases of the Cranial Nerves. Olfactory,...........107 Optic,............108 Motor nerves of the eye,........113 Trigeminus,...........120 Headaches,..........121 Neuralgias,..........128 Facial,............132 Auditory,...........138 Tinnitus,...........138 Vertigo,...........141 Glosso-pharyngeal,.........146 Vagus,............147 Hypoglossal,...........147 Spinal accessory,..........148 Wry-neck, ... ......148 CHAPTER IX. Diseases of the Spinal Nerves. Classification,..........153- Anatomy of cervical group........153 Diseases,...........155 contents. XI PAGE Anatomy of brachial group,.......158 Diseases,...........160 Anatomy of dorsal group,........168 Diseases,...........168 Anatomy of lumbar group,........170 Diseases,...........170 Anatomy of sacral group,........173 Diseases,............173 Tabular summaries,.........178 PART III. Anatomy^ and Diseases of the Spinal Cord. chapter x. Anatomy and Physiology of the Spinal Cord, . 180 Blood supply,..........192 CHAPTER XI. Diseases of the Spixal Cord. General etiology, symptoms, etc.,......196 Classification of diseases,........197 Malformations, .... .....197 Spinal hemorrhage..........200 Caisson disease,..........202 Anemia and hyperemia,........203 Meningitis,...........205 CHAPTER XII. Inflammations of the Spinal Cord. Classification,..........210 Acute myelitis,..........210 Chronic myelitis,..........216 Anterior poliomyelitis,........220 Landry's paralysis,.........227 CHAPTER XIII. Degenerations of the Spinal Cord. Classification,..........229 Locomotor ataxia,.........231 Combined scleroses,.........248 Lateral sclerosis,..........257 Secondary degenerations,........259 Xll CONTENTS. CHAPTER XIV. The Progressive Muscular Atrophies and Dystrophies. PAGE Classification,..........261 Bulbar paralysis,..........2(52 Duchenne-Aran type,.........263 Leg type............268 Amyotrophic lateral sclerosis,.......268 Muscular dystrophies,.........269 CHAPTER XV. Tumors and Cavities of the Spinal Cord- Functional Diseases. Tumors,............277 Cavities,............280 Syringo-myelia,.........281 Functional diseases: Spinal irritation,.........286 Spinal exhaustion..........288 PART IV. Anatomy and Diseases of the Brain. CHAPTER XVI. Anatomy of the Brain, . . .290 Physiology and localization,.......317 CHAPTER XVII. Diseases of the Brain. General symptoms,.........329 Malformations,..........333 Meningitis,...........334 CHAPTER XVIII. Diseases of the Brain Substance. Hyperemia and anemia,........344 Inflammation, abscess,........346 The apoplexies: Hemorrhage,..........353 Embolism, thrombosis,........362 Children's palsies,.........365 contents. xiii CHAPTER XIX. Degenerations and Scleroses. PAGE Multiple sclerosis,..........374 CHAPTER XX. Tumors of the Brain—Syphilis. Tumors,............381 Syphilis of the nervous system,.......396 PART V. Functional Nervous Diseases. chapter XXI. Functional Nervous Diseases. Classification,..........403 The degenerative neuroses: Epilepsy,...........403 CHAPTER XXII. The Degenerative Neuroses— Continued. Hysteria,........... 416 The spasmodic tics,.........431 Paramyoclonus,..........432 Thomsen's disease,.........433 Paramyotonia,.....,.....434 Akinesia algera,..........434 CHAPTER XXIII. The Acquired Neuroses. Chorea,.........• • -436 Tetanus,...........442 Tetany,............443 CHAPTER XXIV. The Acquired Neuroses— Continued. Neurasthenia,..........446 Nervous women,..........452 Sexual neuroses,..........457 Traumatic neuroses,.........460 Exophthalmic goitre,.........462 XIV CONTENTS. CHAPTER XXV. The Acquired Neuroses—Continued. PAGE The occupation neuroses,........468 CHAPTER XXVI. The Late Degenerative Neuroses. Paralysis agitans,..........478 CHAPTER XXVII. Trophic and Vasomotor Neuroses. Progressive facial hemiatrophy, . . . . . 484 Acromegaly,...........485 Angioneurotic oedema,.........487 CHAPTER XXVIII. The Disorders of Sleep. Insomnia,...........490 Nightmare,......... . 493 Pavor nocturnus,..........495 Sleep drunkenness,.........495 Somnambulism,..........496 Hypnotism,...........497 Narcolepsy,...........500 Catalepsy............501 Sleeping sickness,..........502 Sleep-accidents,..........503 CHAPTER XXIX. Cranio-Cerebral Topography, . . 505 SUPPLEMENTARY CHAPTER. On General and Special Neurological Therapeutics, 509 General Index,.........533 Diseases of the Nervous System. PART I. CHAPTER I. GENERAL ANATOMY OF THE NERVOUS .SYSTEM. I shall describe here, first, the fundamental constituents of the nervous system, and next the general facts with regard to their arrangements. The nervous system is derived from the epiblastic layer of the developing ovum, and its constituents are modifications of epi- thelial cells. These cells in the embryo are of two kinds: neuro- blasts, which develop into nerve cells and fibres; and spongio- blasts, which develop into a supporting structure called neuroglia (His). The nervous system is composed of— (a) Nervous tissue proper, viz.: nerve cells and nerve fibres, forming together nerve units or neurons; and neuroglia. (6) Non-nervous tissue, viz.: connective tissue, blood-vessels, lymphatics, and epithelium. These tissues are united together to form a central nervous system, consisting of the brain and spinal cord, and & peripheral nervous system, consisting of nerve fibres, collections of nerve cells called nerve ganglia, and structures attached to the termi- nations of the nerves, called end-organs. The Nerve Cells or Ganglion Cells. — Shape. — They are of various shapes, differing in different parts of the nervous system. They are oftenest irregularly spheroidal, pyramidal, spindle or flask shaped. They give off processes or poles, and are classified usually in accordance with the number or arrange- ment of these. There are four kinds, viz.: (1) multipolar; (2) bi- polar ; (3) unipolar; and (4) small nuclear. The multipolar cells are the common type. Size.—They vary much in size. The larger cells are about ^ inch, the smallest 3^7 inch, in diameter. Structure.—The nerve cells are composed of a protoplasmic body, containing a nucleus and nucleolus. The protoplasm of the body appears granular, and sometimes striated or reticulated. 2 diseases of the nervous system. It often contains yellowish pigment. The nucleus is apparently reticulated. The processes are given off in various directions. In all developed nerve cells, one or more of the processes is pro- longed ; it then receives a myelin sheath and becomes a nerve fibre. This is called the nervous or axis-cylinder process. All nerve fibres are simply prolongations of nerve-cell processes and are really parts of nerve cells. The nervous process sends off Fig. 1.—Multipolar Cell of First or Motor Type (Marchi), showing nervous process and collaterals. lateral fibres at right angles as it passes out, and farther on, when it becomes a nerve fibre, it sends off other processes; these are called collaterals (Golgi, Cajal). It ends finally in a brush- like fibrillation called the "end-brush." The other processes of nerve cells are called protoplasmic. They connect with the blood-vessels and lymphatic spaces and, perhaps, have a nutrient function. They do not, at any rate, connect with other nerve- cell processes. Multipolar cells are said (Golgi, Von Monakow) to be of two types—motor and sensory. In the cells of the motor GENERAL ANATOMY OF THE NERVOUS SYSTEM. 3 type the nervous process passes directly into the axis cylinder of a nerve. In the sensory type the process passes first into a plexus of fibres, out of which a single nerve finally emerges. Some multipolar and most bipolar cells give off two nervous processes; one of these may be medullated, the other not. Many nerve cells of the peripheral ganglia have a membranous sheath or capsule continuous with the sheath of the nerve. The cells Fig 2—Multipolar Cell of Second or Sensory Type (Marchi), showing nervous process and collaterals. of the central nervous system have no capsules. The shape and structure of the various cells are best shown by the accompany- ing cuts. The location of the different kinds of cells is as fol- lows: Multipolar cells are found in the cortex cerebri, basal ganglia, and central gray of the spinal cord and medulla, and in some peripheral ganglia. Bipolar cells in Clark's column and intermediate gray of the cord, and in the posterior spinal ganglia. 4 DISEASES OF THE NERVOUS SYSTEM. Unipolar cells in the posterior spinal and sympathetic ganglia. Small nuclear cells and flask-shaped or Park bye's cells are found in the cerebellum. Besides these, there are described, in the brain cortex, angular, granular, pyramidal, globose, and spindle cells. The nerve fibres of the nerve centres are found chiefly in the white tissue or white matter. In the periphery they form the nerve proper of gross anatomy. The peripheral nerve is composed of bundles of nerve fibres Fig. 3. Fig. 4. Fig. 3.—Multipolar Cell, showing processes, reticulum, nucleus and nucleolus. d, Pigment (Nissl). FIG. 4.—Multipolar (Pcrkinje) Cell from Cerebellum, a, Body; b, nervous process; c, protoplasmic processes. called nerve fasciculi. It is surrounded by a connective-tissue sheath called the sheath of Henle, or epineurium. From this sheath, connective-tissue fibres pass in and surround the fascic- uli. The sheath of the fasciculus is called the perineurium. From the perineurium, strands of connective tissue run in among the ultimate nerve fibres, forming the endoneurium. Lymphatic spaces lined with endothelium exist in the layers of the peri- and endo-neural sheaths. In the nerve centres, the nerve fibres have no regular sheaths, but are supported by a connective-tissue and neuroglia framework. The nerve fibre is a long fine strand of GENERAL ANATOMY OF THE NERVOUS SYSTEM. 5 tissue varying in diameter. It may be white or gray according to its structure. It is composed from within out of (1) an axis cylinder, (2) a myelin sheath, and (3) a neurilemma. (1) The axis cylinder is the essential part of the nerve. It is the prolonga- tion of one of the processes of a nerve cell and consists of proto- plasm. It is itself made up of fine fibrillae (primitive fibrillae) Fig. 5.—Unipolar Cell, a, Body; b, capsule ; c, process. which run longitudinally. By means of reagents, a transverse striation can be seen also. (2) The myelin sheath, medullary sheath, or sheath of Schwann surrounds the axis cylinder. It is composed of a semi-fluid, fatty substance, which chemically con- sists of lecithin, neurin, and some cholesterin. It varies much in thickness, and this is the principal cause of the different sizes of Fig. 6.—From a Transverse Section through the Sciatic Nerve, ep, Epi- neurium; p, perineurium; n, nerve fibres constituting a nerve bundle or fasciculus in cross-section; /, fat tissue surrounding the nerve (Klein). nerves. The myelin sheath is interrupted at regular intervals by constrictions called the "nodes of Ranvier." These constrictions involve the myelin sheath alone. The axis cylinder passes through and the outer sheath (neurilemma) passes over it. There is a lit tie granular matter at the point, called intercellular cement. The nerve fibres, if they divide, always do so at a node (Fig. 10). The 6 DISEASES OF THE NERVOUS SYSTEM. part between two nodes is called a nerve segment. In each seg- ment there is an oval nucleus imbedded in the myelin sheath. The nodes are about 1 mm. apart. The myelin sheath is probably de- veloped, like the axis cylinder, from the epiblast, and is closely related nutritionally to the axis cylinder, which it protects and isolates. Be- tween it and the axis cylinder Mauth- ner describes a membranous sheath (axis-cylinder sheath). Another sheath is said to be between it and the neurilemma (medullary sheath). By means of certain reagents, oblique lines (incisures of Schmidt) or a retic- ular appearance may be developed (network of Ged velst). These appear- ances are, perhaps, artificial. (3) The neurilemma or primitive sheath is a delicate homogeneous covering form- ing the outermost sheath of the nerve. It is of connective-tissue origin. The sheath is absent in the fibres of the central nervous system and in some fibres of the periphery. Fig. 7.—Diagram showing the Different Parts of the Nerve. From without inward we have : 1, Nerve with epineurium; 2, nerve fasciculus, with perineu- rium; 3, nerve fibre and endo- neurium: 4, neurilemma, myelin sheath, axis cylinder, primitive fibrillae. Fig. 10, Fig. 8.—Medullated Nerve Fibre, a, Axis cylinder; n, nucleus ; m, medullary sheath; c, node of Ranvier. Fig. 9.—Medullated Nerve Fibre, showing axis cylinder, nuclei of medullary sheath, nodes, and oblique incisures of Schmidt. Fig. 10.—Medullated Nerve Fibre, showing mode of division. GENERAL ANATOMY OF THE NERVOUS SYSTEM. 7 Variations in the Types of Fibres.—In accordance with the arrangement of the sheaths of the nerve fibres, several kinds are described. The principal types are the medullated and non- medullated. Medullated nerve fibres make up the bulk of the white matter of the brain and cord and cerebro-spinal nerves. They consist of a myelin sheath and axis cylinder, and may or may not have a neurilemma. Fibres with myelin sheath, but without a neurilemma, make up the white matter of the central nervous system. Non-medullated fibres, or fibres of Re- mak, occur principally in the sympathetic system, but they are also found in the cere- bro-spinal nerves. They are grayish and faintly striated, and consist of axis cylin- ders, with a thin, homogeneous, nucleated sheath lying directly upon them. This sheath, however, cannot often be demon- strated (Schaefer). Naked axis cylinders are found in the peripheral terminations of nerves as well as in the brain and cord. Size.—The nerve fibres are of two kinds as regards size. The small fibres are about ■± s 16 b inch in diameter, the large ywsis inch. The small fibres are connected with smaller cells, and either run a shorter course or are distributed to the involuntary muscu- lar fibres of the blood-vessels and viscera. The nerve fibres of the central nervous system give off "collaterals," i.e., small medullated fibres branch out at right angles and pass off to make connections in an un- known way with nerve cells or other fibres. These fibres and those of the nerve roots have no neurilemma, but are surrounded with neuroglia tissue. They always end in a brush-like plexus of primitive fibrils, which surrounds the nerve cells in a network. The peripheral nerve fibres, except the optic, have no neuroglia; they terminate in fine fibrillae among epithelial cells, or in special end organs. Connections of Nerve Cells and Nerve Fibres.—One nerve cell is never connected directly with another, so far as anatomical investigation can show. One nerve process becomes an axis cylinder, receives a myelin sheath, gives off collaterals, and finally Fig. 11.—Non-medullat- ed Nerve Fibre, n. Nu- cleus; 6, striations. DISEASES OF THE NERVOUS SYSTEM. breaks up into a fibrillary " end-brush '' surrounding a cell, but not passing into it. There is physiological, but no apparent anatom- ical continuity (I'ig. 12). The cell and its nerve fibre and end-brush form together the nervous unit or neuron. The typical arrangement of a neuron is shown in Fig. 12. The Neuroglia. — The sup- porting tissue of the peripheral nerves is connective tissue only; that of the central nervous sys- tem is connective tissue and, in addition, a peculiar substance called neuroglia. The neuroglia or supporting tissue of the ner- vous centres is derived from the epiblast. It is composed of cells with very numerous and finely ramified processes, which make a supporting network about the nerve cells and fibres. The neu- roglia cells are known as " spider cells " or Deiter's cells. They dif- fer somewhat in size and shape, but not in general characteris- tics. The fibrillary processes form a felt-like network; and in regions where there is much neuroglia tissue, this looks like a homogeneous matrix. It is, however, made up of the fine fibrils. These connect with the walls of the blood-vessels. In inflammatory conditions the cells multiply, swell up, and as- Fig. 12.-Diagram showing the Neu- sist in carrying off irritating pro- ron and Mode of Connection between ducts (scavenger cells of Lewis). Nerve Units throughout the Nervous Neuroglia tissue is richly de- System. 1, Nerve cell; 2, nervous ~~„;f„/i _u~ j- j.i~ ^ ■> process; 3, collateral; 4, end-brush; 5, Pf^ed about the central canal nerve cell. of tne spinal cord, in the sub- stantia gelatinosa, beneath the ependyma of the ventricles and beneath the pia mater of the brain and cord. The epithelial cells of the central canal and ependyma of the ventricles send down fine processes which form a minor part of the supporting framework. The Non-nervous Tissues. — The Blood-Vessels.— The peripheral nerves are richly supplied with blood. Each nerve re- GENERAL ANATOMY OF THE NERVOUS SYSTEM. 9 ceives arterial supply from many different branches, but al- ways from the same general source. The artery passes to the nerve sheath obliquely, then divides dichotomously and sends branches a long distance up and down on the sheath. It may pierce the sheath, however, first, and then divide, as above de- scribed. The dichotomous branches send off arterioles and capil- Fig. 13. Fig. 14. Fig. 13.—Arteries of Sciatic Nerve (Qu£nu and Lejars). Fig. 14.—Venous Supply of Posterior Tibial Nerve. N, Nerve ; ATP, artery; VTF, vein; MJP, muscle; B, veins to muscle; C, B, veins to nerve (Quenu and Lejars). laries, which form plexuses about the nerve fascicles. These are "the interfascicular arcades." The arteries subdivide in such a way as to prevent sudden impact of a large blood stream into the tissue of the nerve. In this respect the nerve circulation resem- 10 DISEASES OF THE NERVOUS SYSTEM. bles that of the brain and cord. The veins subdivide dichoto- mously, like the arteries. They freely anastomose with the mus- cular veins, so that muscular action helps nerve circulation. The veins of the superficial nerves connect with those of the deep nerves. The blood-vessels of the spinal cord and brain will be described later. Lymphatic vessels and spaces are found in the epi- neurium and perineurium. There are no distinct lym- phatics in the fasciculi, but lymph spaces probably exist. The General Arrange- ment and Functions of the Nervous System. Having described the component parts, I shall now show the way in which these parts are arranged to form the nervous system. The nervous system, as already stated, consists of— I. A central part, com- posed of the brain and spinal cord. II. A peripheral part, composed of nerves, periph- eral ganglia, and end organs. I. The nerve centres are made up of gray and white matter, inclosed in mem- branes called the meninges. The gray matter consists chiefly of nerve cells ar- ranged in groups or masses. The white matter consists of nerve fibres arranged in tracts, strands, or columns. The gray matter is deposited in five principal places. The myelon, or central gray matter of the spinal cord, and brain axis, extending to the tuber cinereum. The corpora dentata. olivary bodies, and red nuclei. The great basal ganglia, viz., corpora striata composed of lenticular and caudate nuclei, the optic thalami, and the corpora quadrigemina. Arteries (Quenu and Lejars). GENERAL ANATOMY OF THE NERVOUS SYSTEM. 11 Cortex of cerebellum. Cortex of cerebrum. Besides these collections of gray matter, there are minor ganglia in the pons, cerebellum, and cerebrum, which will be referred to later. The white matter connects these various ganglionic de- posits of gray matter with each other and the periphery. II. The peripheral nervous system is usually described as con- sisting of a cerebro-spinal and a sympathetic part. Both por- tions, however, are alike made up of nerve fibres derived from and dependent on the brain and cord. Both are composed of nerve fibres connected in their course with peripheral ganglia and ter- minating in end organs. These peripheral ganglia consist of three sets- (1) The spinal ganglia, on the posterior roots; (2) the vertebral or sympathetic ganglia, connected chiefly with the an- terior roots: and (3) the peripheral ganglia proper, including vaso- motor and visceral ganglia, with which fibres from both roots are connected. The nerves which run between centre and end organs carry nerve impulses both ways. They are, therefore, divided into the afferent, centripetal or in-going, and efferent, centrifugal or out-going. The old division into motor and sensory nerves will not answer, for we know that there are many out-going nerves which are not motor. The afferent nerves are— 1. The sensory, including: Nerves of general ( Pain nerves or pathic nerves, heat and sensation. ( cold or thermic nerves. f ( Contact, tvt „ I Tactile, including <, Pressure, Nerves of ' i r -,., • i <- Locality. special - •> +. i A erves of muscular sense. sensation. | A erves of special sense of smell, sight, L taste, bearing, and space. 2. Excito-reflex nerves. The efferent nerves are— 1. Motor nerves, going to voluntary or striped muscles, heart muscle, smooth muscle, including the vaso-constrictor and dila- tor nerves. 2. The secretory. These act upon glands. Impulses to the blood-vessels (vasomotor) generally accompany the secretory im- pulses. 3. The trophic. 4. The inhibitory. These nerves control muscular movements, secretion, perhaps also nutrition. We must admit that afferent and efferent impulses take place also between end organs and certain (so-called) sympathetic ganglia. In other words, the cerebro-spinal axis is not always the 12 DISEASES OF THE NERVOUS SYSTEM. only centre. But these subordinate and peripheral centres are normally in connection with the spinal cord and may be influ- enced by it or by higher parts. There are also Intercentral or commissural nerves, which connect different parts of the cerebro-spinal system together. Some of these con- nect symmetrical parts on each side together. They have co-ordinat- ing function. Others connect higher with lower centres. These latter are made up of ascending and descend- ing fibres. Higher cen- tres send down impulses by the latter, which may stimulate or inhibit lower centres. In the peripheral nervous sys- tem we have also end organs. These are deli- cate and in some cases complex arrangements of the nervous and other tissue at the per- iphery of the nerves. Their object is to allow the nerves to be irri- tated by special stimuli which would not other- wise affect them, e.g., light or sound. Their object is also the proper utilization of efferent impulses upon other tis- sues. Fig. 16.—Diagram showing the Arrangement of the Neurons or Nerve Units in the Architec- ture of the Nervous System. M. Neurons I. and 77., Motor neurons; S. Neurons 7, 77, 777., sensory neurons; A. Neuron, associative or commissural neuron. There are end organs, therefore, for both sensory or afferent and for efferent nerves. The end organs of the afferent nerves are—I. Eye. II. Ear. III. Taste-buds. IV. Corpuscles in the Schneiderian membrane. V. Various tactile cells and bodies. VI. The space-sense organ. For the efferent nerves—I. Neuro-muscular corpuscles in the voluntary muscles. II. Local ganglia about the arteries. III. Local ganglia in the glands. Trophic end organs are not known. In many cases the end organ is nothing but the ter- GENERAL ANATOMY OF THE NERVOUS SYSTEM. 13 Visceral mechanisms. minal fibres of the nerve. These lose both medullary sheath and neurilemma, leaving only the axillary cylinder. These cylinders split up into terminal plexuses, or else without splitting pass be- tween and around the cells which they are to affect. The nerves, centres, and end organs thus described may be arranged in mechanisms, each mechanism subserving a special function. These form the mechanisms of the nervous system proper, and those of the other organs of the body. They are as follows: [ I. The psychical mechanism or mind. II. The automatic mechanisms or the mechanism Cerebro- of inherited and acquired aptitudes. spinal. 1 HI- The sensory mechanism. IV. The voluntary motor mechanism. V. The reflex mechanism. f The secretory mechanism. | The trophic mechanism. 1 The thermic mechanism. [_ The vasomotor mechanism. Various of the simpler mechanisms are combined to form those more complex. Thus the automatic and psychical mechanisms embrace in their activity other mechanisms of lower grade. In the same way mechanisms are combined for the regulation of visceral functions. Thus we have— I. The cardiac neuro-mechanism—a combina- tion of automatic, reflex, inhibitory, motor, and sensory fibres and cells. II. The respiratory mechanism. III. The mechanisms of the digestive tract. | IV. The renal mechanism. V. The thermal mechanism. VI. The skin and sweat mechanism. VII. The vesical mechanism. VIII. The sexual mechanism. In the working of these mechanisms the nerve cell is the agent which generates the energy or nerve force, by which impulses are started, controlled, and distributed. The larger the nucleus of the cell in proportion to its protoplasmic body, the more stable or less sensitive the cell. The larger the amount of protoplasm relatively to the nucleus, the more active the discharging power of the cell. The nerve fibres conduct impulses generated by nerves. These impulses travel at the rate of about 100 to 120 feet per second. It is less in visceral nerves (25 to 30 feet per second). There are no electrical currents in normal living nerves (Landois) except when Compound neuro- mechanisms. 14 DISEASES OF THE NERVOUS SYSTEM. an impulse travels along them. Then an electrical current travels along with the impulse. It is called the current of negati ve variation. The irritability or excitabihty of a nerve is the power it has of responding to a stimulus. When a constant electrical current is passed along a nerve its irritability is modified. This modified condition is called electrotonus. When a nerve impulse passes up an afferent nerve and is then reflected along an afferent nerve, it is called a reflex action. The time required for this process is called the reaction time. This averages from 0.125 to 0.2 of a second. Chemistry.—The nervous tissues are alkaline in reaction, but acidity rapidly increases on activity. Acidity is due to lactic acid. It is greater in the gray matter. The percentage of water is shown in the accompanying table, compiled from Hallibur- ton's figures: Percentage of Water. Portion of Nervous System. Foetus. Age. 20-30. Age. 70-94. ( « i 83 69 84 72 74 68 Nerves have the least water, gray matter of the brain most. Inorganic salts vary in amount, but average 0.5 per cent. PO* is the largest single constituent of the brain; potassium is next (Geoghegan). The nervous system is composed of— 1. Proteids, which make up about half the solids in gray mat- ter, one-fourth those in white matter, and one-third those in nerves. 2. Albuminoids, which are neuro-keratin and nuclein. 3. Phosphorized constituents known as protogon and lecithin. 4. Nitrogenous bodies of unknown composition called, 5, cere- brins; 6, cholesterin, which is a monatomic alcohol abundant in white matter; 7, extractives; and 8, inorganic salts. The following table shows the proportions of the different organic constituents of the brain (Petrowsky): ! Proteids. 1 Lecithin. Cerebrin. Choles-terin and Fat. Other Organic Matter. Salts. 17.24 1 0.53 9.90 0 ks 18.68 51.91 6.71 , CHAPTER II. GENERAL DESCRIPTION OF DISEASES OF THE NERVOUS SYSTEM. The Method of Studying Nervous Diseases. In studying the vital phenomena of the human body, we learn first its normal structure and functions. Then when diseased we note the new phenomena which have developed, the causes which produced them, and the anatomical changes lying back of them; we group our facts and give the disease a name. Finally, we ap- ply the methods by which the disorder can be relieved and future attacks prevented. In fine, we investigate our subject just as we study any branch of natural history. Our study divides itself, therefore, into— Normal Anatomy and Physiology. Symptomatology, a study of the morbid phenomena. Etiology, a study of the causes. Pathology, under which we include a study of the morbid anatomy and physiology. Diagnosis, or the method of differentiating the different groups of diseases. Prognosis, a forecast of the future course of the malady. Treatment and Prophylaxis. Again, although nervous diseases exhibit many phases and have many different morbid changes behind them, there are certain features common to all. It simplifies their study, there- fore, to learn first what these general features are, just as a per- son can better survey and plot out a country in detail if he knows certain general facts about its boundaries and topography. Hence I shall first present in a general way an outline of the fundamental facts that touch more or less on all forms of nervous disease. My first chapters will be devoted to— General Anatomy and Physiology, Symptomatology, Etiology, Pathology, Diagnosis, Prognosis, and Treatment. The subject of anatomy and physiology has already beeu briefly presented. We shall now take up 16 DISEASES OF THE NERVOUS SYSTEM. Symptomatology. I shall begin with a definition of certain terms that are fre- quently used. Neurology is the science of nervous diseases. Psychiatry is the science of mental diseases. A neurosis is a morbid nervous state. The term as sometimes used is restricted to morbid nervous states of functional charac- ter. This is not strictly correct, and in speaking of neuroses I give it the general meaning. A psychosis is a morbid mental state, and is nearly identical with an insanity, but has a broader meaning. The vital activities of the nervous system are shown in the phenomena of the mind, in muscular movements, sensation, con- trol of blood-vessels and secreting glands, in modifications of nutrition, of temperature, and visceral action. The disorder of any one of these functions produces a train of symptoms which receives a name in accordance with its character and class. Disorders of motion are called kinesio-neuroses; those of sensa- tion, ossthesio-neuroses. Correspondingly we have tropho-neuroses, thermo-neuroses, vasomotor, secretory, and visceral neuroses. When mental or nervous functions are disordered, there is an increase, decrease, or perversion of the special function or activ- ity. Certain Greek prefixes are used to indicate this. They are: "hyper," which mean excess; "hypo,"meaning diminution; "a" or "an," which means absence; and " para," which means perver- sion. So we have, for example, hypersesthesia or excessive sensibility; anaesthesia, which means loss of sensation; paresthesia, which means perversion of sensation. From the foregoing it will be seen that the classes or kinds of nervous symptoms are— 1. Mental and cerebral, forming psychoses. 2. Motor and reflex, forming kinesio-neuroses. 3. Sensory, forming sesthesio-neuroses. 4. Trophic, forming tropho-neuroses. 5. Vasomotor and thermic, forming angio-neuroses and ther- mo-neuroses. 6. Secretory, forming secretory neuroses. Combinations of these groups of symptoms may affect vari- ous organs. They are called mixed neuroses. A disorder may affect certain parts of the body, like the extremities—it is then called an acro-neurosis; or certain functions like the sexual or- gans—it is then called a sexual neurosis. GENERAL DESCRIPTION OF NERVOUS DISEASES. 17 K 0 Psycho Aesthesioneuroses Combinations of mental and nervous symptoms form psycho- neuroses. A common and practical division of nervous symptoms is into the objective and subjective. Objective symptoms are those which can be observed and noted by the physician. Subjective symptoms are those which are felt by the patient and give no outward sign. Headache is a subjective symptom; atrophy is an objective one. The particular symptoms which nervous diseases cause are best described and recorded under the several heads given above. 1. The mental symptoms include all those found in insanity,idiocy, and imbecil- ity, and will not be given in detail here. The common symptoms met with by the neurologist are mental irritability, de- pression, emotional excite- ment, morbid fears, voli- tional weakness and lack of self-control, persistent or fixed ideas, weakness of memory and of power of concentration, and a ten- dency to hypnotic and somnambulistic states. Certain symptoms due to disturbance of brain function are often called cerebral, as distinguished from mental. They are: vertigo, disorders of equilibrium, insomnia, somnolence, stupor, coma. Headache, head pressure, and similar feelings are also often de- scribed under the head of cerebral symptoms. 2. Motor Symptoms.—The symptoms of disordered motility may be classified as follows: A. Symptoms of exaggerated motility or hyperkineses. a, fibrillary; t intentional, or tremor on motion, Kinesioneuroses Secretory &iropBc« \&so«mofof Fig. 17.—Diagram illustrating the Prin- ciple of the Classification of Ner- vous Symptoms. Tremor: b, tremor proper: Convulsions or spasms: -, tremor in rest, ( constant. i tonic, } clonic, ( co-ordinate or purposeful. Choreic movements, convulsive tic, athetosis. Muscular tension and rigidity, contracture, myotonia, myo- clonus. Forced movements, associated movements, 2 18 DISEASES OF THE NERVOUS SYSTEM. Exaggerated reflexes, clonus, trepidation. B. Symptoms of lessened motility. Paralysis and ^ monoplegia,hemiplegia, paresis: ( paraplegia, diplegia. Loss of reflexes, superficial and deep. Tremor is the result of a disorder in the tonic innervation of muscles. Muscles are kept normally in a state of slight tension by rhythmical impulses from the brain cortex passing down at the rate of about twelve per second. When the rhythm and force of these normal impulses are interfered with we have tremor. The simplest form of tremor is one in which the normal tonic impulses have an apparently exaggerated force. This causes a fine tremor of eight to twelve vibrations per second. When there is an interruption to some of the impulses we have a coarse tremor. Here the vibrations are five to eight per second. It is caused by a partial or complete dropping out of the alternate impulse. Various technical names are used in describing the tremors. We have the fine and coarse, as described. Intention tremor is one that occurs on voluntary movement, and is opposite in kind to the tremor of rest, which decreases or ceases on voluntary effort. The term paralytic tremor is used to express the tremor of ex- haustion, and the term spastic tremor that of exaggerated motil- ity, as in the tremor of a chill. Ataxic tremor is one in which inco-ordinate movements are combined with the tremor. Fibrillary tremor is a fine twitching of the individual strands or parts of muscles, and occurs usually when they are wasting from lack of neuro-trophic influence. Convulsions consist of abnormal and exaggerated muscular contractions occurring in rapid succession. Convulsions may be clonic, i.e., the muscles rapidly and alternately contract and relax in an exaggerated and irregular way; or they may be tonic, i.e., contracted steadily and continuously. When a tonic muscular contraction is painful it is called a cramp. Convulsions may be co-ordinate. In this case the patient moves the limbs and body in a more or less purposeful way. He throws himself about the bed, jumps, kicks, strikes, tears the clothes, etc. Convulsions are usually accompanied with loss of conscious- ness. Choreic movements are sudden jerking, twitching movements of different groups of muscles. The movements are purposeless and are not under control of the will. Convulsive Tic—When a choreic movement is confined to cer- tain groups of muscles which work together for a common pur- pose, like those of the face, or eyes, or larynx, it is called a " tic." The movements in the " tics " are more definite in character and GENERAL DESCRIPTION OF NERVOUS DISEASES. 19 are limited to muscles physiologically grouped for a definite func- tion. Thus we have tics of the muscles of expression, or of respi- ration, or speech, or locomotion. Athetosis.—This is a name given by Hammond to a peculiar form of movement characterized by slow, successive flexion, ex- tension, pronation, and supination of the fingers and hand and arm, or of analogous movement of the toes and feet. The motion rarely ceases in waking hours except for a short time. The con- tractions are forcible, steady, and even, and sometimes painful. The hand assumes characteristic positions. A contracture is a tonic muscular spasm of long duration, i.e., days or months. A contracture may be functional or organic; and in order to test this, one must find whether it ceases during sleep or under an anaesthetic; if so, it is functional (see Hysteria). Fig. 18.—The Hand in Athetosis (Strumpell). In forced movements the patient suddenly and involuntarily is thrown forward, sideways, or whirled about in various ways. Associated movements are those which occur involuntarily in a limb or muscle at rest when the corresponding limb or muscle is moved on the opposite side. Thus in hemiplegia the movement of the normal arm may ex- cite a movement in the one paralyzed. The patient is given a piece of chalk in each hand, and each hand is placed upon a blackboard lying on the table; attempts at drawing lines with the sound arm cause movements of a similar kind, but less per- fect, on the paralyzed side. Paralysis or akinesis is a loss of motor power. Monoplegia is a condition in which one limb is paralyzed; hemiplegia one in which one-half the body is paralyzed; and paraplegia one in which the tAvo lower limbs are affected. Sometimes a-double hemiplegia or diplegia occurs. The term paralysis is sometimes used to indicate loss of any kind of function, as paralysis of sensation or secretion. Paresis is a term used to indicate a partial paralysis. It is not 20 DISEASES OF THE NERVOUS SYSTEM. to be confounded with the term general paresis, which is a form of insanity. The Reflexes and Their Disorders.—When an impulse started in an afferent nerve reaches the spinal cord or medulla and is thence reflected at once upon an efferent nerve, it is called a sim- ple reflex action. The process is an involuntary one. It ordi- narily occupies one-tenth to one-twelfth of a second. The affer- ent nerve may be an ordinary cutaneous sensory nerve, or it may be a special nerve whose sole function is to excite reflex action. These latter nerves are called excito-reflex. This kind is principally supplied to the viscera. Fig. 19.—Diagram showing the Reflex Arc of Spinal Cord. S, Sensory excito- reflex nerves; 4, motor nerve to muscle; 5, motor nerve cell. In neurology we have to do with four kinds of reflexes; The skin or superficial reflexes. The tendonous or deep reflexes. The visceral reflexes. Idiopathic muscle reflex. All these may be exaggerated, lessened, or absent. Further description of these reflexes will be given under the head of diag- nosis. 3. Sensory symptoms: Anaesthesia is a loss of tactile sensibility. Analgesia, a loss of sensibility to pain. Thermo-anozsthesia, a loss of sensibility to temperature. There may be loss of cold-sense or of heat-sense, or, as is usually the case, of both senses. The term anaesthesia is often used with a general meaning to GENERAL DESCRIPTION OF NERVOUS DISEASES. 21 indicate loss of all forms of sensibility. Anaesthesia in this sense is a symptom referred to the skin, bones, mucous membranes, special senses, or viscera. The muscles have two kinds of sensibility, a sensibility to pain and a special muscle sense. Anaesthesia of the pain sense of muscle is called loss of muscular sensibility or mus- cular analgesia. Anaesthesia of the special muscle sense is one of the factors in causing a symptom known as ataxia. Ataxia is a symptom due to loss of the special sensibility of the muscles, articular surfaces, and tendons. This special sense informs the individual of the degree and strength of muscular movements, and by it definite and co-ordinated movements are made possible. The weight of objects and position of the limbs are also determined by it. In static ataxia there is loss of the power to preserve perfectly the equilibrium when standing. It is due to the form of anaes- thesia just referred to. In locomotor or motor ataxia there is loss of power to co-ordi- nate the limbs properly in motion. In these conditions there is also usually a loss of power to appreciate weights or the position of the limbs. The term muscular anaesthesia, however, is often used to indicate these latter symptoms. Cerebellar ataxia is a form of inco-ordination due to disease of the central organ of equilibration, viz., the cerebellum. The anaesthesias may be incomplete, and special technical terms are sometimes used to indicate such conditions, but they are not necessary. Hyperesthesia is an excessive sensibility to touch, contact, and other stimuli. Hyperalgesia is excessive sensibility to pain, and is nearly identical with tenderness. Dysesthesia is an abnormal sensation such as a "thrill" or feeling of discomfort produced by ordinary tactile or painful im- pressions. Paresthesia is a term applied to all the morbid general sensa- tions except pain. The paraesthesias include such feelings as numbness, prickling, formication, flushing, burning, itching, cold- ness, tickling, feelings of weariness, exhaustion, various peculiar visceral sensations. Ordinarily in speaking of paraesthesiae, however, we refer to such feelings as numbness, prickling, and creeping. Delayed sensation is a symptom in which an appreciable time exists, usually one or more seconds, between the time of applying a stimulus and its appreciation in consciousness. Normally a tactile sensation can be felt and responded to in less than one- tenth of a second. Transferred or referred or reflex sensations are those in which 22 DISEASES OF THE NERVOUS SYSTEM. the irritation is made at one point and felt at another. Thus an irritation in the stomach causes a pain felt in the forehead. The whole class of so-called reflex pains are really transferred sensations, since in reality there is no reflex action in the process, as will be seen later. Allochiria is a peculiar form of transferred sensation in which an irritation applied on one side of the body is referred to a corresponding point on the opposite side. The special senses when disordered cause symptoms which are given special names. These will be described in connection with the special subjects. 4. Trophic Disorders.—These are called tropho-neuroses. They consist, so far as relates to neurology, chiefly of hypertrophy and atrophy of nerves, muscle, cutaneous and mucous tissues, joint degenerations, and various skin eruptions. The tropho-neuroses, if they affect joints, are called arthro- pathies; if muscles, atrophies, hypertrophies, and dystrophies; or if with atrophy there is a great substitution of fat the condition is known as lipomatosis. When nerves are affected there results de- generation. Tropho-neuroses of the skin produce various symptoms such as herpes, pemphigus, and other eruptions, pigmentation, leuco- derma, alopecia, and bed-sores. 5. Vasomotor and Secretory Symptrjms.—The nerves supplying the blood-vessels and secreting glands work together and are usually disordered together. Separate disturbances of the ves- sels and glands, however, occur. Angio-neurosis is the term given to disorders of the vaso- motor centre and nerves. Angiospasm is a condition in which there is increase of vasomotor tone and spasmodic contraction of the muscular coats of the arteries. Angio-paralysis represents the opposite condition. Such disorders affecting the skin are shown by pallor and coolness or by flushing and heat. Angio- ataxia is a condition of variability and irregularity in the tonus of the blood-vessels. 6. The secretory neuroses affect oftenest the skin. Hyperidrosis is an excessive sweating. Anidrosis is excessive dryness. Paridrosis is a perversion of secretion in which peculiar odors or colors are noted. Hemidrrjsis is the term applied to bloody sweating. The secretions of the internal organs are controlled by ner- vous influences, but their special disturbances do not require de- scription here. CHAPTER III. DIAGNOSIS AND METHODS OF EXAMINATION. The diagnosis of a nervous disease may be simply a clinical one; that is to say, one may recognize it as belonging to a certain known and definite group of symptoms. Thus in recognizing the phenomena of epilepsy, one makes a clinical diagnosis. In other cases, and especially in all organic nervous diseases, the physician must make in addition a local, and then a pathological diagnosis. That is, we must determine the seat and nature of the disease. A diagnosis is made by first getting all the obtainable facts in the patient's past history, then by learning from him all his sub- jective symptoms, and finally by making an examination accord- ing to the technical methods to be here described. In examining a patient, it is imperative that a careful search for diseases out- side the nervous system first be undertaken. Then the morbid nervous phenomena should be investigated. The physician should make it an invariable rule to make this examination in a certain fixed and systematic manner. The best method is first to get the family and personal history, and then to go over the mental, cere- bral, and special nervous functions serially in the way indicated under the description of general symptoms, thus: Examine— 1. Physiognomy, general condition of nutrition, complexion, physical defects (stigmata of degeneration), gait, station, pos- ture, speech. 2. Mental and cerebral symptoms. 3. Motor and muscular symptoms, including muscular and joint atrophies, electrical reactions, and the reflexes. 4. Sensory symptoms, general and special. 5. Vasomotor, trophic and secretory. 6. Visceral centres. In investigating the family history, it is often necessary to make very direct and probing inquiries, for patients are, as a rule, inclined to forget or ignore the existence of nervous and mental disease among relatives. The existence of consumption and inebriety, epilepsy and syphilis, in the direct line are very important facts; so also are those concerning birth. The pa- tient should be questioned closely as to his previous diseases, especially syphilis; also as to his habits in relation to sexual indulgence, indulgence in alcohol, and smoking. In women, 24 DISEASES OF THE NERVOUS SYSTEM. the tea habit should be inquired into. The patient may be al- lowed to tell his own story first. Proper queries should be put to supplement this, and finally the patient should be asked to state those symptoms which to his mind are main and dominant. We will now go over the above points in detail. I. The physiognomy, complexion, posture, and gait being noted, the physician looks next for evidences of imperfect physi- cal development. These are known as the stigmata or marks of degeneration. Marks op Degeneration.—General.—Shortness of height, general feebleness of constitution. Left arm and leg larger than right, long fingers. Cranial.—Asymmetry of skull, and especially of frontal bone. Short parietal arc (noted in epilepsy), short frontal arc (noted in petit mal). Peculiar type of skull, e.g., trigonal, scaphocephalic, plagio- cephalic. High, prominent forehead in women. Heavy jaws, lemurian hypophesis, prognathism. Large frontal sinuses, small orbit. High and narrow palate (noted in idiots). Muscular.—Unequal innervation of facial muscles on the two sides. Depression above glabella due to over-action of corrugators (noted in epilepsy). Squints and astigmatism. Other Marks.—Deviation of nose; ears long, or prominent, or set too far back; absence of helix, anti-helix, or lobule. Badly set and badly nourished teeth. Crown of scalp double or out of place. Small or deformed genitals, atrophic uterus. Physiological marks are those of deficient vital activity of the organic functions, such as weak heart, low arterial tension, un- stable vasomotor innervation causing coldness and flushing of extremities, weak digestion, constipation, amenorrhoea, sexual weakness or perversion. Psychical marks are those in general of feeble or erratic mental activity, unstable will, deficient moral sense, and lack of emotional control. While many of the foregoing stigmata have no significance in themselves, yet a combination such as impresses the observer with its preponderance is of great importance, for neuroses or psychoses developed among this class have a much more unfavor- able prognosis. It is especially among neurasthenics, epileptics, severe forms of hysteria, and in the insanities that these signs are to be looked for and studied. Among normal men about two per cent have the stigmata of degeneration; among lunatics, crimi- nals, abortive types of paranoia and primary forms of neuras- thenia, the percentage is about thirty. The accompanying table will be of help in making the in- vestigations relating to the cranium: Table of Cranial Measurements, in Centimetres. Adults. Physiological Variation. New-born. End of 1st yr. lstto7thyr. 10th year. Q _i n 50.0 31.0 1,300 31.0 12.0 11.*.) 7.1 17.2 14.0 83.8 12.3 48.5 to 57.4 28.4 to 35 0 1,201 to 1,751 28 to 38 10.9 to 14.9 9.1 to 14.4 34.0 20.0 385 to 450 22.0 7.7 9.0 34.0 20.0 22.0 7.7 9.0 42.0 25.5 700 to 1,000 28.0 42.0 25.0 34 to 4(5 27 49 47 46.0 to 49.5 49.5 to 52.25 30 ) Taken around glabel- 2. Binauricular arc... la and maximal oc-cipital point. 1,300 through bregma to b, or opposite ext. and. meatus. j Benedict and 28.0 10.0 10.0 1 Huschke. npt. n J3. )3 to a. 12 12 6. Bregmat. lamb, arc 7. Lamb, occipital arc 8. A n t e r o - posterior 12.5 7.0 17.7 14.C 82.2 12.37 13.3 16.5 to 19.0 13 to 16.5 76.1 to 87 10.5 to 14.4 11.5 to 15 70.0 to 74.9 75.0 to 79.9 80.0 to 84.9 over 100 to 150 9. Greatest transverse 10. Cephalic or length-breadth index.... 13. Empirical greatest From n to lowest point of chin. The empirical greatest the sides of the tri- 26 DISEASES OF THE NEKVOUS SYSTEM. To understand it, it is necessary to describe the skull land- marks, and to give briefly the classification and terms used by anthropologists and alienists in describing the dimensions and shape of the skull. Dimensions and Shape of Skull.—General Classification. —Anthropologists make a general classification of skulls into— The dolichocephalic, in which the antero-posterior diameter is to the transverse as 100 is to 75 or less; the brachycephalic, in which the length is to the breadth as 100 is to 80 or more; the mesocephalic, in which the length is to the breadth as 100 is to 75 to 80. The physiological limits of variation in the ratio of length to breadth are from 100 to 70 to 100 to 90. The dimensions and shape of the skull vary with age, sex, individual, race, and with certain pathological conditions and artificial deformities. In general, however, the variations in the shape and size of the Fig. 20.—B,B, Broca's visual plane; m,p,t, the triangle for ascertaining the empirical greatest height (Benedict). skulls of healthy adults of European and American races are fairly uniform. Variations Dependent upon Age.—The proportions of the skull change most considerably in the first year, and continue to change up to the fourth year. After that, modifications are slight in amount and appear more slowly. By the end of the seventh year the skull has nearly reached its full size (see table), more nearly in girls than in boys. The chief measurements dur- ing childhood are given in the table. The protuberances and ridges are less marked in children. The female skull is larger posteriorly, is broader, lower, with higher orbital diameter; often it has no glabella, no super-glabel- lar depression, and is less well marked as to its ridges, promi- nences, and sutures. Variations as Regards Race.—The length-breadth index and other cranial indices and the volume are the only racial differ- ences so far extensively studied. Even these are too indefinite factors to be of any practical value. In general, we may say that DIAGNOSIS AND METHODS OF EXAMINATION. 27 the dolichocephalic or long-headed are: the English, Irish, Scan- dinavians, negroes, 73; Arabs, 74; Chinese, 76. The brachyceph- alic or broad-headed are: the Germans, 81; Russians, Turks, 81. The mesocephalic or medium-shaped heads are. the American In- dians, 79; Hollanders, Parisians, 79. The Variations Dependent upon Artificial Deformities, Acci- dents, Perversions of Growth and Development, and upon Dis- ease.—There are certain more or less pathological variations in the shape of the skull, due to a premature ossification of a suture, or arrest of development in a centre of ossification, or to a hyperplasia, or aplasia of a part of the skull or of its contents. When one part is shut off from its natural expansion, other parts, as a rule, undergo compensatory development. This principle underlies the pathology of cranial deformities. Those deformities which it would be well to look for are— The triangular or trigonocephalic skull. The keel-shaped or scaphocephaly skull. The acrocephalic skull. The oxycephalic or steeple-shaped skull. The flat-headed skull. The plagioceph- alic or obliquely deformed skull. Variations in the Insane, Criminal, Epileptic, and other Psy- chopathic Classes Generally.—Minimal measurements of the fron- tal arc (n /?) are oftener found in insane and criminals. The pa- rietal arc is also said to be often shorter in the insane, defective, and delinquent classes and in epileptics. In these classes, how- ever, maximal excesses also often occur. There is, as yet, no acknowledged special variation or type which is, of itself, an indication of a peculiar mental trait or spe- cific pathological condition, although Lombroso and his followers have tried to make out such. On the whole, it is found that pro- nounced deformities occur often in healthy persons, while in psy- chopathic classes and criminals there is a large proportion of slight variations generally minimal, i.e., below the mean meas- urements from the normal type. For all ordinary purposes the only instruments needed in ex- amining the cranium are a tape, a strip of lead to use as a con- formateur, and a pelvimeter. 2. Investigation of Symptoms of Disordered Motility. —The recognition of gross disturbances such as hemiplegia and paraplegia is easy. To determine the exact extent of the paral- ysis, the patient must be made to move the limbs and contract the muscles in every possible way. The degree of paralysis in some groups of muscles can be measured by dynamometers. The ordinary hand dynamometer of Mathieu measures the degree of paralysis in the flexors. It should be graduated accu- rately in pounds or kilograms. I have devised an instrument by which the strength of the extensors of the hand and fingers can be tested. The average power of pressure on the Mathieu dynamometer is, for an adult, forty to fifty kilograms for the right hand, and three to five kilograms less for the left. A woman has about two-thirds of the power of a man. I have had constructed an apparatus by which the strength of the leg-push, i.e., of the extensors of the leg, and foot and the 28 DISEASES OF THE NERVOUS SYSTEM. extensors of the thigh is tested. The anterior tibial and calf mus- cles can also be tested by means of an instrument called the pedo- dynamometer devised by the late Dr. William R. Birdsall. A good idea of the degree of paralysis can be got by making the patient take the physician's two bands with his own and squeeze each at Fig. 21.—Leg Dynamometer. Fig. 22.—Foot Dynamometer. Tremor is tested by making the patient hold out the hands and arms at full length, spreading out the fingers at the same time. To determine whether the tremor increases on volitional movement, give the patient a full glass of water, let him hold it out for a moment, then bring it to his mouth slowly. If the ;'^a^\"^hju*w -r ■ a-■;,*> v'.i;/,;'' ■- ~m.■" /'-."«/V~v#'aM^1WA^1/ V^w'-v-WllWtotNA^Ufiihj.-,*/ \nm.m,,MmHiii'Mit)iinim mmmmmmimmmmNHm S=10VD Fig. 23.—Diagram of a Fine Vibratory Tremor. Ten of the divisions on the lower line equal a second. tremor increases with this movement it is called " intentional." As a general rule, the tremor of organic disease is increased by volitional movement, and ceases during rest of the extremity. Functional tremors are usually continuous. In some forms of tremor the hand and arm shake as a whole; such tremors are called vibratory. In other forms the tremor in- DIAGNOSIS AND METHODS OF EXAMINATION. 29 volves only the fingers or hand. Such tremors are called oscilla- tory or segmental. The apparent vibration of a tremor may range from five or six to ten or twelve per second. To determine accurately whether the tremor is fine or coarse special apparatus is needed; but one can with a little experience determine this fairly well by observa- tion alone. Or we can use a sphygmograph as shown by Dr. F. Peterson. This instrument is fixed firmly on the table, and the tremulous forefinger held lightly against the lever. Tremor that is hardly observable by the eye can be felt by placing one's hand against the extended fingers of the patient. Tremor of the tongue and lips and facial muscles must be carefully looked for. It is tested by making the patient close the eyes tightly and show the teeth or protrude the tongue. Tremor of the whole head due to the neck muscles must be distinguished from secondary shaking of the head due to a tremor of the trunk. Fibrillary tremor, which involves only certain fibres of the muscle, is seen oftenest in the tongue and face muscles of the extremities. Choreic movements, tics, associated and forced movements, and the other forms of motor disturbance can be recognized by simple observation. Myoidema is a tonic spasm of a part of a muscle near its ten- donous attachment. It is produced by a sharp blow upon the muscle near its tendonous insertion. This causes the muscular fibres to bunch up into a small tumor for several seconds. Its pres- ence indicates rapid muscular wasting from exhausting disease. Idiopath ic muscular spasm is a phenomenon of a similar na- ture. When the belly of a muscle is struck with a dull instru- ment, a welt of contracted muscle appears and lasts several sec- onds. It indicates an exaggerated muscular irritability. The Examination of the Reflexes.—These, as already stated, are of four kinds: (1) the superficial or skin, (2) the deep or tendonous, (3) the visceral, and (4) the muscle reflexes. 1. A skin or superficial reflex is produced by scratching, tick- ling, pinching, or irritating the skin, with hot, cold, or chemical irritants. The result is a contraction of the muscles supplying the parts near the irritation. The skin reflexes which can be or- dinarily brought out are the plantar, cremasteric, epigastric, ab- dominal, erector spinal, interscapular, palmar, and certain cranial reflexes. The plantar reflex is produced by tickling or scratching the soles of the feet. This causes a quick, involuntary jerking up of the foot and leg. The cremasteric reflex is brought out by scratching the inner side of the thigh or the skin over Scarpa's triangle. It causes a drawing up of the testicle on the same side. 30 DISEASES OF THE NERVOUS SYSTEM. The abdominal reflex consists of a contraction of the abdomi- nal muscles, caused by irritating the side of the abdomen. The epigastric reflex consists of a contraction of the upper fibres of the rectus, caused by irritating the skin of the lower part and side of the thorax. The erector-spinrel reflex consists of a contraction of some of the fibres of the erector spimel, caused by irritating the skin along its outer edge. The scapular reflex consists of a contraction of some of the scapular muscles, caused by irritating the skin over them. The palmar reflex is produced by irritating the palms of the hands. The cranial reflexes are the lid reflex, caused by irritations of the conjunctiva or of the retina; the pupillary-skin reflex, which consists of a dilatation of the pupil caused by scratching the skin of the cheek or chin. The levels of the spinal cord through which the impulse travels are indicated in the accompanying table: Table showing the Nerves and Spinal Cord Levels Brought into Play in the Different Superficial Reflexes. Spinal Superficial Nerve. Reflex. 1 Spi Ner 8^ rial ve. Superficial Reflex, 2 9 3 I4 ^ 6 jo o 10 11 12 1' >■ Abdominal 7 Scapular 2 )- Cremasteric 8 3, 1 1. O 3 S 4^ 1 Knee jerk 1 Gluteal > Ankle clonus 4' 1 5 1 6 7. Epigastric $2 3i si 4 5 Plantar DIAGNOSIS AND METHODS OF EXAMINATION. 31 The superficial reflexes that can ordinarily be brought out in healthy persons are the plantar, cremasteric, epigastric, and the cranial reflexes. The palmar reflex is rarely present in healthy people except during sleep, and in children. The superficial re- flexes depend upon the integrity of the reflex spinal arc, and to a less extent upon the degree of cerebral inhibition. When present, they show that the spinal cord at the level through which the impulses travel is healthy. When absent, they do not necessarily indicate much of anything. For they vary in amount in differ- ent persons and at different ages. In cerebral hemiplegia during and for a time after the acute attack, they are generally lessened or absent on the affected side. Later they may be exaggerated. The deep reflexes are sometimes called tendon reflexes. They are brought out by striking a stretched tendon or muscle or even by tapping a bone or striking the muscular fascia. The deep re- flex in these cases is probably a true spinal reflex, though some assert that it is due to the direct effect of the concussion or sud- den stretching upon the muscle itself (Gowers), which is in a condition of slight tonus. Either view involves the integrity of a reflex arc. The deep reflexes are— The patella-tendon reflex or knee jerk. The ankle reflex or ankle clonus. The wrist reflex. The triceps-tendon reflex or el- bow jerk. The jaw reflex or chin jerk. The light (or pupillary) and accommodation (or ciliary) reflexes. The patella reflex or knee jerk consists of a sudden contraction of the quadruceps femoris, vastus internus, and subcrureus caused by striking the patella tendon when the leg hangs loosely at right angles with the thigh. This reflex may also often be pro- duced by striking the lower part of the muscle itself. The ac- tivity of this reflex is increased if, at the same time that the blow is struck, a voluntary contraction of some other muscles is made by the patient. Usually the patient is told to pull on his clasped fingers, or tightly shut the hands. This process is called the re- enforcement of the knee jerk (see Fig. 24). The knee jerk is present practically in all healthy persons ex- cept the aged. Its absence is always of significance. The nerve roots involved are those, in man, of the fourth lumbar pair. The peripheral nerve is the anterior crural. The most essential mus- cle is the vastus internus (Sherrington). Ankle clonus is caused by having the seated patient extend the limb and hold it rather firmly in a semi-fiexed condition. The physician takes the foot by the toe and heel and quickly flexes the foot on the leg. He thus suddenly stretches the calf muscles, and they undergo rhythmical contraction. This phe- nomenon does not occur in healthy people. An ankle-tendon re- 32 DISEASES OF THE NERVOUS SYSTEM. flex, however, is brought out in normal conditions by striking the Achilles tendon when the foot is held slightly flexed by the phy- sician. Fig. 24—Getting the Knee Jerk by Re-enforcement. DIAGNOSIS AND METHODS OF EXAMINATION. 33 The " paradoxical contraction" is a name given to the tonic contraction of the anterior tibial muscles caused by the physi- cian's suddenly flexing the foot on the leg, thus shortening these muscles. This is a rare phenomenon and never found in health. The wrist reflex is brought out by striking the wrist tendons while the forearm is supinated and held limply on the hand of the physician. The triceps reflex or elbow jerk is brought out by striking the triceps tendon while the arm is sup- Fig. 25.—Getting the Elbow Jerk. ported and the forearm allowed to hang down loosely at right angles to the arm. These reflexes occur in normal individuals. The jaw reflex or jaw jerk is brought out by having the patient open the mouth and leave the jaw relaxed. A flat instrument like a paper cutter is then laid on the teeth of the lower jaw, and if this is struck smartly the elevators of the jaw contract. The light reflex is caused by throwing a bright light into the eye, and the ciliary or accommodation reflex by making the pa- tient look at a distant and then at a near object. The pupil 3 34 DISEASES OF THE NERVOUS SYSTEM. normally dilates in the former case and contracts in the latter. When the light reflex is lost while the accommodation reflex re- mains, the condition is called the Argyll-Robertson, pupil. Fig. 26.—Getting Ankle Clonus. The Electrical Conditions in Disturbances of Motility.—These cannot be understood without some description of the methods of using electricity, and hence the technique of electrical exami- nations for purposes of diagnosis will be described under the head of Treatment. 3. Examination of the Disorders of Sensation.—It should be remembered that sensations are of two kinds, general or common and special. A common sensation is one which is referred to the body. A special sensation is one which is referred to the external world, and in particular to the object which causes the stimulus. The pain from a knife cut is referred to the body, and is a common sensation. The coldness felt when a knife blade is laid on the skin is referred to the knife, and is a special sensation. The sensory functions to be examined are: The cutaneous. The muscular, articular, and tendonous. The visual, auditory, olfactory, gustatory, and space senses. Visceral and general bodily sensations. The cutaneous sensations are: (1) The tactile sense, which in- DIAGNOSIS AND METHODS OF EXAMINATION. 35 eludes pressure and contact; (2) the temperature sense, which in- cludes the heat sense and cold sense; (3) the pain sense. The first two are special senses, the last is a general sense.* To test the tactile sense, blindfold the patient and use the sesthesiometer. This is an instrument with two rather blunt points, which can be separated or approximated. A hairpin or two ordinary pins can be used in its stead. Its use depends upon the fact that the power to appreciate the contact of two points on the skin gradually approximated varies with the tactile sensi- bility of the patient. The tongue, finger tips, and lips are the most sensitive points. The back, arms, and thighs the least sen- sitive. The following table shows the average distance at which two points are appreciated as such by an intelligent adult: Tip of tongue, . 1 mm. (^ in.) Tip of toes, cheeks, Tip of fingers, . 2 " Lips, . . . 3 " Dorsal surface of fingers, . . . 6 " Tip of nose, . . 8 " Forearm, . . . 9 " eyelids, . . 12 mm Temple, . 13 " Back of hands, . . 30 " Neck, . . 35 " Forearm, leg, back of foot, . 40 " Back, . 60-80 " Arm and thigh, . . 80 " The figures vary somewhat with the thickness or softness of the skin and with the dulness or keenness of the nervous organi- zation. If the distances are double those given above, it may be considered in most cases abnormal. The tactile sense may also be tested by the writing method (Rumpf). Figures or letters are written upon the skin with a hard-pointed instrument, and the patient asked to tell them. The figures drawn are made larger or smaller in accordance with the decrease or increase of sensibility. The following table shows the different sizes as appreciated on the normal skin: Finger tips, 0.5 cm. (^ in.) high Palm,........1 Neck,........1 Cheeks,.......1 Forehead,.......1 Arm, forearm, and back of hand, . 1.5 to 2.5 Scapula.......1.5 to 2.5 Calf and sole,......3 (fin.) (| to|in.) " (H in.) " * Psychologists deny the independence of the pain sense and assert that it is only a quality or modification of other senses. 36 DISEASES OF THE NERVOUS SYSTEM. The sense of contact which is a form of tactile sense is tested by drawing ones finger or a bit of cotton lightly over the skin. The sense of locality or power to localize a point on the skin that has been touched varies with the tactile sense and with the muscular sense. It is tested by placing the finger lightly on a given spot and telling the patient with closed eyes to place his finger on the part touched. He should come with- in 5 cm. of it. In slight degrees of anaes- thesia dependent upon disease of the sensori- motor areas of the cortex of the brain, this is an important test. Further tests may be made by moving points along the skin and asking the patient to indicate the direction of the motion; or by laying various shaped objects on the skin and asking the patient to tell their shape or position. Still another method is recommended by Oppenheim. It consists in testing at the same time with the aesthesiometer symmetrically situated parts of the skin on the two sides of the body. To test the pressure sense, use, if desired, the bar aesthesiometer. A more convenient way is to have the patient rest the hands on a table and then try and determine the weight of different objects. The lightest weight that can be appreciated on the hands or face is one of about 0.02 gram (gr. |). Differences of light weights of 1 and 5 grams and of 25 and 30 grams are about all that can be ordinarily appreciated by the skin. Much smaller differences, of 0.5 to 2 grams, can be detected if great care is used. Weighted rubber balls may be used in the foregoing test. I prefer to use differently weighted metal bodies, held by a wire. Pressure sense is acute on the forearm and abdomen, where locality sense is feeble; also on the brow, temples, and back of the hand. Most of the above tests are not ordinarily needed. With two pins, using the heads, the presence and de- gree of anaesthesia can be detected and approximately measured. The temperature sense is tested by test-tubes filled with hot and cold water, or by using hot and cold spoons, or roughly by breathing and then blowing on the part. A thermo-aesthesiome- ter may be used. This has a round, flat surface 1 cm. in diame- Fig. 27.— Combination JSsthesiometer. DIAGNOSIS AND METHODS OF EXAMINATION 3? ter, and contains in its terminals thermometres by which the de- gree and differences in temperature may be noted (Fig. 27;. A small heated or chilled surface is appreciated much less easily than a large one. The indifferent range where objects are felt to be neither warm nor cold is from 27° to 30° C. (80.6° to 86° F.). Fine differences (0.2° to 1.5" C.) are appreciated above the in- different range. Lower down in the scale, differences from 1° to 1.3° C. (2° to iT F.) are appreciable. It may be considered a mor- bid symptom if temperatures of 60° to 65° F. are not felt as cold, or temperatures of 8G° to 95° F. are not felt as warm; also if be- tween the ranges of 1° C. (32" F.) and 40° C. (104° F.) differences of 2' C. are not appreciated. A painful degree of sensitiveness to heat or cold sometimes exists. These conditions are called hyper-thermalgesia and hyper- cyalgesia (Skinner, Starr). When the heat or cold is intense, a sensation of pain is felt. Cold-pain is produced more easily in some places, such as the elbow, than others, as, for example, the finger tips. Cold-pain is produced by temperatures of from +•2.8 C. to —11.4C C. Heat-pain is produced by temperatures of from 36.3° C. to 52.6° C. The pain sense is tested by pricking the skin with needles or the sharp points of an aesthesiometer. The faradic battery with metal points or a wire brush may also be used. Instruments for pinching the skin and measuring the sensibility by the strength of the pinch have been devised. The power of localizing pain is lessened in proportion to the analgesia. The muscular sensibility, i.e., the general or pain sensation of muscles, is tested by passing the faradic current through the part. Pain and temperature sense are usually affected together. Delayed Sensation.—The time taken for a sensation to be felt and produce a voluntary response is, for— A touch on the hand, about . . .0.12 second " " foot, " . . .0.17 " Hearing,.......0.13 Sight, ........0.16 " Taste, ........0.15 " The tactile sense, as well as the other special and the general sensations, may show a delay in conduction. The tactile sense especially should be tested on this point. The delay may amount to several seconds. Double Sensations or Polycesthesia.—When the touch of one point is felt as two or more, the symptom is known as polyaes- thesia. Referred sensations and allochiria are described under Symp- tomatology. 38 DISEASES OF THE NERVOUS SYSTEM. Tests for the Condition of the Special Sense of Muscles, Joints, and Tendons, i.e., for Ataxia.—Anaesthesia of the special sen- sory nerves of the muscles, joints, and tendons causes ataxia and inco-ordination. Muscle anaesthesia causes chiefly a loss of weight sense or loss of power to determine weights. It is tested by the use of weights suspended by a string so as to exclude pressure sense; also by causing the patient to squeeze a dynamometer up to a certain fixed number. In articular and tendonous anaesthesia there is loss of posture sense. It is tested by the physician's moving the patients limbs and having the blindfolded patient tell in what direction the movement is made. Or he is told to follow with one limb the movements which the examiner makes with the other. Muscular, articular, and tendonous an- aesthesia usually exist together; there is then a combined ataxia. Combined ataxia shows itself in standing and in locomotion and other voluntary movements. Thus we have a static ataxia and locomotor or motor ataxia. Static ataxia or inability to stand (or sit) without swaying or irregular move- Fig. Fig. 28.—Ataxiagraph. No. 1. 29.—Ataxiagrams. No. 1, Made with eyes open; No. 2, made with eyes closed. ments is tested by making the patient stand with the eyes closed and the heels and toes close together. Normally, the head moves not over an inch in this position, and the patient holds the head and body more rigid with the eyes closed than with them opened. In ataxic states the reverse is true, and decided swaying or even complete loss of equilibrium occurs with the eyes closed, or even with the eyes open, and the base narrowed by putting the feet together. This phenomenon is called the " Brauch-Romberg symptom." In static ataxia, mus- cular and articular sensations are both involved. The degree of this can be accurately measured by the ataxiagraph. With the DIAGNOSIS AND METHODS OF EXAMINATION. 39 eyes open a healthy person standing erect with feet together tends to sway forward. The antero-posterior excursion of the head averages 3.7 cm. (1-J- in.), the maximum being 9 cm.(3i in.). The lateral excursion averages 1.9 cm. (f in.), maximum being 5.4 cm. With the eyes closed the antero-lateral excursion averages 3.4 cm. (li in.), maximum 3£ in.; the lateral excursion 1.9 cm. (If in.), maximum 0.8 cm. (2f in.). In other words, the person stands a little steadier with the eyes closed, the average excursion being 1£ X f in. with eyes open, 1£ X i in. with eyes closed (Bullard and Brackett). Ataxia of motion is tested by the gait. The patient can- not walk a straight line and cannot walk without watching the floor with the eyes. The arms cannot be moved in a co-ordi- nate way. With the eyes closed, the patient cannot place the fin- ger on the tip of the nose, or lobe of the ear, or any indicated spot. Ataxia of motion involves especially the articular and ten- donous sensations, but not these exclusively. It may be measured by noting how close the patient keeps upon a given line ten feet long in walking; how near he can place the finger upon the centre of a board marked like a target. The patient is placed ten feet away, and made to walk directly at it and place the finger in the centre. To sum up the foregoing, we have: Due to Tested by Ataxia Articular and tendonous anaesthesia. Combined forms, e.g., static ataxia... Weights, etc. Position of limbs. Co-ordinate move-ments. Station and gait. There are, besides this, certain forms of inco-ordination which are allied to tremor, and are disorders of the sensori-motor corti- cal areas or efferent nerve tracts. Nor is it absolutely established that in the above-described forms of ataxia there is not an in- volvement of the efferent nerve mechanism. Vision.—The special modes of examination are given under the head of Diseases of the Optic Nerve and Ocular Muscles. The special points which the neurologist must investigate are visual acuity, astigmatism, errors of refraction, limitation of the visual field, exophthalmia, retraction of the bulb, color-blindness, the state of the pupil and its reflexes. Hearing.—The special methods of examination are given else- where. The points chiefly to be investigated are acuity, range, bone conduction, aerial conduction, electrical reactions. Sense of Smell.—See p. 107. Sense of Taste.—See p. 146. CHAPTER IV. THE CAUSES AND THE PATHOLOGY OF NERVOUS DISEASES. General Etiology. The subject of the causes of nervous diseases must be studied from two points of view. First, we must learn the predisposing and exciting causes of nervous diseases in general. Second, we must learn the causes of the particular pathological change which constitutes the disease. I. The causes predisposing to nervous disease relate to age, sex, condition, heredity, race, climate, civilization, occupation, habits, diatheses, infections, and poisons. Age and Developmental Influences.—In early age, paralyses and convulsive troubles are more frequent, while sensory neuroses are rare. In adolescence, many severe constitutional neuroses and neuropathic tendencies develop, but organic disease is rare. In adult life, the inflammatory and degenerative troubles are at their height. In old age, those disorders which are dependent on dis- ease of the blood-vessels, such as apoplexies and softening, appear. The special nervous defects and disorders more especially as- sociated with early developmental influences are these (Clouston): 1. Of the embryonic stage: Acephaly, genetous idiocy. 2. Of the period of most rapid brain growth—birth to seven years: Convulsions, pavor nocturnus, tubercular meningitis, men- ingeal hemorrhage and encephalitis, epilepsy, idiocy, infantile paralysis, neurotic fever, febrile delirium. 3. Of the period of co-ordination of motion and emotion—seven to thirteen: Chorea, epilepsy, asthma, migraine, myopathies, hereditary degenerations of the cord. 4. Puberty and adolescence—thirteen to twenty-five: Epilepsy, neurasthenia, hysteria, migraine, sexual perversions, paranoiac tendencies, hereditary myopathies and myelopathies, insanities. Sex.—Sensory and functional disorders are more frequent in women; motor and organic disorders more frequent in men. Condition and Occupation.—No general facts will be laid down here. Celibates, however, it may be said, suffer more from ner- vous disorders than married people. It will be shown later that certain occupations entail special nervous disorders, and that in-door life promotes functional nervous diseases. CAUSES AND PATHOLOGY. 41 Habits.—Excessive indulgence in alcohol is a most prolific cause of nervous disease, chiefly by the action of this substance on the blood-vessels and the stomach. Excesses in eating, in tea- drinking, irregularity in sleeping, and bad habits of working pre- dispose to nervous disease. Sexual excesses are usually the result rather than the cause of nervous disorders. Heredity.—There are few nervous diseases which are, strictly speaking, inherited. But an over-irritable, unstable, inadequately developed, and badly nourished nervous system—one with a ten- dency to disease—may be inherited. This is known as the neuro- pathic constitution. Excessive intellectual labor and mental strain during the time when children are being propagated tends to produce a neuropathic taint in the descendants. When both parents are themselves of a highly nervous tempera- ment, their children are apt to be more so. The existence of one of the severe forms of constitutional nervous disease, like epilepsy or hysteria, in one parent is likely to produce neuro- pathic children. Intermarriage does not cause neuroses, un- less father and mother are of closely alike temperaments. Excessive alcoholic indulgence in one or both parents, syph- ilis, injuries or fright to the mother during pregnancy, may result in neurotic children. The mother transmits neuroses and neuro- tic tendencies more than the father. A certain form of nervous disease may not be transmitted in the direct line, but will be found in different branches of the same family, as, for example, in uncle, nephew, and cousin. This is then called a "familydis- ease." Climate and Civilization.—Nervous diseases are most frequent in temperate climates, and in those which are dry and elevated. They increase with the progress of civilization and the greater strain, complexity, and luxury of modern social life. Those organic nervous diseases which are largely dependent on vascu- lar disease are frequent in the poorer classes among whom syphilis, alcoholism, and bad feeding prevail. Functional and de- generative disorders are frequent in the higher classes. Nervous diseases, if we except those of the degenerative type, prevail more in urban populations. Diatheses.—The rheumatic and gouty diatheses predispose to nervous troubles, more especially those which are of a peripheral and functional nature. Lithaemia, a condition in which the pro- ducts of tissue waste are not properly oxidized and eliminated, has a similar influence. Trauma and Shock.—Hemorrhages and trauma may be a di- rect cause or may predispose to nervous disease. Trauma and shock may cause functional diseases such as neurasthenia, or may lead to the development of insanity or indirectly to degenerative 42 DISEASES OF THE NERVOUS SYSTEM. organic disease. Mental shock, and especially a fright, oftener than severe bodily injury, leads to the development of functional neuroses. Hemorrhages, exhaustion from excessive work, and anxiety are potent causes. Infections.—In comparison with their frequency, the infective fevers are not great factors in producing nervous disease, but practically they often play an important part. Scarlet fever is the most dangerous disorder in this respect. Measles perhaps ranks next, then follow diphtheria, typhoid fever, and pertussis. Among chronic infections syphilis ranks first; malaria, the pel- lagra, and beriberi are also to be mentioned. Poisons.—Alcohol, tea, coffee, and lead, mercury, copper, arse- nic, are to be placed among the frequent causes of nervous disease. Reflex Causes.—Among other causes are local disease of vis- cera, such as renal, uterine, and ovarian diseases, dyspeptic and liver disorders, visual and auditory troubles. II. The causes of particular pathological types of disease. Inflammatory diseases of the nervous system, as of other sys- tems, are caused almost always by microbie infection. This is brought about directly by injury and exposure to external agen- cies or indirectly through the blood. Inflammatory disorders oc- cur oftenest in early and middle life, and in men oftener than in women. Degenerative diseases are observed oftener in middle and later life, and result from excessive nervous strain, syphilis, ex- posures, poverty, chemical poisons, alcohol. Heredity is also an important factor. Diseases of the blood-vessels occur in middle and later life. Bright's disease, the gouty diathesis, alcohol, syphilis, over-feed- ing, and chemical poisons such as lead are among the causes. Functioned spasmodic diseases usually develop early in life when general in character, like epilepsy and chorea; but later in adult life if local, like writer's cramp and wry-neck. They often follow infective fevers. Hereditary influence is here important. Functional sensory disorders rarely begin before the age of seven to ten, and are more common in women and in temperate climates. A certain class of them, however, like facial neuralgia, develop with the degenerative period of life. General nutritional disorders, like neurasthenia, are more fre- quent in youth and middle life, in active and new civilizations, in temperate climates, especially those which are dry and cool or elevated. Diseases of the peripheral nerves are caused by injuries, and by poisons like alcohol or infections like that of beriberi or by the auto-toxaemia of gout, rheumatism, and diabetes. They occur chiefly in early and middle life. CAUSES AND PATHOLOGY. 43 General Pathology. The nervous system is composed of nerve cells, nerve fibres, connective tissue, the neuroglia, blood-vessels, and lymphatics. Its disorders involve one or more of the above tissues. The following is a list of the forms of disease which affect the nervous system: 1. Malformations, agenesis. 2. Hyperaemia, anaemia, haemorrhage, oedema, and arterial and venous diseases. 3. Inflammations. 4. Degeneration and atrophy, softening, sclerosis, gliosis. 5. Tuberculosis and syphilis. 6. Tumors and parasites. 7. Nutritive and functional disorders. Inflammation.—The pathology of most of the above types of disease will be given elsewhere, and does not call for discussion here. It is, however, of the utmost importance that the student have a clear understanding of the nature of inflammation and degeneration as they affect the nervous tissue. Inflammation is a morbid process which has to deal primarily with blood-vessels, lymphatics, and connective tissue. Inflammation, teleologically, is the reaction of the organism to an irritant. Wherever there is inflammation, there is irritation. The irritant in inflammation is practically always the product of microbic action or of some irritat- ing product of tissue change. Without some microbic or tissue irritant there can be no inflammation. We make this exception only: that certain chemical substances, such as alcohol, arsenic, and lead, may at times excite a form of inflammation which is, however, probably, primarily a degenerative or destructive pro- cess. Inflammation, when the irritant is removed, tends to sub- side. It is a regressive, not a progressive, process. Bearing these facts in mind, it will be found that inflammations of the nervous tissues never or very rarely occur without the presence of some microbe or some destructive process whose irritant products excite inflammatory reaction. Inflammations may be divided into the (1) exudative and the (2) productive forms (Delafleld). The exudative inflammations maybe simple, without necrosis, with necrosis; purulent; pur- ulent and necrotic. 1. Simple exudative inflammation is accompanied with con- gestion stasis, emigration of white corpuscles, and perhaps diaped- esis of red cells, transudation of blood serum, and formation of fibrin, the total result being an exudate containing white blood cells, now called pus cells, and fibrin in varying proportions. 44 DISEASES OF THE NERVOUS SYSTEM. There is, in some cases, no destruction of tissue; and on subsi- dence of the inflammation the tissue returns to its normal condi- tion. In other cases the inflammatory action destroys some of the nerve tissue. In purulent inflammation there is great accumulation of pus cells and less relatively of fibrin. If the tissue is destroyed, it is a,purulent and necrotic inflam- mation. In some exudative inflammations there is increase of connective tissue from the start, and the process continues till the inflam- mation subsides. Most exudative inflammations are acute or subacute. Inflammatory oedema is a form of exudative inflam- mation. 2. Productive or proliferative inflammation is a process in which there is little congestion and exudation, while new con- nective tissue is slowly formed. Productive inflammation is usu- ally chronic; tubercular and syphilitic processes are varieties of productive inflammation. The microbes which are known to produce inflammations of nervous tissues are: the ordinary pyogenic streptococcus, the diplococcus intra-cellularis, the diplococcus pneumoniae, a bacillus like that of typhoid fever. The bacillus tuberculosis sometimes causes a purulent inflammation. The supposed rabies bacillus, the bacillus of leprosy, the anthrax bacillus, and the micro-organ- ism of infectious multiple neuritis may be added to the list. The principle poisons which may cause chronic productive in flammations are alcohol, lead, and arsenic. Certain irritating auto-toxaemic agents, such as occur in gout, rheumatism, diabetes, and states of inanition, appear able at times to cause productive inflammations. Classification of Inflammations. Form. Cause. Example. Simple exudative, with Microbic or toxic. Meningitis. or without necrosis. Poliomyelitis. Purulent, with or with- Microbic......... Meningitis and out necrosis. encephalitis. Acute purulent myelitis. Productive or prolifera- Microbic or toxic. Chronic menin- tive. gitis. Leprous neuritis. Degenerations and Scleroses.—By degeneration is meant a gradual death of the nerve cells and fibres, or in other words of the parenchyma of the organ. The cells swell up, become CAUSES AND PATHOLOGY. 45 granular and fatty, and then either break up and become ab- sorbed or enter into a condition of a dead coagulum (coagulation- necrosis). Degenerations may be acute or chronic, primary or secondary. Acute degeneration causes a condition known as softening or necrosis. It is due to cutting off of vascular supply, direct injury, and to necrotic and inflammatory poisons. Acute degeneration may be followed by a reparative process which is called a repar- ative or reactive inflammation, and which ends perhaps in pro- ducing a cicatrix or sclerosis. Chronic degeneration is accompanied and followed by a prolif- erative process which results in the production of connective tis- sue and sclerosis. Sclei'osis is a process of connective-tissue proliferation, as a result of which the normal or injured parenchyma is supplanted by fibrous tissue. The word sclerosis is usually employed in de- scribing degenerative diseases, though it indicates the result rather than the primary nature of the process. A primary degeneration is one in which the process is due to inherent defect in nutrition or to some poison acting directly on the cell or fibre. A secondary degeneration is one that is due to a cutting off of nerve fibre or cell from its trophic centre, or to an injury or shut- ting off of its vascular supply. Ordinarily, in speaking of second- ary degenerations one refers to those due to. the first-mentioned class. Practically, primary and secondary degenerations often occur in the same disease. Degenerations. Forms. Examples. f C Myelomalacia, Pr-im*™ J Progressive muscular Frimarj.............) atrophy, [_ Locomotor ataxia. {Chronic myelitis, Secondary lateral sclerosis. Degenerations are caused by certain poisons, such as arsenic, phosphorus, lead, and the poisons of infectious disease. Degen- erations also result from obliterating arteritis such as occurs in old age or from humoral poisons. Degenerations sometimes are due apparently to an inherent defect in the cell nutrition—a pre- mature death of it; also to causes yet unknown. The question as to whether certain scleroses are forms of productive inflamma- tion or of chronic degeneration is one still undecided. It is probable, however, that many of the so-called chronic inflam- mations of the nervous system are really degenerative processes, and that the primary trouble is in the parenchyma, and not in the connective tissue. Acute and Chronic < 46 DISEASES OF THE NERVOUS SYSTEM. Gliosis.—It is contended by some French pathologists (Chaslin, D£jerine) that some of the chronic degenerative diseases are the result of a proliferation of neuroglia, not of connective tissue. This process is called gliosis. Its existence is not yet satisfactorily established. Nutritive and Functional Disorders.—A fundamental pecu- liarity of nervous tissue of man must here be noted. Nerve cells once destroyed never develop again. The same is true, though not so absolutely, for the nerve fibres running in the central nervous system. Peripheral nerves may grow again when cut or destroyed. They always groAV from their trophic centre. Nerve tissue in brain, cord, or periphery can never be sutured so that it will functionally unite by direct union. There are a few apparent ex- ceptions. A further peculiarity of nervous tissue is that it is depend- ent for its integrity upon two things, blood supply and trophic influences. The nerve cell is solely dependent on a proper sup- ply of blood, and dies when this is withdrawn. But the nerve fibre is more dependent on the trophic influence of the cell to which it is connected and of which it is a prolongation. It dies when cut off from its cell, but it can get along for a time with but little direct blood supply. Underlying nutritive and functional disorders there exist: A congenital inadequacy of the nervous system to do its work. Dis- turbances in blood supply. Poisonous conditions of the body, due to substances generated within or introduced from without. Reflex irritants. Exhaustive conditions from overwork. CHAPTER V. HYGIENE, PROPHYLAXIS, TREATMENT. In the treatment of nervous disease, the physician attempts-v. 1. To relieve distressing symptoms. 2. To secure radical cure. 3. To prevent return. This calls for various measures which may be classed under the heads of general hygiene, diet, ex- ercise, climate, hydrotherapy, massage in various forms, electri- city, drugs, external applications, and surgical intervention. General Hygiene.—To secure and keep steady nerves, and to prevent the supervention of organic nervous disease, would require a considerable reconstruction of the present social system. I can only give some hints as to the kind of advice physicians should give to help along the desired end. Thus two people of very nervous temperament should not marry. Children should be brought up to eat slowly a mixed diet, to sleep early and long, to play in the open air, to learn self-control and obedience. Their parents should keep from them all infective fevers. Adults need to keep in mind but two words—moderation, exer- cise. With these they need not fear the use of alcohol, tobacco, tea, coffee, or even occasional irregularities in sleeping and eating. Physical and mental shocks, infective fevers, poisons, and syphilis are prolific promoters of nervous disease. Diet.—For brain-workers in general, the best diet is a nitroge- nous one, but it should contain some fat. Water should be drunk plentifully except by the obese, while the total amount of food should be less than when severe muscular exercise is taken. The best foods are meats, especially fowl; fish, eggs, milk, buttermilk, cocoa, green vegetables, and stale bread with plenty of butter. If there is a tendency to constipation, farinaceous foods and green vegetables may be made the prominent articles of diet in one of the daily meals, and stewed fruit and some alkaline water added. The drinks of brain-workers should be mainly plain and alkaline waters. Alcohol can be taken in moderation by some brain-workers without harmful results. It may even secure an increased capacity for work. In persons of a sensitive and irritable nervous system, those who are classed popularly as " nervous," neurasthenic, or hysteri- cal, the above rules apply as to a nitrogenous diet, plus as much 4S DISEASES OF THE NERVOUS SYSTEM. fat as can be digested. There is a class of nervous persons who of themselves find that they cannot take anything sweet without producing headaches, rheumatic pains, and dyspeptic symptoms. These persons should live on meats, fish with butter, oysters, cream and milk, cod-liver oil, and fat pork. Beef tea with the white of an egg or some peptonoids forms a very nutritious dish. It has been the canon of medicine for many years that animal food must be the soul of the neurotic's diet. Most nervous persons find in addition that green vegetables like spinach agree very well with them. Stale bread can be taken twice a day freely, plenty of butter being used upon it. The dietetic breads from which the starch has been removed are sometimes useful, but are, as a rule, unpalatable, and soon cause disgust. When a rigid diet is to be laid down, there is no better list for nervous invalids than the following: fowl; beef; mutton and lamb; fish, boiled or broiled; oysters; milk; butter; eggs, raw or soft-boiled; cocoa; graham bread and gluten bread; spinach; Brussels sprouts; string beans; stewed fruits slightly alkalinized. Nervous patients, especially hysterical patients, should not use alcohol at all. Tea and coffee can be taken in very small amount. The various alkaline mineral waters may be used temperately with impunity, but none of them have much specific effect in re- lieving nervousness or curing the nervous temperament. Water should be drunk between or before meals and a moder- ate amount at meals. At least three pints of liquid should be taken daily. American neurotics do not drink water enough. They have half-desiccated nerves, and desiccation increases ner- vous irritability. An exclusive milk diet is indicated in some forms of hysteria, hypochondriasis, and neurasthenia accom- panied with dyspepsia. Karell's method is to give four to eight ounces of warm skim-milk at 8 a.m., 12 m., 4 p.m., and 8 p.m. The amount is gradually increased. Exercise.—As a prophylactic against nervous disorders, the value of exercise, if taken out of doors, can hardly be overesti ■ mated. Brain-workers are better for moderate exercise, but they do not need much; and after twenty-five, severe intellectual work can rarely be done by persons in athletic training. Before the age of twenty-five, when the system is exuberant with vital- ity, hard study and hard physical exercise can be pursued success- fully together by some. Persons of a neuropathic constitution are benefited by regular exercise only when it interests the mind. In-door gymnasium exercise with the ordinary apparatus does no good except through the bath that follows it. In many forms of chronic organic nervous disease exercise is to be prohibited. These will be discussed later. The best forms of exercise are those (1) which take one out of HYGIENE, PROPHYLAXIS, TREATMENT. 49 doors, (2) interest the mind, and (3) call into play the muscles of the chest and arm. Walking fulfils but two and often only one of these conditions. Calisthenics are useful when they interest and are vigorously done. Horse-back riding and bicycling fulfil best the conditions required for a good form of exercise. And bi- cycling is the cheaper, more practicable, and generally better liked of the two. Dr. Graeme M. Hammond has called attention to the special value of cycling in nervous diseases. Lawn-tennis, bad- minton, golf, are all exercises which can be taken up by both sexes and at nearly all ages. Hydrotherapy.—Hydrotherapy is the science of applying water in the treatment of disease. The modes by which it is used in neurological therapeutics are: I. General hydrotherapy: 1. Tonic hydrotherapy. 2. Sedative hydrotherapy. 3. Indifferent baths for mechanical purposes. II. Local hydrotherapy. 1. Tonic Hydrotherapy.—For purposes of stimulating nutri- tion and increasing vasomotor tone we employ cold plunges, the rain bath or shower, the jet, cold sponging, cold sitz-baths, cold sheets, local applications of ice or cold compresses, or cold rub- bing, ice-bags, brine baths, brief cold packs, and sea bathing. The Cold Plunge.—The patient fills the bath-tub with water at from 60° to 70° F. He then slips in, and at once jumps out and rubs himself vigorously until reaction occurs. The Rain Bath, Jet or Needle Bath.—The patient stands in a tub with the feet preferably in warm water, and allows the cold water to fall on the back and rest of the body for one or two minutes. Or a solid jet of cool water is thrown with force upon the back of the patient, by an attendant who stands ten or twelve feet away. The cold jet may be alternated with warm. Cold sitz-baths are taken at a temperature of 70° to 80° F. from ten to thirty minutes. The cold sheet or drip sheet is used by wring- ing a cotton sheet out in cold water and wrapping it suddenly about the standing patient, who is then vigorously rubbed. Ice-bags are worn upon the spine for one or two hours once or twice, or oftener, daily; or they may be applied for one or two hours at night. Most of these measures have a general stimu- lating and tonic effect. The half-bath and wash-off consists of a tub partly filled with water at a temperature of 65° to 70° F. The water only half covers the reclining body. While lying in it, the patient is vigorously rubbed. A cold cloth may be laid on the head. After five to twenty minutes, affusions of colder water are poured over the shoulders. The bath may be made as warm as 80° at first. 4 50 DISEASES OF THE NERVOUS SYSTEM. Brine baths contain about two per cent of salt, this being about the amount in sea-water—twenty-five pounds to thirty gallons of water. They are given at a temperature of 100 F. for twenty to thirty minutes daily, or cool baths at a temperature of 70° F. may be given for five to ten minutes, the patient exercising meanwhile. Physiology.—Cold applications produce a local contraction of blood-vessels, followed by dilatation. There is usually increased tissue metamorphosis, increased secretion of urine, increased ab- sorption of oxygen, and increased excretion of carbonic acid. In non-febrile persons, cold applications abstract some heat, but they also stimulate the heat-producing centres, so that the total effect is to increase the heat of the body. Only very cold baths lessen heat production as well as excretion of C02. Cold baths at first accelerate and then tend to retard pulse and respiration. Cutaneous sensibility is at first increased. After a cold bath there is a sense of exhilaration and increased muscular power, provided the bath be not too cold or too long continued. The duration necessary to produce a reaction varies with different people, and some weak and sensitive patients never can be made to react. Cold baths systematically taken furnish a kind of vasomotor gymnastics. The neuro-mechanism controlling the blood-vessels becomes more supple, and the tendency to local congestion of the viscera and mucous membranes is prevented. The shower and jet furnish the most valuable means of securing tonic effects in nervous disorders. These are not used with cold water alone. It is often better to apply at first a warm stream at 95° or 105° F., and then gradually lower it, or to apply the hot and cold jets alternately. In this way tonic effects can be ob- tained even with very feeble persons. 2. Sedative Hydrotherapy.—Th.e sedative baths are the luke- warm bath, the wet pack, Turkish and Russian baths, the hot sitz-bath, pedal baths, compresses and fomentations, and hot- water bags. The lukewarm bath is given at a temperature of 95° to 98° F. for ten minutes to half an hour daily. If a slight tonic effect is desired also, the patient should receive an affusion afterward, i.e., basins of cool water at 60° to 70 F. should be poured over the shoulders. The addition of salt or of pine-needle extract is often useful. The Wet Pack.—A large, thick blanket is spread upon the bed, and upon this is laid a linen or cotton sheet wrung out in cold water, 40° to 60° F. The nude patient lies on this, and the sheet is then smoothly wrapped about him, the head and feet not being included. The sheet is carried between the legs and made to lie evenly in contact with the body. Then the blankets are HYGIENE, PROPHYLAXIS, TREATMENT. 51 folded over him, and other blankets may be piled upon this. Sometimes it is well to place hot-water bottles at the feet and a cool compress on the head. The patient lies in this pack for thirty to forty-five minutes and is then rubbed off. A cool affu- sion may be given first. In delicate patients it is well at first to simply wrap the patient in warm flannels until free perspiration results. Then give a cold affusion or wash-off and rubbing. In Turkish baths the patient is exposed to a temperature at first of 130° or 140° F. for fifteen to thirty minutes, and then to one of 160° F. or 200° F. for a shorter time. This is followed by massage and a cold affusion or plunge or shower. The effects of these baths are somewhat tonic if not too prolonged. The pa- tient should never go into the hotter rooms until he perspires, and he should select bath-rooms that are well ventilated. Rus- sian baths have similar effects, but the bodily temperature is raised to a higher degree in them than in Turkish, owing to the lessened amount of perspiration due to the presence of steam. Hot Sitz-Baths—The patient sits in water at a temperature of 100° to 125' F. for twenty or thirty minutes. Sometimes mustard is added. Hot compresses consist of layers of flannels wrung out in hot water and covered with dry flannels and rubber cloth. They are used to relieve local pains and inflammations. They may be applied over the abdomen for insomnia. Hot sprays and douches are used for similar pu rposes as fomentations. The hot spinal bag is applied at a temperature not above 120° F. Physiology.—Warm baths, if applied in the form of the moist pack, followed by sponging with tepid water, lessen tem- perature by increasing heat radiation and conduction. If applied so as to prevent radiation, the bodily heat is raised. Warm baths increase the circulation of the skin, lessen cutaneous sensibility, withdraw blood from the central organs, increase the exhala- tion of C02, but lessen the respiratory activity on the whole. Nitrogenous metabolism is increased from two to three per cent, and more urea is excreted. Pulse and respiration are increased. Nervous excitement is lessened, and the general effect is to cause sedation and a feeling of languor. The wet pack is a most use- ful sedative in neurasthenia and insomnia, and may take the place of medicinal sedatives, like the bromides. It should be given three or four times weekly, or for a short time daily. The luke- warm bath ranks next in its sedative efficacy. It is believed that applications of water to the feet and abdomen especially affect the intra-cranial circulation; given to the thighs and wrists, the pulmonary circulation; cold causing congestion, and heat anae- mia, of the distant parts. Cold to the spine is believed to cause at first constriction, and later dilatation, of the thoracic, abdomi- nal, and pelvic viscera; heat has the opposite effect. Hence cold 52 DISEASES OF THE NERVOUS SYSTEM. applications are used to relieve cold feet and anaemic conditions of the viscera. The fact must be borne in mind that cold baths and frequent bathing of any kind debilitate some few persons. Massage.—The term massage may be made to include all the manipulations of the body for the purpose of curing disease. The different methods of applying it as classified by Jacoby are: Effleurage or gentle stroking. The maximum force to be ap- plied here should not exceed the weight of the hand. Massage a friction or rubbing. Energetic strokes with one hand and strong circular or to-and-fro friction with the other. Petrissage or kneading. Tapotement or percussion with the fingers, hands, or instruments. Functional movements, passive, active, and com- bined with movements made by the operator. The physician may be reminded that a male operator is a mas- seur, a female a masseuse, and that the patient is massed. Massage accelerates the lymph and venous currents, and thus promotes absorption. It increases the rapidity and force of the heart-beat, except abdominal massage, which slows the heart and helps to relieve local congestions and inflammatory deposits. It presses and stretches the terminal nerve filaments, increases the irritability of motor nerves and the contractility of muscles. It may either increase or lessen the irritability of sensory nerves according as it is applied. Of the various forms of massage, ta- potement is the most frequently useful, and is the kind almost exclusively used in neuralgias. It is applied not only with the fingers and hand, but also by the aid of rubber tubes known as muscle beaters, rubber balls with rattan or whalebone handles, percussion hammers and various percuteurs, such as Granville's and Jacoby's. Massage is of considerable value in certain forms of atonic neurasthenia and hysteria, associated with anaemia, dyspepsia, and feeble circulation, in hemiplegia, in the paralyses of periph- eral origin, in functional spasm, especially in some forms of writer's cramp and allied neuroses, in cerebral hyperaemia, in- somnia, constipation, and in headache, and some neuralgias, especially those about the head, neck, and arm. It is contra- indicated in heart disease, arteritis, or where there is danger of dislodging a thrombus. Climate in Nervous Diseases.—The factors which make up a special kind of climate are: 1. Purity of air; 2, temperature; 3, humidity; 4, sunlight; 5, rarefaction of the air; 6, ozone; 7, wind; 8, electricity; 9, soil; 10, trees; 11, social conditions. Regarding these points, some facts are very well settled. The air in the country is purer than in cities. The air on the sea and HYGIENE, PROPHYLAXIS, TREATMENT. 53 at high levels is purer than in other localities. The temperature above the sea-level diminishes about 1° F. for every 300 to 350 feet, and is less the dryer the air. Alterations in temperature are less near the sea and less in the southern hemisphere. The higher the elevation and the colder the air, the less moisture does it con- tain. About the factors of ozone and electricity in the air little definite is known. Climates are classified by Weber into marine, low level inland, and high level inland. These all have great variations in quality, depending upon their temperature, moisture, etc. As a general rule, warm marine climates and sea voyages are best for neuras- thenic invalids of the irritable type. On the other hand, in atonic and anaemic conditions high inland climates are better, at least for a time. Such climates should not be too dry or windy. In organic degenerative diseases of the nervous system, marine climates and low levels are better. Germany, the Riviera, the Bermudas, the West Indies, Florida, and other Southern States are favorite places for sending neuras- thenic Americans. Camp life in the Adirondacks or other forests is also found most useful. Electricity in Nervous Diseases. Physical.—Electricity is assumed to be a material like a fluid, perhaps a condition of the ether itself. It is not a force any more than water is a force, but it produces force by its move- ments. Electrical phenomena are the result of the strain or stress put upon the electrical fluid. Physicists assume that the electrical fluid exists in two conditions, positive and negative, and we speak of positive electricity and negative electricity ac- cordingly. Under ordinary conditions these fluids are united and in equilibrium; but by certain agencies, such as friction, heat, chemism, etc., they can be separated. We assume that the condition of electrical equilibrium is that of zero, and that the earth's electricity is at zero. Positive electricity is raised above, negative electricity pulled below, this zero point. Electrical phenomena result from attempts of the fluids to become equal- ized or stable again at the zero point, just as the phenomena of heat result from differences of temperature and those of gravity from differences of pressure. The distance to which the electri- cal fluids are separated from the zero point is spoken of as the difference in " potential.'" This potential corresponds to the term " degrees" in measuring heat. Now, the greater the difference in potential, the greater the effort of the fluids to return to zero. High and low potentials correspond to high or low intensity of heat. Tension is the result of the widely separated fluids striving 54 DISEASES OF THE NERVOUS SYSTEM. to return to the zero point. It is the same thing as difference of potential, and the term may as well be dropped. When the two fluids, at different potentials, attempt to become equalized, they pass along certain paths and form electrical currents. Electri- city will pass along any substance, but some substances conduct it more easily than others, and these are known as conductors. The relative value of different conductors is shown in the follow- ing table: 1. The metals; 2, charcoal, 3, plumbago; 4, dilute acids; 5, sa- line solutions: G, pure water; 7, living animals; 8, flame. Of the metals, silver and copper are the best conductors. The human body would have about the same conductibility as the saline so- lutions, if it were not for the skin, which is a very poor conductor, especially when it is dry. Those substances along which elec- tricity passes with great difficulty are known as non-conductors or insulators. The following is a list of some of these, the sub- stances arranged in accordance with their relative value: 1. Caoutchouc. 2. Silk. 3. Glass. 4. Wax. 5. Sulphur. 6. Resins. 7. Shellac. 8. Dry air. The electrical fluids may be kept by insulators at different potentials, the insulators preventing them from becoming equal- ized or reduced to the same potential. Electricity in this condi- tion is called static. Its study is called electrostatics. The electric fluid in motion is called dynamical electricity, and its study is electrodynamics. Technical Terms.—There are certain technical terms which it is necessary to understand. Electromotive force (symbol, EJ1F) is the force which tends to set electricity in motion. An electric current results. The current strength (symbol, C) is the term used to express the capacity of the separated fluids to overcome resistance in their attempts to reach equilibrium or equalization again. This current-strength or simply the current, naturally, is in proportion to the strength of the electromotive force, which is constantly disassociating the electrical fluids and generating the current. If, however, as is always the case, the electrical fluid meets resistance in seeking equilibrium, the resistance dimin- ishes its current. Hence we have the formula known as Ohm's law: _ Electromotive force EMF Current strength =-----------------—; or C = _____ Resistance B All bodies offer some resistance to electrical currents, and it is important to have some standard unit of resistance for the sake of comparison. Such standard unit has been adopted and is called an ohm. It is the resistance offered to a current by a cer- tain piece of wire of definite size and length. HYGIENE, PROPHYLAXIS, TREATMENT. 55 A volt is the unit of electromotive force, i.e., it represents the force which will generate a certain amount of electricity in a second of time. A Daniell cell is of not quite one volt strength. An ampere is the unit of working power or current strength. It is the current strength produced by one volt of electromotive force working against one ohm of resistance. A milliampere is one-thousandth of an ampere. A watt is the unit of work. Density.—When a given current flows along from a large into a small conductor, the quantity in this latter conductor in a given section is greater and the current is said to be denser. The in- strument by which the strength of a current is measured is known as the amperemeter: in medical practice, only fractions of the ampere are used, and the instrument is called the mill)'am- peremeter. A rheostat is an instrument for interposing resist- ance in a current. Electrical Appliances.—The batteries used in neurologi- cal practice are of three kinds: the static, the faradic, and the galvanic. The static electrical batteries are mostly modifications of the Holtz influence machine. They are inclosed in glass to prevent the effects of moisture. The instruments made in this country for medical purposes will usually furnish electricity all the year round. A cheaper instrument, made on a different principle by Glaser, of Vienna, is recommended by Lewandowski. The bat- tery accessories consist of an insulated stool and brass-ball elec- trodes with glass handles. The patient is placed on the stool, which is connected by a rod with one of the prime conductors. The battery being started, the patient becomes enveloped, as it were, with a layer of electricity which is at a very high potential and constantly flying off, being retained only by the dry, non-conduct- ing air. The electrode held by the operator, and connected directly or indirectly to the other prime conductor, is now brought near the patient. The electrical fluid bounds to the zero point with such force that some of the metallic parts of the electrode are carried off and ignited, causing the disruptive spark. The pa- tient thus is discharged of the fluid; but it continually reaccuuiu- lates upon him, and thus one can keep on drawing sparks from all parts of the body. The electric spark causes a muscular contrac- tion and, a little later, a small punctate red spot. There is some pain connected with it, but as the electricity penetrates the body for only an infinitesimal period of time, it directly affects the viscera but little, and is not dangerous. Various ingenious electrodes have been devised for modifying the character of the static dis- charge, but they all have much the same effect as the spark. By approximating the prime conductors so that they almost touch, and then connecting the outer surface of the two Leyden 56 DISEASES OF THE NERVOUS SYSTEM. jars which hang from the prime conductors with sponge elec- trodes, one gets the static induced current described by Dr. William J. Morton. The special peculiarity of this current, as well as of the spark discharge, is that it is made up of electricity at a very high potential, and that, being composed of oscillating or alternating currents of extremely short duration, the quantity of electricity is very small. The result is that when a muscle de- generates, it loses its irritability to the static current very early. The static current will thus reveal a beginning degeneration of nerve sooner than the other currents; it also promotes tissue changes more than other forms. It sometimes stimulates a greatly degenerated muscle, so that later the other forms will produce a contraction. It has a powerful psychical effect, and lends itself readily to quackery. In faradic medical batteries the electricity is produced by in- duction. The chief elements are a cell and two coils of insulated copper wire. One coil is placed around the other, the outer coil being longer and of finer wire. The cell generates a current which in turn " induces" the electricity which is received by the pa- tient. The original current is so arranged that it is being con- stantly broken and closed or " made" again. At both break and make, a current is induced in the inner coil of coiled wire; this forms what is called the primary induced current and is made up of a succession of short currents. This current, though theo- retically alternating, is really a current of one direction. For the "make" current is opposed and nullified by the original or bat- tery current. The same is true of the secondary induced current which is excited in the outer coil by the currents of the inner coil. Both currents are really composed of a rapid series of single cur- rents going the same way, and they each have a positive and a negative pole. The primary current is one of lower tension, and is rather less strong. It can be used when the resistance of the parts is not great and a very powerful current is not needed. The secondary current is one of higher tension, it overcomes resistance better, and can be employed in connection with the wire brush and in anaesthesia conditions. It is also the current used in measuring the strength of the faradic application, as will be shown later. The current of the secondary coil resembles that of the static induced current. It has, however, a lower potential, vastly slower alternations, and more quantity. It can contract muscle, which the static current cannot affect. The secondary coil should be made of wire of a standard size, length, and layers of coil. A standard coil of wire 800 metres long, .225 mm. in diame- ter, wound on a spool 100 mm. long, is quite generally adopted now. Faradic batteries are made with the zinc-carbon or (irenet cell the LeclanchS, the silver-chloride cell, or some modification of HYGIENE, PROPHYLAXIS, TREATMENT. 57 these. For general use, the zinc-carbon cell is the most trust- worthy ; but the dry silver-chloride cell is the most convenient. A dry cell made with muriate of ammonia has of late come into use. Galvanic Batteries.—There are two kinds of these in practical use. The one includes the cells which act as soon as the circuit is closed; the other includes those which act only when the elements composing the battery (e.g., zinc, carbon, platinum, copper, etc.) are dropped in the exciting fluid. The former class (known as two-fluid cells) are not touched except to renew water or add some chemical. In the latter (the single-fluid cells), one of the elements is always taken from the fluid when the current is not in use. The first class of cells has a much weaker chemical Fig. 30.—Author's Electrode Set (H. E. Stammers, New York). action and evolves less electricity in a given time. It includes the Daniel cell, the gravity cell, the Leclanche- cell, and the sil- ver-chloride cell. Among the second class or single-fluid cells, the zinc-carbon cell, known as the Grenet or Stohrer's cell, al- ready referred to, is most used. The best portable batteries are made of the zinc-carbon cell or the dry chloride of silver cells. Stationary or office batteries are best made with the Leelanche" cell or some modification of it; or the dry silver-chloride cell may be used. The electric-light current can be utilized to supply con- tinuous and interrupted currents and for purposes of the cautery. It is expensive. The ordinary accessories to the faradic and galvanic batteries are electrodes, rheostat, and milliamperemeter. The electrodes needed for ordinary purposes are: 1. An indifferent electrode measuring 5 cm. by 10 cm. 2. A normal electrode, 10 sq. cm. 3. A unit electrode, 1 sq. cm. 4. A 5S DISEASES OF THE NERVOUS SYSTEM. soft wire brush. 5. Three handles: one 10 cm. and one 40 cm. long, one short handle with an interrupter. 6. A milliampere- meter. 7. A rheostat. (See Fig. 30.) Methods of Application.—Static electricity is applied for fif- teen or twenty minutes daily or tri weekly. For general tonic or sedative effects, sparks are drawn from all parts of the body ex- cept the face. In paralysis or spasm or pain, sparks are applied to the affected area. For headaches and cerebral paresthesias, the electrical breeze is very useful, but it must be strong. The faradic and galvanic currents are used for about the same time and intervals as the static. In some cases, however, the galvanic current should be given daily or even two or three times a day. As a rule, a course of electrical treatment should be con- tinued for six to eight weeks, and then discontinued for a time. The special methods used in applying these currents are: 1. General galvanization and faradization or general electriza- tion. 2. Local electrization by galvanization of the brain, of the neck, of the spine, of the special senses, limbs, and viscera. Or by faradization of the neck, spine, limbs, and viscera. 3. The combined faradic and galvanic currents. These are given by means of the De Watteville switch. General and local electrization can be given in this way. 4. The polar method. This is employed chiefly in using the gal- vanic current. The indifferent electrode is placed on the sternum or back, and the other electrode applied wherever indicated. 5. Cataphoric electrization by means of Peterson's electrode. 6. Electrolytic applications are used in enlarging strictures and affecting inflammatory deposits and neoplasms. In general electrization, whether galvanic or faradic, the in- different electrode is placed on the sternum, feet or back, and the other pole is carried over the limbs, trunk, neck, and, if in- dicated, the head. In some cases, however, the two electrodes are applied together upon the different muscles of the body. In local electrization, the large electrode may be applied on an indifferent spot, and the other applied to the affected limb or limbs, or the two electrodes may be used together on the same segment of muscles. The details for galvanizing the brain, special senses, and viscera must be obtained from special text-books. When an electrode is held steadily upon a part, it is called stabile ; when it is moved over it, it is called labile. The positive pole is called the anode (An), the negative the cathode (Ca). The size of an electrode is indicated in square centimetres. A formula for applying electricity may be written thus: Anod. galvanization, 10 ma. 5-10 cm. daily, stabile. HYGIENE, PROPHYLAXIS, TREATMENT. 59 This means that the positive pole of the galvanic current is to be applied steadily at a given place daily for five minutes with an electrode of ten square centimetres. The terms " ascending " and " descending currents " are rarely Fig. 35. Fig. 33. Fig. 34. Figs. 31 to 36.—Cuts showing Motor Points. The letters refer to points elec- trization of which stimulates certain muscles to contract. These points vary much in different persons. For details seeDe Watteville's " Medical Electricity.'" 60 DISEASES OF THE NERVOUS SYSTEM. used, the name of the pole being employed instead. Thus, anodal galvanization of the brain or arm means that the positive pole is applied at these localities. With the faradic and static currents, neither the pole nor the direction of the current makes much difference. Electro-Diagnosis.—When a motor nerve is cut off from its centre in the spinal cord, or when this centre itself is diseased, the nerve and later the muscle undergo a degeneration. As a result of this, their reaction to electrical currents is changed, and we get what is termed "partial degeneration reactions" and "complete degeneration reactions " according to the degree of disturbance. These reactions are due mainly, if not wholly, to the degeneration in the terminal nerve fibres and motor end plates in the muscle. When the muscle alone is diseased, the reaction is not changed until very late. The change in irritability is due to the fact that as the nerve fibre wastes it takes an electric current of com- paratively long duration and considerable strength to stimulate it. The first effect is to lose its contractility or reaction to weak cur- rents, then to extremely rapid, short currents like the static, then to the faradic, and last to the galvanic. Such change is known as the quantitative alteration in electric irritability. But besides this, the nerve and muscle are affected in a differ- ent way by the different poles of the galvanic battery. In nor- mal nerve and muscle, a contraction is caused more readily by the negative pole than by the positive. But muscles with degen- erated nerve supply sometimes respond as well or better to the positive pole. This forms what is called the qualitative or serial change in the irritability of the muscle. Finally, degenerated muscles respond more sluggishly than normal to the galvanic and faradic currents. The contraction, in- stead of being sharp and jerky, is sluggish and almost tetanic. This is called the modal change in irritability. The qualitative change is only gotten by placing the active electrode over the muscle, but the quantitative and modal changes may be gotten by placing the electrode over the nerve as well as over the muscle. In describing these changes, the following abbreviations are used: DeR = degenerative reaction. AnCC = anode or positive-pole closure contraction. CaCC = cathode or negative-pole closure contraction. AnOC = anode opening contraction. CaOC = cathode opening contraction. Te = tetanus. D = circuit is closed and current flowing. ADTe = tetanic contraction while the positive pole is applied and the circuit closed. HYGIENE, PROPHYLAXIS, TREATMENT. 61 The sign > means greater than; <, less than. Thus AnCC > CaCC means anode closure contraction is greater than cathode closure contraction. Degenerations in nerve do not occur except in lesions of the nerve or spinal cord, and in very late stages of primary atrophy of muscles. Hence when one finds degenerative reactions, he can exclude disease of the brain, functional disease, and primary dis- ease of the muscle. The following rules may be formulated for testing for degenerative reactions: Use the faradic current first. The Faradic Current.—Use a secondary induction coil of .225 mm. diameter, 800 metres long. The distance over which the coil moves is divided into a hundred parts. The strength of current is indicated by percentage or millimetres. In many scales it takes 30 to 40 mm. of CD or coil distance to cause a muscular contraction. Record the minimum necessary for muscular contraction, using the same electrodes and in the same way as in testing with gal- vanism. The Galvanic Current.—1. Place the indifferent pole over the sternum, and a 10 sq. cm. electrode over the muscle. 2. Pass the current for one minute. 3. Then find the minimum strength needed for a cathode closure contraction. 4. Then for an anode closure contraction. Repeat this test three times. 5. With a given cur- rent, note whether the cathode closure contraction is stronger than AnCC, or otherwise. Test this three times. 6. Note the character of the contraction, if sharp or sluggish. 7. Test nerve in same way. The qualitative changes may be expressed by a formula like AnCC = or > CaCC, i.e., the positive-pole closure contraction is equal to or greater than the negative-pole closure contraction. Or, better, the minimum strength of current required to cause a contraction in the muscle is recorded for the positive pole and for the negative. Thus: AnCC 5 ma. or 8 cells. CaCC 4 ma. or 6 cells. Blanks for such records are used in the Post-Graduate Clinic, like the following: Record of Electrical Reactions. Case of______________............—....................No. Muscle. Nerve. Reaction to ( Electrode Galvanic Current, i ....sq. cm. R ea ctiox to 2d ind. coil. Faradic Current. Date. Ant. tibial muscle. Right Side. AnCC 8 ma. CaCC 6 ma. Left Side. AnCC 5 ma. CaCC 7 ma. Right Side. 0 Left 10 CD June 6, 1892. 62 DISEASES OF THE NERVOUS SYSTEM. The following table modified from De Watteville and dia- gram (Fig. 37) show the diseases in which degeneration reactions may be expected. Table showing the Lesion, its Result, the Names of the Diseases, and the Electrical Reactions. Lesion of— l to 2y2. Cortex to cord 3, 4. and 5. Cornua. 2 to 2J4 3 to 5. Lat. cols, and ant. corn. 5 to 6. Trophic cord centres. Nerve. Muscle. Nerve and mus- cle. Result. Paralysis, con- tractures. Paralysis, degen- erative atrophy of nerve and muscle. Paralysis, con- tractures. Degenerative at- rophy of mus- cle. Degenerative at- rophy of mus- cle. Paralysis from wasting of mus- cle. Later, degenera- tion of nerve. Paralysis: degen- erative atrophy of nerve and muscle. Wasting, paresis. Paresis and atro- phy- Disease. Hemiplegia from haemor rhage. Embolism, tumors, lat- eral sclerosis. Acute and chronic ante rior poliomyelitis. Amyotrophic lateral scle rosis. Progressive muscular at- rophy (spinal form), bulbar paralysis; (?). Neuritis; from wounds, toxaemia or pressure. Simple atrophy; primary or idiopathic myositis. Juvenile form of pro- gressive muscular atro- p h y ; pseudo-muscu- lar hypertrophy; other types of primary my- opathies. Rheumatic atrophy and paresis. Electrical Reaction as to Qualitative. Nerve: normal. Muscle: normal. Nerve: DeR. Muscle: DeR. Nerve: normal [ n r> Muscle: partial) utiri" Nerve: normal. Muscle: or partial DeR. When disease is ad- vanced, in early stages, etc. Muscle: DeR. Nerve: DeR. Nerve and muscle nor- mal until late in the disease. No DeR. unless severe. It should be said, finally, that it is the sluggish contraction which is the most important element in showing degeneration; also that it is the muscle which should be tested most carefully, as only over it does one get the qualitative changes. Therapeutics.—Electricity is used as a counter-irritant and as a general mechanical tonic in states of muscular and nervous weakness. It is used in paralysis, spasm, and pain, and for its supposed specific action in certain functional and organic dis- eases. HYGIENE, PROPHYLAXIS, TREATMENT. 63 The faradic and static currents have a counter-irritating, stim- ulating, and excito-reflex effect. The galvanic current has a seda- tive and anti-spasmodic effect. Electrolytic, cauterizing, and cataphoric effects are also pro- Fig. 37. duced, but are rarely needed by the neurologist. A considerable portion of the effects of electricity are psychical, but they are not the less real or valuable. CHAPTER VI. GENERAL DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. The disorders which affect the peripheral nerves are hyper- emia and anaemia, degeneration, inflammation, functional dis- orders, new growths. I shall describe here those disorders of which general facts can be stated, no matter where the trouble is located. Such dis- orders are hyperemia and anaemia of nerves, degenerative pro- cesses, infla-mmation. Next will come a description of diseases which affect the whole or a large part of the whole peripheral nerves simultaneously. Such disorders are multiple neuritis, neuralgia, and certain other neuroses. H yper^emi A.—Etiology.—This is a condition rarely recognized clinically. The causes are cold, injury, neighboring inflamma- tion, rheumatic, gouty poisons and paralytic vasomotor neuroses, metallic and other poisons. Symptoms.—The symptoms are those of burning, numbness, and other paresthesie; tenderness, pain, and muscular weakness. Doubtless many forms of neuralgia are associated with hyper- emia. Pathological Anatomy.—The nerve in hyperemia is reddened, injected, and may be the seat of minute hemorrhages. Treatment.—As hyperemia and anemia are always secondary conditions, the treatment is mainly based on the cause. The ice- bag, leeches, counter-irritation, cupping, and massage may be re- sorted to in hyperemia; local stimulants, hydrotherapy, massage, nitroglycerin, iron, and iodide of potassium may be given. Anaemia of Nerves.—Etiology.—This occurs in conditions of general anemia and cachexia, in spasmodic vasomotor neu- roses, in obstruction of blood-vessels from any cause, and in ob- literating arteritis. Symptoms.—Often no especial symptoms result. Here again, however, we may trace the cause of pains and neuralgias, espe- cially those of the later periods of life when arteritis is present. DISEASES OP THE PERIPHERAL NERVES. 65 Degeneration of Nerves. This is a process in which the nerve fibres gradually die; the myelin sheath and axis cylinder disappear, leaving only a strand of connective tissue. Etiology.—It is caused by destruction of the trophic centres of the nerve or by cutting the nerve off from it; or by direct action of toxic and inflammatory and destructive agents on the nerve fibre. Diseases of the spinal cord, injuries of nerves, and toxic agents are the special causes. There is occasionally also a primary atrophy of peripheral parts of nerves in wasted and dis- used muscles. The symptoms of nerve degeneration are those of sudden or gradual enfeeblement and loss of the nerve's func- tion. There may be some evidence of irritation, such as pain and spasm. Pa- ralysis, anesthesia, and various trophic and vaso- motor disturbances occur in the part affected. Degeneration of nerves is usually secondary to or associated with other dis- eases, and its special symp- toms will be described else- where. Pathology.—There are three forms of nerve degeneration: 1. Primary; 2. Secondary; 3. Neuritic or toxic. 1. The primary form is rare, slight in extent, and of little clin- ical significance. In it there is simply a gradual wasting and dis- appearance of the axis cylinder and myelin sheath. It occurs in wasting diseases and as part of locomotor ataxia (Fig. 38). 2. Secondary degeneration or Wallerian degeneration. This form occurs when the nerve is cut across, or compressed, or de- stroyed by inflammation, neoplasms, or injuries. The peripheral end of the cut nerve shows a loss of nearly but not quite all the fibres as far as its termination. In the central end, the degenera- tion only ascends to the first or second node of Ranvier. A few fibres, however, degenerate as far as the spinal cord. These are afferent in function, they have their trophic centre in the periph- ery, and correspond to the undegenerated fibres in the periph- eral part of the cut nerve. 5 Fig. 38.—Simple Atrophy of Nerve in Marasmus. 6G DISEASES OF THE NERVOUS SYSTEM. "When the section is made between the spinal ganglia and the cord, the fibres all degenerate toward the cord, and even enter it, but the peripheral fibres do not degenerate. Hence the spinal ganglia are the trophic centres of most of the sensory nerves. MR.____ >—= Pc P.MN S.G. " "" Fig. 39.—Cut showing the Effects of Section of Mixed Nerves and Sen- sory Root. P.M.N., Mixed nerve; S.G., spinal ganglion; M.R., motor root; S.R., sensory root; P.c, peripheral trophic cell. The dotted line shows the degenerated nerves. A few, however, have their trophic centre in peripheral nerve cells. Degeneration occurs in the motor nerves, also, when the cells of the anterior horns are destroyed. Hence these cells are the trophic centres for all motor nerves. The essential part of the nerve fibre, the axis cylinder, is sim- ply a prolongation of the process of a nerve cell. Its next essen- Fig. 40.—Showing Different Stages in the Process of Nerve Degeneration on Second, Third, Sixth, and Ninetieth Days after Section (Ranvier). tial part is the myelin sheath. This is of epiblastic origin and consists of a hollow cylinder inclosed in a thin membrane and containing a fatty substance. In degenerative processes of peripheral nerves the medullary sheath is first affected, then the axis cylinder, least and last the neurilemma. The myelin becomes turbid, splits up into frag- DISEASES OF THE PERIPHERAL NERVES. 67 ments and droplets. The axis cylinder also breaks up into frag- ments or swells up and becomes liquefied. Extravasated leuco- cytes pick up the products of disintegration and form fat-granule cells. The neurilemma and its nuclei usually remain intact. The nerve during this time shrinks in volume and looks grayish and translucent, or grayish-red. The nerve finally becomes only a fibrous cord. Changes can be seen in the nerve within forty-eight hours, and by this time its irritability, which was first slightly increased, is lost. In about two weeks the disintegration of the myelin sheath and axis is practically complete. The process of degeneration takes place at about the same time through- out the whole length of the nerve. The motor end plates in the muscles are affected a little the earliest. The fibres of the central stump are affected as far as the first or second nodes of Ranvier. Later, the central stump may degenerate somewhat from dis- use. About the cut end, however, little bulbous tumors may develop, which contain numerous nerve fibrils and connective tissue. The general law is that nerves degener- ate in the direction in which they carry impulses, but this is not always the case, as is seen with peripheral sensory nerves. The relations of nerve fibres to their centres and the effects of section is shown in the accompany- ing cuts. Summary: Peripheral nerve fibres degenerate when cut off from their trophic cells. The degeneration begins at once throughout the length of the nerve. Loss of function occurs in forty-eight hours. The degen- eration is practically complete within two or three weeks. The myelin sheath and its nuclei are affected first, the axis cylinder next. The degeneration takes place in the direction in which the nerve impulse runs except in peripheral afferent nerves. The final stage is one of nerve atrophy. Fig. 41.—Showing the Relations of the Nerves to their Trophic Centres. S., Sensory nerve; M., motor nerve; S.G., spiral ganglion; P.H., posterior horn; A.H., anterior horn; C., cerebral cortex. The dotted line shows the degenerated nerve. 68 DISEASES OF THE NERVOUS SYSTEM. Within the central nervous system the degeneration always oc- curs in the direction of the nerve impulse. The axis cylinder is first affected. There is sometimes a preliminary swelling or hy- pertrophy of the axis cylinder. Degeneration with calcification of the nerve fibres sometimes occurs. In associative or commis- sural fibres the degeneration only extends part of the length of the nerve. 3. Neuritic or toxic nerve degeneration. This form occurs in connection with neuritis, and will be described under that head. Its chief characteristics are that the degeneration attacks the nerve in segments, that the axis cylinders are not so much affected, and the myelin breaks up into small fatty droplets instead of into large masses. Degenerative processes in the non-medullated nervous fibres have been observed in the fine fibres of the cornea and in the submucous and myenteric plexuses of the alimentary tract. Regeneration of nerves is a process that usually follows degen- eration. It occurs only in peripheral nerves—very little, if at all, in the nerves of the central nervous system of mammals. It is a unique process, in that the nerve is the only specialized tissue that can grow again after being destroyed. Regeneration occurs whenever the trophic centres are healthy, when the mechanical obstacles to a union of the divided fibre are not too great, and Avhen the peripheral nerve is not too completely atrophied. It occurs most quickly, therefore, when the cut ends are carefully apposed and when the separation has not lasted for a long time, i.e., for years. It progresses always from the central end toward the periphery. The fibres of the central stump grow out into the degenerated peripheral fibre. Union by first intention or second intention never occurs. Human nerves cannot be made to unite physiologically, but only anatomically. Regeneration may be complete in a few months in short nerves. In the sciatic it may take one or two years. When regeneration takes place, the axis cylinders of the central stump swell and divide into a number of new cylinders which pierce or creep around the intervening tissue, enter in bundles the peripheral nerve, and become inclosed in new myelin sheaths and neurilemma. INFLAMMATION OF NERVES—NEURITIS. Anatomically and clinically, there are two forms of neuritis; 1. Neuritis of single nerves or groups of nerves. 2. Multiple neuritis. Pathologically, there are two forms of neuritis: 1. Interstitial neuritis and perineuritis. 2. Diffuse neuritis with parenchymatous degeneration. DISEASES OF THE PERIPHERAL NERVES. 69 Etiologically, there are two forms : 1. Toxic neuritis, from alcohol, arsenic, lead, etc. 2. Infective neuritis from pyogenic organisms, infective fevers, syphilis, tuberculosis, leprosy, etc. I shall follow the anatomical and clinical classification and describe, first, neuritis of single nerves or groups of nerves; next, multiple neuritis. Neuritis of Single Nerves or Nerve Groups.— Etiol- ogy.—The most frequent cause of neuritis by far is injury, such Fig. 42.—Acute Infectious Neuritis, showing haemorrhage, connective-tissue proliferation, diseased nerve fibres, and* obliterated vessel (Rosenheim). as compression, tearing, stretching, cutting, etc. Next comes, perhaps, lead-poisoning; after this, various infections, such as typhoid fever, variola, diphtheria. Tuberculosis, leprosy, syphilis, are also causes. Symptoms.—These are such as result from irritation and paral- ysis of the nerves affected, and will be described under the head of Special Forms. Pathology.—Injury may not cause a true neuritis, but only a secondary degeneration. When inflammation does occur it is of 70 DISEASES OF THE NERVOUS SYSTEM. an interstitial or perineuritic type, and it may be acute or chronic. In the former case there is hyperemia, with sometimes extravasa- tion of blood. An exudation occurs into the fibrous framework of the nerve, with migration of leucocytes. The inflammation may become suppurative or gangrenous. If severe, it destroys the nerve fibres; but oftenest the axis cylinders are not destroyed, and recovery takes place. Chronic interstitial neuritis and peri- neuritis are accompanied with hyperplasia of the connective tissue, compression and more or less destruction of the nerve. It may as- cend or descend, and it is called, accordingly, ascending, descend- ing, or migrating neuritis. It may affect only certain segments of the nerve, when it is called segmental neuritis or disseminated neuritis. Tubercular and syphilitic neuritis are of the chronic interstitial or diffuse type. These latter forms rarely involve peripheral nerves, but rather the intra-cranial parts of the cranial nerves and the spinal nerve roots in meningeal tuberculosis or syphilis. A syphilitic peripheral multiple neuritis is, however, thought to occur sometimes. Leprous neuritis is a very typical form of proliferating chronic perineuritis. Cancerous neuritis sometimes occurs, and it is of the diffuse type, though sometimes an actual cancerous process invades the nerve. The course, duration, prognosis, diagnosis, and treatment of the above types of neuritis will be given under the special heads. Multiple Neuritis (Polyneuritis, Pseudo-Tabes, Alco- holic Paralysis Beri-beri, Ignipedites, Acrodynia). This is an inflammatory and degenerative affection attacking a number of nerves simultaneously and characterized chiefly by wasting and painful paralysis or by ataxia, with some motor weakness. It generally runs a subacute course. Forms.—Multiple neuritis may be of the paralytic or motor and of the ataxic or sensory type. There are also endemic types and acute pernicious forms. Etiology.—The disease is due to infections, to auto-toxic agents, and to chemical poisons. The special infections are those causing the disease beri-beri, the infection of diphtheria, and probably almost all of the exan- thematous fevers, as well as of puerperal and other septic fevers, cholera, ankylostoma, cerebro-spinal meningitis, and possibly phthisis and syphilis. The most common infection in this coun- try is diphtheria. In the West Indies malaria, in France an infec- tion causing acrodynia, in Japan, China, and various other trop- ical regions the infection of beri-beri are causes. Probably an independent specific infection of unknown character sometimes is a cause. DISEASES OF THE PERIPHERAL NERVES. 71 The autochthonous or auto-toxic poisons are those of rheuma- tism and diabetes. An incomplete form of polyneuritis is some- times seen as the result of exposure to cold and wet, as in han- dling ice. Conditions of inanition sometimes seem to lead to it. The toxic causes from without are those of alcohol, arsenic, lead, anilin, ergot, bisulphide of carbon, illuminating gas, mer- cury, and phosphorus. Practically, alcohol causes multiple neuritis in the great majority of cases (20 out of 31). In this country rheumatism and the infective fevers, especially diphthe- ria, are not infrequent causes, and the metallic poisons, with arsenic leading, come last. Sex.—Multiple neuritis occurs oftener in the female than in the male. This is due to the fact that alcoholic neuritis, which is the common form, affects women oftener. Beri-beri occurs much oftener in the male. Age.—Multiple neuritis is essentially a disease of early adult life. Almost all cases occur between adolescence and the period of degenerative changes, twenty to forty-five. Young children are very rarely subject to it. The youngest age reported is fourteen years (Suckling). A few cases have occurred in persons over sixty; but they are but little less susceptible than children. In beri-beri, three-quarters of the cases are between the ages of fifteen and twenty-five, 6% in children, 1.2£ in old people (Harada). Season and Climate.—The sporadic forms of polyneuritis from alcohol and various poisons and infections occur without much reference to a seasonal influence. Probably more cases occur in spring and fall, owing to sudden changes in temperature. Beri- beri occurs oftener in warm weather. Epidemic influences like that causing cerebro-spinal meningitis may increase the number of cases of multiple neuritis. Practically, in this country, the question of drink settles the question of the distribution of poly- neuritis. It is rare in the temperate rural districts and smaller towns, and much rarer in native Americans than foreigners. Sexual excesses, exposure to cold and wet, insufficient diet, are among the helping causes. Symptoms and Course.—Polyneuritis usually begins somewhat acutely, but runs a slow course of several months. Very rarely it runs a sudden course, ending fatally. We have, therefore, the ordinarily subacute multiple neuritis and acute pernicious mul- tiple neuritis. The endemic infectious forms show other types. The following is the classification followed: 1. Subacute, multiple neuritis. Motor type. Sensory type. Endemic forms: Beri-beri, etc. Malarial forms. DISEASES OF THE NERVOUS SYSTEM. 2. Acute malignant multiple neuritis. 1. This is the type of neuritis produced by alcohol, infections, poisons, and rheumatic influences. It is usually chiefly a motor trouble, but sometimes takes the sensory or pseudo-tabetic form. Prodromata.—The disease often begins with prodromata last- ing several weeks. The patient suffers from numbness, slight pains, and weakness affecting especially the lower extremities. In other cases the attack comes on suddenly, and in a short time the most marked symptoms appear. Onset.—There may be a fever for three or four days, with a temperature of 103° or 104°. This is not the rule. Numbness and pains attack the feet and legs, rarely ex- tending much above the knees. The muscles and nerves are very tender. The fingers, hands, and arms are often similarly but less af- fected. At the same time the skin becomes reddened or slightly cedematous. The muscles of the legs grow weak, and in a day or two the patient may be unable to stand. In a week or two there may be a complete loss of power in the anterior tib- ial muscles and a lesser de- gree of paralysis in the exten- sors of the hand. Nearly all of the leg and forearm mus- cles become eventually in- volved. Atrophy sets in at the same time and very severe pains are present. The motor cranial nerves are in rare cases affected, and pa- ralysis of the facial or of the third, fourth, or sixth nerve has been seen. When the disease is fully developed, which is within a fortnight, there is paraplegia with foot drop, some degree of wrist drop, muscular atrophy, and slight oedema, especially of the feet. The skin-reflexes are often, the knee jerk and elbow jerk always lost. There is some tactile anesthesia, often with Fig. 43.—Alcoholic Paralysis, with Foot Drop and Wrist Drop. DISEASES OF THE PERIPHERAL NERVES. 73 hyperalgesia. Temperature and pain sense are also lessened and slowed in transmission. The anesthesia occurs in patches or diffusely. Muscle and articular sense are lost in the sensory or pseudo-tabetic form, and are usually somewhat involved in the ordinary paralytic form. Pain and sensitiveness continue. The nerves lose their irritability and the muscles show degen- eration reaction, partial or complete, the characteristic being a great variability of reaction over different groups of nerves and at different stages of the disease, and an early loss of faradic and lessening of galvanic irritability. There is sometimes retinal hy- peremia and even optic neuritis. Of the visceral nerves, the vagus seems oftenest to show signs of involvement, in rapid pulse and disturbances of respiration. The sphincters are rarely in- volved. In such cases there is, perhaps, involvement of the cord or of the abdominal and pelvic splanchnics. In alcoholic and occasionally in other forms of neuritis, mental symptoms, such as a low, muttering delirium, are very often present, and occasion- ally a well-marked confusional insanity develops. The disease usually reaches its height in a week or two and then starts on a chronic course; but it sometimes happens that exacerbations occur, or that a paralysis and atrophy progress for several weeks before regression begins. In alcoholic cases there is often great general prostration; the patients lie for several weeks in a delirious condition, and finally develop pneumonia and die. Some further details should be added. Motor Symptoms.—The characteristic paralysis of multiple neuritis is a quadruplegia, all four extremities being involved. The special characteristic is the foot drop, which is indicative of alcoholic neuritis, just as wrist drop is of lead palsy. The paral- ysis is typically a peripheral one. It affects the feet and legs, hands and forearms. It usually involves the anterior tibial muscles more than the calf hiuscles, but sometimes the reverse occurs. The muscles become wasted and flabby. They soon lose in bad cases all reaction to faradism, and they require a strong gal- vanic current to produce a contraction. In anterior poliomyelitis, on the other hand, the diminution in galvanic irritability comes on only after weeks or months. Hence an early loss of galvanic as well as faradic reaction is an important sign of neuritis. As the nerve and muscle recuperate, the galvanic irritability increases. After a time, if the paralysis is great, contractures occur. The feet are extended, the legs are flexed on the thighs, and are al- most immovable, and the patient's condition is most pitiable. Sensory Symptoms.—Numbness, hyperesthesia, severe pains (■dull and sharp), burning sensations, great tenderness, all occur, and are very marked symptoms. They are felt mostly in the feet, 74 DISEASES OF THE NERVOUS SYSTEM. legs, and hands. Hyperesthesia is usually followed by anesthesia to touch and somewhat to pain and temperature. The transmis- sion of these latter two sensations is delayed. The anesthesia sometimes occurs in patches, at other times diffusely over foot, leg, and hand. Muscular and articular anesthesia are common, and in the sensory form are the dominant symptom, causing an ataxia of gait and station. The other special senses are not affected except in rare cases, in which there is optic neuritis. Vasomotor and Trophic Symptoms.— There is often oedema, sometimes redness of the skin; occasionally the epidermis of the soles and palms peels off. Glossy skin and profuse perspiration are rare. Eruptions and ulcers do not occur. Mental Symptoms.—-The most common mental disturbance is that so often seen in acute alcoholism, viz., a muttering delirium. This is associated with great general vital depression. If a true insanity develops, it also resembles, as a rule, alco- holic insanity or acute confusional insanity. The characteristic symptoms are a curious degree of forgetfulness, together with many and varying delusions rapidly succeeding each other. These often relate to the pains and paresthesia from which they suffer. They think that there are gloves on their hands or that something is on their feet. They often think that they have been out walking or riding. They are talkative, incoherent, and sleepless. Organic Centres.—The bladder is ocasionally affected for a short time, the other centres not at all. This freedom from in- volvement of the sphincters is an important characteristic of the disease in distinguishing it from myelitis. From the foregoing it will be seen that the dominant symptoms are paresthesia, pains (burning, lancinating, and dull), muscular tenderness, some anesthesia, paralysis affecting especially the lower extremities and causing foot drop, muscular wasting, with degeneration reactions; with no involvement of the sphincters; sometimes peculiar mental disturbances. The sensory or pseudo-tabetic type of multiple neuritis is caused less often by alcohol and more often relatively by the me- tallic and infectious poisons. The general course is much like that of the paralytic form, but there is less paralysis, and on the other hand there are more of the burning, tearing pains, a greater degree of anesthesia, with a very decided muscular anesthesia causing symptoms of a subacute locomotor ataxia. The paresis, muscular wasting, trophic changes, such as shedding of the epi- dermis and electrical reactions, serve to distinguish the disease. A double facial paralysis sometimes complicates this type. Endemic and Epidemic Types (Beri-beri or Kakke, Igui- pedites, Acrodynia, Malarial Multiple Neuritis).—Beri-beri or DISEASES OF THE PERIPHERAL NERVES. 75 endemic multiple neuritis is seen in this country rarely, and only by accident. Beri-beri is the Indian name; kakke, mean- ing " the leg disease," is its Japanese name. Ignipedites is a name given by Indian physicians to probably the same disease. French physicians gave the name of " acrodynia " to an epidemic disease which prevailed in France and the Crimea in the eai-ly part of this century. It was probably multiple neuritis. There are various types of this disease, in some of which the neuritic symptoms seem subordinate to those of other organs. The forms described by Scheube and Taylor are: The acute pernicious, the acute or subacute benign, the atro- phic or dry, and the dropsical or wet. The symptoms generally resemble those of multiple neuritis, as already described, plus oedema, extensive serous effusions, and gastro-intestinal disorders. The paralysis affects especially the lower extremities, but in beri-beri there seems to be an espe- cial tendency also to involvement of vasomotor and visceral nerves. Malarial Multiple Neuritis.—Jamaica seems to be the only place in which the malarial poison produces an endemic neuritic paralysis (Strachan), and the causation in these cases is not yet demonstrated. Dr. Strachan's description of the symptoms of what he terms malarial peripheral neuritis shows it to be quite extensive, often involving trunk and cranial nerves, and accom- panied with much pain and wasting. Cramps and skin eruptions are often noted, complications that do not occur in the ordinary types. 2. Acute Pernicious Multiple Neuritis.—There is a form of multiple neuritis which comes on suddenly, progresses rapidly, and causes death in a few days or weeks. These cases usually show the ordinary symptoms of neuritic paralysis, with final involve- ment of the cardiac and respiratory nerves, causing death. The agent in these cases is apparently of the nature of sepsis. The neuritis is interstitial and hemorrhagic. Other cases of acute per- nicious multiple neuritis take the form of acute ascending or Landry's paralysis. Here there are few sensory symptoms, no electrical changes or atrophy. The disease is due to an infectious poison which overwhelms the system before it has time to set up any inflammation or organic change. Pathology.—In multiple neuritis the disease affects the per- iphery of the nerves most, and extends up, very rarely reaching the roots. The anterior tibial and musculo-spiral nerves on the two sides are oftenest and most diseased. The process when mild in grade resembles a secondary degen- eration following section of the nerve. In severer cases there is evidence of interstitial inflammation as well as degeneration. 7G DISEASES OF THE NERVOUS SYSTEM. This process, however, varies in degree at different points of the nerve's course. Hence it has been called segmental or dissemi- nated neuritis. In some of these cases and in all acute perni- cious cases there is still more interstitial inflammatory change; small hemorrhages occur, exudation takes place, and collections of leucocytes about the vessel walls and among the nerve fibres are seen. The muscles supplied by the diseased nerves undergo atrophy. This is usually simple and non-inflammatory. But Fig. 44.—Longitudinal Section of a Nerve in Multiple Neuritis, showing rich proliferation of nuclei (Leyden). The process here is inflammatory as well as degenerative. sometimes there is an interstitial myositis with exudation com- pressing the fibres (Senator). The spinal cord is, as a rule, healthy, or presents minor and secondary changes. It will be seen, therefore, that in multiple neuritis there may be. (1) Simple degeneration; (2) degeneration with some evidences of interstitial neuritis (degenerative neuritis); (3) decided intersti- tial neuritis with degeneration of nerve fibres. The changes occurring in nerve degeneration have been de- scribed. In the second class of cases—degenerative or, as it is sometimes called, parenchymatous neuritis—naked-eye changes rarely occur. Under the microscope many of the nerve fibres are found to have disappeared; there is increase in the connective tissue and hyperemia. The vessel walls are usually thickened. DISEASES OF THE PERIPHERAL NERVES. 77 The mast cells of Ehrlich are seen, indicating excessive connective- tissue activity. Diagnosis.—Multiple neuritis must be diagnosticated from diffuse or transverse myelitis, anterior poliomyelitis, locomotor ataxia, spinal meningitis, and hemorrhage and Landry's paraly- sis. Practically, diffuse myelitis is the disorder from which it has oftenest to be distinguished. From this it is recognized first by Fig. 45.—Diphtheritic Neuritis, Chiefly Interstitial (Siemerling) ; with secondary degeneration. investigating the cause and onset. Neuritis begins more slowly and with sensory prodromata; it affects the legs and feet, especially the extensors, and if it ascends it skips the hips and trunks and attacks the forearms. There is more muscular atrophy than in myelitis; the knee jerks are absent. It pro- gresses more slowly, and after four or eight weeks gradually regresses. Electrical degeneration reactions are more varied and decided. There are tenderness over the muscles and nerves and peculiar burning, darting pains. The cutaneous anes- thesia, if present, is not so extensive and complete, as a rule, while muscular anesthesia is more decidedly marked. There is very 78 DISEASES OF THE NERVOUS SYSTEM. rarely involvement of the sphincters, or bed-sores. There may be belt-like constrictions felt round the extremities, but not around the waist. The gradual improvement of the paralysis and atrophy and eventual recovery confirm the diagnosis of neuritis. The presence of neuritis of the cranial nerves would strengthen the theory of a neuritis. From poliomyelitis it is distinguished by the presence of pain and other sensory symptoms, the early fall in galvanic irritability, the age of the patient, and the etiology. From locomotor ataxia, neuritis is distinguished by its more rapid onset, the presence of paralysis and atrophy of muscles, paresis, with degeneration reactions, and the absence of involve- ment of the organic centres. Spinal hemorrhage usually leads soon to a secondary diffuse myelitis easily distinguishable from neuritis by the characters above given. Here there is also usually pain in the back. Spinal meningitis is associated with characteristic pain, tenderness, and stiffness along the back. Acute ascending paralysis in its typical form shows but very slight sensory disorders, and no wasting or change in electrical irritability. The complication of multiple neuritis and myelitis or posterior sclerosis is possible, but is very rare. In the former case the ordinary symptoms of myelitis are added to those of neuritis. In locomotor ataxia there is often some nerve degeneration and occasionally neuritis. The nerve degeneration probably only causes slow atrophic changes and paresis; the neuritis causes pains, anesthesia, skin eruptions, and local trophic disorders. Prognosis.—Alcoholic multiple neuritis is a serious disease, because of its associated conditions. Nearly one-half of my pa- tients have died, mainly because they continued the use of alco- hol after paralysis appeared. They do not die of neuritis, but of alcoholism or of phthisis. Other forms of neuritis rarely cause death. The great majority recover almost completely. It may be from six months to two years before all symptoms disappear. The average time is about a year. Treatment—-The patient needs, first of all, rest in bed. The limbs are often extremely tender and the patient's pains ex- cruciating. To relieve these the legs may be painted with menthol and enveloped in cotton batting. In other cases flan- nels wrung out in hot water and renewed every two hours give relief. Internally phenacetin, antipyrine, salicylate of soda, may be given. In the early stages, salicylate of soda in doses of gr. xx. every two or three hours should be administered. If there is a great deal of depression from alcoholic poisoning, strychnia gr. sV Q. 3 h. and aromatic spirits of ammonia, 3 ss. q. 3 h., should be used. Nitrate of silver is also useful in the early stage. DISEASES OF THE PERIPHERAL NERVES. 79 After the acute stage is passed the labile galvanic current oc- casionally interrupted may be applied, 2 to 6 ma. for ten minutes three times weekly. Later, by the sixth week, the faradic current, massage, and careful exercise should be given. At this time or earlier (third week), strychnia, iodide of potassium, arsenic, and tonics may be given. In old cases in which a great deal of paralysis and contracture have occurred, forcible extension of the limbs, the use of splints and rubber muscles, are needed. With patience and perseverance the worst cases can eventually be brought to a complete recovery. Complicating Forms of Neuritis and Neuritic Degen- eration.—Neuritis and neuritic degeneration complicate many diseases, but they especially mark and modify subacute and chronic rheumatism, locomotor ataxia, diabetes, paralysis agitans, wasting diseases, and old age. A neuritic degeneration almost always affects the nerves in the neighborhood of an old rheumatic joint. The chief result of this is to produce wasting and some paresis of the muscles mov- ing the joint (Pitres and Vailtard). The process is a reflex atrophy (see Arthritic Muscular Atrophy). In locomotor ataxia, parenchymatous degeneration is very often present. It does not produce the cardinal symptoms of this disease. It does, however, cause some of the anesthesia, pares- thesia, muscular atrophy, skin dystrophies, and visceral crises. In diabetes, the neuritis takes the form of the sensory type of multiple neuritis, and causes symptoms like those of locomotor ataxia. The patient has sciatic pains, burning or numb feet, loss of tendon reflex, ataxia. The upper extremities are rarely affected. In Wasting Diseases and Old Age.—In various wasting dis- eases, such as phthisis, cancerous cachexia, long-continued fevers, marasmus, and in senility, a simple parenchymatous degeneration of nerves, with atrophy, occurs (Arthaud, KOster, Jappa). The symptoms caused by these changes are very slight. They con- tribute to the weakness and wasting. In old age, the atrophy of the nerves is one cause of the lessened sensibility and activity of the skin and its underlying muscles. Morvan's Disease, Analgesic Paralysis with Whitlow. —(Neuritic type of syringo-myelia.) This is a very rare disease, characterized by a slowly progres- sive paralysis and atrophy of the hands and forearms, with anal- gesia and painless whitlows. It occurs usually in young or middle-aged males. Occupations, such as handling fish, which involve exposure and trauma, pre- dispose to the disease. The symptoms come on slowly, with, at first, severe pains in the arms and hands. The muscles of these parts gradually get 80 DISEASES OF THE NERVOUS SYSTEM. weak and atrophy. Anesthesia and analgesia are present, Usu- ally there is loss of pain and temperature, but not of tactile sense. Whitlows appear which are painless, and one or more of the terminal phalanges may necrose. There is usually a swelling and hard oedema of the parts. Both upper extremities may be affected, and sometimes the feet are also slightly involved. There is sometimes spinal curvature. Hysteria may complicate the affec- tion. The course of the disease is very chronic, but there may be long periods in which the symptoms are quiescent. Pathological examinations always show a neuritis of the parts involved in the disease. In some cases a syringo-myelia has been found. There is, therefore, a Morvan's disease due to syringo-myelia and neuritis, and another type due to a neuritis alone. The prognosis, so far as cure is concerned, is bad, but the dis- ease may remain stationary a long time or improve. The diagnosis is based on the combination of paralysis, atro- phy, loss of pain and temperature but not of tactile sense, and whitlows. Strychnine seems to have stopped the progress of the malady in one case. The treatment in general is only symptomatic. FUNCTIONAL DISORDERS OF THE PERIPHERAL NERVES. These are: 1. Motor forms: tremor, spasm, paralysis. 2. Sensory forms: neuralgia, paresthesia. 3. Mixed neuroses. 1. Tremor and spasm sometimes occur from peripheral nerve irritation. The cause is over-use of the limbs, and the symptoms are associated with others belonging to the occupation neuroses (see p. 468). Waking Numbness (Night Palsy, Recumbent Palsy). This is a disorder characterized by a temporary paralysis of an extremity, with numbness, noticed on first waking, or after lying down for a time. It is a rare disease and little is known of its cause. It occurs in adults and usually in the neuropathic. Sometimes evidence of weak heart or poor innervation of the vessels is present. The symptoms are much like those caused by temporary com- pression of a nerve when the leg or arm go to sleep. The paral- ysis is temporary and there is no anesthesia. It is often very obstinate. DISEASES OF THE PERIPHERAL NERVES. 81 The treatment consists in giving strychnine, mineral acids, and electricity, with occasional courses of bromides; iron and anti- rheumatics may be needed in some cases. 2. Sensory Neuroses. Neuralgia. Definition.—Neuralgia is a functional disease characterized by pain in the course of a nerve or of nerves. Forms.—Neuralgias may be idiopathic, i.e., developed sponta- neously, or symptomatic, due to some known toxic influence, re- flex irritant, or organic disease acting on the nerve. Thus a central disease of the nervous system or a tumor pressing on a nerve may cause a symptomatic neuralgia. When, however, there is organic disease of the nerve itself, such as neuritis, the disease cannot be called neuralgia. It is often impossible to draw the lines absolutely. Neuralgias are divided, in accordance with their cause, into the epileptiform, hysterical, reflex, traumatic, gouty, etc. Neuralgias are also divided, in accordance with their anatomi- ical location, into trigeminal, cervico -occipital, brachial, inter- costal, lumbar, crural, sciatic, and visceral. Migraine and headache are not classed among neuralgias. Frequency.—Neuralgias of all kinds make up about ten per cent of the nervous disorders for which the neurologist is con- sulted. The most frequent form is the trigeminal; next in order come the sciatic, intercostal, cervico-occipital, lumbo-abdominal, brachial, and visceral neuralgias. Etiology: Predisposing Causes. — Neuralgia never affects young children, and, leaving out migraine and headache, it is rarely met with before the fifteenth year. From that time until twenty-five the frequency very rapidly increases. About one- fourth occur between the ages of fifteen and twenty-five; the relative number then slowly decreases to the forty-fifth year, when there is a rapid fall. Neuralgia is very rare in old age. Women are more affected than men in the proportion of five to three (analysis of 887 cases). In New York most cases occur in winter, next in the autumn. More cases occur in temperate cli- mates and in wet and cold regions. Hereditary influence, neurotic constitution, anemia and de- bility, gouty and rheumatic diatheses, all predispose somewhat to the disease. The exciting causes can be included under the head of toxic agents, infections, exposure, over-exertion, emotional shock, and injuries. Local irritation of nerves may excite neuralgia, direct or reflex in kind. Some help in recognizing the reflex origin of neuralgias and other pains may be gained from the accompanying dia- grams. 6 S2 DISEASES OF THE NERVOUS SYSTEM. Symptoms.—These will be described in detail in the chapters on the special forms. The dominant symptom is, of course, pain. This pain is sharp, darting, boring, stabbing, or burning in character. It comes on in paroxysms of great intensity. In tha intervals there may be no pain or it may be simply a dull acha The pain runs along the course of certain nerves, it is not confined neces- sarily to them, but may be somewhat diffuse. Pain is increased or brought on by cold or heat, or pressure on the affected part. ■j»Tv— Uiaphragnr* Fig. 46.—Diagrams showing the Distribution of the Cerebro-Spinal Strands of Nerves and the Location of Transferred Pains and Neuralgia. Area I... Area II.. Area III. Area IV. Area V.. Area VI. Area VII Strands of Cerebro-Spinal Nerves. Trigeminus, facial, etc. Upper four cervical. Lower four cervical and first dorsal. Upper six dorsal. Lower six dorsal except last. Twelfth dorsal, four lum- bar. Fifth lumbar and five sa- cral. Distribution. Face and its orifices, anterior scalp. Occipital region, neck. Upper extremities. Thoracic wall. Abdominal wall, upper lumbar, upper lateral thigh surface. Lumbar region, upper gluteal, ante- rior and inner thigh and knee. Lower gluteal, posterior thigh, leg. DISEASES OF THE PERIPHERAL NERVES. 83 The skin and nerves are sometimes tender or even exquisitely sensitive. Firm pressure, however, is usually not painful. In about half the cases of long standing, tender points may be found which correspond to the exit of nerves from a bony canal or the substance of a muscle or fascia. In rare cases there is ten- derness over the spine corresponding to the point where the affected nerves arise. Besides feelings of pain, there is often a sense of numbness, coldness, tingling, or heaviness of the limb. Vasomotor, secre- tory, and trophic disturbances may occur; but when these are pronounced, one must suspect neuritis or an organic central dis- ease. Muscular spasm is sometimes present; more rarely there is some muscular weakness. The paroxysms of pain may intermit regularly; sometimes they come on every day, at the same hour. They are apt to be worse at night. The attacks of the disease often run a course of several weeks or months, and in some forms they last for years. Pathology.—Many cases that used to be called neuralgia are now known to be forms of neuritis, e.g., sciatica and brachial neural- gia. Other forms are sometimes due to impaired nutrition of the nerves from an obliterating arteritis (tic douloureux); still others are due to the irritation of nerves from the diathetic poison of gout, rheumatism, and diabetes, or to extrinsic poisons, such as alcohol, lead, and arsenic. In these cases the sensory nerves of the nerve sheaths (nervi nervorum) are affected. There remain many cases in which the trouble shifts from one locality to an- other, or in which no special local or general irritation can be discovered. In these cases we assume that the pathogenic focus is the spinal ganglia or the sensory cells of the posterior horns of the spinal cord. Lesions and irritations of the sensory path above the sensory cells referred to rarely cause pain. There are some forms of neuralgia which may be called " rem- iniscent " or " hallucinatory." The patient, who is an impression- able and sensitive person, has had a genuine cause for neuralgic pains; but this, after lasting some time, has ceased, while the painful impressions continue to remain in the cerebral cortex. The neuralgia is a morbid habit of feeling pain. Such neuralgias are promoted often by the use of morphine. The Diagnosis. —This depends on the fact that neuralgic pains are shifting, paroxysmal, follow the course of nerves, are accom- panied often with tender points and not accompanied with signs of organic nerve disease, such as paralysis and anesthesia and tenderness over the nerve trunks. Thermic sensations of burning or coldness are rarely neuralgic, but are due to neuritis. The prognosis is good, except for the reminiscent neuralgias, 84 DISEASES OF THE NERVOUS SYTSTEM. the neuralgias of hysterical and neurasthenic persons, who are thoroughly anemic, debilitated, and broken down morally and physically. The neuralgias of the degenerative period of life are also very obstinate. The treatment will be discussed under special heads. The Parjesthesic Neurosis (Paresthesia, Numb Hands). This is a not uncommon disorder, characterized by very per- sistent symptoms of numbness, formication, or burning, with little or no pain, and with or without motor weakness. It is a trouble allied to the waking numbness just described. Etiology.—The disease occurs in adult life, and oftenest at or after middle life. Women are oftenest affected, and especially those of nervous temperament, with dyspeptic and rheumatic tendencies. The symptoms are not seen in children or in the aged. They are more marked in the warmer season, and women who wash a good deal are somewhat more subject to them. The dis- order is more frequent in cities. Symptoms.—The patients have feelings of numbness, prickling, heaviness, usually in both hands, extending a little way up the forearm. The sensations are, as a rule, diffuse, but may follow the distribution of a nerve, especally the ulnar. In other cases the numbness is sharply limited to the finger-tips or the second and third phalanges. There is no actual pain or tenderness, nor is there any anesthesia, cutaneous or muscular. Instead of or with the numbness there may be burning sensations, especially felt in the palms or soles. There is often a slight degree of paralysis, but rarely any decided vasomotor or trophic changes. The symp- toms exacerbate, being worse at certain periods of the day, usu- ally in the morning. They may increase at night and prevent sleep. The arms are oftener affected than the lower extremities; and the disease never takes a hemiplegic form, though one arm may be alone involved. The scalp and ears may be involved, though always in a minor degree, the patient complaining of sensations of heat, prickling, flushing, and vertex pressure. Sometimes the knee jerk disappears. The symptoms cause a condition of men- tal unrest and nervousness which add to the sufferings materi- ally. Evidences of overwork, of dyspepsia and constipation, of anemia, or of muscular rheumatism will generally be found. The urine is usually rather light in color and specific gravity (1010 to 1018), slightly cloudy, with excess of phosphates and oc- casional excessive discharges of urates. Pathology.—The pathology is based upon the similarity of the symptoms to those in mild or incipient cases of multiple neuritis DISEASES OF THE PERIPHERAL NERVES. 85 and upon the effects of drugs in relieving symptoms. It is be- lieved that the peripheral nerves are being irritated by some poison circulating in the blood. Co-operating with this are nerves naturally over-irritable, or made so by anemia, hyperemia, and exposure to cold. Diagnosis.—This disease is to be distinguished from hysteria, neurasthenia, and central organic diseases of cord or brain. In hysteria the symptoms are less diffuse, regular and bilateral, while some anesthesia is rarely absent. Paresthesie are very common in neurasthenia, and in some cases here they are due, no doubt, to peripheral irritation. In neurasthenia, the paresthesie are, however, generally in one extremity, less diffuse and as a rule more temporary. There is no motor weakness, and the head and spine are usually complained of more than the arms or legs. Waking numbness and night palsy are intermittent disorders, disappearing within a short time after waking or rising from a recumbent posture. The numbness that is felt with digiti mortui and Raynaud's disease is accompanied with spasm of the blood- vessels and whitening of the fingers. Prognosis and Course.—The disease, if not treated, runs a course of several months, with some intermissions and relapses. It may disappear, to return the next year. It never progresses to any serious condition, and is in almost all cases eventually cured. Treatment.—The patient should receive alkalies, with bro- mides, pepsin, iron, and strychnia. The faradic current, massage, and stimulating liniments are useful. Rest and removal from ex- citing causes, such as exposure, are also indicated. 3. Neuroses of Mixed Origin Affecting the Extremities (Acro-Neuroses). There are certain nervous disorders which affect the extremi- ties. They involve the motor, sensory, vasomotor, secretory, and trophic nerves in various degrees. They are sometimes of central and sometimes of peripheral origin; but as the pathology is lit- tle known, they are best given a clinical classification and placed under the head of peripheral diseases. The acro-neuroses here considered are: Raynaud's disease and digiti mortui. Podalgia, luxation neuralgia. Erythromelalgia. Symmetrical Angio-Neurotic Gangrene, or Raynaud's Disease. (Abortive Form Known as Digiti Mortui.) Symmetrical gangrene or Raynaud's disease is a rare affection characterized by spasm of the vessels of the extremities, coldness, pallor, waxiness of fingers or toes, or by blueness, mottling, swell- 86 DISEASES OF THE NERVOUS SYSTEM. ing, pain, followed often by a dry gangrene of some of the fingers or toes. Etiology.—The disease occurs usually in children and young adults. Women are affected oftener than men. Anemia, and chlorosis, and neurasthenic states predispose to it. Malarial in- fection, acute infectious fevers, menstrual disorders, fright, oc- cupations that lead to exposure, such as washing, are causative factors. Diabetes and syphilis are also put down as causes. The disease comes on rather suddenly and affects oftenest two or three fingers of both hands. In its early and mild degree there is simply a coldness, numbness, and waxy pallor of the fingers. The skin looks shrunken. There is slight anesthesia. They feel Fig. 47.—Hand and Foot in the Gangrenous Stage of Raynaud's Disease. as if dead. After a few hours this passes away, but returns again and may finally become an almost constant condition. Begin- ning in one or two fingers, it may finally involve all. The toes, tip of the nose, and ears may be similarly affected, though this is rare in the milder form. Exposure to cold, even slight, is the common excitant of this form of the trouble, which is commonly known as " digiti mortui," " dead fingers," or " local syncope." In severer grades the fingers become blue, swollen, and there are burning sensations and much pain, but no anesthesia. This condition is known as that of " local asphyxia," and it is usually followed by gangrene. In the gangrenous stage small blisters appear on the distal phalanges, which fill with bloody serum, then dry up, and beneath DISEASES OF THE PERIPHERAL NERVES. 87 the scab ulceration begins, which is shallow and soon heals, leav- ing a scar. The process then stops. In very rare cases the whole tip of the finger or toe, including the bone, becomes involved. The process as stated may attack the ears, lips, tongue, and even parts of the trunk. Along with this gangrenous process there is often a hematuria. The dead-finger trouble may last but a few days or weeks, or it may continue for months. The gangrenous stage lasts about three weeks. It lasts longer if it comes on in one finger after the other. The disease is one of months, and it is liable to recur. The diagnosis must be made from senile gangrene, frost-bite, ergot-poisoning, alcoholic neuritis, endarteritis, and obstruction of nutrient vessels. Pathology.—A neuritis has been found in some cases of so- called Raynaud's disease, but this is secondary. In a few other cases there has been found an obliterating endarteritis (Jacoby). The trouble is in some cases apparently functional and due to the combination of an over-sensitive nervous system and some irritant, such as impoverished blood, malaria, or other toxic agent, which causes spasm of the peripheral vessels. Prognosis.—The cases usually get well. In only the rarest in- stances has death occurred, and then from some complication. Treatment.—Galvanism to the spine and limbs, warm applica- tions, anodynes, tonics, are indicated. Nitroglycerine, the iodides, chloral may be tried. No specific is known. Pains in the Feet of Various Origin (Podalgia). 1. Pains of diathetic, toxic, or neuralgic origin. 2. Pains of reflex origin. 3. Pains of mechanical origin. 1. Pedal pains occur in gout, rheumatism, lithemic states, syphilis, tabes, chronic alcoholism, and diabetes. The pains of latent gout, according to Anstie, are generally located in the dor- sum of the foot. Those of chronic alcoholism have been observed to occur in the wrists and ankles. Those of lithemia are usually in the heels. In syphilis a node can generally be discovered. A differential diagnosis is therefore possible. Erythromelalgia (red neuralgia of the feet, congestive neu- ralgia) is a disease affecting the feet chiefly, and characterized by burning pains and congestion of the parts. The disease occurs usually in men in middle life, after a low fever or severe physical exertion afoot. The disease begins in the ball of the foot or the heel with a pain, which is worse at night. It increases until nearly the whole sole in the distribution of the plantar nerve is involved, and the 88 DISEASES OF THE NERVOUS SYSTEM. pain, though worse at night, is almost continuous. It is much increased by exertion, the feet become very tender, and standing or walking is most painful. Meanwhile there has developed with the pain a flushing of the part upon exertion. In bad cases the parts most affected are continuously marked by a dull, dusky, mottled redness. The hands may be slightly affected. Slight injuries may cause blisters and even ulcerations. The congestion usually disappears in the horizontal position, and this also relieves the pain. The symptoms are worse in warm weather. The disease is very chronic and, though not dangerous to life, makes life very miserable. Pathology.—In the cases of erythromelalgia as described by Mitchell and others, there is: (1) A vasomotor neurosis; (2) a plan- tar neuritis; and (3), in rare instances, spinal cord disease. The diagnosis must be made from alcoholic and gouty pares- thesia, podalgia, local disease of bone and ligaments and from reflex pains. Treatment.—Elevation of the feet and applications of cold give temporary relief. Faradization has sometimes given help; oftener it has not. There is nothing known which gives perma- nent relief. The physician must rely upon rest, bandaging, cold, anodyne applications, hydrotherapy and tonics. The salicylates, turpentine, and mineral acids with strychnia may be given. 2. Reflex or referred pains in the feet are very common. The cause is usually some form of irritation of the genito-urinary tract, such as gonorrhoea, stricture of the urethra, vesical calcu- lus, cystitis, or renal calculus. It may be a misplaced or pregnant uterus. 3. Pains of mechanical origin: (a) Morton's neuralgia. (&) Tarsalgia, or policeman's disease. (a) Morton's neuralgia, so called, is a neuralgia affecting the metatarso-phalangeal joint of the third and fourth toes, and is due, it is thought, to a slight luxation, with consequent pressure on a digital branch of the external plantar nerve. It sometimes affects other toes, however. It is not always due to a luxation. Incipient flat-foot may cause it, and I have seen a typical case in a pregnant woman, disappearing after confinement. The trouble occurs generally in women, and if there is a luxation the cause is external injury or shoe-pressure. Treatment is not very satis- factory. It should be directed to giving rest to the foot, and the avoidance of lateral pressure on the joints by wearing a broad- soled shoe with support to the arch of the foot. Support may also be given by a broad flannel bandage. Amputation of the toe has cured one case. (&) Tarsalgia (policeman's disease) is a neuralgic affection, DISEASES OF THE PERIPHERAL NERVES. 89 due probably in most cases to an incipient flattening of the foot and stretching of the plantar ligaments. Some have ascribed it to a deep-seated contusion of the adipose cushion covering the os calcis. Probably the condition varies somewhat in different cases. It is observed in persons who have been in the habit of going barefoot, and have then gone into the army or taken civil posi- tions obliging them to stand or walk a great deal. It occurs in the policemen of Paris, and but few cases have been seen in this country. This is due to the difference in the shoes and in the gait of American and Parisian guardians of the peace. The name tarsalgia was given by Duchenne. Treatment, medical or surgical, seems to do little for the dis- order, which is very chronic. Patients are better in cold weather, and when resting the feet. Leeches, the cautery, the iodides, and broad shoes with rubber heels are serviceable. Tumors of Nerves. These consist of: 1. Nerve hyperplasia. 2. True neuromata. ) Single. „ .. ' , 3. False neuromata, f,, u. , , -d ; Multiple. ■{ Benign. 1. Hyperplasia or hypertrophy of nerve trunks is very rare. Generally the increase in size is, in fact, due to increase of the interstitial connective tissue. Sometimes there is an increase in the number of fibres and thickening of the myelin sheath. 2. True neuromata are also very rare, and occur almost exclu- sively on spinal nerves. In some there is an increase in medul- lary fibres; in others only an increase of non-medullated fibres, i.e., only the axis cylinders and neurilemma increase. They occur either singly or multiply. 3Iultiple neuromata are generally of a neuro-fibromatous character. Neuro-fibromata when multiple may affect the subcutaneous nerves and form growths known as fibroma molluscum. Nerve fibres united in a mass by hyperplastic connective tissue form what are called plexiform neuro-fibromata. Multiple neu- romata may be true neuromatous growths. True neuromata are usually small, ranging from 1 cm. (two- fifths of an inch) to 6 cm. in diameter. They may be much smaller or larger. Neuromata are usually few in number, or at least there is only a local multiplicity of tumors. Multiple (true) neuromata may, however, be very numerous. Gowers estimates in one case that as many as one thousand were present. Even larger numbers have been observed. 90 DISEASES OF THE NERVOUS SYSTEM. 3. False Nenrom ata.—This term is applied to the various nerve tumors in which a fibroma, myxoma, glioma, sarcoma, carci- noma, or syphiloma grows upon or in the nerve. Fibro-neuroma is the most common form; glio-neuroma has been observed on the auditory nerve. Syphiloma occurs only on the intra-cranial or intra-spinal nerves. Carcinoma of nerves may be primary, but is generally secondary, and is of scirrhous or medullary type, rarely the colloid. Leprous neuritis sometimes forms neuro-fibromatous swellings. Tubercula dolorosa are simply small false neuromata situated subcutaneously on the ends of the sensory nerves. They vary much in histological structure. Malignant Neuromata.—A few cases, about thirty in all, have been observed of multiple malignant neuromata. Trauma and hereditary influence are the etiological factors. The great nerve trunks are oftenest affected, the median, sciatic, and crural rank- ing first. The tumors start from the perineurium; they are at first spindle-shaped, and may grow very large. Sarcomatous cells are of tenest found in them; but they may be myxomatous, fibrom- atous, or mixed. Etiology.—Three general causes exist for the production of neuromata, viz.: 1. A hereditary or a neuropathic predisposition; this tends to cause the true, the multiple, and the plexiform neuro- mata. 2. Injuries, surgical operations; these cause especially the fibro-neuromata of which the amputation neuroma is an example. 3. Diathetic, e.g., tubercular, influences and whatever produces the various tumor formations, sarcoma, carcinoma, form the third etiological factor. Neuromata of the plexiform type are often congenital. Multiple neuromata may develop early in life. Men are far more subject to multiple neuromata than women. Symptoms.—Neuromata often cause no symptoms. Perhaps the most frequent evidence of their presence, however, is pain and some tenderness. The pain is exacerbating, and may be stopped sometimes by pressure on the nerve above the tumor. Paresthesia, anesthesia, paralysis, and reflex spasm may be pres- ent. Some forms of intractable headache are possibly due to multiple neuromata. Multiple and plexiform neuromata cause symptoms less often than a single larger neuroma. A neuroma on the pneumogastric or other splanchnic nerve may cause severe symptoms. Multiple (true) neuromata may last for years and cause no serious inconvenience. Malignant neuromata cause al- ways such symptoms as would naturally follow irritation and compression of a nerve. The diagnosis of neuroma can only be certainly made when the tumor can be felt. In other cases, by exclusion a fairly cer- tain conclusion may be reached. DISEASES OF THE PERIPHERAL NERVES. 91 True neuromata are often multiple; the false rarely. Idiocy, heredity, neuropathic constitution, scrofula, would all favor the view of the disease being a true neuroma. The treatment is essentially surgical. Internal medication and external applications are of little value. Strong galvanic cur- rents, mercury, and the iodides in large doses may be tried in true neuromata and fibro-neuromata. Both true and false neuromata may return after extirpation. CHAPTER VII. DISEASES OF THE SPECIAL NERVES. The peripheral nerves are the cranial, the spinal, and the off- shoots of the cranial and spinal, known as the sympathetic. I shall take up first the cranial nerves. The Cranial Nerves. These consist of twelve pair, viz.: I. The olfactory. II. The optic. III. The motor oculi. IV. The patheticus or trochlear. V. The trigeminus. VI. he ab- ducens. VII. The facial. VIII. The auditory. IX. The glosso- pharyngeal and nerve of Wrisberg. X. The vagus. XI. The ac- cessory vagus or spinal accessory. XII. The hypoglossal. The first two are not strictly nerves, but rather parts of the brain. The remainder are analogous to spinal nerves, and arise from the mid and hind brain. Anatomy and Physiology.—I. The olfactory nerve consists: 1. Of peripheral fibres which are distributed to the superior and middle turbinated bones and upper part of the septum. They are connected with olfactory cells lying in and beneath the mu- cous membrane. They are about twenty in number on each side. They are non-medullated. They pass up through the cribriform plate of the ethmoid bone and enter the olfactory bulb (Fig. 48). 2. The olfactory bulb is in man a rudimentary organ containing a few nerve cells, peculiar bodies, perhaps of neuroglia tissue, called glomeruli, connective tissue, and nerve fibres. It is analogous to a spinal ganglion or to a nucleus of origin of a nerve in the cord or medulla. 3. The olfactory tract, wrongly called a nerve, is composed of cortical nerve cells and of nerve fibres. It has three roots, the lateral, middle, and mesial. In man, only the lateral is of im- portance. This passes along the margin of the anterior perforated space to the uncinate gyrus, hippocampus, and cornu ammonis. Some fibres also pass inward into the anterior commissure, connect- ing the tract and cortex of the opposite side (Fig. 48). 4. The fourth DISEASES OF THE SPECIAL NERVES. 93 Fig. 48. Fig. 49. Fig. 48.—Diagram of Olfactory Nerves and Connections. Fig. 49.—The Optic Nervb and its Central Connections (modified from Obersteiner). R, Retina, dark on the side connected with left hemisphere; No, optic nerve; CA, chiasm; Tro, optic tract; CM, Meynert'scommissure; CG^udden'scom- missure; Tho, thalmus; Cgl, corpus genie, ext.; Qa, corpor. quad.; Ss, optic radia- tions; Co, occipital cortex; Lm, mesial lemniscus. (The shading of the retina and visual field should just reach the vertical lines.) The sense of smell is rudimentary in man, yet it is still the sense by which we can appreciate the most attenuated matter; for the trillionth of a grain of mercaptan, which awakens a sensation in the mind, has weight and dimensions so infinitely minute as to be quite beyond the power of the imagination to grasp. According to Valentin, we can perceive rsTshsirs °f a grain of oil of roses. According to Fischer and Penzoldt, one can per- ceive ■s^TnsVffTnrff of a grain of mercaptan. I have found that one can perceive the odor from 4 cm. of a solution of oil of cloves 1 94 DISEASES OF THE NERVOUS SYSTEM. to 100,000. Matter to be perceived as odor must be in a gaseous form. Odorous sensations co-operating with taste sensations form "flavor." Variety in odorous sensations depends probably upon the rapidity of molecular vibrations as in the case of light; and substances having similar relations in vibration have similarity in odor (Haycraft). Males have a more delicate sense of smell than females (Nicolls and Bailey). The keenness of the olfactory sense is lessened in the insane and criminal classes. II. The optic nerve, so called, is really a central tract of the brain, like the olfactory nerve. Traced from without inward, we find the following parts: 1. The rods and cones, with the filaments connecting them to the ganglionic cells of the retina, really form all that there is of a peripheral optic nerve. These rods and cones number about 3,360,000. 2. From the ganglionic cells of the retina, fibres collect and pass into the cranial cavity as the optic nerve. This nerve con- tains about 438,000 fibres. They are smaller than other nerve fibres, and are distinguished from them by having a neuroglia imbedding substance and by having no neurilemma. 3. The optic nerves pass to the optic chiasm, where about one- third of the fibres cross, in man. In lower animals the decussa- tion is greater. After leaving the chiasm, the fibres form the optic tract. This tract curves up and back around the crus cerebri, and divides into a lateral and mesial root. 4. These roots connect with the external geniculate body, the anterior tubercles of the corpora quadrigemina, and the posterior ganglion of the thalamus or the pulvinar. These ganglia are called the primary optic centres. Through the anterior tubercles of the corpora quadrigemina, and by other means, the optic nerve is con- nected with the oculomotor nerve, and thus reflex movements of the pupils, lids, and eyeballs are brought about (Fig. 49). 5. From these primary optic centres, fibres enter the posterior part of the internal capsule, curve up and back toward the occip- ital lobes, forming the optic radiations of Gratiolet (Ss). 6. They are finally distributed to the cortex of the occipital lobe, and in man chiefly to the cuneus and the upper end of the first occipital gyrus. It will be seen that each retina is connected with the occipital lobe of both hemispheres. It is further known that the outer or temporal half of each retina is connected with the occipital lobe of the opposite hemisphere, and the inner or nasal half of each retina with the occipital lobe of the same side. Further, the upper part of each retina is connected with the lower half of the cuneus, and vice versa (Fig. 49). Other connections exist by which the optic centres on the two DISEASES OF THE SPECIAL NERVES. 95 sides are connected with each other and with other cranial nerves in the medulla. The optic nerve is a nerve of special sense of vision and has no other function except that of an excito-reflex character. III., IV., VI. The motor nerves of the eye are: (a) The third or oculo-motorius, supplying the internal supe- rior and inferior recti, inferior obliquus, the levator palpebre, the ciliary muscle, and constrictor of the iris. (b) The fourth or trochlearis, supplying the superior oblique. b# oVIN Fig. 50. Fig. 51. Fig. 50.—Diagram showing the Arrangement of the Nuclei of the Motor Nerves of the Eye, and the Decussations of the Fourth and Internal Rec- tus Branch of the Third Nerve. Fig. 51.—Diagram showing the Probable Relations of the Nuclei of the Sixth and of the Internal Rectus Branch of the Third to the Brain. (c) The sixth or abducens, supplying the external rectus. (d) The sympathetic, consisting of fibres from the upper cer- vical nerves to the dilators of the iris, to its blood-vessels, and to Muller's muscle. 2. Motor fibres from the nucleus belonging to the third nerve and running out with the fibres of the seventh (Mendel), supplying the orbicularis palpebrarum. The third and fourth nerves arise from a series of nuclei in the floor of the aqueduct of Sylvius. They leave the brain at the anterior edge of the pons. They run in the cavernous sinus and enter the orbit through the sphenoidal fissure. The sixth nerve arises from a nucleus in the floor of the fourth ventricle. It emerges at the posterior edge of the pons, runs in 96 DISEASES OF THE NERVOUS SYSTEM. the cavernous sinus, and enters the orbit through the anterior lacerated foramen. The nuclear gray matter from which these nerves arise is: made up of a series of nests of cells, and each pair supplies a differ- ent set of muscles of the eye, as shown in the diagram. The nucleus of the sixth lies farther back in the floor of the medulla, but it belongs to the same serial deposit of gray matter, and represents the continuation of the anterior horn of the spinal cord (Fig. 51). The motor nerves of the eye, third, fourth, and sixth, are closely connected with each other and other nerves by a long commissure, the posterior longitudinal bundle. The fibres of the third and fourth nerves pass to their nuclei on the same side, then decussate and pass up in the inner part of the crusta to the lower part of the central convolutions of the cortex. A few fibres decussate and enter the nuclei of the oppo- site side. They are connected with the internal rectus nucleus. The fibres of the fourth nerve almost entirely decussate, run- ning forward a long distance before they finally reach their nuclei. Thus it appears that the abducens is the only cranial nerve except the optic which largely decussates before reaching its nucleus. However, those fibres of the third which supply the internal rectus also decussate, as already stated. The arrangement of the nuclei is believed to be about as fol- lows, the upper on the list being anterior; Median line. f Sphincter iridis, Ciliarius. Levator palp., Rect. int. """*"] Rectus superior, Rect. inf. Obliquus inf. IV. N. | Obliquus superior. VI. N. -J External rectus. In order to understand the peculiarities of eye palsies, to be described later, the relations of the sixth to that nucleus of the third nerve which innervates the internal rectus must be under- stood. In turning the eyes to one side, these two nuclei and their nerves act together, causing the external rectus of one eye and the internal rectus of the other to contract at the same time. The impulse from the brain which does this acts first upon the sixth, and through this upon the internal rectus nucleus of the same side. The fibres from this nucleus cross and emerge in the third nerve fibres of the opposite side to the sixth nerve nucleus. This can be better understood by the diagram, Fig. 51. DISEASES OF THE SPECIAL NERVES. 97 Thus lesions in the brain (at a) cause paralysis of the sixth nerve of the opposite side and internal rectus of the same side. The eyes turn toward the side of the lesion. Lesions in the pons (at b) cause paralysis of the sixth on the same side and internal rectus nucleus of the opposite side. The eyes turn away from the side of the lesion. The eye muscles move the eyeball in the following way: The superior rectus elevates the eyeball. The inferior oblique rotates out and up. The inferior rectus depresses the eyeball. The superior oblique rotates out and down. jV. suprotroch Obi- super V. eupraorb. Rect. sup, Levator.- p.- ,V. t'nfrolroch.^---77 FecU'jxed.^--- Beet. inf. ' N. supramax. Fig. 52.—The Attachment of the Eve Muscles to the Globe (Merkel). The superior and inferior oblique, acting together, rotate in- ward. The external rectus rotates outward. The internal rectus "rotates inward. The rectus internus, rectus superior, obliquus inferior, rotate upward and inward. The rectus internus, rectus inferior, obliquus superior, rotate downward and inward. The rectus externus, rectus superior, obliquus inferior, rotate out and up. The rectus externus, rectus inferior, obliquus superior, out and down. The movements of the eyeball are made by the simultaneous action of several muscles. Most of them act as their names indi- cate. But the oblique muscles help to depress and elevate, and 7 98 DISEASES OF THE NERVOUS SYSTEM. then help to rotate in or out according as the internal or external rectus is acting. The cortical centres for the eye muscles are not positively known. Lesions in the inferior parietal lobule sometimes cause paralysis of the third nerve. Lesions of the posterior part of the prefrontal lobes also sometimes cause eye palsies, especially con- jugate deviation. As the optic nerve is the special sensory nerve of the eye. so the third, fourth, sixth, and part of the seventh nerves are the motor nerves. By means of the optic nerve and its receptive and refractive apparatus, the form, color, movement, and, to some extent, rela- tions and distance of objects are determined. The motor nerves Fig. 53.—The Superior Maxillary Division of the Trigeminus (Young- Baker). adjust the eye to near and distant objects, inform us as to size and distance, and enable us to follow moving objects and to shift the gaze readily. They also assist in protecting the eye against injury. V. The trigeminus or fifth nerve is one of the most extensively distributed and most delicately sensitive nerves of the body. Its sensory branches represent the atrophied and lost sensory roots of the third, fourth, sixth, seventh, and twelfth cranial nerves (Gaskill). It has a most extensive primary origin by three principal roots; (1) The ascending, which begins in the upper part of the cervical cord at the level of the second cervical segment; (2) the descend- ing, which rises in the gray matter about the aqueduct of Sylvius as high up as the anterior corpora quadrigemina; (3) the middle, which arises from a nucleus in the pons near the level of the DISEASES OF THE SPECIAL NERVES. 99 nerve's exit. The ascending root is mainly sensory; the descend- ing, sensory and trophic; the middle, motor and sensory. The gray matter from which the trigeminus arises reaches the whole length of the pons and medulla, and is coextensive with the origin of all the other cranial nerves (Fig. 57). Hence the frequency with which its disorders are complicated with those of these nerves. Its cortical origin is probably in the lower part of the pre- and post-central convolutions. The trigeminus supplies sensation to the face, nose, the frontal and maxillary sinuses, the teeth, the palate, tongue, and part of the upper pharynx; also to the scalp as far back as the vertex Gasserian ganglion Fig. 54.—The Inferior Maxillary Division of same (Young). and to the external auditory meatus. It gives sensation also to the anterior three-fourths of the dura mater, the falx, and probably the tentorium. The pia and arachnoid are not sensitive. The posterior fossa and the occipital part of the dura mater are sup- plied by the vagus. The trigeminus also supplies the above-named parts with trophic, vasomotor, and secretory fibres. The vaso- motor fibres are brought to it from the medulla and cervical spinal cord via the sympathetic; the secretory fibres have the same origin. Both are reinforced by the four ganglia with which this nerve are in close connection. An exception is to be made of the lachrymal fibres which are brought by the motor nerves of the eyeball. The trigeminus supplies motion to the muscles of mastication, viz., the two pterygoids, the temporal, masseter, mylo-hyoid, and anterior belly of the digastric. 100 DISEASES OF THE NERVOUS SYSTEM. VII. The facial nerve has its primary origin in a single nucleus deeply situated in the lower part of the pons. It belongs to the same series of nuclei as the motor nuclei of the vagus, glosso- pharyngeal, and of the spinal accessory; in other words, it is a prolongation of the lateral horn of the spinal cord. It has not a nucleus common to it with the sixth, as is usually stated. Those fibres of the nerve which go to the orbicularis, however, appear to come from a nucleus in the third nerve series and to reach the knee of the facial by the posterior longitudinal bundle (Mendel). The deep fibres of the facial take a tortuous course, passing inward, dorsally, then curving down and out around the nucleus of the sixth nerve. The cortical origin of the seventh is in the lower part of the central convolutions, especially the precentral. The fibres pass down in the crusta at the inner side of the pyramidal or motor tract. They decussate and reach the nucleus. The nerve has its exit at the posterior edge of the pons, external to the sixth nerve. It then has to take a long course through a bony canal, during which it receives taste fibres from the second branch of the trigeminus (or the glosso-pharyngeal). These fibres leave the nerve as the chorda tympani, and join the lingual branch of the fifth nerve to supply taste to the anterior two-thirds of the tongue. The facial nerve supplies motion to all the muscles of the face; to the stapedius, stylo-hyoid, buccinator, and platysma myoid. It also contains trophic and secretory fibres. It does not supply, however, the muscles of mastication. The taste fibres of the facial nerve apparently come in many cases from the second branch of the fifth via Meckel's ganglion, the large superior petrosal nerve, and geniculate ganglion. In other cases they come from the glossopharyngeal nerve via the ganglion petrosum, Jacobson's nerve, tympanic plexus, and genic- ulate ganglion. Some think that the intermediary nerve of Wris- berg, which arises in the upper part of the glosso-pharyngeal nucleus and connects with the geniculate ganglion, carries taste fibres to the facial. VIII. The auditory or eighth cranial nerve has two different parts. One portion passes to the cochlea and utricle and saccules; it has to do with the sense of hearing; the other goes to the semi- circular canals, and has to do with that sense by which we ap- preciate position of our body and its relations to space. The eighth nerve is thus an auditory and a space-sense nerve. The auditory fibres enter the medulla by two roots, a lateral or posterior and a median or anterior. The lateral root has mainly auditory fibres. The space-sense fibres enter chiefly by the median root. These roots are connected with three nuclei, viz.: (1) The chief nucleus (dorsal, central, inner nucleus); (2) the DISEASES OF THE SPECIAL NERVES. 101 Carotid i.u„ Spheno- lUB palatine G. large-celled nucleus (Deiter's); and (3) the accessory nucleus (ven- tral, anterior, lateral). The chief nucleus (1) is a large mass of gray matter composed of small nerve cells and lies superficially just beneath the floor of the fourth ventricle. The large-celled nucleus (2) lies to the outer side of and below it. The accessory nucleus (3) lies in the substance of the lateral root, and between it and the median root. The lateral root is the one coming chiefly from the cochlea, and is, as stated, mainly a nerve of hearing. It is connected most ex- tensively with the accessory nucleus, but also with other nuclei. Through the acces- sory nucleus, it con- nects by a few fibres with the superior olives mostly of the opposite side; thence fibres pass up through the lateral lemniscus, to the posterior corpora quadrigemina; thence to the cortex of the first and second convolutions of the tempero- sphenoidal lobes. Other fibres pass up directly through the lemniscus and the tegmental or sensory tracts to the cortex of the temporal lobes. Connections are numerous, also, with other cranial-nerve nuclei. The lat- eral root also sends fibres to the chief nucleus and (via the strie acustice) into the raphe,and thence to the formatio retic- ularis and sensory tract. These fibres go also to the posterior tubercles of the cor- pora quadrigemina and thence to the cortex of the temporal lobe. The median root is connected chiefly with the large-cell nucleus (2), but also with the chief nucleus (1). From these nuclei fibres pass up in the posterior cerebellar peduncle through the direct sensory tract of the cerebellum to the roof nucleus or the emboli- form and globose nuclei. IX. The glosso-pharyngeal nerve arises from three nuclei in Glossopharyngeal Nerve (Young). 102 DISEASES OF THE NERVOUS SYSTEM. the medulla: (1) The sensory or perhaps visceral nerve cells an- alogous in character to those of the column of Clark in the spinal cord. (2) A true sensory nucleus consisting of a long, thin de- posit of gray matter continued from the posterior horn of the spinal cord, and associated with a strand of nerve fibres called the ascending root of the vagus and pharyngeal nerves or respi- ratory bundle. (3) A motor nucleus which is called the nucleus ambiguus, and is a continuation of the lateral horn of the spinal cord (Hill, Gaskill). The nerve, therefore, has motor, sensory, and probably visceral fibres. It supplies general sensation to the tympanum and pharynx (in connection with the vagus) and upper part of the larynx; special sensation of taste to the posterior third of the tongue, and motion to the pharyngeal muscles in connection with the vagus. Its cortical representation so far as taste is concerned is in the hippocampal gyrus. The nerve gives very sensitive reflex fibres to the pharynx and is important in the reflex act of deglutition; it also carries sensations of nausea from pharyngeal irritation. X. The vagus nerve arises from three nuclei in a way entirely similar to that of the glosso-pharyngeal. 1. The sensory and visceral nucleus. 2. The motor nucleus, called the nucleus ambiguus, which is a prolongation upward of the lateral horn, and is common to it and the glosso-pharyngeal. 3. The sensory nucleus, which gives off the fibres of the as- cending root of the glosso-pharyngeal. The nerve is closely connected with the glosso-pharyngeal above and with the accessory (eleventh) nerve below. The accessory portion of the spinal accessory is practically a part of the vagus, and both in mode of origin and function re- sembles it closely. It arises from a nucleus which lies in the floor of the fourth ventricle, and is continuous brainward with that of the vagus. It consists of small cells giving origin to fibres that are small in size and have sensory, vasomotor, visceral motor, secretory, trophic, and excito-reflex functions. The vagus and accessory part of the eleventh together have an extraordinarily wide distribution and diversity of function. 1. First they contain motor, inhibitory, and vasomotor fibres. These fibres go to the pharynx, larynx, trachea, and bronchi; to the oesophagus, stomach, small intestines, and spleen. 2. Sensory fibres, which go to the occipital and transverse sin- uses and dura mater of the posterior fossa, to the external audi- tory meatus in part, to the pharynx, larynx, and trachea, and to the oesophagus. 3. Excito-reflex fibres, which go to the lungs and heart, DISEASES OF THE SPECIAL NERVES. 103 stomach, and to other organs mentioned as supplied by the vagus with sensation. These reflex fibres stimulate or inhibit the vasomotor centre, the respiratory rhythm, -^y and the cardiac rhythm. They also excite reflexly deglutition and respira- tory movements. The secretory fibres go to the respiratory tract, oesophagus, stomach, and pancreas and small intes- tines. Cardio-inhibitory fibres go to the heart, while reflex accelerating fibres and inhibiting fibres go to the lungs. The accessory nucleus supplies the laryngeal adductors and the cardio- inhibitory fibres. XI. The spinal part of the spinal accessory arises from the lateral horn and outer part of the anterior horn of the spinal cord. Its fibres of origin extend down as far as the fourth or fifth cervical roots. The fibres unite in the cranium and pass out through the pos- terior lacerated foramen in the same sheath as the vagus. After their exit from the skull, they di- vide into an internal and external part. It is the external branch which contains the fibres of spinal origin. The nerve receives some sensory fibres from the first and sometimes from the second cervical nerve. The terminal branches receive motor fibres from several cervical nerves. The spinal accessory contains large and small or visceral fibres. The spinal part contains only the large fibres. Fig. 56.—The Vagus and Spinal Accessory Nerve (Young). 104 DISEASES OF THE NERVOUS SYSTEM. The spinal accessory supplies the sterno-cleido-mastoid almost exclusively, but only the upper part of the trapezius; the rest of this muscle is supplied by the cervical and dorsal nerves. The sterno-cleido-mastoid, when innervated, draws the chin up and over toward the opposite side. The upper fibres of the trapezius draw the head back slightly and down toward the same side. Physiologically the spinal part of the accessory nerve is one of the motor cervical nerves; the accessory or medullary portion is part of the vagus, and has visceral and sensory as well as motor functions.* XII. The hypoglossal nerve arises from a long and large nu- cleus lying in the lower part of the floor of the medulla near the Fig. 57.—Longitudinal Section showing the Relative Position of the Cra- nial Nerve Nuclei (Edinger). median line and to the outer and ventral side of the central canal. The nucleus is a continuation upward of the anterior horns of the spinal cord and is homologous with the sixth, fourth, and third nerve nuclei higher up (see Fig. 57). It reaches below as far as the decussation of the pyramids and above as far as the glosso-pharyngeal nucleus. A second small-celled nucleus lies just beneath the nucleus proper. Its cortical representation is in the lower end of the central convolutions, to which it is connected by fibres that pass into the raphe and thence to the anterior pyramids. Its fibres pass out between the olivary body and the anterior pyramid. At its origin it is a purely motor nerve; it receives a few sensory fibres from the cervical nerves and the vagus. It supplies the following muscles: * Dees thinks that the spinal origin of the eleventh is continuous above with the twelfth, not with the anterior nucleus of the tenth He denies that the medullary nucleus sends fibres to the larynx. The internal branch of the eleventh sends motor fibres to the rectus posticus (E. Remak). DISEASES OF THE SPECIAL NERVES. 105 Intrinsic muscles of the tongue: superior and inferior longi- tudinal and transverse. The extrinsic muscles of the tongue: hyoglossus, genio-hyoglossus, and styloglossus. (The palato- JFttnt'c restif. VII Fig. 58.—Diagrams showing the Position of the Cranial Nerve Nuclei and the Floor of the Fourth Ventricle (Merkel.) 106 DISEASES OF THE NERVOUS SYSTEM. glossus and Unguals are supplied by the fifth and seventh cranial nerves respectively.) The depressors of the hyoid: the thyro- hyoid and, with the cervical nerves, the sterno-hyoid and sterno- thyroid. The elevator of the hyoid: genio-hyoid. It is also thought to send fibres to the oral muscles (Tooth). The hypoglossal nerve is concerned in the movements of the tongue and in fixing or depressing the hyoid in mastication and deglutition. When diseased, therefore, speech and deglutition are affected. The small nucleus of the nerve is thought to con- trol the finer lingual movements of articulation. CHAPTER Till. DISEASES OF THE CRANIAL NERVES. Diseases of the Olfactory Nerve. The olfactory nerve is affected clinically by loss of function or anosmia, increased sensitiveness of function or hyperosmia, and perversions of function or parosmia. Anosmia is far the most common disorder of olfaction. Etiology.—Its usual cause is disease of the mucous membrane of the nose. Injuries, inflammations, and tumors affecting any part of the course of the nerve, its bulb or central fibres, may also cause it. Unilateral cortical lesions in the uncinate gyrus may lead to partial loss of smell. It will be not entire, because each nerve receives fibres from both hemispheres. Paralysis of the fifth or seventh nerve may indirectly cause some anosmia. Primary degenerative changes and excessive olfactory stimula- tion cause anosmia. There may also be a congenital absence of the nerves. Anosmia occurs sometimes as a pure neurosis in hysteria or in neurasthenic states. Diagnosis.—This is made by test odors. To test the sense of smell, a bottle of oil of cloves or of some familiar non-irritating odor may be used. To detect quantitative disturbance one may use six phials containing oil of cloves, in purity and in watery mixture of 1 to 10, 1 to 100, 1 to 1,000, 1 to 10,000, and 1 to 100,000. Special olfactometers have been devised. The sense of smell for any single odor is lost in about three minutes, but returns after one minute's rest. Treatment.—For functional anosmia, snuffs containing strych- nine gr. ^ and gum acacia 3 ij. can be used. Weak galvanic and faradic currents are recommended. Usually there is in anos- mia a local catarrhal condition of the nose which requires treat- ment. Hyperosmia occurs only rarely and then in neurasthenic, hysterical, or insane persons. In the latter it is more often a psy- chical phenomenon than a peripheral disorder. Hyperosmia can be cultivated, and this is done sometimes by the blind and by those engaged in certain pursuits, such as tea-tasting and wine- tasting. Hallucinations of smell occur in the insane, as just mentioned, 10S DISEASES OF THE NERVOUS SYSTEM. and a few cases of epilepsy are reported in which the cause was a stench. When all olfactory sensations are disagreeable the con- dition is called kakosmia. Parosmia is a not infrequent condition. In it everything smells alike to the patient, and the odor smelled is perhaps a peculiar or offensive one. This condition may be due to local disease, but is often a symptom of hysteria or neurasthenia. Diseases of the Optic Nerve and Centres. The optic nerve may be affected by nearly all forms of patho- logical change. For the neurologist, however, the especially im- portant conditions are inflammations, degenerations, injuries, and functional disorders. In order to understand the descriptions of these diseases, it is necessary to define some of the symptomatological terms used: Astheniopiu is a condition in which exertion of the eyes is wearisome and painful. Amblyopia is a partial loss or dimness of vision in which there are no observable lesions. Amaurosis is a total blindness in which there is no observable lesion. Hemianopsia is blindness of half the visual field. He miopia is a condition in which there is vision in one-half the visual field. Scotoma is a name given to blind spots or areas in the visual field. Inflammation of the nerve, or optic neuritis, may occur as a papillitis or inflammation of the head of the nerve, a neuro-retini- tis or descending neuritis, a perineuritis or a retrobulbar neuritis. Perineuritis is rare. Neuro-retinitis and papillitis are closely associated clinically and pathologically (Noyes), so that practi- cally only two forms of neuritis need be discussed separately. Papillitis and Neuro-retinitis.—Etiology.—The causes in general are tumor and inflammation of the brain, poisons, infections, and auto-toxamiic states. In particular the causes are tumors, abscess of the brain, meningitis, syphilis, myelitis, nephritis, diabetes, infectious fevers, multiple neuritis, lead, and severe hemorrhages. The disease occurs at all ages and in both sexes. In brain tumors it occurs in two-thirds of the cases, and especially often in cerebellar tumors. It occurs in 80 per cent of cases of tubercular meningitis. Symptoms.—Subjective symptoms are often not present. The vision may remain good for a long time. In other cases there are concentric limitation of the visual field, loss of color sense, and scotomata. For a description of ophthalmoscopic changes, the DISEASES OF THE CRANIAL NERVES. 109 reader is referred to special text-books. It is in this condition that " choked disc," which is a papillitis with much serous infil- tration, occurs. The changes are less striking in neuro-retinitis. The disease may affect one or both nerves. In brain disease both nerves are usually involved. Pathology and Pathological Anatomy.—The process is usually subacute or chronic. Congestion, exudation, small hemorrhages, and collections of leucocytes occur. The sheath of the nerve just back of the globe is often distended with a serous exudate. After a time the nerve fibres atrophy, connective tissue prolifer- ates and takes their place, and we have a secondary optic atrophy. Fig. 59.—Neuro-retinitis (Jaeger). The process is essentially peripheral, but it extends back with lessening intensity into the trunk of the nerve. The purely me- chanical theory of neuritis, that it is due to compression, cannot be accepted in the light of modern pathology. It is probable that the neuritis results from an irritating serous fluid which extends down the sheath of the nerve, this sheath being a prolongation of the arachnoid cayity. Mechanical causes lead to constriction, accumulation of the fluid, and compression of the nerve at its periphery, and hence to inflammation. Sometimes, at least, the irritating fluid contains microbes or microbic poisons. Retrobulbar Neuritis.—In this disease the lesion lies chiefly behind the globe. Its causes are especially toxaemia from alcohol and tobacco. It is also due to rheumatic influences, syphilis, lead, and diabetes. 110 DISEASES OF THE NERVOUS SYSTEM. In the acute cases there is usually rather rapid loss of sight, with some pain and tenderness. The ophthalmoscopic changes are relatively slight. In chronic cases, which are usually toxic in origin and due to alcohol or tobacco, or oftenest to both, there are color scotomata or absolute scotomata and amblyopia. There is no pain. The condition is known as tobacco or alcoholic amblyopia. The prognosis of neuritis varies with the cause. If this is removable, as in the toxemia3, recovery is the rule. This is a proof that in neuritis the connective tissue is the part chiefly in- Fig. 60.—Papillitis, "Choked Disc," in a Case of Cerebral Tumor. volved, for a destroyed or atrophied optic nerve does not recover. In many eases, however, atrophy follows the neuritis. The treatment is based on the cause. In acute cases one may use cups, salicylates, the iodides, and mercury; later, the iodides and strychnia. Perfect rest to the eyes should be enjoined. Degeneration of the Optic Nerve, or Optic Atrophy. —This condition may be primary or secondary. Secondary atro- phy is usually the result of a neuritis. I shall describe here pri- mary optic atrophy. Etiology.—It occurs oftener in men than women (three to one). It occurs as part of locomotor ataxia in less than half the cases; other degenerative diseases of the cord, like multiple sclerosis, may accompany it. Next to the spinal cord, it occurs oftenest with degenerative diseases of the brain, such as multiple sclerosis DISEASES OF THE CRANIAL NERVES. Ill and general paresis. Hemorrhages, alcoholism, and lead may be causes. It may occur without known cause. The symptoms are those of gradual decrease of acuity of vision, concentric limitation of the visual field, loss of color sense, dilata- tion and immobility of the pupil. The sense of sight may remain good for a long time. Ophthalmoscopically, the nerve disc is opaque, grayish, or dirty looking, and often has a cup-shaped or " cupped-disc " appearance. The vessels are smaller and few in number. The pathology and pathological anatomy is that of a paren- chymatous degeneration with loss of nerve fibres, which are re- placed by connective tissue. The prognosis is almost uniformly bad. The treatment is that usually of the cerebral or spinal disease. Mercury, iodides, strychnia, phosphorus, and iron are given. Warm baths and salicylate of soda sometimes have a temporarily good effect. Strychnia in physiological doses gives, however, the best symptomatic results. Electricity is not of any use. Stretch- ing the nerve does no good. Eserine, pilocarpine, and santonin or nitrate of silver may be tried. The optic nerves and their primary and cortical centres are subjected to various other diseases. So far as these are organic, they will be described in detail under the head of brain dis- eases. But there are certain symptoms often of functional origin which are best described here. These are: (1) Amblyopia and amaurosis; (2) retinal hyperesthesia and dysesthesia; (3) hemi- anopsia. Amblyopia and Amaurosis.—Etiology.—The causes are inju- ries and shocks, hysteria, migraine, concussion of the brain, light- ning stroke, and severe hemorrhages. There are also certain toxic causes, chiefly alcohol and tobacco, quinine, and salicylic acid. Other causes are glycosuria, uremia, and reflex irritations, especially of the trigeminal nerve. Night-blindness and snow- blindness are forms of functional amblyopia. The symptoms are diminution or loss of vision, usually sudden, temporary, and involving both eyes. Amblyopia in hysteria is usually greater in one eye and associated with concentric limita- tion of the visual field and disturbance of color sense. Underlying functional amblyopia there may be a peripheral anesthesia, a psychical or cortical anesthesia, minute hemor- rhages, causing temporary pressure, vascular spasm, and anemia. The prognosis is usually good. The treatment is purely a causal one. In most cases one must examine for drug poison, uremia, diabetes, migraine, or a hemor- rhage. Retinal or ocular hyperesthesia is a condition in 112 DISEASES OF THE NERVOUS SYSTEM. which the eye is abnormally sensitive to light. It may be due to exposure to extreme light or to seclusion in a dark room. The neurologist sees it oftenest as a symptom of hysteria (vide Hysteria) and perhaps in hypnotic states. It occurs in mydriasis and al- binism. It is not to be confounded with photophobia due to irritation of the conjunctiva. Nyctalopia, or the sense of seeing better in a dim light, is a form of the disease. Hemianopsia or half-sightedness may be due to a functional or organic disorder of the nerve or its centres. It is a symptom of many lesions and conditions and can only be described gen- erally here. Etiology.—Its principal functional causes are migraine, lithe- mia, gout. Its organic causes are tumors, inflammations, soften- Fig. 61.—Showing Lateral Homonymous Hemianopsia. This is not quite complete, there being a space on the blind side where the patient can see (Noyes). ings, or hemorrhages involving part of the optic nerve or its cen- tral connections. Symptoms. —Various descriptive terms are used to indicate the character of the hemianopsia. In lateral hemianopsia a vertical half of the field is involved. In lateral homonymous hemianopsia there is half-blindness on the left or right side of each eye, as the case may be (Fig. 61). In temporal hemianopsia the outer half of each eye, and in nasal the inner halves, are involved. The upper or lower segments or irregular segments of the visual field may be involved. These various forms of hemianopsia depend upon the location of the lesion which cuts into and destroys the optic fibres in their course from the eye to the visual centre in the occipital cortex. The mechanism will be understood when it is remembered that each occipital lobe is supplied by nerve fibres from one-half of the retina of each eye. A cut shows this better than any descrip- DISEASES OF THE CRANIAL NERVES. 11J tion (Fig. 49). In temporal hemianopsia the lesion must be at Ch, in front of the chiasm. In nasal hemianopsia it must be double and at N and N'. In lateral hemianopsia the lesion must lie farther back than the chiasm, in the tract, the primary centres, the optic radiations, or occipital lobes. In hemianopsia from disease of the nerve as far back as and in- cluding the primary centres in the optic thalamus and corpora quadrigemina, there is a loss of light-reflex when a ray of light is thrown upon the blind side of the retina, but the pupil still contracts when light is thrown on the sensitive side of the retina. This phenomenon is called " Wernicke's hemiopic pupillary re- action.1' If in hemianopsia the light-reflex is preserved, the lesion is back of the primary centres and involves the optic radiations or cortex. A test for the condition of hemianopsia in its early stage, and one that is useful in stupid or partially comatose patients, is the following: When the finger is suddenly brought in front of the eye on the sound side, there is a wink; if brought in front from the blind side, the orbicularis does not contract. Hemianopsia is almost always the sign of organic disease. It is not found in hysteria, but does occur in migraine and lithe- mia. It is best made out and recorded by means of the perimeter. Its course and treatment depend upon the cause. Diseases of the Motor Nerves of the Eye. The common affections of the ocular muscles are: 1. Paralyses or ophthalmoplegias, which may be acute, chronic, or progressive. 2. Pareses or amyosthenic states, called ordina- rily muscular asthenopias. 3. Spasms, such as strabismus, nystag- mus, and blephorospasm. There are many special terms which are used to indicate the peculiar effects of various paralyses and spasms of the ocular muscles and nerves, and some of these I will define here: Erroneous projection is a condition in which the patient is unable to judge exactly of the relation of external objects to the body. For this relation is determined by the movements of the ocular muscles, and these being weak, wrong sensations are con- veyed to the brain. Vertigo may result from this disturbance of muscular sensation. Diplopia or double vision is a condition due to the erroneous sensation resulting from eye-muscle palsy, and to the fact that the images of the object fall upon non-corresponding retinal fields. Diplopia is simple or homonymous when the false image is seen on the same side as the affected eye. When a red glass is placed over this eye two images are seen, the red one being on the side 8 114 DISEASES OF THE NERVOUS SYSTEM. of the eye involved. Diplopia is heteronymous or crossed when the false image is on the opposite side to the sound eye. Conjugate deviation of the eyes is a condition in which both eyes turn strongly to one or the other side. It may be paralytic or spasmodic. The mechanism is a complicated one and not perfectly understood. In general, destructive lesions of the brain cause a paralytic deviation toward the side of the lesion. Similar lesions in the pons cause a deviation away from the side of the lesion. The palsy involves the sixth cranial nerve and the branch to the internal rectus from the third. The sixth nerve nucleus is the dominant one, and impulses from the brain go to it first (see Fig. 51). Returning now to the diseases of the motor nerves of the eye, it is found that the paralyses occur in various ways, which may be best grouped as follows: Ophthalmoplegias: 1. Paralyses of the third nerve. ) Acute. 2. Paralyses of the fourth and sixth nerves, f Chronic. 3. Progressive paralysis of all or part of these nerves. The Ophthalmoplegias. I. Paralysis of the Oculo-Motorius or Third Nerve. —Etiology.—The commonest causes are exposure to cold and syphilis. Other causes are basal meningitis, intracranial tumors, injuries, compression from orbital tumors, the diphtheritic poison, and excessive exposure to light; excessive use of tobacco, and alcohol, morphine, or other poisons may be a cause. Temporary palsy sometimes occurs in migraine, or it may take the place of an attack of migraine. A palsy of some of the muscles supplied by the third is sometimes caused by cerebral lesions involving the inferior parietal lobule. Partial palsies also occur in loco- motor ataxia and in certain primary mus- cular atrophies. The common causes, how- Fig. 62.—Double Ptosis. ever, are, as stated, rheumatic influences and syphilis. There occurs, in rare cases, an acute inflammatory degenera- tion of the nuclei of the ocular muscle nerves similar to acute an- terior polio-myelitis. This condition has been called " polio-en- cephalitis superior." Symptoms.—When all the muscles supplied by the third nerve are paralyzed, there is dropping of the lid (ptosis); the eye can only be moved outward and downward and inward; there is there- DISEASES OF THE CRANIAL NERVES. 115 fore divergent strabismus and double vision (diplopia). The pupil is somewhat dilated and does not contract to light, owing to paral- ysis of the constrictors of the iris; and there is loss of power of accommodation, so that the patient cannot read print close to him. The patient suffers under annoyance from the lid drop and the double vision, and there is sometimes vertigo and photo- phobia. Only one nerve is involved at a time as a rule. The various eye muscles supplied by the third are rarely all attacked. Fig. 63.—Shutter for Testing Pupil-reflex. The apparatus admits of using colored glasses for testing hysteria and malingering; also of the use of a Maddox prism for testing the eye muscles. The levator may escape almost entirely the ciliary muscle and iris may also be but slightly involved; but these latter muscles are never involved alone in ordinary types of the disease. The affection usually runs a subacute course, lasting but a few weeks. Functional palsies last but a few days; syphilitic palsies are usually temporary (one to three weeks), but may relapse or become extremely obstinate. Periodical palsies occur every year or six months or even oftener; they last a few days or weeks and are accompanied at first with some pain. They continue to recur for years. 116 DISEASES OF THE NERVOUS SYSTEM. In diphtheritic eye palsies the first three or four nuclei of the series making up the origin of the third nerve are oftenest af- fected, causing paralysis of accommodation, paralysis of the iris and of the internal rectus, the three muscles concerned in accom- modating the eye to near objects (Fig. 62). Pathology.—In the rheumatic palsies there is a low grade of peripheral neuritis, and the same is true of most diphtheritic and other palsies of infectious origin. In syphilitic palsies there is usually a specific basilar meningitis involving the nerve roots. The meningitis may be slight or may amount to gummatous de- posit. In functional and some periodical palsies there is a vaso- motor disturbance causing congestion or amcmia or perhaps sim- ply inhibition of the nuclear centres. Some periodical palsies have been found to be due to small tumors involving the nerve root. In rare cases there is primary muscular atrophy of the eye- ball nerves, or primary degeneration of the nuclear centres, or a cerebral lesion of the inferior parietal lobule.* Diagnosis.—One must first determine how extensively the muscles supplied by the third are involved. If only the levator palpebre, there is simply falling of the lid. If the eyeball muscles are involved, we get the following symptoms. They are: Limitation of movement of the globe. Strabismus and secondary deviation. Erroneous projection. Double vision or diplopia, which is either simple or crossed. Paralysis of the iris or iridoplegia and of the ciliary muscle or cycloplegia. Concentric limitation of the visual field. All these points must be tested, but the detailed knowledge of them is best gained by consulting ophthalmological works. The extent of involvement of eye muscles can generally be sufficiently tested by making the patient move the affected eye in various directions, and by testing for accommodation and for the pupillary reaction to light. Paralysis of the iris, or iridoplegia, and of the ciliary muscle—cycloplegia. The motor fibres of the third nerve to the iris supply the sphincter, and when paralyzed there is dilatation and immobility of the pupil, a condition known as mydriasis. Fibres from the same nucleus innervate the ciliary muscle, and the iris and this muscle are usually paralyzed together. Paraly- sis of the ciliary muscle is called cycloplegia. In this latter con- dition there is loss of power of accommodation. Iridoplegia and * Some diphtheritic palsies are probably nuclear. DISEASES OF THE CRANIAL NERVES. 117 cycloplegia are usually due to local disease of the eye or to the use of mydriatic drugs. Occasionally they are observed after diph. theria or in multiple sclerosis. Paralysis of the levator palpebre, causing ptosis, is sometimes seen alone, but usually other branches of the third nerve are in- volved. A functional palsy of the lids sometimes occurs in anemic and nervous people at the time of waking. It is a temporary morn- ing or waking ptosis. Paralysis of the sympathetic fibres of the eye causes con- traction of the pupil (myosis) from the unopposed action of the third nerve. There is also a slight prominence of the eye and slight ptosis from an involvement of the nerves that supply Midler's muscle. The pupil does not dilate when the skin of the cheek or neck is irritated. This is a condition known as loss of skin-reflex. In locomotor ataxia there is often a rigidity of the constricting fibres of the iris, while the ciliary muscle continues to act. The pupil is then small and does not respond to light, while it does respond to accommodation. This is known as the Argyll-Robert- son pupil. II. Paralysis of the Fourth Nerve.—This is a rare affec- tion and not always easily detected. The causes are much the same as those of palsy of the third nerve. The symptoms are slight convergent strabismus when the eye is moved downward and diplopia on looking down. There is defect in the movements of the eye downward and outward. Paralysis of the sixth nerve (abducens) is the most fre- quent of eye palsies, and occurs especially often in syphilis and in locomotor ataxia. It causes convergent strabismus and double vision. III. Progressive Ophthalmoplegia.—Besides the palsies already described, there occur certain forms which have a pecul- iar origin and course. They begin slowly, as a rule, and steadily progress. In some cases only do they reach a certain stage and then remain chronic. The term " progressive " applies fairly well to them. They often affect the third, fourth, and sixth nerves together. In accordance with the muscles invaded, these palsies are called external, internal, parti'al, and total. Thus if those branches of the third nerve supplying' the iris and ciliary muscle are involved alone, it is ophthalmoplegia interna; if the other branches are involved, it is called ophthalmoplegia externa. Definition.—Progressive ophthalmoplegia is a degenerative disease of the nuclei of the motor nerves of the eye. It is in most cases the same disorder as of bulbar paralysis and progressive muscular atrophy. It is sometimes called polio-encephalitis su- perior. 118 DISEASES OF THE NERVOUS SYSTEM. Etiology.—It develops between the ages of fifteen and forty, but may occur later. The sexes are equally affected. Lead, diph- theria, traumatism, syphilis, appear sometimes to be the cause. It may complicate locomotor ataxia; more often it forms part of progressive muscular atrophy. The symptoms are often not noticed until the disease is far advanced. The vision is not disordered, and there is only a gradual limitation of mobility of the eyeball. A slight drooping of the lids, causing a sleepy look, or a slight squint, usually diver- gent, is noticed. Then upon examination it is found that the eye cannot follow the finger, except to a slight extent. The iris reacts to accommodation and light usually. Double vision may be present. Usually the patient accustoms himself to monocular vision. The disease lasts a long time, and it may become sta- tionary. If complicated with progressive muscular atrophy, however, the course is relatively rapid, death occurring from the latter disease in two or three years. Pathological Anatomy.—In all progressive cases there is a de- generative atrophy of the nuclear cells. In a few rare cases no lesion has been found, and in a few stationary cases the anatom- ical change is that of neuritis. The treatment is that for the disease which it complicates or the condition which causes it. That is to say, it is the treatment for locomotor ataxia, progressive muscular atrophy, syphilis, or lead-poisoning. Iodide of potassium, strychnia, arsenic, nitrate of silver, and phosphorus may be given. Electricity is of very doubtful value, and only the galvanic current would be indi- cated. General tonic measures and rest to the eyes should be employed. Muscular Asthenopia and Muscular Insufficiencies. —This is a term employed to indicate a lack of equilibrium of the muscles of the eye, as a result of which the visual axes cannot be kept parallel without an effort. This effort is often unconscious, and shows itself only by a ready tiring of the eye on attempting to read, or by the production of headaches and cerebral pares- thesie. Examination of the eye by means of prisms reveals the spe- cial character of the trouble. When the eye muscles act normally the condition is called one of orthophoria. When some of the muscles are weak it is called heterophoria. There are various forms of heterophoria, viz.: esophoria, a tend- ing of the visual lines inward, from weakness of the externi; ex- ophoria, a tending of visual lines outward; hyperphoria, a tend- ing of visual line of one eye above its fellow. The condition is tested in various ways. The simplest is this: DISEASES OF THE CRANIAL NERVES. 119 Refractive errors having been corrected, a series of prisms is placed over the eye at flrst with the base inward while the patient looks at a candle twenty feet distant. The prisms are increased in strength until the patient can no longer coalesce the images. The degree of prism is noted, and this indicates the strength of ab- duction or of the externi. The same process is gone through with for the interni, the base of the prism being out. The externi should overcome a prism of about 8°, the interni one of 23° to 25° or more. There are great individual variations, and there is also considerable variation in individuals. The above tests measure the amount of abduction and adduc- tion. To test the presence of heterophoria, the writer uses the Mad dox double prism held in a frame. The line where the bases of the two prisms unite is brought directly over one eye, and is held there in a perfectly horizontal position while the patient looks at a candle twenty feet away. A red glass is at the same time held over the other eye. With the eye covered by the double prism the patient sees double, one flame being above the other, with the other eye he sees a red flame lying just between the two white ones. If the red flame is directly in a vertical line, there is orthophoria, but if it lies to one side or the other, there is ex- ophoria or esophoria according as the red flame was on the oppo- site side to the eye covered with red glass or on the same side. If heterophoria is found, prisms are placed over the eye until the three lights are in a vertical line. The number of the prism re- quired to correct the heterophoria indicates its extent in degrees. By changing the double prism so that its common base line is vertical, the test for hyperphoria can be made.* Muscular asthenopia is said to cause a disturbance of vision, vertigo, migraine, cerebral paresthesia, and pains in the head, more particularly in the occipital and cervical region. It is be- lieved to be a possible factor in producing choreic twitchings in the face. In neurasthenic persons it may cause a wider range of nervous symptoms. It is said to be an essential factor in caus- ing epilepsy, chorea, and hysteria. The author cannot accept this latter view, and believes that the importance of muscular asthenopia in causing general nervous symptoms is not great. Much of it, if not all, may be relieved by correcting refractive errors and by helping the general health of the patient. The treatment of it, after all myopia, or hypermetropia, or astigmatism, if present, is relieved, consists in the systematic use of prisms for training the muscles, the wearing of proper glasses, * More elaborate and exact methods have been devised by Dr. Stevens and are employed by many ophthalmologists. 120 DISEASES OF THE NERVOUS SYSTEM. and graduated or complete tenotomies according to the method of Stevens. Spasmodic Diseases of the Ocular Muscles. These are- (1) Conjugate deviation from spasm, (2) irregular and associated spasms from convulsive and irritative brain dis- order: (o) nystagmus. Etiology.—Spasmodic conjugate deviation occurs from an irri- tating lesion of the ocular nuclei or of the brain in its cortical motor areas and tracts. Irregular spasmodic movements occur in meningitis, hydro- cephalus, and in lesions involving the semi-circular canals. Pecul- iar associated spasms occur in hysterical attacks. Various spasmodic movements and contractions of individual eye muscles occur from ocular disease, errors of refraction, mus- cular weakness and paralysis of certain eye muscles. Rhythmical spasm or nystagmus occurs as the result of hered- itary visual weaknesses and refractive errors of various kinds, in albinoes, and in chronic hydrocephalus. It is found usually in neurotic cases associated with ocular defects, in epilepsy, chorea, hysteria, neurasthenia, and insanity. It occurs in certain degen- erative nervous disorders such as disseminated sclerosis, heredi- tary ataxia, tumors, especially of the cerebellum, and other focal lesions, and in meningitis. It occurs in miners, and is called miners' nystagmus. It may be a reflex symptom from a remote irritation. In nystagmus the oscillation of the eyeballs is usually lateral. It may be brought out when slight in degree by causing the pa- tient to look steadily to one side. Vertical and a kind of rotating nystagmus sometimes occur, and are due to much the same causes as those of lateral nystag- mus. Spasm of the levator palpebre is sometimes seen, and is usually tonic. DISEASES OF THE FIFTH CRANIAL NERVE—THE TRIGEMINUS. The common affections of this nerve are headache, migraine, tic douloureux, and various neuralgias. The rarer diseases are anesthesia, reflex cough and asthma, masticatory paralysis, tris- mus, trophic and secretory and vasomotor disorders. Many of the disorders referred to the fifth nerve are in reality only symptoms of some general neurosis, constitutional disturb- ance, or of some remote local disease. As a matter of conven- ience, however, they may be treated here. DISEASES OF THE CRANIAL NERVES. 121 Headache (Cephalalgia). Headache is the name given to attacks of diffuse pain affecting different parts of the head and not confined to the tract of a particular nerve. It usually comes on in paroxysms at various intervals, but may be continuous. '•■■•-■- Fig. 64.—Showing the Motor and Sensory Nerves and the Arteries an» Veins of the Face (Merkel). a, Frontal nerve ; b, supra-orb.; c, temporal; d, lacrymal; c, supra- and infra-trochlear; /, auriculo temp.; g, nasal; h, malar; i, seventh nerve; fc, infra-orbital; m, mental. The veins have longitudinal, the arteries oblique striations. The nerve i is the facial; all the other branches are trigeminal 122 DISEASES OF THE NERVOUS SYSTEM. Etiology.—Headache is the most common of nervous symp- toms. Ten to fifteen per cent of school children, twenty-five per cent of men, and over fifty per cent of women are subject to it more or less. The headache ages are from ten to twenty-five and thirty-five to forty-five; most cases occur between the ages of eight and twenty-five, especially in females. The number of headaches in- creases gradually from the period five to ten years up to the period fifteen to twenty, then falls till the thirty-fifth year, and rises again till about the age of forty. Early childhood and de- clining age are practically exempt from chronic functional head- aches. Women suffer from it more than men in the proportion of about three to one. It is more frequent in city populations and among the wealthier classes. Headaches are more common in the spring and fall and in temperate climates. Headaches may be classed, in accordance with their causes, as follows: 1. Hemic causes, in which impoverished or disordered blood is brought to the brain, as in (a) anemia and congestion; (5) diathetic states: gout, rheumatism, diabetes, uremia; (c) infec- tions: malaria, fevers. 2. Toxic causes: lead, alcohol, tobacco, etc. 3. Neuropathic states: epilepsy, neurasthenia, hysteria, neu- ritis. 4. Reflex causes ocular, naso-pharyngeal, auditory, dyspeptic, sexual. 5. Organic disease, including arterio-sclerosis, syphilis, tumors, meningitis, and diseases of the cranial bones. The anemic, dys- peptic, ocular and neurasthenic are the common forms of chronic and recurrent headache. Symptomatology.—Headaches may be classed in accordance with their location and the character of the pain. We have ac- cordingly; 1. frontal headaches; 2, occipital headaches, 3. parie- tal and temporal headaches; 4, vertical headaches; 5, diffuse headaches and various combinations of the above. The most common form of headache is the frontal, next the fronto-occipital or diffuse, next the vertical, and then the occip- ital. The kind of pain differs with different persons and with differ- ent causes. We have: 1, pulsating, throbbing headache, 2, dull, heavy headache; 3, constrictive, squeezing, pressing headache; 4, hot, burning, sore sensations; 5, sharp, boring pains. The first form characterizes headaches with vasomotor dis- turbances, and usually indicates migraine. The second is of a toxic or dyspeptic type. The third is found in the neurotic and neurasthenic. The fourth in rheumatic and anemic cases. DISEASES OF THE CRANIAL NERVES. 123 The fifth in hysterical, neurotic, and epileptic cases. The accompanying diagram shows some of the relations of localized pain to the cause. A large experience both in my own practice and in that of others shows it to be approximately cor- rect. Headaches may continue for a day or may last for weeks and months. Some persons have headaches only when constipated or bilious, or when they have an attack of indigestion. Others suffer from a little pain nearly all the time, exacerbations occurring at various periods. Neurasthenic and ocular headaches are gener- ally of this type. When headaches are persistent, examination should be made of the eyes, of the nose and sinuses; the patient should be questioned as to syphilis, the continuous use of tobacco, and chronic dyspepsia. The possibility of brain tumor, of pachy- ^ ,rEye. Z~/-~> Decayed teefli. -/- ^--..Pharyngitis. '•'^''' Otitis media "~—----Uterine, " - Spinal irrita- tion Fig. 65.—Showing the Location op the Pain in Headaches from Different Causes. meningitis from blows, or sunstroke or chronic alcoholism should be considered. The persistent headaches not relieved by ordinary treatment are due to eye trouble, anemia, neurasthenia or spinal irritation, syphilis or pachy-meningitis. Eye strain may cause true migraine or ordinary headache. Eye-strain headache is usually asociated with some weakness of eyesight and pains and discomfort about the globe, besides severer pains at times in the brow or occiput. The cause of the eye strain is usually astigmatism and hyperme- tropia. Occasionally it is due to weakness or lack of balance of the eye muscles. Symptoms Associated with Headache.—The symptoms often- est associated with chronic and recurrent headaches are vertigo, somnolence, sensations of heat and pressure (cerebral paresthe- sie), and nausea. Vertigo goes oftenest with headaches of dys- peptic origin; some of the so-called bilious headaches of early life develop later into attacks of vertigo; this symptom often occurs with frontal headaches. Somnolence occurs oftenest with anemic and malarial headaches; it may develop also with syph- Constipation. Caries of incisor Error of eye-refraction.. Gastric dyspepsia; - cured by acids. 124. DISEASES OF THE NERVOUS SYSTEM. ilitic head pains. Nausea I have found oftenest with occipital headaches. Pathology.—Headaches are to be distinguished from neural- gias and from a special and common form of head pain known as . migraine. Headaches are diffused pains caused, as a rule, by irritations located in or referred to the peripheral ends of the fifth nerve. Their seat is usually within the skull. Neuralgias, on the other hand, are caused by irritations of the trunks of these nerves. The pains are local and confined to the single branches of the nerve. Migraine is a periodical neurosis in which there is a discharge of nerve force, not only affecting the trigeminus, but often other cranial nerves as well as sympathetic fibres. It is a general disease of which the headache is only one symp- tom. The nerves of the dura mater are those most involved. Head- aches, when occipital, involve the sensory fibres of the vagus and the upper four cervical nerves. There is no anatomical change in the nerves except in organic headaches. But in many cases the membranes of the brain and their sensory nerves are congested or anemic. Diagnosis.—No symptom requires more careful investigation as to its cause than that of headache. The diagnosis is always to be made, not of this symptom, but of its cause. Most of the fore- going description accordingly refers to etiology. It is important, however, to decide whether the case is one of migraine, or neuralgia, or of headache. Headache is usually diffuse and bilateral. It is more or less persistent. Migraine comes on paroxysmally, lasts a short time, and then leaves the patient feeling perfectly well or even better than ever. Migraine is often accompanied with nausea, flashes of light, strong pulsations of the head, vertigo, pallor or, more rarely, congestion of the face. Neuralgic pains are sharp and shooting, they run along the tract of the nerve, and often are associated with suffusion of the eye and oedema. Tender points are felt. Treatment.—The constitutional treatment is based upon the etiology. Regulation of diet and digestion, securing a regular movement of the bowels, attention to ocular troubles, abstention from tobacco and alcohol and overwork are the important points requiring attention. The symptomatic treatment consists in giving antipyrine, anti- febrin, phenacetin, salicylate of soda, caffeine, muriate of ammo- nia, and sometimes morphine or codeia, and bromide of ammonia. Antipyrine can be given in doses ofgr. v. every twenty minutes DISEASES OF THE CRANIAL NERVES. 125 till three or four doses are taken. Phenacetin often needs to be given in large doses of ten or even twenty grains. Antifebrin is less trustworthy and must be given in small doses. Exalgin is not a very good or safe remedy. It may be tried in doses of gr. iij. to gr. v. Muriate of ammonia is an excellent remedy given in very large doses, 3 ss. toSi., well diluted. Menthol in doses of gr. v. to gr. x. in hot water sometimes stops headaches. In head- aches from anemia, caffeine and ammonium muriate are best. In headache from nervous exhaustion, similar stimulating anodynes are usually most efficacious. Combinations of caffein citrate and salicylate of soda or benzoateof soda are often better than the sin- gle drug. Caffeine in any case must be given in larger doses than is ordinarily done, i.e., gr. iv. or v. Local applications of a twenty-per-cent solution of menthol, the ice-bag, cloths wrung out in hot water, or a piece of sheet lint soaked in chloroform liniment two parts and tincture of aconite one part are efficacious measures. A cathartic, rest in a darkened room, light diet—all these are measures which many patients themselves learn to adopt. Finally, in headaches from organic disease we have often to resort to iodide of potassium, mercury, and the use of some prep- aration of opium. As will be seen, each case of headache requires special treat- ment and a certain amount of experimentation in order to learn the idiosyncrasy of the patient. Migraine, Sick-Headache, Hemicrania.—Migraine is a constitutional neurosis characterized by periodical attacks of pain chiefly in the course of the fifth nerve. The pain is often asso- ciated with nausea or vomiting, mental depression, vasomotor disturbances such as flushing or pallor of the face, by flashes of light, vertigo, tinnitus aurium, and in rare cases by partial paral- ysis of one oculo-motor nerve. It will thus be seen that migraine is more than ordinary head- ache and unlike an ordinary neuralgia. Etiology.—The disease is very common in civilized countries and is frequent in America. It occurs oftenest in women in the proportion of about three to one, and it begins in most cases at or a little before the age of puberty. It may begin as early as the fifth or even the second year. It occurs in neurotic families, and there is very often a history of direct inheritance. Other neuralgic troubles, epilepsy, and gout may be found in the family history. The attacks occur oftenest in the winter in our climate. The cases that begin in childhood and early life are some- times started by overwork at school, but usually no especial cause can be found. When they begin after maturity, a history of 126 DISEASES OF THE NERVOUS SYSTEM. excesses in work, injury, shock, or exhausting disease is found. Migrainous patients usually have some refractive disorder of the eye or a weakness of eye muscles, and this condition is one factor in bringing on or keeping up the headaches. Symptoms.—The patient for several days may feel a sense of malaise and depression; usually, however, the prodromal stage lasts only a few hours or a day. The attack often comes on in the morning and gradually increases in intensity until the vic- tim has to give up work and lie down. The pain starts in one side of the head, usually in the forehead, but often in the occiput. It increases and finally may involve the whole head. The pain is of a tense, throbbing, blinding character, increased by jars, light, and noises. It is accompanied by dimness of vision, often by flashes of light or dark or light spots variously colored floating before the eyes. Restriction of the visual field, sometimes in the form of hemianopsia, may occur. Vertigo, tinnitus aurium, confusion of ideas, feeling of stupor, disturbances of memory, are not uncommon; nausea and even vomiting are the rule. The vom- ited matter is at first chiefly mucus, but it may later get yellow and bitter from the presence of bile. Hence the term " bilious headache," which is an improper one, because the bile is only the result of retrostaltic action from the vomiting. Migraine is not the result of gastric or liver disorder. The patient's face usually is pale and gives the evidence of acute suffering. The flushed face is very rare; the distinction between angiospastic or pallid migraine and angioparalytic or congestive migraine is not of clinical value. The pulse is small and hard and may be lessened in rapidity. The temperature often rises in children. The attack lasts from six to twelve or twenty-four hours, occa- sionally even two or three days. As the intensity of the pain les- sens the patient sinks to sleep, and awakens next morning feeling refreshed and better than before the attack. The attacks occur at varying periods, fortnightly or monthly, and even weekly. In women they often occur during men- struation. Some women are entirely free from them during preg- nancy. At about the time of the menopause in women, and at about the same time of life im men, the disease lessens in sever- ity and as a rule disappears. Some form of neuralgia or some neurosis in rare cases takes its place. Complicating Symptoms.— Partial oculo-motor paralysis, tem- porary aphasia, slight hemiplegia, hemi-numbness, peculiar odors or tastes, convulsive movements of the body, almost resembling epileptic attacks, occur. Cases presenting these symptoms are rare. When they occur in one case, however, they always occur in each attack unless it is modified by treatment. DISEASES OF THE CRANIAL NERVES. 127 Vicarious Attacks.—Migraine is sometimes associated with epi- lepsy, locomotor ataxia, or insanity; that is to say, persons in early life have had migraine and later developed the diseases mentioned. The relation between these diseases, however, is not so close as some writers would lead us to infer. The attack of migraine can be sometimes replaced by an attack of gout, or visual disorders, or other sensory symptoms, or even by an oculo- motor paralysis. Sometimes, instead of a fully developed attack the patient has a sense of mental depression, with confusion of ideas. Cases have been reported in which acute mania took the place of the headache. Types.—Writers have described the angioparalytic and angio- spastic types; also the typical, subtypical, and supratypical; and finally the ordinary type and the ophthalmic type. Practically we find two classes: (1) The typical, associated with visual disorders and having most of the symptoms described above. (2) The irregular or mixed type in which with many symptoms of ordinary migraine there is a history of rheumatic influences, and often of anemia or dyspepsia. These are cases of a true mi- grainous affection complicated with some form of symptomatic headache, such as has been already described. The mixed or ir- regular migraines are important to recognize, for they call for special treatment. They occur almost altogether in women; the attacks are often associated with weather changes and may be of a neuralgic character. Many women have their sick-headaches and their neuralgic headaches, so called, and have to distinguish be- tween them. In mixed attacks the face is usually also pale, the eyes are not suffused, nor is there any visual or aural disturbance, as in migraine. Sometimes the pain remains in the occipital nerves, and I have met with one patient who localizes her pain there en- tirely, and who always vomits during the attack. Pathology.—The seat of the disease is chiefly in the intracra- nial branches of the fifth nerve and of the pneumogastric; the upper cervical nerves, however, are often involved. There are no morbid anatomical changes known. The most plausible theory of the disease is that it is a fulgurat- ing neurosis, in which there are periodical discharges of nerve force, or nerve storms. The seat of the discharge is perhaps in the cerebral cortex, but more likely in the primary sensory centres, i.e., the root ganglia of the fifth and vagus nerves. The disease is certainly not in the sympathetic system, as was once taught. Diagnosis.—The diagnosis is based upon the hereditary his- tory, the periodicity and seat of the attacks, the nausea, the com- plicating visual and other sensory symptoms. It should not be 128 DISEASES OF THE NERVOUS SYSTEM. forgotten that the same patient may have migraine and other neuralgias, or may have also an organic brain or renal disease. Treatment.—Prophylaxis.—Children of families in which this neurosis exists should be carefully watched during the ages be- tween five and twenty. The eyes and nose should be examined. They should not be subjected to excessive mental or visual strain, and if attacks develop they should be promptly treated. The appli- cation of glasses should be considered, but not hastily adopted. As regards constitutional treatment, the best measures for cur- ing a case of migraine consist in correcting any visual or nasal defect, such diet and exercise as secure tone to the nerves, and the continuous use internally of bromide of potassium, nitrogly- cerin, cannabis indica, or arsenic. Of the above drugs, cannabis indica, either with or without arsenic, is the most trustworthy, while the bromides are the least. The hemp should be given in large doses and for a long time, gr. $ to gr.' i. ter in die. Much stress is laid by some upon ocular muscular insufficiencies, and I believe that such condi- tions should be remedied, but place little confidence in them alone. On the other hand, the correction of small or large de- grees of astigmatism and hypermetropia sometimes produces surprisingly good results. The reported cure of numerous cases of migraine by treatment of nasal hypertrophies and catarrh should not excite too much confidence in such measures. In fact, since migraine is a constitutional neurosis, one cannot expect permanent results from removing reflex irritants alone. The daily use of a strong galvanic current four to eight milliamperes (eight to ten cells) for ten minutes is useful. For the relief of the attack the following drugs may be given : Salicylate of soda, gr. xx.; caffeine, gr. ij. to v., with benzoate of soda, gr. x.; antipyrine, gr. v. q. £ h.; phenacetin, gr. x. to xv. or more; powdered guarana, gr. xx.; menthol, gr. v. to x. in hot water, muriate of ammonia, gr. xxx. to 3 i.; bromide of potassium, gr. xx. Antipyrine and phenacetin are the most certain of the above drugs, but they lose their effect after a time, as do almost all the other drugs, and finally patients give up treatment or resort to codeia or morphine. Chloral and a hot foot-bath break up attacks sometimes. Locally galvanic currents are sometimes helpful, and so are static sparks. Hot applications and pencilling with menthol give relief to some. Quiet and rest are spontaneously resorted to. Neuralgias of the Trigeminus.—The trigeminal nerve is .subject to two types of neuralgia, viz.: 1. The symptomatic form. 2. Tic douloureux. 1. The symptomatic neuralgias are by far the most frequent. DISEASES OF THE CRANIAL NERVES. 129 They are called supra-orbital, infra-orbital or supra-maxillary, infra-maxillary or dental, and mixed forms. The most common type is the supra-orbital; next, the mixed form. Etiology.—The female sex is oftenest affected; most cases are seen in the first half of life; most attacks occur in the winter and spring. The left side is oftener affected. The second and third branches of the fifth nerve are most susceptible to rheumatic in- fluences, the first branch to malarial and septic poisons. Dental disorders naturally are frequent factors in neuralgia of the sec- ond and third branches. Anemia, exposure, child-bearing, and other depressing influ- ences are factors in caus- ing these neuralgias. Oc- ular and nasal disease may cause pain in the su- pra-orbital nerve. Gout, diabetes, syphilis, mala- ria, hysteria, epilepsy, trauma, rheumatism, all may be factors in causing trigeminal neuralgias. Symptoms.—The pains of trigeminal neuralgia are sharp and intense, with exacerbations and remissions. The pain of- ten lasts for days with- out entirely ceasing. It then goes away and may not return for a long time. The characteristic af neuralgia is that it <*tays till its cause is re- moved. In supra-orbital neuralgia there is some- times great oedema of the lids and the parts about, together with suffusion of the eyes. There are tender points over the course of the nerves. The common points in supra-orbital neuralgia are supra-orbital, palpebral, and nasal; in infra-orbital neural- gia, nasal, malar, and gingival; in infra-maxillary neuralgia, inferior dental and temporal. In the mixed forms we find various combinations of the above. There is often also a tender point over the parietal eminence and vertex. The pain may radiate to the ear or occiput or it may be located in the orbit. Dental irritation may also cause an otalgia or a neuralgia in the upper branches of the fifth. Fig. 66.—Showing the Distribution of the Sensory Nerves of the Face. /, II, III, First, second, and third branches of the fifth. The shaded part is supplied by the cervical nerves; 2 C. a. br., second cervical anterior branch; 2 C. p. br., second cervical posterior branch. 130 DISEASES OF THE NERVOUS SYSTEM. There is sometimes a dilatation of the pupil, and in severe cases a reflex facial spasm occurs. Tic Douloureux (Prosopalgia, FothergilVs Neuralgia, Epilep- tiform Neuralgia).—Tic douloureux is a special form of trigem- inal neuralgia, unusually severe in its symptoms and obstinate in its course. It ought to be distinguished sharply from the ordinary forms of trigeminal neuralgia. These latter are symptomatic pains almost altogether; while tic douloureux is an idiopathic disorder, or at least is one dependent upon changes in the nerve itself. Etiology.—It occurs, as a rule, in persons who are over forty, and is seen in the very aged. It is indeed the only neuralgia which old people have. It is brought on by exposure, overwork, and depressing influences; sometimes, perhaps, by local dis- eases of the teeth and jaws. It occurs in men and women in about equal frequency, in my experience. Symptoms. —It is characterized by intense, darting pains which usually start in the upper lip and by the side of the nose. From here they radiate through the teeth or into the eye and over the temple, brow, and head. They are confined to one side of the head. During a paroyxsm the face usually flushes, the eyes water, the nose runs, and the patient assumes an expression of the greatest agony. The attack lasts for a few minutes, then becomes somewhat less, but the pain rarely ceases entirely. A breath of cold air, speaking, eating, putting out the tongue—all bring on paroxysms. The pains are worse in winter and often become less or cease during summer. Occasionally they come on for a few months every year, usually during the spring. Spasmodic movements of the face may be associated with the pain. Examination rarely reveals any objective trouble, but in a few cases some anesthesia may be noted. Pathology.—The disease is usually a degenerative one, and probably is due to irritative and atrophic processes occurring in the nerve. A low grade of neuritis, perhaps from alveolar dis- ease, has been found sometimes, but as a rule the nerve does not appear much changed. The arteries supplying the nerve, how- ever, often undergo the changes of endarteritis, their calibre is much lessened, and the nerve cannot get its proper supply of blood. Thus an obliterative arteritis underlies some cases of the disease. Treatment.—In cases which occur in old people, the use of nitroglycerin given in doses of gr. T^ q. 2 h. sometimes has a happy effect. The best single remedy, however, is undoubtedly crystalline aconitia given in doses of gr. ^T until its physiological effect is obtained. After this come injections of cocaine. Be- DISEASES OF THE CRANIAL NERVES. 131 sides these measures, galvanism daily, iodide of potassium in large doses, gelsemium, croton chloral, codeine, external applica- tions of menthol, freezing with chloride of methyl, and heat—all may be found useful. The common practice of pulling out all the teeth is almost always unsuccessful, and ought not to be un- dertaken without specially good reason. Tonics containing iron, phosphorus, quinine, or arsenic are generally helpful, and should always be given after a course of specifics. In younger patients the remedies recommended under the head of Migraine and Head- ache may be given. Change to a warm, equable climate may be tried; it is not a certain resource. Finally, surgical interference may be necessary. The removal of the nerve at as deep a point as possible is the only operation to be seriously entertained. This sometimes causes cure, but, as a rule, the pain comes back in six or twelve months. Even such a respite, however, is often gladly seized upon. Removal of the Gasserian ganglion has been attempted with some success. Liga- ture of the common carotid has been tried also, but of late years the operation has been generally abandoned. Simple drilling out of the infra-orbital nerve with a dental probe made of piano wire has given long relief. There are numerous methods of operating upon the different branches of the trigeminus. For buccal neuralgia, Zuckerkandl has devised a method. For superior maxillary neuralgia," the method of Carnochan, modified by Abbe, is, in my opinion, the best. Others favor Langenbeck's method. Ullmann, Mikulicz, Obalinski, and many others have devised special methods. Hartley, of New York, has devised an operation by which he enters the middle fossa through an opening in the temporal bone, thus reaching the root of the nerve. Trigeminal Paresthesia.—Sometimes persons suffer from peculiar numbness, thrilling, or formication in the course of the trigeminus. The sensation may be nearly constant and excessively annoy- ing. It never amounts to actual pain. It occurs in anemic, nervous, and hysterical persons. It is to be regarded as an abortive form of neuralgia, and so treated. Trigeminal Anaesthesia.—This occurs from various path- ological lesions in the course of the nerve or in its nuclei. The most common organic cause is syphilitic disease of the membranes at the base of the brain. Trigeminal anesthesia occurs together with anesthesia of other areas in hysteria and in organic disease of the nerve centres. It is sometimes noted in tic douloureux and facial hemiatrophy. Herpes, flushing, pallor, lachrymation, salivation axe all symp- toms of disturbance of the trophic, vasomotor, and secretory 132 DISEASES OF THE NERVOUS SYSTEM. fibres running in the trigeminal nerve. They are usually, if pathological, only concomitant symptoms of other diseases. The diseases of the motor branch of the trigeminus are rare, and generally symptomatic of some more general disorder. Trismus (lock-jaw) is the only important independent affec- tion of this motor nerve. It is a tonic spasm of the muscles of mastication. Etiology.—It occurs in infants, usually through infection from the umbilicus. It is then known as trismus nascentium. It forms part of the symptoms of tetanus. It may be symptomatic of brain disease, and forms one of the manifestations of the epilep- tic fit. There may be a reflex trismus from irritations of the teeth and jaw, and from gastro-intestinal trouble. Neuritis and hysteria are causes of trismus. Symptoms.—There is, as shown above, a symptomatic, an in- fectious, a reflex, a neuritic, and a hysterical trismus. In all, the symptoms are very manifest. The jaws are firmly locked and the masseters and temporals stand out. If the disease is uni- lateral, which is rarely the case, the lower jaw is pushed over toward the sound side. « The treatment of both tonic and clonic spasms depends upon the cause. Symptomatically, morphine is to be given, and later the antispasmodics, such as the bromides. In rheumatic cases hot applications and diaphoretics are indicated. Diseases of the Facial Nerve. The facial nerve being motor, its diseases are spasmodic and paralytic. The two common types are facial tic and facial palsy, but there are other minor forms. The sapsmodic disorders are (1) diffuse facial spasm or mimic tic and (2) spasm of single branches, including (a) blepharospasm and (b) nictitating spasm. Facial Spasm (Mimic Tic).—This is a disease characterized by intermittent, involuntary twitchings of the facial muscles. It is always chronic and generally unilateral. Etiology.—It is a disease of middle and later life, and occurs oftener in women; there is usually a neuropathic constitution; it is not hereditary. The exciting causes are anxiety, shock, injury, and exposures. It often has a reflex cause, usually from irrita- tion of some branch of the trigeminus or the cervico-brachial nerves, rarely from eye strain. Organic diseases, such as tumors and softening, affecting the nerve nucleus in the pons or the cerebral centres, cause a symptomatic tic, but not the true disease. DISEASES OF THE CRANIAL NERVES. 133 Thus we may have a post-hemiplegic tic or a tic due to cortical lesion and associated with epilepsy. True facial tic may be caused by irritation or disease of the nerve. Symptoms.—The disease usually begins slowly and the orbic- ulis muscle and zygomatici are earliest affected. It rarely goes above the eyebrows, i.e., to the corrugator supercilii and fron- talis. The lower branch of the facial is little affected. The spasm is a clonic one, the muscles of the face are affected by a series of lightning-like twitches, with intervals of rest. Some- times the contraction becomes tonic and lasts several seconds or more. There is no pain. The spasm is increased by emotions, nervous excitement, conversation, exposure to light and cold, and is at its worst when the patient himself is most depressed. It is a very good gauge of the general nervous sta- bility of the patient. There is no paralysis or atrophy, and there are no secretory or trophic symptoms. The taste fibres are rarely involved, though occasional subjective sensations of taste have been felt. The electrical irritability is either unchanged or slightly in- creased. Associated movements of the eyes, of the jaw muscles and cheek muscles are sometimes seen. Pressure over the motor points of the nerve will sometimes arrest the movements for a time. The disease is a unilateral one. It lasts for years and even for the lifetime. Pathology.—There is no known anatomical change in idio- pathic cases. The disease is allied in character to wry-neck and other chronic tics. It is a motor correlative to the severe neuralgias like tic douloureux. It is sometimes a pure reflex neurosis from ocular or dental irritations. Diagnosis.—Idiopathic facial spasm is chronic, unilateral, un- accompanied by pain or paralysis. It is distinguished from facial spasms of organic origin by the fact that the latter always have some other symptoms. Thus facial habit-chorea is bilateral: spasm from cortical disease is attended by disturbance of con- sciousness and comes on in paroxysms; the spasm occurring after hemiplegia is usually tonic, and so is hysterical facial spasm. Prognosis.—The disease is in most cases incurable, especially after it has lasted some time. If a reflex cause exist, the progno- sis is better. Life is, however, never endangered by it. Treatment.—The most important thing is attention to the general health, removal of all depressing influences, rest, and free- dom from excitement. Among specific remedies arsenic, the bromides, cannabis indica, gelsemium, conium, hyoscyamus, strychnia, codeine, and morphine are recommended. Morphine is 134 DISEASES OF THE NERVOUS SYSTEM. useful, but must be tried carefully and in small doses. Conium lessens the spasm, but this drug has to be given in large doses and is not entirely free from danger. Hyoscine and gelsemium sometimes do good. Careful examination of the teeth, eyes, nose, stomach, and uterus for reflex irritation is imperative. Galvanism, if carefully and persistently applied, almost al- ways helps. It should be given daily. Various methods are de- scribed. The best way is to place the negative pole on the ster- num or back of the neck, and the positive pole over each motor point of the nerve for one to two minutes, then over the occiput and over the facial cortical area for the same time. Currents of two to five milliamperes should be used. Neurectomy of the supra-orbital, continuous pressure on the motor points, stretch- ing the nerve itself, are all measures which may be considered valueless. Freezing the skin over the nerve with chloride of methyl has been recommended by Mitchell. Blistering and cauterization are needless inflictions. The an- esthetization of the conjunctiva with cocaine is often helpful,. both in diagnosis and treatment. Blepharospasm is the name given to a tonic spasm of the orbicularis palpebrarum. It is generally caused by diseases of the eye, and its nature and treatment are matters belonging to ophthalmology. It is a rare symptom of hysteria. Nictitating or winking spasm is a clonic spasm of the obic- ularis, and usually forms part of habit-chorea or is a symptom of hysteria. Facial Palsies. The paralyses of the facial nerve may be due to lesions that are central, nuclear, meningeal, or peripheral. Facial palsy of central origin is almost invariably an accom- paniment of hemiplegia and is due to hemorrhage, softening, inflammation, or tumor of the brain. The lower two branches of the facial are chiefly involved. Facial palsy of nuclear origin is very rare and is an accom- paniment of glosso-labial palsy, of diphtheritic palsy, or of gross lesions of the pons. Facial palsy of meningeal origin is due to tumors, meningitis or fracture of the base of the brain and is accompanied by lesion of other cranial nerves. Syphilis is the most important factor here. All these forms are simply part of other diseases. Peripheral facial palsy (Bell's palsy) is the common type of facial paralysis. Etiology.—The typical cases of this disease are due to expo- DISEASES OF THE CRANIAL NERVES. 135 sure and rheumatic influences. Males are oftener affected, and the common age is between twenty and forty.* It is more fre- quent in the winter and in temperate climates. It is not hered- itary. A neuropathic tendency and the rheumatic diatheses predispose to it. Syphilis rarely causes an isolated facial palsy; in fact, it is apt to leave this nerve alone (Hutchinson). Facial palsy may occur in multiple neuritis and in locomotor ataxia. Non-typical and accidental cases of peripheral facial palsy are due to injuries, fracture of the petrous bone, or ear disease. Forceps pressure in difficult labor causes some cases, and a very few have been congenital. Symptoms.—The disease comes on rather suddenly, and reaches its height within a few hours or, at most, two or three days. Pre- ceding and accompanying the onset there may be some pain about the ears and a little swelling is sometimes seen. The patient feels a subjective discomfort on the paralyzed side of the face. He finds that he cannot completely shut the eye; if he tries to chew on the affected side, food gets between the teeth and cheek. He cannot pucker the lips, and his speech is a little muffled. The appearance of the face is most characteristic. On the affected side the wrinkles are smoothed out, the angle of the mouth is lower, the mouth is drawn at first to the sound side, and owing to this distortion the tongue appears not to be protruded straight. In laughing or other emotional movements of the face, the trouble is most clearly brought out. But the most characterized appearance is produced by telling the patient to shut the eyes tightly and draw out the angles of the mouth so as to show the teeth. The eye on the palsied side is not closed, and the eyeball turns up, showing the white of the eye. This test of the palsy is better than any examination of the wrinkles and folds of the face, for in children and in the young and plump these differences in the two sides of the face are not very marked, especially in the slighter cases. The nostril on the affected side does not expand on forced inspiration; the eye is apt to be watery and the conjunctiva somewhat injected. If the disease extend well up into the Fallopian canal so as to involve the nerve to the stapedius, that muscle is paralyzed, the tensor tympani acts unopposed, the drum is tightened, and unusual sensitiveness to sounds results. This is rare, however; most of the ear symptoms in facial palsy being due to a concomi- tant disorder of the tympanum or the acoustic nerve. If the disease involve the nerve between the geniculate gan- * Among; 14 cases there were 9 males, 5 females. The ages were: Fifteen to twenty, 2; twenty-one to thirty, 7; thirty-one to forty, 3; forty-one to fifty, 2. Left side, 9; right, 5. 136 DISEASES OF THE NERVOUS SYSTEM. glion and the point where the chorda tympani is given off (see Fig. (5S), some loss of taste follows, and this is a frequent symptom, but not one of long duration. If the disease is located more cen- trally than the geniculate ganglion or more peripherally than the chorda nerve, taste is not involved. Usually, when there is no taste involvment, it is because the lesion is peripheral. By an examination of the taste sense and of the hearing, the location of the trouble can be accurately made out. After a few weeks some wasting of the face may be noted, but this is never very great. The electrical reactions are characteristic and important, since typical or partial degeneration reactions can usually be observed. For a few days there is an increase in irritability of the mus- cles to both faradic and galvanic currents. This is followed by a gradual loss or diminution in faradic irritability, while the gal- vanic irritability remains sometimes increased for a while and then falls. At the same time a reversal of poles and a sluggish contraction, particularly the latter, may be noted. At the end of five or six weeks faradic irritability ought to begin to return. Great variations are found in the electrical reactions dependent upon the severity of the case. If the disease lasts for two months or more and the palsy is not a complete one, secondary contractures begin to appear. The mouth now becomes drawn to the affected side, and the naso- labial fold becomes deeper than that on the sound side. In smil- ing or speaking or other facial movements there is an excess of movement on the paralyzed side, the teeth and upper gums in particular showing abnormally. Pathology.—The disease in its typical form is due to a diffuse neuritis of rheumatic character. This attacks the periphery of the nerve in the face and extends rapidly up into the Fallopian canal as far as the geniculate ganglion. The inflammation some- times attacks most the peripheral filaments; at other times it is more central. The old idea that it was always a perineuritis of the nerve in the Fallopian canal is incorrect (Minkowski). Diagnosis.—The recognition of the palsy is made easy by causing the patient to contort the face. In children it requires more care to detect the side affected. It is important to determine whether the palsy is cerebral, nuclear, basilar, or peripheral. If the cause is cerebral, the upper branch of the nerve is little affected and the patient can close the eye. The nerve and muscles show no degenerative reactions. Nuclear palsy is very rare and is accompanied with other symptoms, especially those of involvement of other cranial nerves. A history of diphtheria, lead palsy, or bulbar paralysis is ob- tained. DISEASES OF THE CRANIAL NERVES. 137 In palsies due to lesions at the base of the brain such as gummy meningitis, the auditory and other cranial nerves are in- volved and there are signs of brain syphilis. By testing the sense of taste and hearing the location of the peripheral trouble can be made out (Fig. 68). Thus if there be loss of taste on the anterior two-thirds of the tongue, the lesion must be between the geniculate ganglion and the point at which the chorda tym- pani is given off. If the taste be not involved, the lesion must be central or peripheral of the part of the nerve which includes the chorda. Practically in most cases it is peripheral to it. If central, the disease is usually of syphilitic or tubercular origin; the palsy is severe and the loss of ability to close the eye very great. Prognosis.—The prognosis of peripheral palsy (Bell's) is good, although an absolutely complete recovery often does not take place. In syphilitic cases the prognosis is not so good, though patients often recover. In central palsies the prognosis is the worst, be- cause the lesion usually does not disappear. However, the cen- tral cases are from the beginning of a mild type, and give an- noyance mainly from the secondary contractures. Bells palsy usually lasts three to five months. Occasionally there are mild cases that get well within a month. The progno- sis as to duration is much helped by a close study of the electri- cal reactions. In proportion as the degeneration reaction is com- plete and persistent the outlook is bad. Treatment.—In the acute peripheral cases the patient should be treated promptly and thoroughly. He should be given a di- uretic and purgative and a blister should be placed over the exit of the nerve. This should be followed or accompanied by hot fomentations. Salicylate of soda in full doses of twenty grains should be given during the first week. After the paralysis is es- tablished, iodide of potassium is indicated in moderate doses. Electricity is to be employed with care at first. After a week it may be given daily for five minutes, using the galvanic currents just strong enough to contract the muscles. After three or four weeks, if the faradic current causes contraction, it may be used, otherwise the galvanic current is to be continued. At the end of a month an application every other day is sufficient. At the end of three weeks, if the paralysis is severe, the corner of the mouth should be drawn up by means of a bent hook, which is carried back and fastened behind the ear. The patient should wear this most of the day-time, but not at night. The object is to take off the strain caused by the pulling of the muscles on the sound side. At the end of a couple of months, if secondary contractures 138 DISEASES OF THE NERVOUS SYSTEM. set in massage may be tried, and the patient should practise facial gymnastics daily. Acupuncture combined with weak faradic currents and local injections of strychnia maybe tried in obstinate cases. If the eye cannot be closed it should be protected by a shade. DISEASES OF THE EIGHTH NERVE. The diseases of the eighth or acoustic and space-sense nerve which are of especial interest to the neurologist are auditory paralysis or nervous deafness, hyperacusis, tinnitus aurium, and auditory vertigo or Meniere's disease. These diseases correspond with loss, excess, and perversion or irritation of function. Nervous Deafness (Acoustic Paralysis). Nervous deafness may be due to lesions (1) of the cortical centres of hearing, (2) of the acoustic nuclei, and (3) of the acoustic nerve itself or its end-organ. Practically it is almost always the nerve and the internal ear which are affected. Etiology.—1. Cortical nervous deafness has been known to occur in a few instances from lesions of both temporal lobes (Mills). A lesion in the left temporal lobe causes a form of sen- sory aphasia called word deafness. A lesion in the right temporal lobe may cause some deafness in the left ear. The deafness of hysteria is of cortical orgin. 2. Deafness from lesion of the acoustic nucleus or nerve root. Cerebro-spinal meningitis in the young and syphilitic menin- gitis in the adult are the more frequent causes of this form. Tumors and hemorrhages may also be causes. When the audi- tory nucleus and nerve root are affected by these diseases, its peripheral terminations in the labyrinth are also often involved, so that sharp distinctions cannot always be drawn between this form and that due to labyrinthine disease. 3. Deafness' from Labyrinthine Disease.—The causes are drugs, such as quinine and the salicylates; inflammations, includ- ing syphilitic exudates, injuries, hemorrhages, tumors, primary atrophy which may occur in locomotor ataxia; mechanical causes, such as the constant noises and jarring to which locomotive en- gineers and boiler-makers are subject. Symptoms of Nervous Deafness.—The dominant symptom is loss of hearing, but this may be accompanied with vertigo, tin- nitus, and even forced movements. In hysterical deafness the loss of hearing is rarely complete, is unilateral, and especially involves high and low notes. Deafness from involvement of the nucleus and nerve root is usually accom- DISEASES OF THE CRANIAL NERVES. 139 panied with other symptoms of a basilar meningitis or lesion of the pons and medulla. Labyrinthine deafness is often associated with vertigo, tinnitus, and forced movements, when it may be- come a symptom-complex known as " Meniere's disease." Sudden total deafness is characteristic of syphilitic disease of the internal ear. In genuine nervous deafness, unless the deaf- ness is absolute, bone conduction is lost, while aerial conduction is preserved. A tuning-fork vibrating on the skull or mastoid is not heard by the affected ear, though it is heard when held in the air close by this ear. Changes of reaction to the electrical current occur, but the tests are difficult and the results unsatis- factory. The treatment depends upon the seat and nature of the lesion. In labyrinthine deafness it is generally limited to the use of iodide of potassium, mercury, pilocarpine, leeches, and the gal- vanic current. Local applications and surgical interference may be required. The treatment of nervous deafness in which ver- tigo, forced movements, and tinnitus are the dominant symp- toms will be discussed under these heads. Tinnitus Aurium, Tinnitus Cerebri (Noises in the Ear and Head). Subjective sounds resembling hissing, buzzing, humming, beating, musical notes, etc., are classed together under the gen- eral head of tinnitus aurium. It is a very common symptom. Etiology.—The disease attacks adults in middle and later life. Men and women are alike affected. Neuropathic constitutions and an unstable circulation favor it. The arterio-sclerosis of old age, cerebral anemia and congestion, sunstroke, tobacco, and alcoholism lead to it. It occurs often in melancholia and in neu- rasthenia. Some local disease or congestion of the middle or in- ternal ear is usually present. Tinnitus occurs in Bright's disease, gout, and dyspepsia. Disease of the auditory nuclei and auditory tracts rarely, if ever, causes tinnitus; but chronic pachy-meningitis, such as fol- lows blows on the head, sunstroke, alcoholism, etc., may be at- tended with most annoying tinnitus, which is often not so much in the ears as in the head—a tinnitus cerebri. In old people with thickened arteries and imperfect brain nutrition a similar condi- tion may occur. Tinnitus accompanies insanity sometimes, and may be the source of aural hallucinations. A kind of tinnitus may accompany migraine and take the form of an aura in epilepsy. Despite this long list of causes, the chief factors may be 140 DISEASES OF THE NERVOUS SYSTEM. summed up as neurasthenic states, local ear disease, humoral poisons and irritants, reflex irritants, arterio-sclerosis. The symptoms are indicated by the name of the malady. They may come on suddenly, but usually develop slowly. Some deafness and occasional vertigo are often present. The noise is located in one ear as a rule. Sometimes it is said to be simply "in the head." The sounds are generally present all the time, giving the patient little rest and making life a burden. They vary greatly in character and intensity. These variations are indicated in the study of the diagnosis. The Diagnosis.—The recognition of the symptom is easy. The principal thing is to discover its seat and cause. The ear should of course be examined for external or middle ear disease. If the tinnitus is pulsating and synchronous with the heart- beats and stopped by carotid compression, it may be inferred that it is due to vasomotor paralysis, or inflammatory conges- tion, or aneurism. If the sound is not in the ear, but in the head, and not asso- ciated with deafness or ear disease, the trouble is probably cen- tral, and most likely is of meningeal or arterio-sclerotic origin. Noises which are complex or take the form of musical sounds or words are probably central. Constant rushing, knocking, pulsating noises are due to con- gestion, hemorrhage, or inflammatory effusion in the labyrinth. Moist sounds of a gurgling, bubbling, boiling, singing, whis- tling, shell-like roaring character indicate disease of the middle ear, with fluid exudation or catarrh of the Eustachian tube, or irritation of the external auditory canal, mastoid cells, or post- nasal spaces. Dry roaring and ringing noises are due to non-suppurative catarrh of middle ear, disease of the muscles or nervous supply of the tympanum, meningitis, tumors, and syphilis. The condition of the digestion should be inquired into and the existence of renal, arterial, or of central nervous disease inves- tigated. Treatment.—Hydrobromic acid and the other bromides are the surest remedies for this trouble, given in ordinary doses. They may be combined with digitalis. Iodide of potassium and iodide of ethyl often are useful. Nitroglycerin is sometimes of value in patients with hard arteries. A combination of digitalis, bromide, and nitroglycerin has given me the best results. Occa- sionally tonics are indicated. I have seen but little good from electricity or counter-irritation. Of course middle-ear disease must be treated if it is present. DISEASES OF THE CRANIAL NERVES. 141 Vertigo (Dizziness, Giddiness). Vertigo is a disturbance of consciousness characterized by ap- parent movements of external objects or of the person himself. If external objects whirl around, the vertigo is called objective; if the person himself seems to move, it is called subjective. Ver- tigo is almost always a symptom. In rare cases it appears to be idiopathic. Vertigo is connected more or less with our space sensations, and hence it will be described here under disorders of the eighth cranial nerve and its central representations. Etiology.—The causes of vertigo may be classed somewhat like those of headache, as follows: 1, Hemic: anemia, hyperemia, toxemia, from tobacco and alcohol; 2, arterio-sclerosis; 3, acoustic-nerve irritation; 4, neu- roses : epilepsy, neurasthenia; 5, reflex: ocular, gastric; 6, organic brain disease; 7, mechanical causes like electricity, swinging, etc. Based mainly on the etiology, we have as a practical classifica- tion of ordinary cases of vertigo: toxic, auditory, gastric and bilious, ocular, neurasthenic, and epileptic forms. The various causes of vertigo act partly by irritating the space-sense nerve and thus disturbing our sense of relation to external objects, partly by irritatiug the cortical centres of the brain. Symptoms.—Vertigo comes on suddenly, and lasts, as a rule, for but a moment. The floor rises up and sinks down, or objects whirl around (objective vertigo), or the patient seems whirling around or falling. The ideas are confused, there is a sense of alarm and a feeling of faintness. The patient totters, sometimes falls; there may be nausea or vomiting. In some forms there is momentary loss of consciousnses, or syncope. Vertigo usually comes on in short attacks, but in toxemic states as in alcoholism or nicotinism it is almost constant while the poison is in the sys- tem. Vertigo may become chronic or nearly so; and if severe it forms what is called the status vertiginosus (Mitchell). Vertigo is increased by rising or sudden movements and lessened by lying down. Vertigo due to organic lesions of the cerebellum and its peduncles, or of the labyrinth, is associated with forced movements of the body. Symptoms of Special Forms.—Auditory Vertigo (Meniere's Disease).—A large proportion of vertigoes are due to disease or irri- tation of the eighth nerve and its centres. The common cause is local disease of the labyrinth. When this produces severe at- 142 DISEASES OF THE NERVOUS SYSTEM. tacks of vertigo with nausea and perhaps syncope, it is called "Meniere's disease." The name is often applied to any form of auditory vertigo. Meniere's type is always due to organic disease of the labyrinth. It is accompanied with progressive deafness, and sometimes with tinnitus and forced movements, or even an utter inability to walk steadily. When the deafness is complete the vertigo ceases, because the nerve end-organ is destroyed. Mild forms of auditory vertigo present nothing unusual except those due to involvement of the nerve of hearing. Many forms of vertigo, such as the gastric and toxic, occur through a reflex disturbance of the eighth nerve. The auditory nuclei are connected with those of the vagi. The labyrinth is supplied with blood by the vertebral artery, whose calibre is con- trolled by sympathetic fibres which are in close connection with fibres to the stomach. Hence reflex effects may occur through contiguity of the central nuclei and by reflex spasm of the vessels of the internal ear. " Stomachal vertigo" is the name given to a very severe form of reflex vertigo. It occurs generally in persons whose stomachs are overloaded and digestion paralyzed by its load. It is accompanied by loss of consciousness. Bilious and Lithemic Vertigo.—In conditions of dyspepsia, constipation, and hepatic torpor, the disordered stomach and bowel suddenly discharge into the blood irritant substances which pass to the brain and by direct action on the nervous cen- tres cause vertigo. This is probably the explanation of the ver- tigo of biliousness and constipation. It is a paroxysmal vertigo, noted most in the morning, not very severe, and often accom- panied with nausea. Neurotic Vertigo.—The symptoms of epileptic vertigo will be described under that head. Neurasthenic vertigo is a not uncommon symptom. The at- tacks are short, generally subjective, not severe or accompanied with nausea or syncope, but they often cause much alarm. Un- derlying them are exhausted and irritable nerve centres, with ocular, gastric, and humoral irritations. A neurotic vertigo occurs sometimes in the form of attacks almost exactly resembling seasickness. There is intense vertigo, nausea, and faintness lasting for hours, coming on suddenly with- out known cause except overwork or excitement. The attacks occur in neurotic subjects and are analogous to other nervous crises. It is a periodical neurosis of the space-sense nerve. In some nervous subjects there occurs a sudden giving way of the legs. There is no conscious vertigo, yet such probably exists. The symptom is noted in exophthalmic goitre. It is a " stumbling vertigo." Ocular vertigo is a rare symptom, but is, when present, chronic DISEASES OF THE CRANIAL NERVES. 143 and annoying. It is caused by refractive errors and unequal action of the ocular muscles. The mechanical vertigoes are such as are produced by swinging, whirling, the movements of the ship, steam-car, and elevators. Railway mail-clerks, elevator boys, often suffer from chronic dis- turbances of a vertiginous character. Ocular and auditory nerve sensations enter into the causation. Arterio-sclerotic Vertigo, Senile Vertigo.—This occurs in per- sons who have arterio-sclerotic changes in the brain-vessels, either from disease or senility. The symptom is caused by impaired brain nutrition with consequent anemia. Senile vertigo may also be due to a weak and fatty heart. Pathology.—The consciousness of the proper equilibrium of the body and of its relations to the external world depends upon the continuous inflow of nervous impulses from the eye and its muscles, from the nerves of the muscles, joints, and viscera, and from the ear. Anything which suddenly disorders this even in- flow may cause a disturbance of consciousness and sensations of vertigo. The aural impulses come from the semi-circular canals and ampulle; they are the most important. These impulses are not felt in consciousness normally, but go to certain lower centres chiefly in the vermis of the cerebellum. From this point they influence the acts concerned in holding the body in equilibrium. When impulses from the eye and its adjusting mechanism do not flow in normally, there may be disturbance of consciousness and a feeling of vertigo. Probably visceral impulses can produce a similar disturbance. Everything which suddenly interferes with the nutrition of the cortex of the brain, such as anemia and poisons, may lead to giddiness by lowering the level of conscious- ness and confusing the sensory inflow. Diagnosis.—In investigating vertigo the physician should find (1) whether it is subjective or objective, (2) paroxysmal or chronic, (3) accompanied with ear symptoms, nausea, tinnitus, and loss of consciousness. He should then direct himself to finding the spe- cial cause and seat, remembering that the auditory, gastric, toxic, and neurasthenic are the common forms. In elderly persons the arteries should be carefully examined. In young persons the possibility of epilepsy must be remembered. The prognosis depends upon the cause. Epileptic vertigo and vertigo from organic disease are most serious. Labyrinthine vertigo usually ceases when complete deafness occurs. The other forms of vertigo are usually susceptible of relief. Treatment.—The attack is treated by rest in the horizontal position and the administration of a volatile stimulant. The disorder must then be treated in accordance with the cause. 144 DISEASES OF THE NERVOUS SYSTEM. In Meniere's vertigo the use of quinine by Charcot's method is said to' be useful. Quinine is given in doses which are gradually increased until cinchonism results. Then the drug is stopped. Mitchell advises the addition of hydrobromic acid; Gowers ad- vises the use of salicylate of soda in five-grain doses instead of quinine. Hirt recommends ten drops of a two-percent solution of pilocarpine injected hypodermically every other day. Neurasthenic vertigo is cured by rest and attention to diet, laxatives and mineral acids being used. Hydrobromic acid with pepsin and glycerin are often very helpful here. Gastric vertigo is to be treated with saline laxatives and simple bitters before meals. In the vertigo of " biliousness " and lithemia there is often a neurasthenic element, and a similar attention to diet and to the digestive organs is indicated. In arterio-sclerotic and senile ver- tigo small doses of nitroglycerin and iodide of potassium, with or without digitalis, should be given. Rest and warmth of the ex- tremities are indicated. In all forms of vertigo bromide of potas- sium is helpful and will relieve the symptoms for a time. It is the best symptomatic remedy. Counter-irritation to the neck or mastoid region by the cautery does good occasionally. There are two peculiar forms of disease to which the name vertigo has been attached which may be described here. Laryngeal Syncope (Laryngeal Vertigo, L. Epilepsy). —This is a rare form of disorder characterized by attacks of paresthesia of the throat, with coughing, followed by sudden syn- cope, and sometimes by slight convulsive movements. The disease occurs chiefly in males at about the age of fifty, though the range of age is thirty-five to seventy. Neurotic con- stitution is often present. There may be a history of injury and the use of stimulants. Laryngitis, bronchitis, apical phthisis, and asthma may be present. At the onset of the attacks a burning or tickling sensation is felt in the larynx or trachea; there is a spasmodic cough, per- haps some asthmatic or dyspnceic symptoms, when the patient suddenly falls, unconscious for a short time. The attacks may occur daily or only once in a few weeks. Most cases are curable, yet the disease is not without danger. It is probably a reflex neurosis, not a true epilepsy. The treatment should be directed to the relieving any local condition or pulmonary trouble. Bromide of potassium should also be given. Paralyzing Vertigo (Gerlier's Disease).—This is a dis- ease occurring only on the farms in southern France and Switzer- land. The symptoms consist of sudden attacks of ptosis, vertigo, paresis of arms and legs, and cervico-occipital pain. The disease is most prevalent in the summer-time. It attacks chiefly males. Single attacks last not over ten minutes, but may occur fre- quently. diseases of the cranial nerves. 145 The cause is supposed to be a special microbe developed in the stables during the heat of summer. We are not aware of its occurrence in America, though Seguin calls attention to the close similarity of the symptoms to those of poisoning by conium maculatum. Hyperacusis (Auditory Hyperesthesia).—When there is undue keenness of the sense of hearing, the condition is called hyperacusis. It occurs in hysteria and hypnotic states. Some persons have naturally an extraordinary keenness of hearing. In facial paralysis there is sometimes hyperacusis due to paralysis of the stapedius. When ordinary sounds cause painful feelings, the condition is called dysacusis. This occurs in the neurasthenic and hysterical, in persons of enfeebled vitality, in the brain congestion of fevers, and in meningitis; also in local ear troubles of an inflammatory character. Fig. 67.—Case for Testing Sense of Taste .and Smell. io 140 DISEASES OF THE NERVOUS SYSTEM. Diseases of the Glosso-Pharyngeal Nkrve. The motor fibres are affected with spasm causing dysphagia and a feeling called globus; they are also affected by paralysis in the disease called glosso-labio-laryngeal palsy. The sensory fibres are affected also in globus. The special sense of taste is affected, causing ageusia or loss of taste. Of these diseases no one belongs to the glos- so-pharyngeal nerve alone. It will be con- venient, however, to de- scribe disorders of taste here. Ageusia (loss of the kesse of taste) is an affection in which the power to discrimi- nate the tastes of bit- ter, sweet, salt, acid, and alkaline substances is lost. Etiology.—It occurs oftenest in an incom- plete form in facial palsy and in hysteria. Fig. 68.—Modified from Erb, showing the Re- Injuries of the trigem- lations of the Seventh and Glosso-Pharyngeal inus and glosso-pharyn- Nerves and the Course of the Taste Fibres. The geal nerves catarrhal lines 1,2, 3, 4 and 5 mark off different segments of digeases of t'he mucous the nerve; iv./., facial nerve; A.a., acoustic nerve; G.ph., glosso-pharyngeal nerve; G.g., geniculate membrane of the mouth ganglion; N.p.s., great superficial pelvosal frcm and nose, are frequent fifth nerve; N.c.c.p.t, tympanic plexus; the dotted causes. It is not caused line Sps indicates salivary fibres; the other dotted byorganic brain disease line indicates taste fibres; Ch.t., chorda tympani' f N.st., stapedius nerve; F.st., stylo-mastoidforamen. so *ar as known. Symptoms. — Some ageusia is present in the imbecile, and the sense of taste is less keen in the lowly organized and criminal classes. The symptoms are subjective and may not be noticed at first by the patient. In hemiageusia from facial palsy and hysteria it has to be looked for, as the patient does not complain. The tests are made with solutions of salt, sugar, vinegar, and quinine. A DISEASES OF THE CRANIAL NERVES. 147 single solution of sugar usually answers. But the different parts of the tongue differ in sensibility to different substances (Fig. 67). Care must be taken to exclude the nose as a factor in taste. Pathology.—Ageusia occurs as the result of disease of the roots of the trigeminus, especially of the second, also from disease of the facial when the chorda tympani is implicated and from dis- ease of the glosso-pharyngeal root. Disease of the trigeminus and facial usually causes ageusia on the anterior two-thirds of the tongue, with loss of taste, espe- cially for sour and bitter substances. Sometimes, however, dis- ease of the trigeminus or disease of the tympanum involving the tympanic plexus and chorda tympani causes ageusia of the whole tongue on the affected side. Ageusia from disease of the glosso-pharyngeal alone is very rare, and then causes loss of taste on the posterior third of the tongue, soft palate and pillars of the fauces, with loss of taste to sweets and acids. A few cases have been reported in which paralysis of the glosso-pharyngeal caused complete ageusia on the affected side. It must be inferred, therefore, that taste fibres run sometimes wholly in the fifth, more rarely wholly in the ninth nerves, and usually in both. The treatment depends on the cause. Locally, cleansing and stimulating mouth-washes and electricity may be used. Parageusia or perversions and imperfections in the taste sense are very frequent. They are generally due to irritation of the taste nerves from catarrhal inflammation of the stomach or mouth. They also occur in hysteria. Diseases of the Pneumo-gastric Nerve and of the Bulbar Portion of the Spinal Accessory. These nerves are essentially visceral in character. Their dis- eases call for a study of laryngeal, pulmonary, cardiac, and abdom- inal neuroses, which would bring us into the domain of laryngol- ogy and general medicine. Hence, despite their great importance, I have thought it best not to try and present them here. Some of the symptoms are described in connection with locomotor ataxia, progressive muscular atrophy, exophthalmic goitre, and angina pectoris. Diseases of the Hypoglossal Nerve. The diseases of this nerve consist of lingual spasms, lingual palsy, and lingual hemiatrophy. Lingual spasms take part in the disorders of articulation, helping to cause stuttering and speech cramps. Such troubles are 148 DISEASES OF THE NERVOUS SYSTEM. often developmental in origin and belong to the habit-choreas or convulsive tics. Stuttering is a spasmodic disorder in which the tongue mus- cles are involved, preventing the proper enunciation of words and sentences. Stammering is an imperfect articulation due sometimes to disease or defect in the hypoglossal nerve and its muscles. It is not a spasm. Aphthongia is the name given to a form of spasm occurring in speakers and similar in nature to writer's cramp. Clonic lingual spasm occurs in chorea, hysteria, and during the attacks of epilepsy. Unique cases of this spasm also occur from reflex irritation or central nervous disease. Tonic lingual spasm occurs in hysteria, and sometimes as an independent affection due to unknown causes, generally those of a debilitating and nervously depressing character. Reflex irrita- tion may be a cause. Lingual paralysis (glossoplegia) is usually one of the symptoms of glosso-labio-laryngeal palsy. It may be caused by a bilateral lesion in the cerebral hemispheres. The condition is then known as pseudo-bulbar paralysis. Diseases of the medulla and of the nerve itself may cause the paralysis. The paralysis may be either unilateral or bilateral. The symptoms are an impairment of speech and of swallowing. Fuller details will be given under the head of Bulbar Palsy. Progressive Lingual Hemiatrophy.—A progressive hemiatro- phy of the tongue sometimes occurs. It is analogous in all re- spects to facial hemiatrophy, with which it is sometimes associ- ated. It is probably due to a low grade of degenerative neuritis of the nerve. It is very rare. DISEASES OF THE SPINAL PART OF THE ACCESSORIUS. This is a purely motor nerve, and its disorders are therefore spasm and paralysis. Torticollis (Wry-Neck, Caput Obstipum). Torticollis is a disease characterized by clonic or tonic spasm of the muscles supplied by the spinal accessory and often of other muscles of the neck. There are several forms of wry-neck, which must be distinguished from each other. They are: 1, congenital wry-neck; 2, symptomatic wry-neck; 3, spurious wry-neck, from spinal disease; 4, true spasmodic wry-neck. 1. Congenital wry-neck is due to some intra-uterine atrophy or obstetrical injury of the sterno-cleido-mastoid. It occurs oftenest after breech or foot presentations. The right side is DISEASES OF THE CRANIAL NERVES. 149 usually affected. There is no spasm at all, but the neck is fixed to one side by the shortness of the muscle, and also rotated to the opposite side. The deformity becomes more noticeable as the child grows older, because the parts atrophy. The atrophy affects not only the shortened muscles, but the face on the af- fected side. 2. Symptomatic wry-neck is usually due to a rheumatic myo- sitis, and occurs chiefly in children. It may be due also to tumors, adenitis, abscesses, and local syphilitic disease. In these cases there is always pain and tenderness associated with the deformity. 3. Spurious wry-neck is an apparent or real spasm of the neck muscles due to caries of the spine. Treatment.—Congenital wry-neck, if taken early, can be cured by tenotomy of the sterno-mastoid and subse- quent fixation of the neck for a time. When osseous changes have occurred per- fect relief is impossible. Symp- tomatic rheumatic wry-neck is a trivial and temporary af- fection, which needs only to be palliated by hot applica- tions and saline purges until e.j'. cure takes place. „, . , Fig. 69.—Wry-Neck of Right Side. Spurious wry-neck re- quires suitable orthopedic measures, such as the plaster jacket and jury-mast. 4. Spasmodic Wry-Neck.—This is a purely nervous disease characterized by spasm of the muscles supplied by the spinal accessory and sometimes by the upper cervical nerves. Etiology.—Women are much oftener affected than men. It occurs in early adult and middle life, never in children or old people. A neuropathic constitution and heredity often exist. The exciting causes are occupations which put the lateral muscles of the neck on a strain, depressing emotions, physical shocks and blows, rheumatic influences, and perhaps malaria. Sometimes no cause can be detected. Reflex irritations, perhaps, exist in some cases, but it is difficult to find them. Symptemis.—The disease begins with slightly painful sensa- tions in the neck, which are soon accompanied with spasm. The spasm is at first clonic and intermittent. The sterno-mastoid is oftenest involved of single muscles; but the rule is that the upper fibres of the trapezius are also affected. The patient's 150 DISEASES OF THE NERVOUS SYSTEM. head is inclined toward the affected side by the trapezius, the chin is raised and the head rotated to the opposite side by the sterno-mastoid and trapezius, and this is the typical position in the disease. If both trapezii are affected the head is pulled back, but this is a rare form. It is called retrocollic spasm. The corn- plexus and obliquus superior are the only other neck muscles which can rotate the head to the opposite side. They are sup- plied by the upper cervical nerves and are sometimes involved in wry-neck. In torticollis the muscles affected with spasm have a similar physiological function. Hence while the sterno-mas- toid, trapezius, complexus, and superior oblique on one side are attacked by the spasms, muscles on the other side may be at the same time implicated. The opposite muscle commonly affected is the splenius, which inclines the head laterally and rotates it to the same side. Probably the deep muscles, recti capitis postici, major and minor, and the inferior oblique, which draw the head back and rotate to the same side, are also at times affected. The list of muscles that may be involved and their nerve supply is as follows: Function. Turning Head to Opposite Side. Turning or Inclining Head to Same Side. Nerve Supply. Muscles usually Muscles rarely Recti capitis postici, maj., min., infer, obliq., splenius. Extreme rotation without much retraction of the head would indicate involvement of the sterno-cleido-mastoid and opposite splenius. Retraction of the head indicates involvement of both trapezii. The disease may start in one muscle and gradually extend to others, even involving the facial, masticatory, and brachial nerves. As it progresses the spasm becomes more constant, and finally it may be tonic, never yielding except to artificial means or during sleep. The pain associated with the disease gradually decreases. The affected muscles hypertrophy, the muscles thrown into dis- use atrophy. There is some deformity, in time, of the neck and shoulders, but facial asymmetry does not occur in this form unless it begins, as is very rarely the case, before maturity. The disease may be complicated with or alternate with other neuroses. I have known epilepsy to be associated with it. Pathology.—The disease is a neurosis involving the bulbar and lower cerebral centres. The neuro-mechanism controlling the movements of the neck is unstable and out of control. Conse- DISEASES OF THE CRANIAL NERVES. 151 quently it sends out intermittent and irregular discharges of nerve force. The seat of the typical disease is never in the nerve alone, probably not in the cortex. It is a disturbance of nutrition and function; it has no patho- logical anatomy, though vascular disturbances of the nerves and centres may be present. The diagnosis has to be made from the other forms of wry- neck mentioned. The age, history, and fixed character of the spasm serve to distinguish congenital wry-neck. The history, the pain and tenderness, and the temporary duration differen- tiate the rheumatic forms. The increased rigidity on passive motion, the pain, deformity, and other signs of cervical caries are sufficient to diagnosticate vertebral disease. Prognosis.— The disease is not fatal. It generally reaches a certain stage and then remaius chronic. In rare cases it is cured; in many others it can be much ameliorated. Cases occur- ring in young people, in the hysterical, and in those without a decided neurotic history are the most favorable. Treatment.—The drugs which are efficient are opium, atropia or hyoscyamine, conium, gelsemium, valerianate of zinc, asa- foetida, chloral, bromides, arsenic, and cocaine. Of these, opium, atropia, gelsemium, and zinc are generally the most efficacious. Opium must be given with great caution. Atropia should be given hypodermically in increasing doses up to intoxication (gr. TV) (Leszynsky). The galvanic and faradic currents are useful adjuvants in helping to relax the spasm and keep up the nutri- tion of the muscles; but alone they are not curative. Massage and stretching the neck in a Sayre apparatus, together with systematic exercise of the neck muscles, often help; neck-stretch- ing will even sometimes cure. The only surgical measures to be advised are nerve-resection, and possibly the partial cutting of the sterno-mastoid muscle. A very few cures and many failures have followed surgical interference. Splints and mechanical fixation apparatus do no good as a rule. Resection of the posterior branches of the upper three or four cervical nerves as suggested by Keen has done great good in a few cases (Powers). Spasmus Nutans (eclampsia nutans, nodding spasm, salaam spasm, oscillating spasm).—This is a disorder occurring chiefly in children and characterized by rhythmical nodding or oscillat- ing movements of the head. Etiology.—The disease occurs in young children who are anae- mic and badly nourished. Dentition, digestive disorders, basilar meningitis, gross disease of the brain, are causes. Sometimes it is 152 DISEASES OF THE NERVOUS SYSTEM. only a kind of habit chorea, and occasionally this habit contin- ues during life. Symptoms.—The disease may come on suddenly; more rarely it develops slowly. The patient has paroxysms usually of a rather violent character, lasting for minutes or hours, or even continuing nearly all the time except during sleep. The head moves thirty to sixty times a minute usually, but the motion may be slower or faster. Movements of the eyes and facial mus- cles often complicate the affection. The paroxysm may end in an epileptic attack. The diagnosis is easily made by the symptoms. The prognosis and treatment depend upon the etiology. Bromide of potassium, hyoscine, and syrup of iodide of iron I have found useful. Paralysis of the Spinal Part of the Accessory.—Eti- ology.—The causes are injuries, caries of vertebra, progressive muscular atrophy, and all forms of spinal disease reaching high up in the cervical cord. Symptoms.—When one nerve is paralyzed the head may still be held straight, but there is inability to rotate it perfectly. The prominence of the sterno-mastoid is absent—atrophy takes place. No spasm of the other muscle occurs, and there is no such thing as paralytic torticollis (Gowers). The involvement of the trape- zius causes a depression in the contour of the neck, especially noticeable on deep inspiration. There is some trouble in raising the arm, the scapula is drawn away from the spine, and the lower angle is rotated inward. When both nerves are paralyzed there is great difficulty in rotating the head or raising the chin. Paralysis of both sterno-mastoids causes the chin to drop back- ward, while paralysis of both trapezii in their upper parts causes the head to drop forward. Atrophy of the muscles attends the paralysis of the nerve, and degenerative reactions may be noted. The cervical nerves appear sometimes to supply the sterno-mas- toid and upper part of the trapezius so much that in disease of the accessories decided paralytic symptoms are absent. When both parts of the spinal accessory are involved, dropping of the palate, dysphonia, and rapid pulse are added symptoms. The diagnosis depends upon a thorough examination of the motility of the parts. The treatment is based on a knowledge of the cause of the disease. CHAPTER IX. DISEASES OF THE SPINAL NERVES. Anatomy and Physiology.—The spinal nerves arise from the spinal cord by two roots, anterior and posterior. These roots unite outside the spinal canal to form mixed nerves. The mixed nerves divide and go to their various destinations. There are thirty-three pair of spinal nerves, viz.: Cervical, 8 Dorsal, 12 Lumbar, 5 Sacral, 5 Coccygeal, 3 (all rudimentary) 33 The last two coccygeal nerves are microscopic in size, and the first pair is very small, so that practically there are but thirty sets of spinal nerves. The posterior roots are connected with ganglia lying in the intervertebral canal, and called intervertebral ganglia, or ganglia of the posterior roots. The mixed nerve is connected, by fibres that come chiefly from the anterior root, with the sympathetic or prevertebral ganglia. For the purpose of conveniently studying the diseases of the spinal nerves, we divide them into six different groups, each having a somewhat definite work to do. These groups are shown in the accompanying table, also on p. 82. Strands of Spinal Nerves. Distribution. Associated Ganglia of Sympathetic. Group I___ " II.... " III.... " IV.... " v.... " VI.... Upper four cervical. Lower four cervical and first dorsal. Upper six dorsal. Lower six dorsal ex-cept last. Twelfth dorsal, four lumbar. Fifth lumbar and five sacral. Occipital region, neck. Upper extremities. Thoracic wall. Abdominal wall, upper lumbar, upper lateral thigh surface. Lumbar region, upper gluteal, anterior and in-ner thigh and knee. Lower gluteal, pos^rior thigh, leg;. First cervical. Second and third cervical, first dor-sal. First to sixth dor-Fifth to twelfth dorsal. First to fourth lum-bar. First to fifth sa-cral. Group I. The Upper Cervical includes the flrst four of the spinal nerves. These divide into an- terior and posterior branches. The posterior branches supply the muscles and skin of the back of the neck and the occiput. The 154 DISEASES OF THE NERVOUS SYSTEM. principal nerves are the suboccipital and great occipital. The an- terior branches form the cervical plexus. Its principal branches are the auricularis magnus, occipitalis minor, and phrenic. The Fig. 70.—Thb Spinal Nerves, showing their groupings and plexuses (after Baker). special distribution of the nerves is shown in the table and Fig. 71. The upper cervical nerves supply motion to the muscles which rotate the head and draw it back and sideways. One branch, the phrenic, supplies the diaphragm; other nius- DISEASES OF THE SPINAL NERVES. 155 cles assist in fixing the thorax in forced inspiration. They inner- vate some of the hyoid and thyroid muscles, but have no influ- ence on phonation or deglutition. This group of nerves is in close connection centrally with the trigeminal nerve, whose descending root reaches down into the cervical cord. The fibres to the scalp and face also anastomose with the trigeminus in their peripheral distribution to the scalp and chin. The diseases of the upper cervical group are spasms, paralyses, and neuralgias. Spasmodic Diseases.—Torticollis may be limited to the cervical nerves, as has been shown. Tonic spasm causing a rigid neck is a frequent symptom of meningitis, and forms part of epileptic and other convulsions. In oscillatory and rotatory spasms the cervical nerves are in- volved. Hiccough is a clonic spasmodic disorder of the phrenic nerve. It is usually due to gastric disturbance, with flatulent distention of the stomach. When chronic, it is caused by hysteria, neuritis, diaphragmatic pleurisy, or some pressure upon the nerve in its course. 1 have seen a case in which it was probably a pure spasmodic neurosis. Ordinarily, hiccough can be stopped by simple carminatives like spirits of chloroform or lavender. In obstinate cases in which no known cause can be found, pilocarpine, hyoscine, and bromides are useful. Counter-irritation along the neck helps some cases. A most effective measure is to lay the patient supine over a thick bolster so that the head hangs down and the thorax arches up. Paralyses and Atrophy.—The cervical muscles are para- lyzed in progressive muscular atrophy and in pachy-meningitis hypertrophica, and occasionally in vertebral and peripheral dis- ease or injury. Some deformities and weakness in head move- ments result, but the most serious consequence is involvement of respiration through palsy of the phrenic. Paralysis of the Phrenic Nerve.—Etiology.—Such pa- ralysis may be due to disease or injury of the cervical cord, and also to peripheral disease, to which the nerve is somewhat liable owing to its long course through the anterior mediastinum. Pleurisy, peritonitis, mediastinal tumors, rheumatic and toxic influences, and hysteria are among the special causes of phrenic paralysis. Spinal-cord disease is, however, the commonest eti- ological factor. Symptoms.—In diaphragmatic paralysis, if bilateral, as is usu- ally the case, there is either no movement of the abdomen or the epigastrium and hypochondrium are drawn in. On slight exer- tion there is dyspnoea and increase of respiration. 156 DISEASES OF THE NERVOUS SYSTEM. Diagnosis—If no other muscles than the diaphragm are in- volved, the cause is probably in the trunk of the nerve. Inflam- matory disease of the diaphragm may cause a paralysis which is recognized by its painful character and the febrile reaction. Treatment—This is to be guided by the cause. It need only be said here that there is a motor point in the neck where by Fig. 71.—Showi.ng : (1) The relation of the spinal nerve roots to the spinous pro- cesses; (2) the arrangement of the brachial plexus; (3) the level of origin and (4) the distribution of the chief motor and sensory nerves of the arm. Small letters refer to sensory distribution, figures to mixed nerves; capital letters represent the nerve roots from which the nerves are derived, a, Great occipital; b, small occipital; c, clavicular; d, circumflex; e, posterior dorsal; /, musculo-spiral; g, lateral dorsal; h, external cutaneous; i, internal cutaneous; j, musculo-cutaneous; fc, radial; I, ulnar; m, median. 1. Suprascapular. 2. Subscapular. f Supinators. (From 5 and 6 C.) (From 5 and 6 C.) Ext. carp. rad. 3 and 6. Musculo-spiral. and ulnar. (From. 4, 5, 6, 7, 8 C-j Ext. com. dig. roots.) Ext. pollicis. Triceps and ( anconeus. Pronators. Flex. carp. rad. Flex. subl. dig. 7. Median. -j One-half flex.prof.dig. (From 6, 7, 8 C.) Abd. oppon. and one- half flexor pollicis. .One-half lumbricales. 4. Musculo-cutaneous. j Biceps. (From 4 and 5 C. roots.) I Brachialis ant. Flex. carp, ulnar. One-half flex. prof. dig. interossei. One-half lumbri- cales. One-half flex, pollic. .Add. pollicis. 5. Ulnar. (From 8 C. and 1 D.) DISEASES OF THE SPINAL NERVES 157 careful electrization one can get a contraction of the diaphragm. In paralysis this fact should be utilized. Cervico-Occipital Neuralgia—Neck "Paws—Etiology.— Pains in the back of the head and neck occur in migraine, in hysteria, spinal irritation, and neurasthenia, as a result of eye strain, as a true neuralgia, and as a symptom of brain tumor, meningitis, and rheumatic in- flammation of the neck mus- cles and nerves. True cervico- occipital neuralgia is not rare, is much more common in women, occurs between the ages of twenty and thirty-five, and is often a reflex of pelvic disease. Symptoms. — Migrainous pains have been described. In spinal irritation and hysteria the trouble is central, or per- haps shifting; it is especially characterized by a sharp boring pain just below the occiput. With it there may be evidences of cerebral congestion or anae- mia, with vertigo and faintness, but not vomiting. The boring pain is almost pathognomonic of spinal irritation. In neuras- thenia the pain is more of a tired, aching character. In typical neuralgia the pain is usually unilateral, paroxysmal, and sharp, sometimes reaching the intensity of a tic doulou- reux. There are tender points over the exit of the nerves. The disease lasts for five or six weeks. If of reflex origin, it may become chronic. The pains may alternate with or take the place of a trigeminal neuralgia. The nerves involved are the great and small occipital from the second pair and a branch from the third pair. J2 JO // 7] Cervical J] a Bovral 9 6] I] m m 7} Lumbar Fig. 72.—Showing the Relation of the Spinous Process to the Roots op Ori- gin of the Spinal Nerves. The small squares to the right indicate the spinous processes; the large spaces indicate the nerve roots and the variation vertically in their origin. The relation of nerve root to spine, therefore, varies considerably (Reid). 158 DISEASES OF THE NERVOUS SYSTEM. Treatment.—General constitutional treatment consists in the use of anti-rheumatics, such as the salicylates. The muriate of ammonia has done me good servcie. In women pelvic troubles should be looked for; in both sexes the eyes must be attended to. Locally, counter-irritants, cupping, and leeching are useful; mus- tard and capsicum pastes are often a great relief. The ice-bag also is of service. Trephining the occipital bone has cured one obstinate case, and resecting the occipital nerves another. Group II. The Lower Cervical Nerves and Brachial Plexus. Anatomy and Physiology.—The anterior branches of the lower four cervical nerves and first dorsal nerve unite to form the brachial plexus. This gives off short nerves to the shoulder and trunk and long nerves to the arm. The mode of formation of the brachial plexus is shown in the diagram (Fig. 73). It is in accordance with the descriptions of Walsh and Allen. The short or upper branches supply the shoulder and intercostal muscles. The long or lower branches supply the arm and hand. The neurologist needs to know: (1) the muscular distribution of each nerve and the function of the muscle; (2) the cutaneous sensory distribution; and (3) the level of origin of the nerves. The accompanying figures and table give these points, and will be found useful for study and reference. They are based upon the investigations of Ferrier and Yeo, Thorburn, and also on Abbe's and my own experiments. The Arrangement of the Brachial Plexus.—It is made up of three nerve trunks, which in turn make up three cords, these cords giving off various branches, thus: lm TrS l^^S Iforms outer cord< (Sxt-a !*• thforacic- and seventh - hi h ■ ftfT' - Musculo-cutaneous. cervical roots ) wtlIcn glves ott ( Outer head median. f Inner head median. 2. Trunk from eighth 1 f . , | Ulnar. cervical and first }-,0J^jln^lL °5?M Int. cutan. dorsal roots j which gives off ] lnt. ant. thorae< [ Intercost.-hum. 3. Trunk from fifth, "| fQ sixth, seventh, [forms posterior cord, J ^uDscapular. and eighthcerv. f which gives off i ^ircumnex. and first dorsal J L Musculo-spiral. The following table shows the origin, muscular distribution, and effect of paralysis on the motor but not on the sensory nerves. This latter is indicated in the figure (Fig. 71); DISEASES OF THE SPINAL NERVES 159 Nerves and Roots of Origin. Muscular Distribution. Function as Shown by Effect of Paralysis. Posterior thoracic. Fifth and sixth cervical. Circumflex. Fifth, sixth, seventh, and eighth cervical. Suprascapular. Subscapular, short. Fifth and sixth cervical. Subscapular, long. Fifth, sixth, seventh, and eighth cervical. Anterior thoracic. Musculo-cutaneous. Fourth and fifth cervical. Musculo-spiral. Fourth, fifth, sixth, sev- enth, and eighth cervical Median. Fifth, sixth, seventh, and eighth cervical. Ulnar. Eighth cervical,first dorsal Serratus magnus. Deltoid. Teres minor. Supraspinatus. Infraspinatus and teres minor. Subscapulares. Teres major. Latiss. dorsi. Pectoralis major. Biceps and brachi- alis anticus. Triceps. Supinatores. Extensor carp. rad. Extensor carp. uln. Extensor c o m m . digit. Extensor p. i. pollic. Extensor s. i. pollic. Extensor oss. met. pollic. Pronatores. Flexor carp. rad. Flexor sublim. dig. Flexor prof und. dig. radial half. Two lumbricales. Abductor pollic. Flexor pollic. Flexor carp, ulnar. Flexor profund. dig ulnar half. Interossei. Two lumbricales. Flexor minor digit. Adductor pollicis. Inner half of flexor brev. pollicis. Posterior edge of scapula is rotat- ed out when arm is raised and carried forward. Weakening of elevation of shoul- der and of inspiration. Loss of power to raise arm. Weakened power to raise arm ; head of humerus tends to fall. Loss of abductors, motion forward and inward rotation of humerus. Loss of rotation of humerus out- ward. Weakens inward rotation of arm. Weakens power of elevating shoulder. Weakens power to depress shoul- der and to pull arm backward and to side. Loss to pull arm down and for- ward and to shrug the shoulder. Loss of flexion of forearm and weakness of inspiration. Loss of extension of forearm. Loss of supination. Extension of wrist lost except when fingers are flexed ; lateral deviation. Impaired extension of first pha- langes and wrist. Impairment of extension of thumb. Loss of pronation. Weakened flexion of wrist. Weakened flexion of second and third phalanges of first and sec- ond fingers. Loss of abduction and flexion of thumb. Weakened flexion of wrist; radial deviation. Weakened flexion of second and third phalanges of third and fourth fingers. Loss of flexion of first phalanges and of extension of second and third. Diseases of the Lower Cervical Nerve Group and the Brachial Plexus.—The nerves of this group are sub- ject to the pathological disturbances common to all nerves. I shall describe them from the clinical side, which gives the follow- ing disorders: f Combined arm palsies. j Upper-arm type or Erb's palsy. ] Lower-arm type. t Paralysis of individual nerves. Paralyses. 160 DISEASES OF THE NERVOUS SYSTEM. Spasmodic Disorders. ■{ Occupation neuroses. < Brachial neuralgia. Sensory Disorders. -j Digital neuralgia. (Numb-hands. Secretory, Trophic, t and Vasomotor] Neurotic o?dema. Disorders. ( Brachial Paralyses, Arm Palsies.—These occur as com- bined or total arm palsies, upper-arm and lower-arm types, and paralyses of single nerves. Combined paralysis of the brachial nerves is a condition in which all or nearly all the branches of the plexus and its branches are involved. Total arm palsies make up about six per cent of all peripheral paralyses, and are about one-fifth as frequent as single-nerve paralyses. Etiology.—They occur oftenest in men, but are not rare in in- fants, being then due to injuries during parturition. After in- fancy they are most frequent in early and middle life. The exciting causes are obstetrical and other injuries; deep- seated inflammations and tumors; shoulder dislocations; pri- mary neuritis; crutch and other forms of mechanical compres- sion; functional palsies, from overwork and hysteria; in rare cases, spinal-cord and brain disease. The symptoms vary with the severity and extent of the lesion. With regard to severity, there are three degrees. In the first there is simply a transient palsy, due to lying too long on the arm. The arm feels heavy, numb, and " asleep." In a few min- utes or hours this palsy disappears. In the second degree the nerves are so much compressed as to be mechanically injured. If the patient has been drinking hard, even moderate pressure may set up an inflammatory or destructive process that leads to quite a serious palsy. In the third degree the nerves are actually cut or torn across, or so compressed as to lose their anatomical integrity. The resulting symptoms are those common to all nerve in- juries, viz., paralysis, wasting, changes in electrical reaction of the muscles. Pain, tenderness, anaesthesia, trophic, secretory, and vasomotor disturbances are also present in varying degree. The distribution of the paralysis, atrophy, and sensory dis- turbance depends, of course, upon the arm nerves chiefly in- volved. The diagram (Fig. 71) will enable one to see in any case where the trouble is localized. There are three common symptoms, however, of which it is often very important to analyze the cause. These are the loss of DISEASES OF THE SPINAL NERVES. 161 power for elevation of the arm and for flexion and extension of the forearm. Flexion of the forearm is performed by the biceps and brachi- alis anticus, and is helped by the supinator longus. These mus- cles are supplied by the musculo-cutaneous nerve, except the supinator, which is supplied by the musculo-spiral. Hence when a person cannot flex the forearm, the musculo-cutaneous is chiefly affected. Extension of the arm is done by the triceps, which is supplied by the musculo-spiral. Elevation of the Arm Outward.—Inability to raise the arm is the common and striking symptom in combined brachial palsies. The arm is raised by a number of muscles. The deltoid acts first and most, but it can only raise the arm to a right angle. It is supplied by the circumflex nerve from the posterior cord of the plexus. After the arm is raised to a right angle, it is further elevated by rotating the scapula, and this is done chiefly by the middle part of the trapezius (lower cervical and upper dorsal nerves) and by the serratus magnus, supplied by the posterior thoracic nerve. A number of other muscles combine to strengthen elevation of the shoulder, but this action can only be abolished by paralysis of the deltoid or trapezius and serratus magnus. The diagnosis of these cases involves, first, the consideration of the seat of the lesion and the special nerves involved; next, that of the nature of the lesion. A recognition of the seat of the lesion and of the special nerves involved depends entirely upon the study of the distribution of the palsy and of the atrophy and sensory disturbance. It is important to determine whether one is dealing with a total arm palsy, an upper-arm type (Erb's palsy), or a lower-arm type. In ErVs palsy there is involvement of the deltoid, biceps, brachialis anticus, and supinator longus, with at times paralysis of the supinator brevis, and even of all the muscles supplied by the median nerve. The lesion is either in the cord formed by the fifth and sixth cervical nerves or a little lower in the brachial plexus, where the fibres supplying the musculo-spiral, circumflex, and musculo-cutaneous lie close together. At all events, the lesion involves the central parts and upper cords of the plexus. The arm hangs by the side and the forearm cannot be flexed. In the lower-arm type the triceps, the flexors of the wrist, the pronators, the flexors and extensors of the fingers, and the hand muscles are involved. The arm can be raised and the forearm flexed and supinated, but the hand is useless and the extension of the forearm is impossible. The lesion here involves chiefly the nerves from the seventh and eighth cervical and first dorsal roots. n 162 DISEASES OF THE NERVOUS SYSTEM. If the lesion is in the nerve there will be atrophy, changes in electrical reaction, sensory disturbances, and often, if there is neuritis, pain over the nerves. The reflexes will be lessened or absent. If the lesion is in the spinal cord, symptoms in other parts of the body will be present, or, if not, there will be no sen- sory disturbance, as in an arm palsy from anterior poliomyelitis. In rare cases arm palsies may be caused by spinal tumors or a local meningitis, in which case diagnosis is difficult. The prognosis is usually good. Nearly all these cases get well, the duration of the incapacity being from two or three months to a year. Even in the severest cases recovery is possible after one or two years. If, however, the nerves are torn across and the ends Fig. 73.—Illustrating the Formation of the Brachial Plexus; also the Involvement of the Plexus in Degenerative Neuritis (Le.-zynsky). widely separated, recovery is doubtful unless an operation is promptly done. The treatment consists in electrical applications, mechanical support, with potassium iodide internally and abstinence from alcohol. Local injections of nitrate of strychnine are useful, and massage should be used if it can be applied carefully. In brachial palsies due to severe injuries, dislocations, frac- tures, etc., in which there is evidence, from the extreme atrophy and absence of electrical reaction, that the nerve is entirely cut across and that the ends are not in apposition, a surgical opera- tion is stringently needed. The nerves should be exposed and the ends brought as near together as possible. Decalcified bone- tubes or sterilized macaroni may be used to give a passage for the central end to grow into the peripheral. In these cases, however, it must be remembered that the two ends do not unite; but the DISEASES OF THE SPINAL NERVES. 163 central end grows down into the tract of the old degenerated peripheral stem. The upper-arm type and loicer-arm type palsies are caused by much the same factors as the combined palsies; their symptoms have been indicated above. The upper-arm type is especially frequent in infants and constitutes one of the obstetrical paral- yses. It may in some cases be due to injury or hemorrhage in the cord. A peculiar form of combined nerve palsy sometimes occurs, due apparently to a.primary brachial neuritis. It begins in the plexus and involves first the nerves of the upper cervical roots. It may extend down and involve the ulnar, median, or musculo- spiral. It occurs in adult men generally and in those exposed to rheu- matic influences. Perhaps lead-poisoning may exist. It begins gradually with slight pains and weakness in the shoulder and arm muscles. Atrophy and anaesthesia follow, and degeneration reactions are present. There is not a great deal of pain (Fig. 73). The disease is usually confined to one side. It lasts several months, and nearly complete recovery finally takes place. Relapses may occur. It is differentiated from progressive muscular atrophy by the pain, anaesthesia, and electrical reactions and from arthritic atrophy, by the absence of any history of arthritis and the pres- ence of degeneration reactions and anaesthetic areas. Paralyses of Single Nerves.— Paralysis of the Pos- terior Thoracic Nerve.—Etiology.—This rare trouble usu- ally occurs in male adults and is due to injury or sudden strains. Its paralysis may be part of a progressive muscular atrophy. The nerve goes to the serratus magnus. Symptoms.—'When paralyzed, there is difficulty in raising the arm above the horizontal position and the movements of the shoulder are weakened. When the arm hangs by the side the lower angle of the scapula is drawn a little nearer the vertebral column and protrudes slightly. When the arm is held out hori- zontally the inner edge of the scapula protrudes and is drawn toward the middle line. When the raised arm is brought for- ward there is a deep groove formed between the inner border of the scapula and the thoracic wall. The disease often runs a long course and is accompanied with pain. Paralysis of the Circumflex Nerve.—The nerve goes to the deltoid, teres minor, third head of the triceps, and shoulder joint. It gives sensation to the skin of the shoulder. It is very often paralyzed. The commonest cause is a fall or injury, dislo- cation, and rheumatic inflammation of the joint. The arm can- 164 DISEASES OF THE NERVOUS SYSTEM. not be elevated or rotated outward. There is atrophy, anesthe- sia, and sometimes pain. Paralysis of the Suprascapular Nerves.—The nerve goes to the spinati muscles, teres minor, and shoulder joint. Dis- ease of this nerve alone is rare. The supraspinatus rotates the shoulder in, the infraspinatus and teres minor rotate it out. When paralyzed, there is an im- pairment of rotation and some impairment of elevation of the shoulder. Paralysis of the Musculo-Spiral Nerve (Wrist Drop, Lead Palsy, Compression Paralysis).—The distribution of this nerve is given in the table and cut. Its function is to extend and supinate the forearm, to extend the Avrist and fingers, and to ad- duct and abduct the fingers slightly. It extends directly only the last or ungual phalanges, the first and second phalanges being extended by the ulnar nerve. Etiology.—The musculo-spiral, owing partly to its course, is the most frequently affected by paralysis of all the arm nerves. Pres- sure on the nerve during sleep, especially when the patient is in- toxicated, crutch-pressure, fractures, wounds, tumors, lead-poi- soning, arsenical, alcoholic, and other forms of multiple neuritis are the causes of its disordered function. Symptoms.—The symptoms of this paralysis are "wrist drop," due to an inability to extend the wrist or fingers. The first and second phalanges can be extended somewhat by the interossei and lumbricales, but the last phalanges cannot be extended at all. The first finger is least affected. The fingers can only be slightly abducted, supination is generally lessened or lost; if the lesion is high up, the triceps is involved and the power of extend- ing the forearm weakened. There may be atrophy of the mus- cles and degeneration reaction. A swelling over the tendons of the wrist joint may occur. Some numbness and tingling exists, and occasionally there is anaesthesia in the distribution of the radial nerve on the hand. The disease lasts but a few weeks if due to compression; for months if due to neuritis, lead-poison- ing, or severe injury of the nerve. Eventually recovery takes place. When the disease is due to lead-poisoning there are some peculiarities in its course. Thus the supinator longus usually es- capes; the palsy begins gradually and usually involves both arms; it may extend to the upper arm. Partial degeneration reactions are present. There is rarely any anesthesia and but little pain. There is a lead line on the gum and a history of con- stipation and colic. In alcoholic and other forms of multiple neuritis there is pain and paresthesia, both arms are involved, and the flexors and DISEASES OF THE SPINAL NERVES. 165 other forearm muscles are somewhat implicated. There are marked sensory disturbances. The legs are also affected. In compression palsy the supinators and often the triceps are involved. When the lesion of the nerve is high up, as in crutch pa- ralysis, there is but little anesthesia, and that is found on the anterior surface of the forearm, in the distribution of the exter- nal and internal cutaneous nerves. Lesion of the nerve lower down may give rise to some anesthesia along the radial border of the forearm and back of hand; but the anesthetic area varies a great deal. The diagnosis of the paralysis is easily made. The most im- portant point is to find out the cause. The different charac- teristics of lead palsy, neuritic palsy, and compression palsy have been indicated in the description of the symptoms. One must be sure to exclude also progressive muscular atrophy. Fig. 74.—Author's Dynamometer for Measuring the Strength of Extensor and Flexor Muscles of the Forearm and Hand. The treatment consists of mechanical measures such as electri- city, massage, the application of rubber muscles, and in bad cases the fixation of the forearm and hand in hyperextension by means of a splint and plaster-of-Paris bandage (Gibney). Internally in the early stage it is best to administer iodide of potassium and sulphate of magnesium (in lead palsy), the salicylates or nitrate of silver in neuritis; later, hypodermic injections of strychnia may be given. Static sparks, galvanism, and other forms of elec- tricity unquestionably do good in some cases, as I have had op- portunity to prove. Paralysis of the median nerve is rare as an isolated trouble, and is almost always due to injury or neighboring lesions. Embolism of the axillary artery after labor has produced it. When paralysis occurs the grip is weakened. Flexion and ab- duction of the thumb and flexion of the first and second fingers are impaired. Atrophy of the thenar eminence may occur. The anesthetic area varies, but is well shown in the accompanying cut from Ruxton (Fig. 75). 166 DISEASES OF THE NERVOUS SYSTEM. Paralysis of the Ulnar Nkrvk. — Etiology.— The ulnar nerve is rather commonly affected by paralysis, the occurrence ranking next in frequency to musculo-spiral palsy. It is rarely affected in lead-poisoning, but is usually early involved in pro- gressive muscular atrophy. It is sometimes attacked by a prim- ary degenerative neuritis. Injuries are the common cause. The symptoms are shown by the table. The hand cannot be closed tightly, the little and ring fingers being especially weak. The first phalanges are drawn back and the second and third phalanges flexed; when the interossei and lumbricales atrophy, the result is the "griffin claw" or main en griffe. The fingers cannot be adducted or abducted except feebly. There is anesthesia over the area of distribution of the ulnar (Fig. To); there may be pain and tenderness. Fig. 75.—Area of Anesthesia in Total Paralysis of the Median Nerve. Symmetrical Spontaneous Ulnar Neuritis.—A form of neuritis of the ulnar nerve sometimes occurs which has certain peculiar characters. It develops slowly in persons with a neuro- pathic history, and without known exciting cause. There is first some pain and paresthesia in the region of the ulnar nerve of one hand; this is followed by weakness and atrophy of the muscles supplied by the ulnar nerve, and characteristic deformity appears. Anesthesia develops coincidently. The other hand soon becomes affected. The disease is very chronic, and complete recovery is rare. It is probably a form of degenerative neuritis. Spasmodic Disorders of the Arm.—The arms and hands are especially subject to tremors, choreic and other spasmodic movements. The only spasmodic disorders, however, which may be said to be especially located there are writer's cramp and allied occupation neuroses. These are described elsewhere. Sensory Disorders of the Brachial Nerves.—Cervico- Brachial Neuralgia.—This is a painful affection involving DISEASES OF THE SPINAL NERVES. 1G? the sensory nerve of the neck, shoulder, and arm. It is a some- what rare form of neuralgia, and like most other forms occurs oftenest in women, before middle life. The ordinary causes of neuralgia produce it, but rheumatism and gout are rather prominent factors. Reflex irritation from carious teeth and uter- ine disease have been found to be causes. It occurs symptomat- ically in locomotor ataxia and other cord diseases. A low grade of neuritis probably often exists. Symptoms.—It begins somewhat gradually with aching pains in the neck, shoulder, axilla, and along the course of the nerves. The pains gradually increase and are usually worse at night. The pain is increased by use of the arm and by exposure. Only one arm is affected. Painful points may be felt in the axilla, at the lower end of the scapular, over the deltoid, over the ulnar near the wrist, over the lower part of the radial and sometimes on each side of the lower cervical vertebre. There are usually paresthesie and numb feelings. If there is a complicating neuri- tis, burning sensations are felt (" causalgia "). There may be anes- thesia, vasomotor disturbances, herpes, and muscular weakness and atrophy. Brachial neuralgia generally involves all the nerves of the plexus. If special nerves are involved the ulnar is oftenest affected, next the musculo-spiral, and last the median. Digital neuralgia sometimes occurs. The pain is often lo- cated in a single finger. The cause is usually a local injury or neuritis. Sometimes it is a reflex pain due to some remote trou- ble. In a few cases this remote trouble is uterine. Diagnosis.—The etiological diagnosis is most important. In- quiries as to a rheumatic or gouty element should be made. The presence of any serious amount of neuritis would be shown by local tenderness and motor weakness. Organic cord disease must be excluded. The prognosis, if the neuralgia is functional, is good. If a neuritis complicates it, it is more serious. If the neuritis, how- ever, is slight, and is secondary to a trauma, or is rheumatic or gouty, the prognosis is favorable. Ordinary attacks last about six weeks. The Treatment.— Salicylate of potassium, iodide of potassium, or muriate of ammonia should be given and in large doses. Aco- nitia and gelsemium are of not much value. The electrical cur- rent, either faradic or galvanic, has a very decided effect for good. Leeching helps some cases. Blisters may be used in neuritic cases. The analgesic drugs like phenacetin and antipyrine and antifebrin are useful symptomatically. Hot local applications often give some relief. Colchicum cures some cases of gouty origin. 168 DISEASES OF THE NERVOUS SYSTEM Migrating neuritis is a serious but rare malady which deserves some mention. It occurs as a sequel to some wound of or opera- tion upon a nerve. The local neuritis extends usually up the arm (ascending neuritis). It is accompanied with intense pain, anesthesia, paralysis, and atrophy. The disease is very chronic and intractable. Group III. The Dorsal Nerves. Anatomy and Physiology.—The dorsal nerves are twelve in number. The first is the largest and belongs functionally to the arm nerves. The dorsal nerves carry motor and sensory fibres to the voluntary muscles, skin, and other tissues of the trunk wall. They also carry splanchnic fibres to the lungs and abdominal viscera. They divide into anterior and posterior branches. The anterior form the intercostal nerves, of which the first six are distributed to the wall of the thorax and the last six to the wall of the abdomen. All these nerves give off lateral and anterior branches. The posterior branches of the dorsal nerves are small, and supply the muscles and skin of the back. Besides the above, there are recurrent branches which enter the spinal canal and supply the intraspinal veins and mem- branes. The first six dorsal nerves contain fibres which enter the sympathetic and supply the pleura and lungs. Fibres from the last six enter the sympathetic and supply the pelvic viscera. The intercostal nerves in their course lie part of the way beneath the pleura; they also pass along in close company.with the inter- costal artery and vein, lying just above these in the groove on the internal surface and inferior border of the ribs. The upper six dorsal nerves, including both branches, are mainly inspiratory in function. They also extend and rotate the dorsal and cervical vertebre. The lower dorsal are expira- tory nerves; they also assist in compressing the abdominal vis- cera, and in flexing, extending, and rotating the spine. The diseases of the intercostal nerves are almost entirely of a sensory character. They are intercostal neuralgia, symptomatic side pains, herpes zoster. Paralyses and anesthesie occur in connection with vertebral and spinal-cord diseases. Intercostal Neuralgia; Side Pains.—Etiology.—This is a very common neuralgia. It occurs much oftener in women (partly from corset-pressure) than in men (seven to one). The favorite age is twenty to thirty-five; the season, winter. An- emia, neurasthenic and hysterical conditions, child-bearing, pelvic disorder, dyspepsia, heart disease, malaria, and lead-poison- ing are frequent causes. Exposure and muscular strain are rare exciting causes. Symptoms.—The disease comes on suddenly. The pain in typical cases is sharp and stabbing, but not much increased by respiratory movements. There are tender points at the seat of pain, which is usually greatest over the side at the exit of the lateral nerve branches. Often a tender point is felt over the exit DISEASES OF THE SPINAL NERVES. 169 of the dorsal or of the anterior branch. It is rare to find all three points. The disease runs about the course of facial neu- ralgias, i.e., of two to six weeks, but it is sometimes very obsti- nate, lasting for many months. The sixth to tenth nerves are those oftenest involved. The left side is more susceptible than the right (three to one). Pathology.—In most cases the nerve is irritated by poor or poisoned blood. In a minority of cases the pain is reflex from stomach, pelvis, or heart. Sometimes there is a neuritis. Diagnosis.—Probably one-half the pains in the side are myal- gic in nature, and should be classed as pleurodynia. These pains can be distinguished by the history of their origin and of rheu- matic influences, by their diffuseness and dulness, by the great tenderness on pressure, and the pain produced on taking a deep breath. There is another considerable proportion of cases in which the pains are mainly neuralgic, but yet there are some evidences of muscular complications. Some of these pains are reflex. In the third class of cases there is the pure stabbing neural- gia. The diagnosis is based on the exclusion of pleurisy, rheu- matic and reflex causes, by the character of the pain, and the presence of tender points. Prognosis.—The prognosis is good, except for a few chronic cases due probably to a degenerative neuritis. In some of these cases there is lead-poisoning. Treatment.—The most efficacious treatment is a blister and ferruginous tonics with quinine. In all cases the heart, pleura, stomach, and pelvic organs must be examined, and any disorder relieved. Iodide of potassium and chlorodyne have cured some very bad cases in my experience. If there is a rheumatic and muscular element, give salicylates or the analgesics, apply heat, and secure rest by adhesive straps. Mammary neuralgia (mastodynia) is a form of intercostal neuralgia involving the anterior and lateral branches of the three or four upper dorsal nerves. Etiology.—It is caused by local tumors, or it may be an essen- tial neuralgia. The causes in the latter class are anemia, pen- dent breasts, pressure from badly fitting corsets, and injury. Mammary neuralgia also occurs in hysterical women and young girls sexually precocious; it may occur in pregnancy and during lactation. Many mammary pains are due simply to local dis- order of the gland. Symptoms.—Mammary neuralgia is unilateral, often very se- vere, and if it occurs in middle life is liable to cause much men- tal depression from fear of cancer. The treatment depends upon the cause. It requires general 170 DISEASES OF THE NERVOUS SYSTEM. tonic measures and attention to the proper support and protec- tion of the gland. Herpes Zoster, Dermatitic Neuritis (Shingles).—Almost the only recognized form of neuritis of the intercostal nerves is known under the name of herpes zoster. This is an acute derma- titis, secondary to the neuritis. Etiology.—Its causes are wounds, infections, the morphine habit, rheumatic, gouty, and syphilitic poisons, and emotional influences. The inflammation affects not only the nerves, but the spinal ganglia. Symptoms.—It begins gradually with the development of pain and a herpetic eruption upon one side of the trunk. It gener- ally involves the lower dorsal nerves. The eruption follows the course of the nerve, rarely extending to the opposite side. The pain gradually subsides, and the disease itself runs its course in a few weeks. Treatment.—In the early stage the galvanic current is effica- cious. Local anodynes and protective ointments may be applied. Anti-rheumatics and analgesics are to be administered internally. Group IV. The Lumbar Nerves. Anatomy and Physiology.—The lumbar nerves are five in number. The posterior branches supply the erector spine, in- terossei, multifide spine and interspinales, and also the skin of the back. The anterior branches of the upper four unite to form the lumbar plexus. The fifth or lumbo-sacral nerve semis most of its fibres to the sacral plexus. The branches of the lum- bar plexus are: (1) the ilio-inguinal, (2) ilio-hypogastric (from first lumbar), (3) genito-crural and (4) external cutaneous (mainly from the second), (o) obturator (from third and fourth lumbar), (6) the anterior crural (from second, third, and fourth—Fig. 7(3). The first four branches of the plexus are comparatively short and supply sensation to the abdominal wall and external geni- tals. The last two are longer and supply the hip and knee joints, the muscles of the anterior, inner, and outer part of the thigh, the skin over this region and the inner side of the leg and dor- sum of the foot (Fig. 76). The diseases of the lumbar nerves and plexus so far as they form independent disorders are mainly the neuralgias. Paralyses and spasmodic troubles of the lumbar nerves are not rare, but are usually symptomatic of some ex- trinsic and often serious disease. Etiology.—Hence it is well to catalogue here those affections which may produce lumbar palsies or spasms. They are pelvic tumors or injuries, impacted feces, caries of the spine, psoas abscess, obturator hernia, hip disease, and pressure of the foetal head. DISEASES OF THE SPINAL NERVES. 171 Symptoms. —When the upper two lumbar nerves are involved, only sensory symptoms in the distribution of their branches occur (Fig. 76). If the next two are also involved, there may be trouble in extending the leg and flexing the hip on the trunk. The patient cannot raise himself to a sitting posture. If there is irritation and spasm, the thigh is drawn up and adducted. In making a diagnosis of lumbar-nerve disease, one should remember that of the six branches of the plexus the upper four are mainly sensory, the lower two mixed nerves. Bartorius; anterior) Anterior thigh muscles. J crural nerve Adductors and ) r\Mnw<-^ external rotators -°^U™*0r of the thigh. ) uerve- „, f = ( Superior Glutei. ( gluteal nerve. Piriformis obturator int. gemelli. ! Muscular j nerves. Quad, fern., 1 Small sciatic Glut. max.J nerve. Adduct. magn. flexors I <-___* of knee, extensors "'F„2„ of foot, calf muscles, I ?,c„lano foot muscles. J DerTe- Bladder, 1 perineum, i Pudic genitals, f nerve. sphincters. J Fig. 76.—Diagram showing the Origin and Distribution of the Motor and Sensory Nerves of the Lower Limbs. In paralysis of the obturator nerve there is loss of power to adduct the thigh and cross the leg, and weakness of outward ro- tation of the thigh. Anesthesia over the inner side of the thigh may be present. In paralysis of the anterior crural nerve there is weakness of the muscles of the anterior surface of the thigh, loss of power of extending the leg, and anesthesia or pain over the crural area. Paralysis of the posterior branches of the lumbar nerves causes weakness or paralysis of the erectors of the spine. The lumbar curve is very greatly exaggerated, the shoulders being 172 DISEASES OF THE NERVOUS SYSTEM. thrown far back and the belly protruding. This condition occurs in progressive muscular atrophy, particularly in the pseudo- hypertrophic form. Neuralgias and Reflex Pains of the Lumbar Nervks. —Etiology.—Neuralgias of the upper branches of the lumbar nerves are called lumbo-abdominal. They occur oftener in women and usually after the thirtieth year. To the ordinary causes of neuralgia we add straining, constipation, and pelvic dis- ease. True essential neuralgia is rare; but myalgic and reflex pains from uterine disease are very common, especially in women. Symptoms.—There is pain in the loins, back, and buttocks, extending down to the hypogastrium or genitals on one side. The pain in the back, however, is often bilateral. Painful points may be found after a time, as in intercostal neuralgia. Some- times the pain is located in the side of the penis (penile neuralgia). Neuralgia of the long lumbar branches is called femoral or crural. A common form of this constitutes what is called painful thigh. The patient complains of pain in the front of the knee and the anterior and outer parts of the thigh, but has no pain posteriorly and none below the knee. The internal branches of the anterior crural nerve do not seem to be affected, while the middle and external cutaneous branches and the genito-crural nerve are in- volved. Reflex and Symptomatic Pains.—Disease of the hip or of the sacro-iliac joint or vertebre may cause a reflex pain in the ob- turator nerve, localized especially in the knee and back of this joint. The foetal head sometimes compresses these branches, causing a symptomatic neuralgia. Diseases of the internal geni- tal organs are especially liable to cause reflex pain in the lumbar nerves. Diseases of the external genitals and bladder more often reflect pains upon the sacral nerves. In biliary colic pains are felt in the ilio-inguinal and hypogastric nerves. Local disease Of the psoas muscle or iliacus, in the neighborhood of Poupart's ligament, causes pains in the lumbar nerves. Lumbar neural- gias generally run a favorable and not very long course. Diagnosis.—They are distinguished from lumbago by the uni- lateral position, the distribution and paroxysmal character of the pain, and the lack of severe suffering on motion and pressure; the tender points and the absence of any organic disease. Lumbago comes on suddenly, with a history of exposure, is confined to a single group of muscles, which are tender on deep pressure. In lumbar sprain the onset is also sudden, with a his- tory of injury, great local tenderness, and evidences of trauma. The treatment is the same as that for neuralgia in general. The frequent presence of pelvic disease and of anemia and a rheumatic history must be borne in mind. DISEASES OF THE SPINAL NERVES. 173 Group V. The Sacral Nerves. Anatomy and Physiology.—The sacral nerves are five in num- ber. The first four divide into anterior and posterior branches. The fifth has no anterior branch. The posterior branches es- cape through the posterior sacral foramina and supply the mul- tifidus spine and the skin over the sacrum and coccyx. The flrst three anterior branches, with the lumbo-sacral nerve and a branch from the fourth sacral, unite to form the sacral plexus. This lies upon the pyriformis muscle in the pelvis, and escapes at the lower part of the sacro-sciatic foramen. The great mass of the fibres go to make up the sciatic nerve. The roots of origin of the sacral and coccygeal nerves form the canda equina. The branches of the sacral plexus are the superior gluteal, muscular, small sciatic, inferior gluteal, pudic, great sciatic, per- forating, cutaneous, and articular. These are distributed to the muscles, skin, and joints of the buttocks, thighs, legs, and feet. Their distribution is shown in Fig. 76. The sacral nerves are the main agents in station and locomo- tion. They control the legs entirely, also the posterior muscles of the thigh and buttocks; they give sensation to these parts. They carry also fibres that regulate the sexual function, bladder, and rectum. From the sacral portion of the cord there is an outflow of nerves to the sympathetic, thence to the pelvic organs. The diseases of the sacral nerves may be classified in a similar way to those of the brachial plexus. I shall here also follow the clinical method and study the paralyses, spasmodic disorders, and neuralgias of this group of nerves. Peripheral Leg Palsies.—Paralyses of the lower limbs from disease of the nerves may be either combined or single, just as is the case with arm palsies. A combined sacral palsy is one in which all or nearly all of the branches of the sacral plexus are involved. Etiology.—Such palsies are due to much the same causes as those affecting the lumbar nerves, viz., injury, dislocation, hip disease, tumors, and neuritis. Hysteria may cause a functional sacral palsy. Symptoms.—-The symptoms are indicated by a study of the distribution of the nerves, varying, however, in degree. The foot cannot be moved; the leg can be slightly flexed by the anterior crural, but not extended; the thigh cannot be drawn back freely or rotated perfectly. There is anesthesia over the distribution of the sacral nerves; pain may be present; wasting and vaso- motor and secretory disturbances occur unless the paralysis is functional. The course depends on the severity of the lesion. If the nerve is totally cut or torn across, it may require one or two years for perfect recovery, which, however, occurs if the severed ends are properly approximated. 174 DISEASES OF THE NERVOUS SYSTEM. The diagnosis of a sacral palsy is based on the history and on the distribution of the anesthesia, and of the muscular paralysis. The sacral nerves do everything for the lower limb except extend the leg, flex and adduct the thigh, and to some extent rotate it. They supply sensation equally extensively (see Fig. 76). The distinction from spinal-cord disease is chiefly based on the unilateral symptoms, the absence of disorder of the sphincters, and the combination of paralysis, wasting and sensory troubles, in the course of the sacral nerve. Single-Nerve Sacral Palsies.—The symptoms of paralysis of single nerves are indicated by their function. The nerves rarely affected are the superior gluteal, muscular, and small sciatic. The nerve oftenest affected is the great sciatic, and especially its anterior tibial branch. In the latter case a condi- tion called " drop foot" is produced. In the pathology and treatment of sacral palsies there is noth- ing especial that can be said. Spasmodic Disorders of the Sacral Nerves.—Tremor, rigidity, clonic and tonic spasms, myoclonus, athetoid movements, all affect the lower extremities, but they are almost invariably part of some general or central disorder, such as chorea, paraly- sis agitans, hysteria, etc. Under the head of occupation neuroses there occur certain rare spasmodic troubles special to the legs. Saltatory spasm involves the legs alone. These disorders are, however, general neuroses. Sciatica (Neuralgia of the Sciatic Nerve, Sciatic Neuritis).—This is a form of neuralgia occurring in middle life and characterized by intense pain in the course of the sciatic nerve. A large proportion of the cases are due to a neuritis. Etiology.—The disease occurs three times as often in men as in women, and is the only neuralgia of which this can be said. Most cases in this country occur between the ages of forty and fifty; next between thirty and forty.* The gouty and arthritic diathesis, occupations which lead to exposure and strain, predispose to the disease. It is not rare, therefore, among laboring men. In younger persons a neurotic constitution predisposes to the disease, and in this class the trouble is more truly of a neuralgic character and less of a neu- ritis. Most cases occur in the autumn and winter. The exciting causes are constipation, pressure from hard seats, exposure, mus- cular strain from heavy work, and pelvic disorders. Symptomatic * Personal statistics (102 cases) and those of Dr. L. Putzel (53 cases) give males, 111; females, 44. Ages: 10-20,4; 21-30, 30; 31-40, 43; 41-50, 44; 51-60, 18; 61-70, 12; 71-80, 4. DISEASES OF THE SPINAL NERVES. 175 sciatica may be caused by the pressure of pelvic tumors, injury to the nerves, inflammation, vertebral and spinal disease; sciatica occurs in diabetes and in phthisis. In elderly persons of a rheu- matic constitution inflammatory processes about the hip joint complicate or cause the neuralgia. Symptoms.—The disease begins rather suddenly. Pain is felt in the back of the thigh, running down the leg in the course of the nerve. Generally it is most marked in the thigh, extending up often into the lumbar region. Sometimes the disease begins like a lumbago; more rarely pain is first felt in the calf or foot. The pain is increased by motion, and the patient holds himself in a constrained position. The pelvis is tilted up toward the sound side and the trunk inclined over to the diseased side. After a time this leads in some cases to a characteristic deformity (sciatic scoliosis) in which the convexity of the curve of the vertebral spines is directed toward the diseased side. The pain is almost continuous, with paroxysms of great severity, which often occur at night. During these paroxysms the pain is sharp, burning, and lancinating. In the intervals it is dull. Besides the pains the patient suffers from feelings of numbness, tingling, and a sense of coldness and weight in the affected limb. There are al- most always tender points over the course of the nerve. These may be found at the sciatic notch, at the middle of the hip, be- hind the knee, just below the head of the fibula in the middle of the calf, behind the external malleolus, and on the back of the foot (Fig. 77). A pain running up the back of the thigh may be caused by pressure over the back of the knee when the leg is extended at a little more than a right angle. This is diagnostic (Gowers). If the patient lies on his back and the leg is kept extended, and then the whole limb brought slowly up until it is at an acute angle with the trunk, a sharp pain in the sciatic notch is felt; this too is diagnostic. Anesthesia over the course of the nerves occurs very rarely. When present, it indicates a severe neuritis or injury to the nerve. Muscular wasting and weakness occur after a time, and in old and severe cases partial electrical degeneration reactions may be observed. Herpetic eruptions over the course of the nerve occur in rare cases. The affected limb usually feels colder and shows evidence of enfeebled vasomotor supply. The disease usually lasts two or three months; not rarely it lasts six months or even a year or more. It has been known to extend slowly upward and involve the sacral plexus or even the spinal cord. Pathology.—The trouble is, as already stated, a chronic peri- neuritis in the majority of cases. 170 DISEASES OF THE NERVOUS SYSTEM. Diagnosis.—Sciatica has to be distinguished from hip-joint disease, organic disease of the cauda equina or cord, muscular pains in the hip and leg, and from pains caused by tumors. Pure sciatic neuralgia ought also to be distinguished from sciatic neu- ritis. A consideration of the facts already given ought not to make the diagnosis difficult. Pure sciatic neuralgia occurs in eary life and is not accom- panied with much local tenderness. There is no paralysis or wasting of the limb. Double sciatica is most always symptomatic of diabetes or organic disease. True sciatica is rarely double. Prognosis.— Almost all cases get well in from three to six Fig. 77.—Showing the Tender Points in Sciatica. Fig. 78. Plantar Form of Sciatica; Plantar Neuritis, showing area of pain (Mitchell). months. Severe attacks in people over forty are the most intrac- table. Relapses occur, but not as a rule. Treatment.—In all cases which are seen early, the most im- portant indication is rest. The patient should be put to bed, and the whole lower extremity secured in a Thomas splint ex- tending from ankle to axilla. Ice-bags or linseed poultices or leeches should then be applied over the course of the nerve. A blue pill (gr. v.) may be given twice daily at first. In less severe or older cases large blisters should be applied over the nerve in the thigh, and the application repeated in a week. If there is a rheumatic history, potassium salicylate or iodide should be given in full doses. The bowels must be freely opened. Hypodermic in- jections of morphia or cocaine (gr. }) may be needed for a few days, the cocaine being repeated if necessary. When the disease has be- come more chronic a strong galvanic current may be given daily DISEASES OF THE SPINAL NERVES. 177 with large electrodes, one over the lumbar region or sciatic notch; the other, which should be the positive pole, over the leg and foot. As so-called specific remedies we have oil of turpentine in doses of fifteen drops t. i. d., and this may be advantageously com- bined with oil of gaultheria. Massive doses of antifebrin or anti- pyrine sometimes stop the pains (gr. x., q. 2 h.). There are a great many local remedies which at times prove useful. Among these mustard plasters, menthol, chloroform liniment, setons, acupunc- ture, cups, and the actual cautery and chloride of methyl can be recommended. Bandaging the limb in sulphur to which a little menthol is added is often very efficacious. Kneading the nerve with a glass rod and an anodyne ointment is sometimes beneficial. Very little can be expected from nerve-stretching, but it may be tried as a last resort. If tried, however, great cau- tion should be exercised in pulling on the nerve. Not over thirty to forty pounds pull should be used. The operation of cutting down on the nerve and dissecting off the sheath for a space of several inches may be tried. Plantar Neuralgia.—In rare cases the pain of sciatic neural- gia is limited to the plantar nerves, and is accompanied with pares- thesia and even anesthesia of this region. The condition here is probably a neuritis combined sometimes with arthritic changes. Erythromelalgia may be regarded as a form of plantar neuralgia. Coccygodynia is a neuralgia affecting the lower posterior branches of the sacral nerves. It occurs oftenest in women and is caused by exposure, injury, and labor. Coccygeal pains occur in spinal irritation and reflexly from pelvic disease. The disease is a most annoying one, as it interferes with sitting and walking. There is often also pain at stool, and the parts are tender to pres- sure. The disease is usually one involving the fibrous structures of the coccyx, and is more an articular and bony than nervous disorder. Surgical treatment, such as amputation of the coccyx, may be needed. Recapitulation.—The student should understand that, de- spite the great clinical variety of peripheral nervous disease, there is an underlying unity as regards the pathological condition, the cause and the symptoms. In order that this may be clearly brought out, I append the following tables. The student will remember that the causes of nearly all periph- eral nerve-diseases can be classed under the following heads: Heredity and neuropathic constitution; sex; age—infant, youth, etc.; injuries; diatheses—rheumatism, gout, diabetes; exposures; mental and physical excesses; infections—chronic, e.g., syphilis and the febrile; poisons—narcotic, metallic, etc.; anemia and marasmus; arterio-sclerosis. The table as given applies to ad peripheral nerves. The cranial nerves are, however, more affected by syphilis and brain disease. 12 178 DISEASES OF THE NERVOUS SYSTEM. Table I.—Peripheral Nervous Disease? Causes. -Types and Type of Disease. 1. Anemia and Hyperemia: f Multiple neuritis. Inflammation. ] Mono- neuritis. Degenerations. 1 ( Primary. Principal Causes. (Female, young adults. Poisons— alcohol,arsenic; Infections—feb- rile, endemic; Diatheses—rheu- matism, Exposures. {Male, infants, adults. Injuries, over-use; Poisons—lead; Infec- tions—febrile, syphilis; Diathe- ses—gout, rheumatism. (Male, mid-age, senility. Maras- mus, Loc.ataxia; Poisons—lead; Infections—diphtheria. (Injury, destruction, or inflamma- tion of nerve or its trophic centre. j Injuries, compression by tumors, \ etc. Heredity, injuries, operations. Chronic infections. fWith signs f Heredity, neuropathy, female, of nerve ■{ youth, and mid-age. Over-use. irritation. |^ Poisons—narcotic, metallic. ,-. t -,„„„,, f Diatheses—rheumatism, gout, dia- d e n r el J betes; Infection—syphilis; Aine- ep es-K mia, Arterio-sclerosis; Malnutri- slon- { tion. The symptoms of peripheral nervous diseases are shown in irritation and excess, diminution and loss, and perversion of function. Since nerves are sensory, motor, visceral, trophic, re- flex, etc., many combinations of symptoms result. These have been already described. Destruction. Tumors. Functional neuroses. L Secondary. | Single. \ Multiple Table II.—Peripheral Nervous Diseases—Types and Symptoms. Type. Anemia and Hyperemia. Multiple neuritis. Inflammation. Principal Symptoms. j Sensory irritation: neuralgia, | numbness. f Acute onset, chronic course. At first sensory irritation, followed ■{ by loss; motor weakness; trophic and vasomotor disturb- ances ; recovery one to two years. f Acute or chronic: nerve irritation, later diminution and loss of Mono- I function; trophic, vasomotor, neuritis. and secretory disorders; recov- ery the rule, one-quarter to one I and one-half vears. DISEASES OF THE SPINAL NERVES. 179 Degenerations. ^ Destruction. Tumors. Functional neuroses. f Gradual loss of function, little irri- f Primary. -{ tation, much trophic disturb- [ ance; very chronic; rarely a cure. f Rapid loss of function, a little irri- [ Secondary. < tation; course chronic; cure fre- [ quent. {Sudden irritative symptoms, pain, spasm, etc.; then loss, like a secondary degeneration. ( Single. j Irritative symptoms. Or no symp- ( Multiple. ( toms, chronic. f Of irritative j Neuralgia, paresthesia, oedema, J kind. ] local asphyxia, spasm. 1 Of depres- ] Occupation palsies, reflex palsies, t sive kind. ( etc. CHAPTER X. DISEASES OF THE SPINAL CORD. Anatomy and Physiology. Anatomy.—The spinal cord is a slender, cylindrically shaped organ. It is from 42 to 43.7 cm. (sixteen and one-half to eighteen inches) long, being shorter absolutely and relatively in women. Its weight is about thirty-three grams (one ounce). It is suspended in the vertebral canal, where it reaches in all persons over one year of age as far down as the second lumbar vertebra. In new-born infants it extends to the third lumbar vertebra. It is divided into cervical, dorsal, lumbar, and sacral portions, corresponding with the nerves it gives off. These are respectively four, ten and one-half, two, and one and one-half inches long (see Fig. 79). Its shape on cross-section is nearly round, except in the lower cervical region, where it is flattened antero-posteri- orly. Its average diameter is 1 cm. (two-fifths of an inch). It has two swellings or enlargements, the cervical and lumbar. Their position, size, and extent are shown on the diagram. Its specific gravity is 1030. It is surrounded by three membranes, all of which are continu- ous with the corresponding envelopes of the brain. They are the dura mater, the arachnoid, and the pia mater (Fig. 80). The dura mater is the external covering. It is a long sac at- tached to the edge of the foramen magnum above and extending down until its walls fuse together at the level of the second sacral vertebra. Its cavity, therefore, is much longer than the spinal cord. It is attached to the bony canal at its lower end, and is held loosely by twenty-two lateral ligaments (I. denticulata) throughout its length. The arachnoid is a thin, semi-transparent membrane lying loosely over the cord and roots. Internally it is connected by numerous connective-tissue fila- ments with the innermost membrane, the pia mater. This latter is a thin vascular sheath applied closely to the cord and roots. The space between the dura and arachnoid is called the arachnoid cavity. It contains a very little cerebro-spinal fluid. That between the arachnoid and pia is called the subarachnoid cavity; it con- tains a good deal of cerebro-spinal fluid. Both cavities connect with those of the brain and probably with each other. The dura has a mechanical protective function, the arachnoid a serous and the pia a vascular function. The spinal cord is movable in its canal to the extent of one- half to one inch. The Nerve Roots.—The spinal nerve roots are covered with the pia and arachnoid. They pierce the dura in two places and unite to form a mixed nerve. The dura mater is prolonged over the nerves as they pass through it, forming a tubular sheath. DISEASES OF THE SPINAL CORD. 181 The anterior roots are the larger. At the point of exit of the nerves from the cord a slight depression is formed. The Root Ganglia.—Oto. each posterior root, outside the dura, Fig. 80.—Transverse Section of the Spine, showing the relations of the cord to the spinal canal (Keys and Retzius). 5 U Conus medullaris. Filum terminale. Fig. 79.—Showing the Rel- ative Size of the Different Parts of the Cord (after Allen). Fig. 81.—Showing the Relations of the Gray Matter to the White. A, Anterior; L, lateral and P, posterior col- umns; the anterior (a) and posterior (p) horns and intermediate gray matter. Fig. 82.—Showing Further Subdi- visions of the White Matter and the Location of the Different Cell Groups in the Gray Matter. D, P, Pyramidal tracts; CB, col. Burdach; G, col. Goll. is a posterior spinal ganglion. The ganglia lie in the interver- tebral canal, except those on the sacral nerves. Fissures.—Throughout the whole length of the cord there are two median fissures, called the anterior and posterior. 182 DISEASES OF THE NERVOUS SYSTEM. Columns.—These fissures and the lines formed by the exit of the roots divide the cord into four columns—anterior, posterior, and two lateral. The Composition of the Cord.—The cord is composed of white and gray matter. The white matter lies outside and is composed mainly of nerve fibres, the gray matter mainly of nerve cells. Each has also neuroglia, connective tissue, and blood-vessels. In the gray matter is a central canal lined with epithelial cells. 'ihe gray matter is arranged, as shown in the figures, some- what in the shape of a letter H- Its different parts are called the anterior and posterior horns and intermediate gray. At certain levels there are lateral horns. The gray matter changes in shape at different levels of the cord. It is greatest in amount at the lumbo-sacral junction (23.;J3 sq. mm.); next at the cervical enlargement (sixth cervical) (17.32 sq. mm.). It increases in amount relatively to the white matter from above downward (Fig. 88). The Commissure.—The gray matter of the two halves of the cord is connected by a bridge or commissure. The anterior part is composed chiefly of white medullated nerves, and is called the white commissure. The posterior is composed of very fine nerve fibres, mostly medullated collaterals, called the gray commissure. Between the two is the central canal, and surrounding it is the central gelatinous substance, composed of neuroglia. The posterior horns reach tc the periphery. They are divided, beginning from without, into the rim zone or Lissauer's column, the spongy zone, and the gelatinous substance of Rolando. The rim zone is composed of very fine nerve fibres; the spongy zone and gelatinous substance are composed chiefly of neuroglia* and small nerve cells. To sum up, we have the gray matter— Arranged in: Composed of: ( anterior, a. A ground substance of neu- 1. Horns: -J lateral, roglia and connective tissue ( posterior. forming the substantia spon- 2. Intermediate gray. giosa. b. Cell groups: internal, anterior, etc. c. Plexuses of fine nerve fibres, e.g., in the rim zone. d. Masses of neuroglia: (1) The central gelatinous sub- stance. (2) The gelatinous substance of Rolando and the spongy zone. e. Blood-vessels and connective tissue. Now, taking up some of these factors in detail, we find that (a) The ground substance of the gray matter is made up of a fine meshwork of fibres which are the processes of neuroglia cells and of nerve cells. Besides this, there is some connective tissue, and there are prolongations from the base of the epithelial cells lining the central canal. * Weigert's new stain seems to show that the substance is not neuroglia. DISEASES OF THE SPINAL CORD. 183 ^P^ Cell groups. inner antero-lateral lateral anterior median central postero-lateral median central inner postero-lateral. (6) The nerve cells are arranged in groups with the long axis parallel to that of the cord. The cells are surrounded by a rich plexus of cell-processes and nerves, as well as by the supporting neuroglia matrix, a little con- nective tissue, and many small blood-vessels. The cell groups are named in accordance mainly with their position—in- ternal, antero-lateral, lateral, median, posterior or sensory spindle cell, and the cells of Clark's column (Fig. 83). The cells are arranged in groups which overlap each other. Each group has the special duty of presiding over certain sets of muscles or other organs which have a common function. The cells of the anterior horns are large in size, 35 to 100n ( ^ to -^ in.); they are multipolar, having five or six processes, one of which is an axis-cylinder process. The cells in the central parts of the horn are the smaller; the cells in the lumbar swelling are largest, be- cause they are connected with long nerves. The cells of the cervical swelling are next in size. The cells of the poste- rior horn are small and multi- polar. The cells of Clark's column are bipolar, 30 to 00/" (-gfa to jfoj in.) in diameter, and are ar- ranged with their long diame- ter parallel to the axis of the cord. They are grouped to- gether in a kind of nest at the inner and central part of the posterior horn (see Fig. 82). Clark's column is most distinct from the eighth dorsal to the second lumbar nerves, but ex- tends up as far as the last cer- vical. An analogous group of cells is found at the level of the second and third sacral nerves. The spindle-cell group con- sists of small cells lying in the intermediate gray matter at the Fig. 83.—Showing the Arrangement of base of the posterior horns. Cell Groups of Anterior Horns and There are other minor groups Intermediate Gray in the Upper Half of cells which it is not neces- of the Cord. Showing also the levels to sary to describe here. which each group extends. lateral. antero-lateral. median , 184 DISEASES OF THE NERVOUS SYSTEM. The white matter of the cord is composed mainly of nerve fibres, running in a supporting net-work of neuroglia, connective tissue, and blood-vessels. Surrounding it, and lying just beneath the pia mater, is a thin layer of neuroglia 5 to M /j. (.-^ to fa in.) thick. The nerve fibres are medullated, but have no neurilemma, and but few, if any, nodes of Ranvier. There are two kinds, the large (81 to 20//) and the small (2 to 3« in diameter). The small fibres make up the postero-internal ( ^^ and the bromides sometimes give relief. Suspension is not often of value, and may do harm. Secondary Degenerations of the Spinal Cord. When any of the long-fibre tracts of the cord are cut across or destroyed, there soon results a degeneration. This extends Fig. 116.—Showing the Tracts Affected in Secondary Degenerations of the Spinal Cord in Lesions at Different Levels. 1, Descending degeneration after lesion at sixth cervical; 2, ascending and descending degeneration, lesion at sixth dorsal; 3, ascending and descending degeneration,lesion at twelfth dorsal ; 4, ascend- ing degeneration, lesion at first sacral. up or doAvn in accordance with the direction in which the tracts carry impulses. Thus when the crossed pyramidal tract is cut across the degeneration extends down; when the column of Goll is involved it extends up. The degenerative process begins al- most immediately and is complete in a few Aveeks. The myelin sheath SAvells, gradually breaks up and disintegrates; the axis cylinder is involved next. At the same time the connective tissue 260 DISEASES OF THE NERVOUS SYSTEM. proliferates and takes the place of the wasted nerves. Finally, long tracts of connective tissue haA-e taken the place of the nerve tissue. The process may not be a complete one if the lesion does not entirely destroy the tract. The short-fibre tracts degenerate only a little way up and down (Fig. 116). Secondary degenerations complicate and add to the patholog- ical change in all organic diseases of the cord. In brain disease, involving the motor tract, as in hemiplegia, secondary degenera- tion extends into the cord and adds to the seriousness of the dis- ease. Degenerations of the spinal cord, however, do not extend up to the brain except in the case of disease of the cerebellar tracts. The accompanying figures show the extent of the secondary degeneration in total transverse lesions of the spinal cord at dif- ferent levels. There is still some doubt as to the degeneration of the antero-lateral ascending tract, Avhich some (Mott) assert is part of the cerebellar tract and goes to the vermis. CHAPTER XIV. THE PROGRESSIVE MUSCULAR ATROPHIES AND MUSCULAR DYSTROPHIES. The result of modern studies is to show that the anterior cor- nual cells of the spinal cord, the motor nerves and their terminal end-organs, the muscles, form a trophic unit, and that the same degenerative disease may attack either end or any part of this physiological mechanism. There is a clinical and pathological unity in all the different spinal and muscular types of atrophies. Fig. 117.—Showing : 1, Segment of spinal cord with anterior horn cell, end-brush, and lateral tracts, the parts affected in progressive muscular atrophies ; and, 2, the muscle and its nerves, the parts affected in progressive muscular dystrophies. But there are sufficient differences, also, to oblige us for conven- ience' sake to make certain classifications. Thus those disorders which attack chiefly and first the anterior horn cells and the pyramidal tract are called progressive muscular atrophies; those disorders attacking first the muscle tissue and its nerves are called progressive muscular dystrophies (Fig. 117). The pro- gressive muscular atrophies of central origin may attack the mo- tor nerve cells of the eye, of the throat and lips, of the upper or lower spinal cord. In accordance with the level affected the dis- ease has received a different name. Sometimes the pyramidal tracts of the spinal cord are first and most involved. This has fur- nished excuse for another type. Then, again, Avhile most cases of the muscular atrophy are acquired, there is one type of it which is a hereditary one. Thus we find the disease classified as follows. 262 DISEASES OF THE NERVOUS SYSTEM. f Progressive ophthalmoplegia. Progressive mus- I Progresshe bulbar palsy. cular atrophies of I Progressive muscular atrophy (arm type). central or nervous j Progressive hereditary muscular atrophy origin. (leg type). [Amyotrophic lateral sclerosis. The progresshre muscular dystrophies have also been much subdivided, but they are essentially the same disease, as will be seen later. Of the muscular atrophies, I have already described ophthal- moplegia. Beginning from above I Avill describe here bulbar paralysis, for though anatomically it belongs to disease of the brain, pathologically and clinically it belongs to the cord. Glosso-Labio-Laryngeal Paralysis (Progressia'e Bulbar Paralysis). This is a disease characterized by progressive wasting and paralysis of the muscles of the tongue, lips, palate, and throat, due to an atrophy of the nuclei of the nerves supplying those parts. Etiology.—It is a disease of the degenerative period of life, most cases occurring after forty and betAveen that time and sev- enty. It occurs rather oftener in men than women. A neurotic heredity is sometimes noted. Exposure to cold and excessive use of the muscles, mental strain, debilitating influences, lead, and syphilis are causal factors. Symptoms.—The tongue is the part first affected. The patient speaks indistinctly and cannot articulate the lingual consonants I. v, n, and t. The tongue cannot be elevated and is protruded only a little distance. It looks scarred and wrinkled. The lips become Aveak and the patient cannot whistle nor make the con- sonants p, b, m or the vowel o. The saliva begins to dribble from the mouth. Disturbance in swallowing soon develops. Hard solids are taken with difficulty, next fluids, while semi-sol- ids are generally managed best. The lips finally become so para- lyzed that the mouth cannot be shut, and the lower part of the face is motionless and expressionless. The upper face wears an ex- pression of anxiety and suffering, the saliva dribbles constantly, and the whole physiognomy of the patient becomes characteristic and pitiful in the extreme. The facial nerve may get some- what invohred. Articulation becomes almost entirely lost; the voice has a nasal twang from paralysis of the palate. The patient has tired and uncomfortable sensations of dryness and stiffness about the throat. There is no pain or anesthesia, MUSCULAR ATROPHIES AND DYSTROPHIES. 263 but occasionally there is impairment of the sense of taste. The throat reflex is usually lost, so that tickling it causes no reaction. Electric irritability is at first unchanged, but in the later stages partial degeneration reaction occurs. In rare cases there is a rapid pulse and still more rarely glycosuria. The laryngeal reflex becomes weak, the adductors also, but abductor paralysis is rare. The mind is not affected, but there is often an emotional weakness and tendency to tears—not entirely unreasonable in view of the distressing nature of the malady. The disease is often the terminal stage of spinal muscular atrophy; it may be associated with the latter, with amyotrophic lateral sclerosis or with ophthalmoplegia. All these types may occur together. It runs a progresshTe course, with remissions of a few weeks or months. It lasts from one to three or four years. In one case it has lasted seAren years. The termination is eA-entually fatal. Death occurs through in- terference with SAvalloAving, and inanition or a broncho-pneu- monia or bronchitis may develop which ends the patient's life. Pathology.—The primary lesion is found in the nuclei of ori- gin of the hypo-glossal, glosso-pharyngeal, Aragus, and spinal accessory nerves. The raphe fibres and the anterior pyramids are also usually somewhat inA^olved. There is sometimes atrophy of the cells of the facial nerve and of the nucleus ambiguous, which is the motor nucleus of the A-agus. The brunt of the disease falls, therefore, upon those more superficial or posterior nuclei which are representative of a continuation of the anterior cornual cells. If the disease is complicated with amyotrophic lateral sclerosis, or progressive muscular atrophy, or ophthalmo- plegia, Ave find atrophy in the cord or ocular nuclei. The atro- phic process is similar to that observed in the spinal disease. The muscles of the tongue, and to a less extent of the orbicu- laris oris and throat, shoAv evidences of degeneration and atrophy. In some cases the tongue is not shrh-elled, OAving to the presence of a fatty deposit, and on account of this the disease has been divided into atrophic and paralytic types, but this distinction is unnecessary. A few cases have occurred in which no bulbar lesion was discoverable, even by the microscope. In these cases the disease lay probably in the brain or peripheral ner\Tes. Diagnosis.—The disease must be distinguished from polio- encephalitis inferior, bulbar apoplexy, tumors, and softening, from multiple sclerosis, and from chronic lesions of the cerebral hemispheres causing pseudo-bulbar paralysis. The sIoav onset, the progressive course, the bilateral character, the absence of in- volvement of sensory nerves, and the degenerative reactions are 264 DISEASES OF THE NERVOUS SYSTEM. always sufficient for a diagnosis. It is important ahvays to note whether there is ophthalmoplegia and spinal muscular atrophy associated with the disease. Treatment—The patient should be kept quiet; he must be overfed and given massage and electricity in moderation. The same drug treatment as in the spinal disease is indicated. Small doses of morphine, gr. fa to fa, and of atropine may be given also. Electricity should be tried for a short time twice or even thrice daily, if possible. The faradic current may be used, alternating or combined with the galvanic. Galvanization of the neck and medulla appears to do no good. After a time it may be neces- sary to feed Avith a tube or even to do tracheotomy. Progressive Muscular Atrophy (Progressive Spinal Amyotrophy; Duchenne-Aran's Disease). This is a disease characterized by a slow, progressive muscular atrophy of the muscles of the extremities and trunk, with conse- quent paralysis, not accompanied with any notable sensory dis- turbance, and due to a progressive atrophy of the motor and trophic cells in the spinal cord. Etiology.—The disease affects persons in the middle period of life (twenty-five to forty-five). The extremes are fourteen and seventy years (Gowers). It is more frequent in males. Heredity is rarely, if eArer, a factor. Great mental strain, exposure, trau- matism, excessive use of certain groups of muscles, acute infec- tious diseases—especially typhoid, measles, cholera—child-birth, acute rheumatism, syphilis, and, more than anything else, lead- poisoning are causes. It may complicate locomotor ataxia. The causes, as may be seen, are much the same as those of bulbar paralvsis. Symptoms.—The patient suffers at first from slight rheuma- toid pains in the shoulder or arm, associated with some feelings of numbness and weariness. Muscular wasting then begins to appear, and usually in one hand. The adductor longus pollicis is very early affected, also the thenar muscles and the interossei. The atrophy spreads from muscle to muscle, and does not follow the distribution of nerves, although the ulnar nerve supply is most seriously disordered. The ball of the thumb becomes flat- tened, and the patient cannot abduct or flex it well. When the radial interossei are reached the forefinger cannot be abducted, and this is often an early sign. The disease gradually extends upward, attacking the flexors and extensors of the forearm, then the upper arm and shoulder. Meanwhile the hand has become thin and flattened, flexion of wrist and extension of fingers are lost, and a characteristic " griffin-claw " appearance results. Mean- MUSCULAR ATROPHIES AND DYSTROPHIES. 265 while (three to nine months) the other arm begins to be affected. Occasionally there is a remission for a time. In a few cases the atrophy begins first in the shoulders and arm, attacking the deltoid, biceps, and triceps, then extending downward to the hands. This constitutes the " upper-arm type." If, as is usually the case, the disease continues to progress, it passes from the shoulder girdle to the deep muscles of the back, then doAvnward, inA'olving successively the hip and thigh mus- cles, the glutei, the crural extensors and abductors being oftenest chosen. The leg muscles may be finally involved, but they usu- ally escape. The disease as it descends continues its progress in the trunk, imolving the intercostals. It sloAvly ascends the neck also, and finally leads to paralysis of the diaphragm, or a bulbar palsy may set in. It will be seen that the ordinary course of the disease is from the loAver-arm-muscle groups (ulnar and median) up to the shoul- der group (middle cervical nerves), then doAvn through the dorsal and lumbar nerves, rarely reaching the sacral groups. In very rare cases it begins in the legs and ascends. Along with the Avasting there is a corresponding Aveakness and paralysis, but the paralysis is the result of the atrophy and does not precede it. Fibrillary tAvitchings of the muscles occur; the idiopathic muscular contraction caused by striking it a blow is very marked; myoid tumors are easily brought out. In some cases the muscles are flaccid and toneless, and the deep reflexes, knee jerk, and arm jerk disappear early (atonic atrophy), but in other cases the rigidity and tonicity of the muscles are increased, the knee jerks exaggerated, and Ave have tonic atrophy. This con- dition may be so marked as to give rise to a special clinical type of progressive atrophy knoAvn as amyotrophic lateral sclerosis. The electrical irritability of the muscles lessens to both gal- vanic and faradic currents, but no marked qualitative changes occur at first. Eventually we may get partial degeneration reac- tions, but these occur late in the disease, unless this runs a very rapid course, when fairly typical degeneration reactions may be got. A peculiar contraction of the upper limbs is sometimes pro- duced by placing the negative pole of the galvanic battery over the fifth cervical vertebra, and the positive in the triangle just below the lower jaw (diplegic contraction of Remak). A peculiar palmar spasm is described by Voeter, caused by suddenly inter- rupting a faradic or galvanic current passed along the affected arm. In typical cases of progressive muscular atrophy there is no anesthesia; and when such symptoms develop, the presence of peripheral disease or of syringo-myelia or spinal tumor must be expected. The patients may suffer from rheumatic-like pains and from paresthesie. 266 DISEASEJS OF THE NERVOUS SYSTEM. The affected parts often show excessive sweating and con- gestion and evidence of vasomotor disturbance. This may in- ATolve the face on one or both sides; one pupil may be larger than the other, due to irritation of the cilio-spinal centre. The iris-reflex, howeArer, is preserved, and the optic nerve is never in- vohTed. The sexual power is often weakened, but the sphincters are not attacked. The urine shows variations in the amount of urea. There is usually an increase of lime salts. Complications.—The most common complication is an exten- sion of the process to the medulla, causing disturbance of speech and swallowing. Muscular atrophy complicates locomotor ataxia, but is rarely complicated by it. A high degree of spasm and rigidity of the legs, particularly, may occur, causing the condition known as amyotrophic lateral sclerosis. Course and Duration.—The disease usually progresses stead- ily until it has reached an adA^anced stage, when it may stop. Remissions may occur earlier, however, and eAren some improve- ment take place; the disease then ordinarily progresses again. It lasts from two years to thirty or more, but on the a\*erage not OA7er ten or twelve years. Death usually occurs from pulmonary disease, owing to the Aveakness of the respiratory muscles. Some- times the extension to the medulla and involvement of the mus- cles of deglutition and of the larynx is the cause of death. Pathology.—The primary anatomical change is a degenera- te atrophy of the cells of the central parts and anterior horns of the gray matter of the spinal cord. The atrophy gradually extends and involves the whole anterior horn. It also extends vertically, flrst down, then up. Along Avith this atrophy are degenerative changes in the lateral columns ; consecutive to this there is atrophy of the anterior roots, peripheral nerAres, and the muscles. The disease begins in the deeper parts of the anterior cornua, involving the central and median groups of cells. These are more concerned in nutrition and in the finer muscular movements of the extremities. Hence atrophy always precedes, or at least keeps pace with, paralysis. The levels af- fected are the lower cervical and upper dorsal; but if the dis- ease is extenshre, the dorsal, lumbar, and sacral cord are also in- volved. The affected part is nearly free from nerve cells, and those present are atrophied, their processes are short or absent, and the cell has lost its angular appearance. Sclerotic and pig- mentary changes are observed. The neuroglia and connective- tissue cells are increased in number, but there are no marked changes in the blood-vessels, though these may be much dilated. There is always some degeneration of the lateral columns, and this may be very complete. It is confined chiefly to the pyra- MUSCULAR ATROPHIES AND DYSTROPHIES. 267 midal tracts, but extends somewhat anteriorly into the mixed lateral column. It does not affect the cerebellar or ascending lateral tracts. The degeneration has been traced up into the brain as far as the internal capsule and even to the cortex. The anterior columns may be slightly affected. The posterior horns, columns, and roots are normal. The affected muscles show various degrees of degeneration. They are pale and streaked Avith yellow due to fatty deposits. Some fibres may be simply narroAv and shrunken, others have lost their striation and become granular from deposit of fat globules or degenerated muscle elements. Other fibres haA^e lost their striations and look as if filled with a homogeneous, glassy- looking substance containing a fe\v fat granules (vitreous degen- eration) ; others shoAv a longitudinal striation. The interstitial connect he tissue is increased and in places has taken the place entirely of the muscles. The capillaries and small Aressels are distended. Healthy fibres may be seen among the diseased. Changes haA'e been found in the sympathetic nervous system, but they are unimportant. The diagnosis has to be made from the progressive muscular dystrophies, chronic poliomyelitis anterior, syringo-myelia, neu- ritis, and neuritic family atrophy. In the muscular dystrophies there is commonly a history of heredity; the disease begins usually in childhood or adolescence. It attacks the loAver limbs oftener; it is slower in progress; there are no fibrillary contractions, and the degeneration reaction does not occur. Chronic poliomyelitis anterior begins suddenly and, having reached its height, does not progress, but remains stationary or improves. The paralysis occurs first, the wasting follows. It affects groups of muscles physiologically related, Avhile progres- sive muscular atrophy attacks muscles only anatomically related. There are cases, however, Avhich seem to be on the border line between the two diseases. Syringo-myelia is distinguished by the presence of peculiar sensory and trophic disorders. Neuritis caused by lead-poisoning is detected by the history of the case, its tendency to affect the extensors of the arm chiefly,and the absence of a progresshTe tendency. Sometimes, howeA'er, lead- poisoning and palsy end in true progressive muscular atrophy. Ordinary multiple neuritis is distinguished easily by its rapid onset and the presence of painful symptoms. The hereditary or " leg type " of progressive muscular atrophy is characterized by its beginning in the legs, by a good deal of sensory disturbance, typical degeneration reactions, and heredi tary or family history. 268 DISEASES OF THE NERVOUS SYSTEM. Treatment—The patient should be Avell fed and have rest, quiet, and fresh air. Careful local faradization and galvanization of the spine and neck are indicated. Massage does no good. Hypodermic injections of strychnine in the affected member, gr. fa to fa daily, the internal use of arsenic, phosphorus, iron, quinine, and cod-liver oil sometimes are beneficial. Iu a few cases Avith a syphilitic history, mercury and iodide of potash have proved useful. The essentials of treatment are rest, electricity, strychnine locally, the administration of powerful tonics, and over-feeding. Nitroglycerin, morphine, atropine, ni- trate of silver, chloride of gold and of barium, and the nitrate of uranium may be tried. Progressive Hereditary Muscular Atrophy of Leg Type (Charcot-Marie Type). This is a hereditary or family muscular atrophy of central (or neuritic?) origin, beginning in the legs and extending upward. It affects males more than females, but the difference is not great. It almost always begins before the age of twenty. It attacks first the muscles of the leg, not the foot, involving the peronei, then the extensors of the toes, then the calf muscles. The thighs escape till later. After some years the upper extrem- ities and small hand muscles are reached. The shoulder and arm, neck and trunk muscles escape. There are occasionally fibrillary contractions; and always partial or complete degener- ative electrical reactions. The patients complain of some pain and numbness, but there is no anesthesia. The disease runs a long course, Avith remissions, and resem- bles in prognosis the dystrophies. The outlook is better than in the arm type, but the disease is not curable. Some authorities assert that the disease is due to a progressive degenerative neuritis. In the writer's opinion the anterior horns of the spinal cord are primarily attacked.* The treatment is the same as for the other forms of hereditary muscular atrophy. Amyotrophic Lateral Sclerosis. This is a form of progressive muscular atrophy associated with spastic symptoms and paralysis. It ends in or may be early as- sociated with bulbar paralysis or even with ophthalmoplegia. The etiology resembles that of ordinary forms of spinal mus- cular atrophy. * The writer has seen the disease in a typical form in one member of the flrst generation, in two members of the second. A child of one of the latter had, at the age of two years, a typical attack of anterior poliomyelitis. MUSCULAR ATROPHIES AND DYSTROPHIES. 269 The symptoms of typical cases such as were first described by Charcot are those of a slowly developing paralysis. This affects the upper extremities first and spreads diffusely. The atrophy is less marked than the paralysis. • There is rigidity, exaggerated reflexes, and sometimes tremor. Fibrillary contractions are pres- ent. There are no notable sensory symptoms. The legs are affected later; the paralysis and spastic condition of the legs are antecedent to the atrophy. The visceral centres are not in- volved. The disease progresses rather rapidly and finally in- vokes the medulla, causing bulbar paralysis and death. Some- times ophthalmoplegia is also present. In less typical cases the disease begins with spinal and bulbar symptoms almost simultaneously. In a case under the Avriter's observation there was ophthalmoplegia, bulbar paralysis, and spinal atrophy beginning at nearly the same time. Ordinary cases of spinal muscular atrophy may also be early associated Avith rigidity and exaggerated reflexes. The jaw jerk is often increased in this disease, which cannot be said to be really dis- tinct from progresshTe spinal muscular atrophy; it runs usually a rapid course, causing death in two or three years. THE PROGRESSIVE MUSCULAR DYSTROPHIES. This name is given to various forms of progressi\*e muscular atrophy in which the disease is hereditary in character and at- tacks primarily the muscles. Although a muscular disease, yet its close relationship with spinal muscular atrophies leads us to describe it here. A number of types have been described, the distinctions being based chiefly on the part of the body flrst affected. These types are not of great importance, but may be enumerated here for convenience: 1. Pseudo-muscular hypertrophy. (a) Leyden-Mobius or hereditary type, appearing in children, beginning in back and lower limbs. 2. Erb's juvenile type, or scapulo-humeral type, beginning in childhood or youth, usually in the shoulder girdle or trunk. 3. Landouzy-Dejerine type, or infantile progressive muscular atrophy of Duchenne, or facio-scapulo-humeral type. It resembles the preceding form, with the exception that it involves the face. 4. The peroneal or leg type has been classed with the dys- trophies, but is probably of spinal or neuritic origin, and has been described with the atrophies (see page 268). The essential unity of all these different forms is shown by the fact that cases occur in which pseudo-hypertrophy takes place in the scapulo-humeral and other types, by the fact that a dis- 270 DISEASES OF THE NERVOUS SYSTEM. ease resembling pseudo-hypertrophic paralysis occurs without any hypertrophy, and by the fact that different types occur in the same family. The unity of the spinal and muscular forms is shown by the same kind of clinical evidence. Fig. 118.—Showing the Parts First Attacked in the Different Types of Muscular Dystrophy and Muscular Atrophy. The shaded parts in A show the place of onset of progressive muscular atrophy of ordinary or Duchenne-Aran type, of leg type, and of types 2 and 3 in text. B shows place of onset of types 1 and (a) in text. At the same time the classical types of dystrophies are very different clinically from the spinal amyotrophies and hence must be separately described. The differences will be shown under the head of diagnosis. Pseudo-Muscular Hypertrophy (Atrophia Musculorum Lipomatosus). This is a disease beginning in childhood and characterized by a progressive weakness of the legs associated with an apparent muscular hypertrophy due to a deposit of fat in the wasting muscles. MUSCULAR atrophies and dystrophies. 271 Etiology.—The disease attacks boys much oftener than girls. It begins, in the vast majority of cases, under the age of ten, often at the close of infancy, very rareJy not till after puberty. Heredity is a very important factor (in three-fifths of cases), the hereditary influence being almost always transmitted by the mother. A psychopathic or neuropathic condition is often found in the ancestry. Neuroses, syph- ilis, intemperance, consanguin- ity, are not factors in hereditary causation. Injury and an acute disease sometimes appear to act as exciting causes. Symptoms.— The first symp- tom noticed is a weakness in the legs, Avhich shows itself in a peculiar " wad- dling gait" and a tendency to stumble and fall. A little later (fifth or sixth year) an apparent hypertrophy of leg muscles, particularly of those of the cahres, develops. The extensors of the knee or one of them and the gluteal and lumbar muscles may also be af- fected. Sometimes the hypertrophy is very great, at other times it is barely noticeable (Fig. 119). The affected part has a peculiar, hard, non-elastic feeling to the hand, not like that of normal mus- cle. In the upper part of the body the hypertrophy oftenest attacks the infra- spinatus. The supra-spinatus and del- toid may be somewhat involved. The lower parts of the pectoralis major and latissimus dorsi are also usually atrophied, giving a characteristic appearance to the shoulders. The upper-arm muscles are often slightly Avasted, the forearm, neck, and face rarely. The tongue may be hyper- trophied. Along with the pseudo-hypertrophy there occurs an atrophy of certain groups of muscles; and after a time the pseudo-hyper- trophy disappears and an atrophy takes its place. In the lower limbs the muscles most atrophied are the flexors of the hips, then the extensors of the knee and those of the hip. The calf muscles fail before the anterior tibial. The atrophy and consequent weakness of the lower-limb muscles causes great difficulty in going upstairs, the gait becomes more waddling, and the pa- tient loses the power of getting up when lying on the floor. These peculiarities are due chiefly to the weakness in the exten- flg. 119.—pseudo-muscular Hypertrophy (Erb). DISEASES OF THE NERVOUS SYSTEM. sors of the knees, the extensors of the hip, and the flexors of the hip. By reason of the same defects, the child ay hen standing has an antero-posterior curvature of the spine with the concavity backward (lordosis). This is due to the weakness of the exten- sors of the hips, which, acting from the hips, are unable to tilt the pelvis back. On sitting this lordosis disappears, and is replaced often by a curve in the opposite direction due to weakness of the erectors of the spine. There may be some lateral curvature also. In consequence of the Aveakness and contractures of the leg mus- cles, there early develops a talipes equinus, and later the legs may become flexed on the hips and the forearms on the arms. The muscles show no fibrillary twitchings and rarely any de- generative reactions, but there is sometimes a peculiar tetanic contraction with both the faradic and the galvanic current. The knee jerks and elbow jerks gradually Aveaken and in time are lost. There is no pain or other disturbance of sensibility. The affected parts feel cold and look reddened as if from defi- cient vasomotor innervation. The organic spinal centres are not involved. Intelligence is usally good. Course.—The disease runs a chronic but variable course. Its progress is at first slow; after walking becomes impossible it may progress. It lasts from ten to twenty-five years. In a few cases patients have reached the age of fifty or sixty years, even when the disease began in youth. The earlier the disease begins the more rapidly it extends; the more pronounced the tendency to lipomatosis, the more rapid is the course. Pathological Anatomy. —This disease, like the other forms of dystrophy, is a degenerative one, the process affecting first the muscle fibres; the connective tissue and terminal nerve filaments being secondarily involved. In the same patient and even the same muscle the most varied changes may be noted. In the early stages there is a true hypertrophy of some of the fibres, a condition thought to be characteristic of the muscular dystro- phies in distinction from the spinal atrophies. Besides swelling and hypertrophy of fibres, one sees atrophy of the fibres; the bundles are rounded; there is increase of muscle nuclei, splitting of fibres, vacuolization, and tendency to break up into fibrille (Erb). The connective tissue at first shows evidence of irrita- tion and proliferation. Finally, as the muscular atrophy pro- gresses, connective tissue increases and takes its place, until a dense, hard myo-sclerosis results. In some parts there is deposit of fat in the connective-tissue cells, and this may increase until an extensive lipomatosis exists. In the later stage of the disease the fat deposits are absorbed and there is only atrophied mus- cle and connective tissue. The nerves and spinal cord are usu- MUSCULAR ATROPHIES AND DYSTROPHIES. ' 273 ally normal; when changes are found they are secondary to the muscular disease (Fig. 120). The process is then, first, hypertrophy of muscle fibre and in- crease of muscle nuclei, swelling and rounding of fibres, and spill- ing of the same; then increase of connective tissue, with corre- sponding atrophy of muscle and deposit of fat. The process is a primary degeneration due to an inherent nutritional weakness of the muscle. In a measure it is true that S V V Fig. 120. — Partially Diagrammatic, showing A, hypertrophied fibres ; B, mixture of hypertrophy and atrophy ; C, D, atrophy and fatty deposit; v, vacuoli- zation ; s, splitting ; h, hypertrophy of fibres ; g, thickened blood-vessel (Erb). those muscles embryologically latest developed are earliest at- tacked. 2. The juvenile form of Erb or scapulo-humeral form of dys- trophy begins in childhood or early youth, a little later than pseudo-hypertrophy. The shoulder girdle is first affected, later the arm. The forearm and legs are attacked very late. Part of the pectorals, part of the trapezii, latissimus dorsi, rhomboid, upper-arm muscles and supinators are affected, while the supra and infra spinati and forearm and hand usually escape. There may be true and false muscular hypertrophy. There are no flb- rillary contractions or degenerative reactions. 18 274 DISEASES OF THE NERVOUS SYSTEM. 3. The facioscapulo-humeral form or infantile progressive muscular atrophy begins in early childhood (third or fourth year) usually, but may develop late. The atrophy attacks flrst the face, giving a, characteristic appearance knoAvn as the myopathic facies. There is a Aveakness of the oral muscle, Avhich causes the lips to protrude and produces a symptom called the " tapir- Fig. 121. Fig. 122. Fig. 121.—Muscular Dystrophy having Characters of Juvenile Type (2) and Pseudo-Hypertrophic Type (la) (Putzel). Fig. 122.—Juvenile Type, showing atrophy in shoulder and arms (Erb). Prognosis.—The patient never recovers, but the disease some- times comes to a standstill and there may even be some improve- ment, especially in cases beginning late. Treatment—The prophylaxis is important. It consists in pre- venting the marriage of women belonging to dystrophic families; if a dystrophy has developed in one child, it would be unwise to take the risk of bringing others into the world. Or if children are already born, they should receive the most careful nourish- MUSCULAR ATROPHIES AND DYSTROPHIES. 275 ment, out-door life should be secured, and the dangers from trauma and the infective diseases be prevented. Infants should not be suckled by the mother if she belongs to the dystrophic family. The moderate use of massage and gymnastics is very impor- tant and useful. All kinds of tonic measures are indicated, such as cold baths, good nourishment, arsenic, strychnine, and phos- phorus and fats. Tenotomy and other orthopedic measures may be useful in the later stages. Fig. 123.—Showing Changes in Arthritic Muscular Atrophy. 1, Normal fibre ; 2, atrophied fibre ; 3, vacuolated fibre ; 4, connective-tissue proliferation (Darkschewitch). Arthritic Muscular Atrophy. In inflammation of joints the muscles moving are affected by a simple atrophy which is called arthritic. Etiology.—Rheumatic arthritis is the commonest cause. Symptoms.—The shoulder-girdle muscles are oftenest affected. Whatever the joint, it is the extensor muscles which are first and most attacked; the muscles above the joint are more susceptible to the atrophy than those below. The atrophy is rather rapid in the first few weeks and then becomes slower. The muscles 276 DISEASES OF THE NERVOUS SYSTEM. affected waste throughout their whole length. They show no fibrillary contraction and no degenerative electrical reaction. There is often an increased irritability, so that an exaggerated tendon reflex or even clonus may be produced. There is no pain or tenderness or anesthesia in the muscles. Pathology.—The anatomical change is a simple atrophy and shrinking of the muscle fibres, Avith some increase in muscle nuclei, little ATacuolation, no sAvelling or splitting of fibres (Dark- schewitch—Fig. 123). There is some increase in interstitial tis" sue, but this is slight. The neiwes and spinal cord are normal. The atrophy is probably due to reflex action. It is a reflex tropho-neurosis. EAren a neuralgic joint may cause an atrophy. The prognosis is good. If the arthritis gets Avell the muscles are also restored. The treatment consists of electricity and gentle massage and exercise. Internal treatment must be directed to the arthritis. Occupation Muscular Atrophies. As a result of constant over-use muscles sometimes atrophy. This applies especially to the smaller muscles of the hand. Thus there occurs an atrophy of the thenar eminence in lapidaries and in persons who constantly use this group of small muscles. The biceps sometimes Avastes in smiths, and I have seen afro- phy of the calf muscles in a ballet-dancer. The disease does not tend to extend beyond the muscular group first attacked. Its seat is probably the muscles themselves. The treatment is rest. CHAPTER XV. TUMORS AND CAVITIES OF THE SPINAL CORD. Etiology.—Tumors occur rarely in the spinal cord. The largest tables of cases include less than one hundred. The commonest age is thirty to fifty; tubercle occurs earlier (fifteen to thirty-five —Herter) and lipoma is con- genital. Males are more sub- ject than females. Tuber- culosis, syphilis, and cancer predispose to the disease. Injuries and exposures ap- pear sometimes to excite the growth of spinal neoplasms. Symptoms. — These vary with the location, character, size, and rate of the growth of the tumor. No definite clinical picture can be drawn. The symptoms are such as re- sult from a foreign body slow- ly and progressively irritating and destroying the roots and substance of the spinal cord. Pain appears early and is very constant, continuous, and severe. It is generally re- ferred to nerves running out from the cord in the region of the tumor; a girdle sensa- tion is felt. Numbness, hy- peresthesia, and later anes- thesia occur. Tenderness over the spine and rigidity are not i fe*y |||P p very frequent. The sensory Fm_ 124.-Showing the Condition in a symptoms are usually more Brown-Sequard Paralysis due to a Tumor on one Side, but may become Growing in the Left Side of the Spinal bilateral. Spasm, contracture, C°RD- 0n,the left side hyperesthesia ataxia, paralysis, exaggerated reflexes. At and exaggerated reflexes usu- the upper limit is a band of anaesthesia. On ally soon develop, involving right side, anaesthesia. 27S DISEASES OF THE NERVOUS SYSTEM. one or both legs or an arm and leg. Later paralysis, atrophy,. loss of control of the bladder and rectum, and bed-sores follow, and death ensues from exhaustion. When the disease is cervical the four extremities and trunk muscles may be gradually involved, and there is rigidity of the neck and optic neuritis. If loAver down, there develops a hemi- paraplegia, later a complete paraplegia, usually with exaggerated reflexes. If the tumor is in the lumbar region the reflexes are sooner lost and the sphincters early invohred. A rather frequent type of symptoms caused by spinal tumors is that knoAvn as a Bro/rn-Sequardparalysis or hemiparaplegia_ In a typical case of this kind there is paralysis of motion and muscle sense on the side of the lesion, paralysis of cutaneous sen- sation, especially of pain, and temperature on the opposite side. On the side of the lesion the temperature may be slightly raised; Fig. 125.—Showing the Mechanism of the Production of a Brown-Sequard* Paralysis. The shaded part on the left represents the lesion. This involves the pyramidal tract and motor fibres M, causing paralysis and spasm on same side; also the muscle sense nerves M S on same side and the cutaneous sensory nerves C S of opposite side. there is often hyperesthesia, and reflex action is increased. There may be a band of anesthesia at the level of the lesion and on the same side (Figs. 124, 125). The symptoms Arary according as the tumor is outside or in- side the dura. The common extra-dural forms are lipoma, cancer, gumma, and sarcoma. The greater amount of motor and sensory irritation, the evidence of some vertebral disease, existence of malignant tumor elsewhere, the absence usually of hemipara- plegia, characterize extra-medullary tumors. The common forms of intra-dural or medullary tumor are glioma and tubercle. In these cases pain and spasm and rigidity are rather less com- mon in the early stage; hemi-paraplegia is more common. A secondary myelitis sometimes develops. The duration of the disease ranges from three months to five years, the average being two or three years. Pathology and Pathological Anatomy.—All forms of tumor occur, but the commonest are gliomata and sarcomata, and after TUMORS AND CAVITIES OF THE SPINAL CORD. 279 this fibromata, myxomata, gummata, and tubercles. Cancer is rare; echinococcus and cysticercus are the only parasitic tumors found. The majority start from the membranes, next from the cord, and fewest from the vertebre. The meningeal tumors are mostly sarcomata and their various modifications, fibroma, enchon- droma, carcinoma, and lipoma. The myelonic or intra-spinal tumors are commonly glio- mata, sarcomata, tubercle, and syphilomata. Spinal tumors are small in size, ranging from one-fifth to one and one-fifth inches (one- half to three centimetres) in diameter. The glioma may diffuse itself for a long dis- tance through the centre of the cord, forming cavities (syr- ingo-myelia). The sarcomata may likewise be irregularly spread along the surface of the cord. Spinal tumors are usu- ally single, but fibromata, the parasites, and sarcomata may be multiple. The favorite locations for spinal tumors are just below the mid-cervical, the upper and the lower dorsal regions. The secondary changes produced by tumors are softening, hem- orrhages, secondary degenera- tions, and inflammatory reac- tion. The origin and histology of spinal tumors does not differ from that of tumors elsewhere. The Diagnosis.—The disease has to be distinguished from vertebral caries, transverse myelitis, and hypertrophic pachymen- ingitis. The points to be noted as regards caries are the absence of an external tumor or kyphosis; the small degree of tenderness and rigidity, the age, and absence of tubercular diathesis. The progressive course, beginning with pain, followed by motor and then sensory paralysis, and the localization of the symptoms ex- cludes myelitis. The differentiation from hypertrophic pachy- meningitis is often very difficult. Fig. 126.—Sarcoma of Spinal Cord, Mid-cervical Region. 280 DISEASES OF THE NERVOUS SYSTEM. The character of the tumor cannot often be determined cer- tainly. The probabilities are in favor of sarcoma or glioma, es- pecially in middle life. Syphiloma may be suspected from the history and results of treatment. Tubercle is very rare. The prognosis is bad except in syphiloma, and even here it may be serious. Tubercle may perhaps cease to grow. Surgical interference now saves the life of some cases. Treatment.—In syphilitic tumors appropriate remedies may do good and should be Aigorously used. In tubercle, tonic treatment, iodine, and cod-liATer oil may be of service. In gliomata and sarcomata, nitrate of silver and arsenic may be tried. In other forms, symptomatic treatment is all that can be recom- mended medically. In all cases of spinal tumor surgical inter- ference should be considered; extra-dural tumors, if taken early, can be removed with great benefit. EATen in medullary tumors enucleation may do some good in the early stage. Exploratory operations are justifiable if there is no question as to the diagno- sis of tumor. The mortality from such operation in capable hands is very low, though it is more dangerous than trephining the skull. CAVITIES IN THE SPINAL CORD. The cavities of the spinal cord are known as 1. Hydromyelia. 2. Myelitic cavities. 3. Syringo-myelia. There may be various combinations of these processes, the most common being a combination of hydromyelia and syringo- myelia. Hydromyelia. This is a dilatation of the central canal of the cord, the cavity being filled with fluid. The condition may be associated with hydrocephalus or with spina bifida, or it may be independent of these conditions. The dilatation may be cystic and irregular or, as is more usual, extend throughout the cord. The dilatation extends more posteriorly, because the posterior columns are formed latest. The abnormality may be slight and give rise to no symptoms. Or a pathological process like a gliomatosis may de- velop upon it. Myelitic and Hemorrhagic Cavities. Such cavities may be formed in the cord by a central excavat- ing myelitis or by small hemorrhages. These cavities are usually small, irregularly distributed, and are lined with connective tis- sue. They may be formed in rare cases in connection with hy- dromyelia or neoplasms. TUMORS AND CAVITIES OF THE SPINAL CORD. 281 Syringo-Myelia. Syringo-myelia is a disease of the spinal cord characterized by a development of gliomatous tissue in the central parts, with for- mation of cavities. Clinically the disease is sometimes charac- terized by peculiar disturbances of sensation and nutrition. In many cases, hoavever, the symptoms are atypical and the dis- ease cannot be recognized during life. The description here given corresponds to the classic mani- festation of the disease, and it is intended to refer to syringo- myelia produced by gliomatosis only. Etiology.—The "disease is rare, about tAVO hundred cases hav- ing been reported. It is more frequent than amyotrophic lateral Fig. 127.—Distribution of Cutaneous Anesthesia in Syringo-Myelia. 1 shows area of analgesia ; 2 shows that of thermo-anaesthesia. The darker shades show where there is anaesthesia to pain and temperature (Bruhl). sclerosis and rather less frequent than multiple sclerosis. It oc- curs oftener in men than women, and de\relops early in life, be- tAveen the ages of fifteen and twenty-five. It occurs especially in persons who follow manual occupations such as butchers, tailors, etc. Traumatism, pregnancy, and in- fectious diseases seem occasionally to give rise to it. Heredity, syphilis, and alcohol are not causal factors. Symptoms.—The disease begins insidiously with some aching pains in the neck and arms and paresthesia of the hands. There is soon a muscular atrophy of the hands resembling spinal pro- gressive muscular atrophy, with perhaps anesthesia. As the dis- ease progresses the weakness and atrophy of the hand muscles become more noticeable and gradually extend toward the trunk. The atrophy comes on in both extremities at about the same time. 28^ DISEASES OF THE NERVOUS SYSTEM. Fibrillary contractions and partial degeneration reaction may be obserA-ed. Cutaneous anesthesia of the affected hand and arm to temperature and pain, but not to touch, takes place; and this is so marked as to be al- most pathognomonic of the disease (Fig. 127). The legs do not become affected until late, and then generally shoAv a spastic paraplegia. The throat and face are rarely in- volved. There is a scolio- sis of the spine, generally in the dorso-lumbar region (Fig. 128). Vasomotor, secretory, and trophic symptoms are prominent. The hands- may be oedematous or red and congested. Sweating or dryness of the skin may occur. Eruptions appear on the skin, such as bulle, herpes, and eczema. Pain- less whitlows attack the fingers and may destroy the terminal phalanges. Erosions and ulcerations also occur. The nails be- come dry, brittle, and drop off (Fig. 129). Arthropa- thies and spontaneous frac- tures have been observed. The pupils may be un- equal and the bulb re- tracted. Late in the disease symptoms of involvement of the medulla develop. At this time also the bladder, rectum, and genital centres are attacked. The disease progresses slowly for years, with remissions of various degree. The cardinal symptoms are a progressive muscu- lar atrophy, Avith a pecu- liar partial anesthesia, trophic disturbances, and scoliosis. Pathological Anatomy.—The seat of the disease is the sub- stance of the cord. On opening it by transverse sections one finds one or more cavities extending in various degrees up and down. The most frequent primary site is the cervical swelling. From here it usually passes down and may reach the whole length of the cord. It also extends upward and may involve Fig. 128.- -Showing Curvature of Spine in Syringo-Myelia (Erb). TUMORS AND CAVITIES OF THE SPINAL CORD. 283 the medulla and the nuclei of the cranial nerves. The cavities are of irregular shape, small size, and filled with a liquid like the cerebro-spinal fluid. They are situated oftenest posterior to the commissure and involve one or both posterior horns, but they may be so extensiA^e as to involve almost the whole of the centre of the cord at some levels. The walls are usually lined by a membrane and surrounded by a gliomatous tissue (Figs. 130-135). This membrane is composed of a rather dense gliomatous tis- sue. It may be absent in some parts. The glia cells are in vari- ous stages of development and degeneration. In parts of the cord the new growth may form a large and solid mass occupying Fig. 129.—Showing Hand in Syringo-Myelia of Type of Morvan's Dis- ease (Erb). most of the centre of the cord. Small hemorrhages and foci of myelitis may be present. In some cases there is evidence of a dilated central canal, with neuroglia hyperplasia of the walls and a gliomatous infiltration about this. The epithelium of the cen- tral canal may form part of the wall of the cavity. Pathology.—At about the sixth week of foetal life the central canal of the cord is large, diamond-shaped, and reaches nearly to the anterior and posterior surfaces of the cord. This cavity grad- ually contracts and unites in the middle, the anterior part forming the central canal and the posterior part the posterior septum. The posterior part may, through some embryological defect, fail to close, and a congenital cavity may be left. About this a gli- oma may develop, and we have syringo-myelia. The central canal 284 DISEASES OF THE NERVOUS SYSTEM. may remain imperfectly contracted, and a syringo-myelia may deArelop in connection Avith it. Probably most cases of syringo- myelia are developed on the basis of an embryological defect. Gliomata were formerly thought to be practically identical Avith sarcomata. It is believed now, however, that they are of epiblastic origin, and like nerve cells are modifica- tions of epithelial tissue. This tissue in its normal state is called neuroglia. It is a nervous substance. It is composed of small cells, round or of irregu- lar shape, Avith a large nucleus and fine fibrillary prolongations. In glioma these cells are relatively much more numerous, while the fibrillary net- work is less conspicuous. There is considerable va- riation in the relative richness of cells and ii 1 ires, however. When the for- mer are very frequent the term gliosarcoma has been wrongly given to the tumor. The glioma is penetrated by small blood-vessels. Avhose walls are often diseased, so that minute hemorrhages oc- cur and the glioma be- comes stained and pig- mented. In other cases it is gray or yellowish in color. The rich cellular pro- liferation in gliomata has suggested an analogy in its growth to that of in- flammation, and the term gliosis is used as analo- gous for neuroglia to inflammation for connec- tive tissue. Gliosis dif- fers from sclerosis, how- ever, in the fact that in the latter process the multiplication of fibres dominates, while in the former it is the cells; besides this, in gliosis there is a tendency to softening and formation of cavities; and all nerve fibres dis- appear. In sclerosis some nerve fibres remain, and one observes the presence of granular and amyloid bodies. Peculiar Types.—1. The disease may be latent, giving rise to very few symptoms or to none that are characteristic. Fig. 132. Figs. 130-132.—Sections of Spinal Cord at Dif ferent Levels in Syringo-Myelia (Bruhl). TUMORS AND CAVITIES OF THE SPINAL CORD. 285 2. There may be a period of irritation and pain in the extrem- ities followed by paraplegia, Avith few sensory troubles, the course suggesting a chronic transverse myelitis or a Brown-S6quard paralysis. 3. There is a type in Avhich bulbar symptoms develop early, but differing from ordinary bulbar paralysis in the in- Arolvement of the trigeminus and other cranial nerATes not commonly at- tacked. 4. There is a form characterized by a rather rapid as- cending paralysis. None of these types can ordina- rily be recognized during life. 5. There is a type characterized by the symptoms of muscular atrophy with analgesia and felons (Morvan's disease). In this type there is prob- ably a complicating neuritis. Some as- sert that all cases of Morvan's disease are cases of syringo- myelia, but this is not proven. Diagnos is.—The disease is distin- guished in its clas- sical form by (1) its beginning at the period of adoles- cence, (2) by the progressive muscu- lar atrophy com- bined with the pe- culiar dissociated disturbances of sen- sibility, (3) by the trophic disturb- ances and scoliosis. It has to be distinguished from progressive muscular atrophy and dystrophy, and amyotrophic lateral sclerosis, hypertrophic cervical pachymeningitis, chronic transverse myelitis, Morvan's disease and anesthetic leprosy. The sensory and trophic disorders and scoliosis enable one to distinguish it from progressive muscular atrophy. In leprosy Figs. 133-135.—Sections of Spinal Cord at Different Levels in Syringo-Myelia (Bruhl). 286 DISEASES OF THE NERVOUS SYSTEM. the dissociation of the sensory symptoms is not present, and the anesthesia is distributed along the course of the nerves or in sharply circumscribed plaques. In some cases the peculiar tu- bercular disease of the skin and the history of the case make the diagnosis easy. In leprosy, also, there is a perineuritis, and the enlarged inflamed nerves may be felt. Portions of the skin may be excised and examined for the leprous bacillus. As regards the differentiation from Morvan's disease, this cannot often be done. Still whitlows are rare in ordinary forms of syringo- myelia. Morvan's disease begins in one hand and slowly extends, with remissions, to the other. Usually there is loss of tactile as well as thermic and pain sense. The prognosis so far as life is concerned is bad. But the disease has often a long course, ranging from five to twenty years, and periods occur in which the progress of the disease seems arrested and improvement occurs. Treatment—It is not impossible that Ave may find some drug which acts specifically on gliomatous tissue, checking its growth. At present we know of only two things which may possibly do this: nitrate of silver and arsenic. These drugs should be given; and for the rest, tonic and symptomatic treatment are indicated. FUNCTIONAL DISORDERS. Spinal Irritation. This name is given to a functional disorder characterized by great pain and tenderness along the spine and associated with a neurasthenic and hysterical condition. The disease has been described as spinal hyperemia (Hammond) and as spinal anemia. Etiology.—Spinal irritation is far more frequent in women than in men. It occurs between the ages of fifteen and thirty- five chiefly. A neuropathic constitution usually exists. The exciting causes are mental shocks and trauma, which latter need be only slight; excessive physical and mental work in young people; uterine displacements, sexual irritation, eye strain; and sometimes infectious fevers. I have seen cases which Avere the residuum of sporadic cerebro-spinal meningitis. Symptoms.—The disease usually comes on slowly, with feel- ings of tenderness, pain, and burning in the back. Walking in- creases this; sitting and using the arms soon do the same. The neck tires on any exertion; and severe paroxysms of a boring neckache or of headache or backache occur. The patient has to lie down nearly all day, and finally in bad cases remains in bed. There are tender points on each side of the spine, generally at about the level of the sixth cervical, fourth to sixth dorsal, and dorso-lumbar junction. These points vary in position and sensi- tiveness. Pressure on them may cause nausea, pulse disturb- ances, paresthesia, or radiating pain. The skin over the back is FUNCTIONAL DISORDERS OF THE SPINAL CORD. 287 sensitiATe, and there may be sensitive points ov^er the ovaries and epigastrium. The reflexes are exaggerated; there is some motor weakness, and the patient may be unable to walk, stand, or use the arms very much, but this is due more to the weariness and pain that result than to actual paralysis. Some wasting occurs in the limbs, but degenerative reactions are never found. Occasion- ally the patient has cramps and twitchings in the extremities. Sometimes there occurs in spinal irritation a nearly complete paraplegia. This is usually hysterical and always is functional. When such a combination of spinal irritation and paraplegia is caused by injury, it is called "concussion of the spine." Mental symptoms such as undue despondency, irritability, nervousness, and emotional crises are often present. Neither hysteria nor men- tal feebleness, however, necessarily characterizes spinal irritation. Many patients are unusually bright, hopeful, and intelligently anxious to recover. Sleep is usually poor and disturbed by dreams. The hands and feet are often cold and clammy; the pulse is rapid and of Arariable tension. The urine is of light spe- cific gravity, Avith relative excess of phosphates. Visceral symptoms are common in most cases. They consist of sensations of respiratory oppression, palpitations, anorexia, nausea and Aromiting, constipation alternating with diarrhoea, attacks of polyuria, and sometimes vesical and genital weakness. The symptoms are usually exaggerated at the menstrual period. The disease runs a chronic course; it ahvays lasts months, often years, depending largely upon treatment and surroundings. Some of the symptoms of the trouble may remain for a lifetime. Pathology.—The symptoms of the disease correspond exactly to Avhat would follow from an irritation of the spinal meninges and posterior branches of the mixed spinal nerves. Hence the name spinal irritation can hardly be improved upon at present. The fact that classical cases follow an acute meningitis leads me to believe that a hyperemia generally underlies the condition. Diagnosis.—This must be made from cervical caries, organic disease of the spine and of the cord. In caries the rigidity, de- formity, and localized pain are generally sufficient helps. Chronic meningitis is distinguished by the history of an acute onset, the symptoms are more stable, there is more rigidity, and the pains are extrinsic and radiating. The hysterical symptoms are absent, and the tendency, on rest, is always toward recoATery. If there is a chronic meningo-myelitis or myelitis, the paralyses will be per- haps greater, and there may be degenerative muscular changes, anesthesia, and involvement of the sphincters. In a functional palsy there cannot be complete degenerative electrical reactions or permanent sphincter paralyses. 288 DISEASES OF THE NERVOUS SYSTEM. Prognosis.—Nearly all cases get well eA'entually. Persons Avith a weak will, feeble body, and neuropathic constitution have the worst outlook. Traumatic cases, if uncomplicated, are not much worse than others. Treatment—The treatment must be a mental as Avell as phy- sical one. The patient may be put to bed at first, but she should be kept employed and interested if possible, and she should soon be encouraged to Avalk and work a little. Her surroundings should be not too sympathetic, and her daily life should be sched- uled exactly for her. She should be well fed, but not stuffed. Internally it is customary to give strychnine, iron, mineral acids, salicine, and quinine as tonics; moderate courses of bromides in- terrupted at times, or small doses of codeia and valerian, may be used as sedatiA'es. Indian hemp and the analgesics may be of service. I have seen no good from arsenic, nitrate of silver or gold. Iodides and the salicylates, however, are useful. For sleeplessness give a draught of quassia water at night, and make the patient lie on a hop pilloAV or inhale the steam from boiling water in Avhich hops haA-e been thrown. Locally, counter-irrita- tion along the back must be kept up at stated intervals. For this purpose one may use mustard, iodine, blisters, the cautery, and the galvanic current. The faradic current Avith a Avire brush is most efficacious for removing the cutaneous hyperesthesia (Anstie) if the patient can be persuaded to stand the pain. Cups, leeches, Baumgartism and splints, jackets and braces all may haATe to be resorted to eventually. A very great deal de- pends upon the perseverance and personality of the physician. Spinal Exhaustion (Spinal Neurasthenia). This is a condition which is nearly the opposite of spinal irri- tation. It occurs as often in men as women and during middle life or the climacteric. Etiology.—It occurs oftenest in brain-workers and the edu- cated classes. The principal exciting causes are shock, injury, overwork, sexual excesses, and exhausting diseases. The symptoms, which come on slowly, consist chiefly of a gen- eral motor weakness and condition of exhaustion. The patient cannot walk far or stand long. His reflexes are weak, the mus- cles get wasted and flabby. There are some pains and burning or creeping feelings along the back when any exertion is made. The stomach is weak, the bowels irritable, the sexual poAver nearly gone. Headaches, insomnia, mental depression, and hypo- chondriasis are present. The disease, in fact, presents many of the spinal and neurasthenic characters of spinal irritation, but the pain is less and the motor weakness much greater. FUNCTIONAL DISORDERS OF THE SPINAL CORD. 289 When this latter reaches the point of paraplegia and follows shock or injury, the trouble is also called "concussion of the spine." Whether an anemia underlies it we do not know. There is certainly a nutritional defect. The diagnosis, course, and prognosis are much the same as in spinal irritation. Treatment.—The disease may be associated with sprains or surgical injuries which need attention. Aside from this, the treatment must be largely in the nature of the rest cure. Mas- sive doses of tine, nux vomica may be used (m, xxx. to xl. t. i. d.), combined sometimes with a little opium or codeia. At the same time, electricity, massage, baths, and strong feeding are required. The patients usually improve on flrst going under treatment, then relapse a little. The physician must keep something in re- serve for these relapses, J9 CHAPTER XVI. ANATOMY AND PHYSIOLOGY OF THE BRAIN. Anatomy. — The nervous system is developed from a hollow tube formed by a folding of the epiblast. The brain or enceph- alon grows out from its anterior part. This swells into three cavities called the anterior, middle, and posterior cerebral vesi- cles. From the anterior a secondary vesicle develops; the pos- terior divides into two: so that eventually there are five vesicles. Out of them the different parts of the brain are formed. Fig. 136. Fig. 137. Fig. 136.—The Cerebral Vesicles. Fig. 137.—Further Development of Vesicles into Fore-brain (Vordkrhirn), 'Tween-brain (Zwischenhirn), Mid-brain (Mittelhirn), Hind-brain (Hinter- hirn), and After-brain (Nachhirn). The cavities (Hohlen) of the vesicles are being formed into the ventricles (Edinger). 1. From the secondary anterior vesicle there grow the cerebral hemispheres, corpus callosum, fornix, anterior commissure, and corpus striatum. This forms the fore-brain. 2. From the primary anterior A-esicle come the optic thalami, optic commissure, infundibulum, and corpora albicantia. This forms the 'tween-brain. The olfactory lobes and optic nerves are connected with this vesicle. 3. From the middle cerebral vesicle there grow the corpora quadrigemina and cerebral peduncles. This is the mid-brain. ANATOMY AND PHYSIOLOGY OF THE BRAIN. 291 4. From the fourth ATesicle come the cerebellum and pons. This is the hind-brain. 5. From the fifth vesicle, the medulla, which constitutes the after-brain. The development of these parts is shown in the accompanying diagrams. In man the fore-brain is enormouslv developed, the Fig. 138.—Still Further Development of A7esicles. The cerebrum is being formed out of the flrst vesicle l2 (Edinger). 'tween-brain moderately deA-eloped, the olfactorv lobes atrophic, the mid-brain almost rudimentary, the hind-brain Avell developed, the after-brain relatively not much developed. In the process of development of the brain, the neural canal becomes variouslv enlarged and constricted, until the ventricles of the brain, the foramina of Monroe, and the aqueduct of SyMus are formed. The ventricles are the two lateral, the third, fourth, and fifth. Fig. 139.—Further Development. The dotted lines show the original sub- division into vesicles (Edinger). The foramina of Monroe connect the lateral and third ven- tricles ; the aqueduct of Syhrius connects the third and fourth Aentricles. The different segments of the brain as thus enumerated are composed of deposits of ner\re cells forming gray matter or gan- glia, and strands of nerve fibres connecting these ganglia. Most of the general description of these parts must be gotten from treatises on anatomy. I propose, hoAveArer, to enumerate and de- 292 DISEASES OF THE NERVOUS SYSTEM. scribe the A'arious ganglionic deposits found in the brain; then show the Avay in which they are connected Avith each other and the spinal cord. The sixteen ganglionic deposits of the brain are arranged in the different segments as shoAvn here: 1. Cerebral cortex. ) 2. Corpus \ Caudate nucleus. > Fore-brain. striatum. / Lenticular nucleus. ) 3. Olfactory lobes. 4. Optic thalamus. "| 5. Corpora geniculata. J. iTween.brain. 6. Corpora niannl. [ 7. Luys' body. J 8. Corpora quadrigemina. } 9. Red nucleus. - Mid-brain. 10. Substantia nigra. 1 11. Cerebellar cortex. ) 12. Cerebellar nuclei. [- Hind-brain. 13. Pons nuclei. ) 14. Olivary body. ) 15. Nodal nuclei. :- After-brain. 16. Cranial nuclei. ) The Cortex Cerebri and the Convolutions.—The gray matter of the surface of the brain is called the cortex cerebri, and it is by far the largest and most important deposit of nerve cells in the body. The cortex is from 2 to 4 mm. (one-twelfth to one-fifth of an inch) thick, and its total superficial area is 1,800 to 2,700 sq. ctm. The area of gray matter lying in the fissures is about tAvice that lying on the surface (Donaldson). The cerebral cortex is arranged in folds or convolutions (gyri) separated by fissures or sulci. These fissures divide the brain also into lobes. The fis- sures of the brain are divided into primary and secondary. The former are permanent, and present little change in size, location, or direction. The latter are variable in all these respects, and are often called sulci for purposes of distinction. The primary fissures of the brain are: The longitudinal. The transverse or choroidal. The fissure of Rolando or central. The fissure of Sylvius. The parietal. The parieto-occipital. The calcarine. The position of these fissures is indicated on the accompany- ing diagrams, which are based on descriptions of Wernicke, Eber- staller, Wilder, Cunningham, and many observations of my own. I have not space to give detailed descriptions. The secondary fissures or sulci will be enumerated in describ- ing the lobes. They are divided into the typical or more or less constant and the atypical or tertiary fissures. The primary fissures divide the cerebrum into various por- tions called lobes. The lobes are: Frontal. The central or island of Reil. Parietal. Olfactory. Temporal. Limbic. Occipital. Fig. 140.—Showing Convolutions and Fissures. (Convolutions in capitals.) F1, First frontal; F2, second frontal; F3, third frontal; O, operculum ; Prirc, Proocentral ; Paste, post-central ; S P, superior parietal lobule; M G, marginal gyrus, A Ci, angular gyrus, making the 5 inferior parietal lobule ; T1, first temporal ; T'-\ second temporal; T3, third temporal; LOT, lateral occipito-temporal or lingual ; MO T, median ►> occipitotemporal or fusiform, which unites with UNO, uncinate, and HIPPO, hippoeampal; Can, cuneus; PrC, pra?cuneus; Pnrctc, para-central; H GP, gyrus fornicatus ; I, isthmus ; G F + I + Hippo + Unc = limbic lobe. (Fissures in Italics.) Primary: S, Sylvian (r<, anterior ; v, vertical branch); r, Rolandic ; po, parietooccipital ; p, parietal (inter-parietal); call, arcuate or callosal; calc, calcarine. Secondary : /', P, P, first, second, and third frontal; r, rostral (fronto-marginal); orb, orbital; ol, olfactory; cm, calloso-maiginal (super-callosal, subfrontal); mjic, median praecentral; spr, superior prapcentral; ipr, inferior prrecentral; re, retrocentral; pn, precuneal; P, t*, ts, /4, first, second, third, and fourth temporal; £§ h, hippoeampal ; lo, lateral occipital ; ac, anterior occipital (ascending temporal); t, transverse occipital (anterior occipital). 2'J4 diseases of the nervous system. There are eight fissures and seven lobes. The frontal lobe is limited behind by the fissure of Rolando, and on the median surface by the calloso-marginal or subfrontal fissure and its ascending branch. It has the following sulci. 1. Superior frontal and superior pra'central. 2. Inferior frontal and inferior pra'central. 3. Olfactory. 4. Tri-radiate. In the frontal lobe are the folloAving convolutions: 1. Pra^cen- tral or ascending frontal, having on its median surface (a) the paracentral lobule. 2. First or superior frontal. 3. Second or middle frontal. 4. Third or inferior frontal (Fig. 140). The parietal lobe is limited behind by the parieto-occipital and anterior occipital fissures, below on its outer surface by the Sylvian fissure and a line drawn back from its upper end to the lower part of the anterior occipital. In front it is limited by the fissure of Rolando. On its median surface it is limited in front by the ascending branch of the calloso-marginal or subfrontal fissure, behind by the parieto-occipital, and below by the sub- parietal fissure. Its important sulci are: 1. The parietal or inter- parietal. 2. The post-central. The convolutions formed are, on the convex surface: 1. The post-central or ascending parietal. 2. The superior parietal lobule, having on its median surface (a) the quadrate lobule or precuneus. 3. The inferior parietal lobule, Avhich is composed of (a) the supra-marginal gyrus, {/>) the angu- lar gyrus. These latter gyri are variously described, but it is best to regard one, (a) the supra-marginal, as that surrounding the posterior end of the fissure of Sylvius; the other, (b) the angular, as that beginning at the upper limit of the first temporal fissure and extending back as far as the anterior occipital fissure. The Occipital Lobe.—This is limited on its comex surface, anteriorly, by the parieto-occipital fissure, laterally to this by the anterior occipital and inferior occipital fissures. These in apes form a single continuous fissure sharply separating the occip- ital from the other lobes.* On its median surface the parieto- occipital fissure limits the lobe in front. On the under surface the anterior edge of the tentorium about marks the anterior limit. The sulci are: 1. The transverse occipital (ape fissure of some writers). 2. The superior or lateral occipital. 3. The inferior occipital. On the median surface: 4. The calcarine, which joins the parieto-occipital. 5. The inferior occipito-temporal or fourth temporal. The convolutions on the convex surface are: 1. The superior occipital. 2. The middle occipital. 3. The inferior occipital. 4. The descending occipital. On the median surface we find: 5. The cuneus. 6. Descending occipital. The Temporal Le>be.—The convex or lateral surface shoAvs the following sulci: 1. The first temporal or parallel sulcus. 2. The second or middle sulcus. On the under and median surfaces are: 3. The third or inferior temporal sulcus. 4. The fourth temporal or inferior occipito-temporal or collateral sulcus, which extends into the occipital lobe. 5. The hippoeampal sulcus. The convolutions are. 1. The first temporal convolution. 2. The second temporal convolution. 3. The third temporal con- ATolution. 4. The lateral occipito-temporal or fusiform convo- lution. 5. The median occipito-temporal or lingual convolu- tion. 6. The hippoeampal convolution, which is an extension of * There is still some doubt about the homology of these tissues. ANATOMY AND PHYSIOLOGY OF THE BRAIN. 295 4 and 5. 7. The uncinate convolution, which is an extension of 6. The Island of Reil (lobus centralis, lobus caudicis).—This has a circular sulcus surrounding it, and several more or less short sulci dividing it into from five to seATen short gyri. The limbic lobe, if described as a separate lobe, is made to in- clude anteriorly the gyrus fornicatus or gyrus cinguli, back of this the isthmus, then the hippo- eampal, uncinate, and dentate con- 0SSSzff%^- volutions (Fig. 140). 'tej&$*>_- The olfactory lobe is rudimen- ; "7 tary in man. Its position is shown V | in the diagrams. The operculum is the part of the brain that overlaps the island of Reil. It consists of a fronto-pari- etal part, formed by the lower end h Flu. 141. Fig. 142. Fig. 141.—Section op Cortex op Frontal Lobe Stained by Weigert's Method, showing the fibre systems and layers. 1, 2, 3, 4, The ganglionic cell layers; a, neuroglia layer; b, tangential fibres; c, super-radial network; d, outer stripe of Baillarger or Glennari's stripe; e, inter-radial network; /, inner stripe of Bail- larger; g, radial fibres of white matter (after Obersteiner and Edinger). Fig. 142.—Section op Cortex op Frontal Lobe (after Golgi). 1, Neuroglia or barren layer; 2, small pyramidal layer; 3, large pyramidal layer; 4, irregular and spindle-cell layer. At G6, a deposit of granular cells forms a fifth layer in the sensory occipital area of the cortex. 296 DISEASES OF THE NERVOUS SYSTEM. of the tAvo central convolutions, a frontal part formed by the base of the inferior frontal convolution, and a temporal part formed by the tip of the temporal lobe. The cuneus, precuneus and paracentral lobule are important subdivisions on the median surface of the brain. Their position and boundaries are sIioavu in the cuts. Mic/oscopical Anatomy of the Convolutions.—The cortex of the cerebrum is composed of neiwe cells, a network of nerve fibres and processes, and of neuroglia tissue. Superimposed upon it is a \Tery vascular membrane, the pia mater, Avhich sends a rich plexus of A-essels into it. We shall proceed to study: 1st, the structure and arrangement of the nerve and neuroglia cells; 2d, the arrangement and connections of the nerve plexuses. On both these points new facts are being constantly added, and the present description must be in many respects only provisional. 1st. The cells are arranged to a certain extent in layers. In the outer layer, next the pia mater, is a deposit of neuroglia tissue containing " spider cells." Beneath these are small, somewhat irregularly shaped pyramidal cells (angular cells of Lewis); next come large pyramidal cells; and deepest of all irregularly shaped cells (including the granule cells of Lewis) and spindle-shaped cells. In the above I haA^e described four layers of cells, and this may be considered the type. Some anatomists describe five typi- cal layers, the fifth being made by a subdivision of the fourth (by Meynert) or of the third (by LeAvis). The common four-layer type is found in the central convolutions and frontal lobe. In the occipital region there are six (LeAvis) or eight (Meynert) layers described. These are formed by the interposition of granule cells Avhich subdivide the third layer. Various types of cortex are described depending upon the different degree of develop- ment of the cell layers and upon the fibre arrangements. The common or motor type, as has been stated, has four layers. The large pyramidal cells are here numerous and are arranged in clusters. The sensory type has at least five layers, as described for the occipital cortex, and here the large pyramidal cells are few and isolated. The pyramidal cells are arranged Avith their apices pointing to the periphery. They give off apical, lateral, and basal processes. The basal process of the pyramidal cells is continued as an axis cylinder. Some of them pass down into the Avhite matter; others turn up and enter the fibre systems of the cortex. The spindle cells point toAvard the periphery also, except at the bottom of the sulci, Avhere they lie parallel to the surface. Their processes connect neighboring areas and are called associ- ative fibres. The small pyramidal and spindle cells measure about 10 xl8/^; the large, 20x40// (tAt) x Tritar m-)- There are in the upper central and paracentral convolutions giant cells (of Betz) Avhich measure 125 x 55 fi (^x^in.). Despite the great variety and complexity of the cortex, it is probable that there are but three principal classes of cells: (1) those which receiA^e nervous impulses and which lie chiefly in the second and granule layers; (2) those which associate and co- ordinate these impulses, and Avhich partly lie in the second and partly deep in the fourth layers (small pyramidal and spindle cells); and (3) those Avhich discharge impulses and which lie in the third layer (large pyramidal cells). ANATOMY AND PHYSIOLOGY OF THE BRAIN. 297 The fibres and plexuses oi the cortex are composed of processes from the nerve cells and terminals coming in from the white mat- ter. They collect into seAreral close netAvorks. One, lying just under the neuroglia layer and running parallel to the surface, is called the tangential layer of fibres; a second layer runs among the large pyramidal cells, forming the outer stripe of Baillarger; and a third layer, beneath this, is called the inner stripe of Bail- larger. Besides these, there are radiating fibres, running in from the white matter and forming inter-radial and supra-radial net- works (Fig. 142). The cortical gray matter, as will thus be seen, contains layers of nerve cells, into which nerve fibres penetrate. These termi- nate, as do all fibres, in end-brushes, Avhich surround the receptive -zz: n ? h^y W~\— "4"' 1 v_c -* V V A Fig. 143.—Diagramatic Representation op the Relation op the Cells of the Cortex to Each Other and to Distant Parts. A, Motor type of cortex. 1, Neuroglia cell; 2, small pyramidal and granule cell; 3, large pyramidal cell; 4, spin- dle cell; o, tangential fibres; 6, stripes of Baillarger; c, associative fibres. B, Sensory type of cortex (A7on Monakoff). //., III., V., Second, third, and fifth layers of cor- tex; hx, large pyramidal cell; sx, granule cells. In A, impulses are received by the small cells 2, distributed and associated by the tangential and other fibres a, b, c and by the spindle cells 4; impulses are emitted by the large cells 3. or sensory cells. An enormous number of fine fibres are giAren off by the cells; some of these form layers in the cortex and con- nect neighboring parts, others run out and connect more distant parts or pass down to lower levels. There must be three kinds of fibres—afferent, associative, and efferent—just as there are three types of cells (Fig. 143). The different convolutions and lobes of the brain are connected with each other by association fibres and Avith parts below by projection fibres. The association fibres consist of short fibres connecting neigh- boring convolutions, long fibres connecting neighboring or dis- tant lobes, and commissural fibres connecting the two halves of the cerebrum. 2DS DISEASES OF THE NERVOUS SYSTEM. The short association fibres are numerous: they lie close be- neath the gray matter and connect coirvolutions of the same lobes. The course of many of the long association paths is not yet well known, the descriptions commonly given being not alto- gether correct (H. Sachs). The occipital lobe is connected by long tracts to the temporal lobe, and perhaps slightly to the in- ferior parietal lobe (H. Sachs). The temporal lobes are con- nected only to the occipital. The frontal lobe is apparently connected with the parietal. Its connection with the temporal is denied (H. Sachs). All the lobes of the two halves of the brain are connected with each other by commissural tracts in the cor- pus callosum and anterior commissures. Fig. 144.—Nerve Cells of Corpus Striatum with Processes Running into Internal Capsule. I will describe the projection fibres later. The corpora striata are composed of two parts • the caudate nucleus and lenticular nucleus. These two nuclei are separated dorsally by the white fibres forming the internal capsule. Below they are continuous. Their shape and relations are not easily appreciated except by actual inspection of specimens. They are indicated in the accompanying figures (148-150). The head of the caudate nucleus is connected with the gray matter of the anterior perforated space. The tail extends into the temporal lobe, where it is continuous with the gray matter of the cortex, called at this point the amygdalum, and Avith the claustrum. The lenticular nucleus is also continuous with the gray matter of the anterior perforated space. It is divided into three por- tions; the external is called the putamen, the two inner the globus pallidus. These.parts are separated by white fibres. The caudate nucleus, putamen, and probably all of the corpus striatum are modifications of the cerebral cortex. ANATOMY AND PHYSIOLOGY OF THE BRAIN. 299 The corpus striatum has (1) fibres which pass to it from the cortex, (2) fibres Avhich pass through it from the frontal and parie- tal cortex, (3) fibres Avhich originate in it, and (4) fibres connect- ing its different parts. 1. The fibres joining the ganglion to the cortex are few and merely associative. 2. The fibres which pass through it pass chiefly into the dorsal part of the cerebral peduncles (or tegmentum) and are connected with the sensory tracts there. 3. Fibres which originate in the caudate nucleus and putamen collect together and join with the cortical fibres to form the Fig. 145.—Showing the Relations op the Optic Thalamus to Other Parts (Edinger). " lenticular loop" (ansa lenticularis). Some go to the subthal- amus (Luy's body) and optic thalamus; most go to the inferior olives and thence connect Avith the cerebellum. Some perhaps go to the posterior longitudinal bundle, which is a band of com- missural fibres that connect together the cranial nerve nuclei in the medulla. 4. Fibres connect the caudate nucleus and putamen with the globus pallidus. The corpora striata are relatively rudimentary ganglia in man. They contain sparsely distributed multipolar and fusiform cells, tAtt to fa-n in. in diameter, the larger being in the lenticular nucleus. They are chiefly of the sensory type (Marchi—Fig. 144). The Optic Thalami.—These ganglia form the chief part of the 'tween-brain. They lie at the base of the brain, posterior and in- 300 DISEASES OF THE NERVOUS SYSTEM. ternal to the corpora striata. They are continuous Avith each other by means of the middle gray commissure. The upper or dorsal surface forms part of the Avail of the lateral ventricles; the mesial surface forms the lateral Avail of the third ventricle. Ex- ternally is the band of white fibres called the internal capsule; beloAV this is a rather large mass, the red nucleus, external to a small gray nucleus called the subthalamic ganglion (Luy's body). Around and below these is a complex netAvork of fibres called the stratum intermedium. Below this, on the base of the brain, are the corpora mamillaria. The thalamus is composed of four nuclei —the anterior, lateral, and median or posterior. The last is called the pulvinar. Besides these there is on the median surface a small ganglion called the g. habenulse. The optic tracts Avind around the posterior and outer edge of the thalamus; and con- nected Avith these and the thalamus are two other ganglia, the Fig. 146.—Nerve Cells op Optic Thalamus (Marchi). external or lateral and internal or median geniculate bodies. Thus the thalamus is in close anatomical relations with five small ganglia; three beloAV it—the corpus mamillare, red nucleus, and subthalamus; two postero-external to it, the geniculate bodies. To these may be added the corpora quadrigemina. The thala- mus is composed of multipolar nerve cells rather more numerous and larger than in the striatum, but not grouped closely together. Nerve fibres pass in among these cells, Avhich are said (Marchi) to be of the motor type (Figs. 145, 146). The Corpora' Quadrigemina.—The mid-brain contains as its chief ganglia the corpora quadrigemina. These consist of four tu- bercles, two anterior and tAvo posterior (Fig. 145). In man they are rudimentary in structure and relatively unimportant in func- tion. In man also the posterior tubercles are deA'eloped more rela- tively than in most lower animals. They together measure about 14 mm. (| in.) in sagittal direction. In front lies the pineal gland and third Aentricle; beneath is the aqueduct of Sylvius and the ANATOMY AND PHYSIOLOGY OF THE BRAIN. 301 structures of the upper pons and cerebral peduncles. This inferior boundary is shown by the dotted line in the cut (Fig. 147). Micro- Fig. 147.—Section Through the Corpora Quadrigemina (Q), Tegmentum (TG), and Cerebral Peduncles. SS, Substantia nigra; Pp, peduncles; AS, aqueduct of Sylvius. scopically the anterior lobes consist of layers suggesting a cortical type (Spitzka); the outermost is made up of optic-tract fibres, the next is a thin layer of small nerve cells, then optic fibres again, Fig. 148.—Longitudinal Section, showing the lenticular (In) and caudate nucfta (cri) separated by the internal capsule (ic), the corpus callosum (cc), the anterior commissure (ac), the optic tract (II.), the optic thalamus (tK), the corpora genicu- lata (g), and the pulvinar (p), the crusta (cr), the tegmentum (tg), pons (P), and cerebellum (C); p, putamen ; g, globus pallodus (G. Stewart). and deepest of all a layer containing a few large cells. The pos- terior lobes are more homogeneous and contain small multipolar cells and a ganglion. 302 DISEASES OF THE NERVOUS SYSTEM. The accompanying figures show the relationships of the basal ganglia and other parts. The Substantia Nigra.—Below the corpora quadrigemina and lying between the upper, sensory part (tegmentum) of the pedun- cles of the brain and the lower motor part [crusta) is the sub- stantia nigra. It contains large multipolar, angular, and fusiform cells deeply pigmented (Fig. 147). The Red Nucleus.—Dorsal to the s. nigra and at about its Fig. 149.—Horizontal Section, showing the frontal (F), temporo-sphenoidal (TS), and occipital lobes (O), with their gray and white matter, the island of Reil (R), its gray and white substance, the claustrum (cl), the external capsule (ec), the lenticu- lar nucleus (to), the caudate nucleus (en), the internal capsule (ic), the optic thalamus (th), and pulvinar (p), the corpus callosum (cc), the anterior and posterior commis- sures (ac and pc), the lateral ventricle (LV), with the choroid plexus (ch) (G. Stewart). middle extent is the red nucleus. It is spherical or oblong, very vascular, and contains numerous small cells. The subthalamic (Luy's body) lies more dorsally, but in about the same plane as the substantia nigra. It measures about \ by i inch and contains a few cells and a very fine plexus of nerve fibres. The position and relation of these bodies are shown in Figs. 156-158. The nuclei of the pons varolii are irregularly distributed ANATOMY AND PHYSIOLOGY OF THE BRAIN. 303 masses of nerve cells lying deep among the longitudinal and transverse fibres. A special nucleus lying low down in the pons is known as the superior olive. In the after-brain or medulla we have the gray matter of the floor of the fourth ventricle and its cranial nerve nuclei, the olivary bodies, and certain small de- posits of gray matter called the nodal nuclei. The cerebellum in man consists of a median portion or vermis and two lateral hemispheres. It is connected to the cord and rest of the brain by anterior, middle, and posterior peduncles. It is composed of an external layer or cortex of gray matter, of white matter, and central ganglia. The gray matter lies in A^ery close, narrow folds, producing with the white matter an appear- Fig. 150.—Section Through the Middle op the Basal Ganglia, Pr.ecentral (AF) and Part op Post-Central (AP) Convolutions, and (TS) Temporal Lobe. It shows the corpus callosum (cc), the fornix (6), the fifth ventricle (Y), lateral ven- tricles (LV), small part of thalamus (th), internal capsule (ic), caudate nucleus (ch), lenticular nucleus (In), external capsule (ee), claustrum (cl) (G. Stewart). ance on section called the arbor vita;. The vermis and hemi- spheres are divided by sulci into a number of lobes and lobules. The vermis is divided into superior and inferior portions. Its further subdivisions and those of the hemispheres are shoAvn in ihe cuts (Figs. 151, 152). In the white matter of either hemisphere is a nucleus of small multipolar cells, the corpus dentatus or ciliary body. To the median side of this, and belonging structurally to it, is a small nucleus, the emboliform nucleus. In the inferior vermis is a collection of larger multipolar cells, the nucleus fastigium or tegmental nucleus; just to the outer side, between it and the emboliform nucleus, is a small collection of cells, resembling those of the n. fastigii, called the nucleus globosus. The cortex of the cerebellum is divided from within out into 304 DISEASES OF THE NERVOUS SYSTEM. a granular layer, a layer of large cells, and a molecular layer. The granular layer is composed of minute round cells and larger or Purkinje cells with processes. The cells are all of nervous character; possibly some belong to the neuroglia tissue. They Fig. 151.—Showing the Lobes and Other Subdivisions of the Cerebellum, Dorsal Surface (Edinger). send up processes into the molecular layer, and some end in a network around the Purkinje cell. The large or Purkinje cells (20 x 30 (j) have very rich branching processes running up into the molecular layer as far as the periphery, where they turn doAvn, and an axis-cylinder process running down into the Avhite matter. The processes do not anastomose and the cells Fig. 152.—Cerebellum, Ventral Surface (Edinger). are not pigmented. The molecular layer contains large and small cells, some of which are multipolar, and send processes which end in a basket-work plexus around the Purkinje cells. Fibres coming in from the Avhite matter appear to terminate also in end-brushes around these cells (Fig. 154—Cajal). The fibres of ANATOMY AND PHYSIOLOGY OF THE BRAIN. 305 the cortex are, as in the cerebrum, radiating and tangential. The tangential fibres are at the level of the Purkinje cells, among the processes of which they run. Just beneath the pia is a thin connective or neuroglia tissue membrane which sends radial fibres down through the gray matter, affording it a support. It will be seen that the general arrangement of the cerebellar cortex is analogous to that of the cerebrum. Associative and re- ceptive cells are found in the granular and molecular layers, and they send processes forming a rich network around Purkinje's cells which are efferent in function. The comparatively small number of the large cells is in harmony with the view that the cerebellum is an organ that receives and adjusts nerve impulses for co-ordinate distribution. All parts of the cerebellar cortex are anatomically alike. Fig. 153. Fig. 154. Fig. 153.—Section Through Middle op Vermis and Pons. Fig. 154.—Cerebellar Cortex op Embryo. D, Purkinje's cell; G, granule cell receiving a fibre and sending an end-brush or arborization to the Purkinje's cell (Cajal). The white matter of the cerebellum consists of nerve fibres some of which go to form the peduncles. Others form anterior and posterior commissures running through the two extremities of the vermis and connecting the hemispheres. There is also a longitudinal commissure in the vermis. The white matter around the corpus dentatum is called the fleece. Having described the general arrangement of the different divisions of the brain and the collections of gray matter found in them, we are prepared to study the tracts of white matter which connect the different parts. The white matter, as already shown, is made up of: ( Short, 1. Association fibres. •] Long. ( Commissural. 2. Projection fibres. 20 306 DISEASES OF THE NERVOUS SYSTEM. 1. The association fibres of the cortex have been already de- scribed. Besides these, there are association fibres connecting different ganglia of lower leA'els. They are named . Vicq d'A/.yrs bundle, the fasciculus retroflexus or Meynert's bundle, the teg- mental bundle, the brachia of the corpora quadrigemina and the posterior commissure. These maybe called ganglionic associa- tion tracts. Some of these will be described later and indicated in the figures. Commissural association fibres connect similar and symmetri- cal anatomical levels. They are the corpus callosum, the anterior Fig. 155.—Sections op Cortex op Same, but Older. A, Neuroglia layer ; B, zone of bipolar cells; C, molecular layer; D, granular layer; e,f,g, bipolar cells of molecular layer; j, o, y, n, fibres from the white matter which end in end-brushes or arboriza- tions capping the cells of Purkinje ; h, Purkinje cell with axis cylinder and collateral. and middle commissures, the fornix, and the anterior and pos- terior cerebellar commissures. 2. The projection fibres are long tracts which connect higher with lower levels. Some of them haA-e a long and some an inter- rupted course. The long projection fibres extend from the fron- tal and parietal cortex doAvn into the spinal cord. They pass as a narrow band of fibres between the lenticular nucleus and the caudate nucleus, helping to form the internal cajisnle; thence into the loAver part of the cerebral peduncle, forming the crusta; thence through the pons and medulla. At the lower part of the medulla they form the anterior pyramids. About 90 per cent of the pyr- amids crosses over and passes down in the lateral columns as the crossed pyramidal tract; the other ten are continued down in ANATOMY AND PHYSIOLOGY OF THE BRAIN. 307 the anterior column as the direct pyramidal tract. Its fibres cross OA-er in the anterior commissure. Both tracts connect Avith the cells of the anterior horns. The entire traject of fibres from the cortex cerebri to the anterior horns forms the voluntary motor tract. The interrupted projection fibres consist of the sensory tracts and the cerebro-pontine tracts. The sensory tracts starting from the brain cortex in part connect Avith the thalamus, in part pass directly through the posterior portion of the internal capsule, then through the upper part of the cerebral peduncles, forming there the tegmentum, and thence through the pons and medulla as the lemniscus and formatio reticularis. In the medulla some fibres cross over, forming a " sensory decussation," and end in the nuclei of the columns of G-oll and Burdach; others run in the formatio reticularis, pass down in the posterior and lateral columns, cross \^C. Goll. C. £urclacJz. -J? C. Tract Fig. 156.—A, Connections of spinal cord with pons and medulla ; N, nodal nuclei; O, olivary body ; PN, pons nuclei ; L, lemniscus ; 3 to 12, cranial nuclei: x, decussa- tion ; ST, Sensory tracts ; AFC, anterior fundamental columns ; LFC, lateral fund. cols.; DC, direct cerebellar tract. over at various levels, and connect with cells of the posterior horns. The cerebro-pontine tracts are described under Fig. 158. Architecture of the Brain.—The relations of the ganglionic deposits of the brain with the cord and Avith each other cannot be described in any brief way. But by the aid of the accom- panying diagrams the student can, after some study of ordinary descriptive anatomy, get an idea of the architecture of these parts. It is best to begin from below with the spinal cord, and show first the relations of its different columns to the medulla and pons varolii. In Fig. 15G it will be seen that only the anterior and lateral fundamental columns of the cord are connected Avith the gray matter of the medulla and pons. The motor and sensory tracts pass through it uninterrupted. The antero-lateral fundamental columns connect with Ararious deposits of gray matter in the me- dulla and pons which are called nodal nuclei. These in turn are connected with the cerebellum and pyramidal and sensory tracts. There is a long band of fibres in the medulla and pons called the 308 DISEASES OF THE NERVOUS SYSTEM. posterior longitudinal bundle. It is an analogue of the anterior fundamental column of the cord and connects the cranial nuclei. It is connected above Avith the basal ganglia. Fig. 157 shows the relations of the spinal cord to the cerebrum and cerebellum. The pyramidal tracts, having mostly crossed in the lower medulla, go straight up through the internal capsule to the motor area of the cortex. Fig. 157.—Connections op Spinal Cord with Cerebrum and Cerebellum. Motor tracts go straight to cerebral cortex. Postero-internal and part of postero- external (sensory) tracts go to their nuclei, then to the cerebellum in part, to optic thalamus (and corpora quadrigemina ?) and lenticular nucleus and cerebral cortex. The antero-lateral ascending tracts go via formatio reticularis to optic thalamus and cortex. The direct cerebellar tract to vermis and then via anterior cerebral peduncle to opposite red nucleus and thalamus. The anterior fundamental and lateral funda- mental columns to pons and nodal nuclei and to cerebellum, ANATOMY AND PHYSIOLOGY OF THE BRAIN. 309 The sensory tracts cross in part, while part have crossed al- ready in the cord. They go up, forming the inter-olivary tract, then the lemniscus or fillet. In part then they enter the dorsal portion or tegmentum of the cerebral peduncle, pass through the posterior part of the internal capsule to the motor area of the cortex and parietal lobe. Some fibres enter first the basal ganglia. The cord is connected Avith the cerebellum by the direct cere- bellar tracts, the posterior columns, and antero-lateral funda- mental columns. All these columns carry afferent impulses ex- cept those of the antero-lateral tracts, Avhich are made up of asso- ciative fibres. Fig. 158.—Connections of Medulla-Pons-Cerebellum with Higher Parts. Nuclei of columns of Goll and Burdach with optic thalamus, lenticular nuclei, and cerebral cortex. Olivary body, with lenticular nuclei and cortex. Pons nuclei with frontal and occipito-temporal cortex. Cerebellum, via middle peduncles, to pons nuclei and so to cerebrum. Cerebellum, via anterior cerebral peduncles, to red nucleus, optic thalamus (and corpora striata and brain cortex?), acusticus and tri- geminus, posterior corpora quadrigemina. In general, the spinal cord is connected with the vermis and fibres surrounding the dentate nuclei, the pons and medulla are connected Avith the cortex cerebelli and vermis, while the ante- rior peduncles arise chiefly from the dentate nucleus. (Marchi gives other relations.) The connections of the pons, medulla, and cerebellum are shown in Fig. 158. The olivary body is connected Avith the cerebellum on the one hand and to the lenticular nucleus and cortex on the other. It is not connected Avith the cord. Impulses pass from the cerebellum to the olives, thence up to the brain. Nuclei in the pons are connected Avith the cortex of the cerebellum and "with fibres running in the ventral part of the cerebral peduncle 310 DISEASES OF THE NERVOUS SYSTE.M. on either side of the pyramidal tract, to the frontal and temporal and probably occipital lobes, and island of Reil. The nuclei of the acoustic, glosso-pharyngeal, and vagus, perhaps other sensory nerves, are connected Avith the cerebellum by a " direct sensory tract" which goes to the nuclei of the cerebellum. The nodal nuclei are connected, as has been stated, with the cerebellum. Fig. 159 shows the relations of the optic thalamus and cor- pora quadrigemina to other parts. The corpora quadrigemina, by the posterior tubercles, are connected to the cerebellum and acoustic nerve, internal geniculate body and temporal lobes; by the anterior tubercles to the lemniscus and spinal cord, the Fig. 159.—Connections op Corpora Quadrigemina and Optic Thalamus with Other Parts. OT, Optic thalamus ; CQ. corpora quadrigemina ; RN, red nucleus ; S, Luys' body, or subthalamus ; SX, substantia nigra ; OX, optic nerve ; AN, acous- tic nerve ; L, lemniscus ; SO, superior olive. optic nerve and optic thalamus, external geniculate body and occipital lobes. The thalamus is connected to the spinal cord by the lemniscus, to the medulla and cranial nerves by the posterior commissure, to the optic nerve and external geniculate body, to the cortex of the frontal, parietal, occipital, and temporal lobes, to the corpora mamillaria and fornix, and to the subthalamus and lenticular nucleus. All its connections cannot be shown or described; but it is the most richly connected ganglion of the brain. Fig. 160 shows the relations of the corpus striatum to the other parts. It is connected with the spinal cord by the lemniscus(?), with the red nucleus,.subthalamus and thalamus, Avith the substantia ANATOMY AND PHYSIOLOGY OF THE BRAIN. 311 nigra, pons nuclei, and olives. Its connections with the brain cortex are slight and those with the motor tract doubtful. The corpus striatum seems to haA-e its closest relations with the cere- bellum, partly through the red nucleus, partly through the nuclei of the pons. The 3Iembranes of the Brain.—The membranes of the brain are the dura mater, the arachnoid, and pia mater. The dura mater lines the inner surface of the skull. It is attached loosely to the concaA-ity, but closely to the base. It splits into two layers to form the venous sinuses of the skull. The inner of the two layers at certain points projects imvard to form membranous Fig. 160.—Connections of the Corpus Striatum with Other Parts. septa. These are known as the great longitudinal or cerebral falx, the lesser longitudinal or cerebellar falx, and the tentorium. Hence both ATenous sinuses and membranous septa are formed out of the inner layer. The outer layer forms the periosteum of the bone. The dura mater is supplied with sensory nerves chiefly by the trigeminus, but posteriorly by the Aragus. The blood sup- ply will be described later. The arachnoid is a thin, transparent, fibrous, non-vascular membrane lying betAveen the pia and dura and continuous with the spinal arachnoid. It bridges over the fissures and the de- pressions at the base of the brain and forms betAveen the pia and itself certain lacunar or spaces. These are the central lacuna found at the beginning of the fissure of Sylvius, the callosal and those of the transverse fissures, and of the lateral aspect of the 312 DISEASES OF THE NERVOUS SYSTEM. pons varolii. The space between the dura and arachnoid is called the subdural or arachnoid cavity. It is lined Avith epithe- lium and resembles other serous caAities. The inner surface of the arachnoid is connected Avith the pia by numerous delicate fibrous processes. The space betAveen these membranes is called the subarachnoid space. It communicates with the subdural space by means of the foramen of Magendie, Avhich lies in the part of the arachnoid that passes OATer the pons and medulla, closing in the fourth Arentricle. The subdural and subarachnoid spaces contain a serous fluid. The normal amount ranges from tA\o drachms to tAvo ounces, it being greater in old people. The arachnoid contains no nerves or blood-vessels. It is described by some as a part of the pia mater. The pia mater lies beneath the arachnoid and is closely applied to the brain in all its folds. It is continuous with the spinal pia. It is very Avascular and supplies the Avhole periphery and part of the interior of the brain Avith blood. It consists of tAvo layers: an outer holding the larger Aessels, and an inner delicate layer closely associated Avith the superficial neuroglia of the brain. The pia mater folds upon itself and passes through the trans- Aerse fissure into the third and lateral ventricles of the brain. These Avascular folds form the velum interpositum, which gives off a choroid plexus to the lateral and third A^entricles. Another fold, the inferior choroid plexus, is given off to the fourth Aentri- cle. The pia mater has Aasomotor, but no sensory nerves. Functions of the Brain Membrane.—The dura mater, by its outer layer, acts as a periosteum; by its inner layer as a lymph sac. It is also, by virtue of its sensitiveness, a protection against injury and disease. The arachnoid forms the inner wall of the lymph sac. The pia mater is a vascular and nutritive organ. It is, howe\*er, also closely connected Avith the lymphatic system of the arachnoid. The blood supply and lymph supply of the brain \Tary in amount. In congestion the lymph can pass into the spinal canal or be rapidly taken up by the absorbents. In anaemia there may be compensatory increase of lymph. This fluid in dis- ease may accumulate in the arachnoid sac, the subarachnoid space, or the ATentricles, these spaces being all in communication with each other. The Blood Supply of the Brain axd its Membranes. —The Arascular supply of the scalp, skull, and dura mater comes from the external carotids; that of the eye, brain, and pia mater from the internal carotids and Arertebrals. The arrangement is ' Occipital, inferior meningeal, arteries. Posterior auricular. ( Anterior. - Temporal < Middle. (Posterior. Ascending pharyngeal, posterior meningeal. Internal maxillary, middle meningeal, small L meningeal. 'Anterior meningeal. Anterior cerebral. - Middle cerebral. Posterior communicating. Anterior choroid. shown here: External carotid gi\'es off Internal carotid gives off ANATOMY AND PHYSIOLOGY OF THE BRAIN. 313 Vertebral and basilar give off f | Posterior meningeal. | "j Inferior cerebellar. ■{ Anterior cerebellar. j Superior cerebellar. [Posterior cerebral. The general arrangement and distribution of the arteries of the scalp and dura is shown in the accompanying diagram (Fig. 161). Fig. 161.—Showing the Blood Supply op the Scalp and that op the Dura Mater by the Middle Meningeal. The blood supply of the meninges comes from the anterior middle and posterior meningeal arteries. These all come, except the small anterior meningeal branches and a small posterior branch, from the external carotid. The blood passes into the diploic veins, and from there passes chiefly into the lower occipi- tal and lateral sinuses. Some of it, howeA-er, returns in the venge comites. It all returns down toward the base of the skull. The most important of the arteries is the middle meningeal, both on account of its size and its distribution above important func- tional areas. The blood supply to the pia mater and brain substance comes 31-t DISEASES OF THE NERVOUS SYSTEM. from the internal carotid and the vertebral arteries. The branches of the former artery gi\'e off the anterior and middle cerebral, the posterior communicating, and anterior choroid. The vertebral arteries give off the inferior cerebellar, while the basilar branch of the vertebrals gives off the transverse, anterior cerebellar, superior cerebellar, and posterior cerebral arteries Fig. 162.—Showing the Arteries at the Base op the Brain. On the right side the brain is cut away, showing the cerebral arteries and the course of the pos- terior cerebral. The cerebral arteries, anterior, middle, and posterior, are the three largest and most important. By their anastomoses the circle of Willis is formed. From the circle of Willis and the beginnings of the three arteries mentioned, several groups of vessels, six in all, are given off. They enter the base of the brain ANATOMY AND PHYSIOLOGY OF THE BRAIN. 315 and supply the great basal ganglia and adjacent white matter. They are called the central arteries, and they are the A-essels usually affected in cerebral hemorrhages of adult life. They do not anastomose Avith each other. The cortical arteries are the terminal branches of the great cerebral arteries. They anasto- mose Avith each other but slightly. They are distributed very widely and carry much more blood than the central groups. Their distribution is shown in Fig. 163. The cortical arteries are distributed in the pia, and from there they pass in two sets, a superficial and a deep, into the gray matter, and for a short distance into the Avhite matter. They pass straight in at right angles to the surface. They haATe richly arborescent branches which do not anastomose; consequently a knife plunged straight into the brain does not cut many A'essels. The cortical arteries Fig. 163.—Showing the Distribution op the Artery of the Sylvian Fissure, a Prolongation of the Middle Cerebral. The area in front of the shaded part is supplied by the anterior cerebral, that behind by the posterior cerebral. probably anastomose somewhat Avith each other, though not very freely. There is slight if any anastomosis betAveen the cortical and central arteries. The pressure is thought to be less in the A'essels of the gray matter. The capillaries are surrounded by spaces called perivascular spaces Avhich serATe as lymphatic channels. The neuroglia cells send processes which connect Avith or form passages to the ATessel walls (Fig. 164). The blood of the convex and mesial cerebral surface, flowing up from the base, leaAres the capillaries and enters A-eins. Thence it still passes upward, and for the most part enters the longitu- dinal sinus. The most of the ATessels enter the posterior portion of the sinus and in a direction forward and upward, i.e., against the current in the sinus. The course of the blood current is, therefore, opposed both to graAgitation and to the A^enous flow. 316 DISEASES OF THE NERVOUS SYSTEM. The veins of the cerebrum are: 1, the superficial cerebral; 2, the deep cerebral veins; and, o, the cerebral sinuses. The superficial cerebral veins are venie comites. Those on the convex and mesial surfaces empty chiefly into the superior longitudinal sinus, as described; those on the basal surface empty into the cavernous and lateral sinuses. These \Teins have no valves, and their Avails are very thin and Avithout muscular fibres. The deep cerebral veins, or ATenae Galeni, receive the blood from the lateral ventricles and from some of the central arteries supplying the basal ganglia. They empty into the straight sinus. The cerebral sinuses are fifteen in number. The important ones are the superior and inferior longitudinal, the straight, the lateral, the occipital, the cavernous, and the superior and inferior Fig. 164.—Showing the Neuroglia Cells of the Brain, their Relation to the Blood-Vessels ; also the Sustentacular Processes of the Epithelial Cells of the Lateral A'entricle (Marchi). A, Epithelial cells lining lateral ventricle ; a, process of same ; b, spider or neuroglia cell; c, blood-vessel. petrosal. They carry blood for the most part in a direction from before backward, and conArey it eventually to the internal jugular. Most of the blood of the convexity and mesial surface must pass into the longitudinal sinus, but there is a slight connection of some of the veins with the superior petrosal and straight si- nuses. The superior longitudinal sinus also communicates slightly with veins of the scalp and with the facial vein. Some of the blood from the mesial surface also goes to the veins of Galen. On the whole, however, the system of the convex and mesial cerebral surface is a close corporation, the blood haA-ing to pass into the superior longitudinal sinus and torcular Herophili, where ANATOMY AND PHYSIOLOGY OF THE BRAIN. 317 it meets that of the straight and occipital sinuses, and flows for- ward through the lateral sinuses to the internal jugular. The circulation of the basal surface is less isolated. All the basal si- nuses communicate with each other freely, and there are slight communications between the ATeihs of the scalp and the cavernous, lateral, and inferior petrosal sinuses. It is safe to tie any of the sinuses, except the lateral and the posterior part of the longitu- dinal. The cerebellar veins, superior, inferior, and lateral, empty into the straight, the lateral, and superior petrosal sinuses. None of the cerebral veins or sinuses have valves. The pressure in the internal carotid arteries is about 150 mm., that in the cerebral sinuses 70 to 80 mm. (Gerhardt), and that in the jugular Aeins is almost negative. Both arteries and veins are more delicate than the extra-cerebral vessels. Except its gray matter, the brain is not a very vascular organ, but this gray tissue ranks in richness of blood supply with the lungs and liver. The amount of blood in the brain at any one time is only about one to two per cent of the total blood in the circulation, or about four ounces (Ranke). The diameter of the common carotids is 6.7 mm. (Thorne), that of the subclavians 6.2 mm., that of the internal carotids 4 mm., and that of the vertebrals 3.5 mm. (Gerhardt).* The Functions of the Brain—Cerebral Localization. ■—The brain is the seat of conscious intelligence and mental activ- ity. It has also control and direction of voluntary movements, it is the seat of instinctive acts, and it regulates in a measure the vasomotor, trophic, and secretory mechanisms of the body. The Prefrontal Lobes.—The prefrontal lobes, or that part of the brain in front of the prgecentral convolution, are concerned Avith volition and the power of self-control, concentration of thought and attention. The posterior part contains centres for the movements of the head and eyes. Injuries in this part of the brain produce changes of character, indicated by peevishness and irritability of temper, mental enfeeblement, lack of power to con- centrate the mind or to control the acts or emotions. The Central Convolutions, Paracentral and Upper Parietal Lobules.—This part of the brain is called the motor area, because it is concerned in the production of nervous impulses which cause voluntary motions of the body. Certain parts of this area are in relation with certain groups of voluntary muscles on the oppo- site side of the body. These areas preside not so much over sin- gle muscles as over those groups of muscles which act together in producing definite purposeful acts. The lower part of the central convolutions, known as the central operculum, is a centre for movements of the larynx, mouth, tongue, and face. Abo\re this area and about the middle third of the central convolutions is the centre for the movements of the shoulder, arm, hand, and fingers. Still farther up, near the longitudinal fissure, and extend- * J. Crichton Brown gives the last two diameters 2.8 and 2.2 mm. respectively. 318 DISEASES OF THE NERVOUS SYSTEM. ing OATer into the mesial surface and back into the superior parie- tal lobule, is the area for the trunk, hips, legs, feet, and toes. The base of the first and second frontal convolutions is the centre for movements of the head and eyes. The exact arrangement of these centres, Avhich have been determined by experiments upon monkeys and other loAver animals as Avell as by clinical and sur- gical observations on man, is shown in the accompanying dia- grams. Probably the motor area is also the centre for the cuta- neous sensations of the parts corresponding to the muscular groups which it supplies, so that Avhat is called the motor is really a sensori-motor area. The motor area, when irritated by disease, Fig. 1C5.—The Cortical Centres. produces paresthesia and convulsive movements in the groups of muscles which it represents. Destruction of it causes not only a paralysis, but a certain amount of cutaneous anesthesia. The various sensori-motor centres are not sharply limited, but lap one over the other, so that the motor area for the forearm, for example, extends over somewhat into that for the shoulder. The corresponding sensory areas are still more diffuse, so that it takes a much more extensive destruction of a certain area of the motor cortex to produce an anesthesia of the arm than it does to produce a paralysis of the arm (Figs. 165, 166). Bilateral Representation.—Those muscles of the tAvo sides of the body which act together have a double representation in the brain. For example, each group of muscles used in inspiration ANATOMY AND PHYSIOLOGY OF THE BRAIN. 319 has a centre in both hemispheres; consequently, when one centre is destroyed no paralysis results, for the reason that the other centre continues its work. In the same Avay some of the muscles of the face, such as those for closing the eyes, have a double rep- resentation, and a lesion destroying the centre for the orbicularis palpebrarum on one side will not usually cause paralysis, because of the continued action of the centre of the other side. The more perfect and habitual the associated action of the muscles of the two sides of the body, the more completely can one centre do the work of its associate. The best examples of the mus- cles haAdng the double representation are the orbicularis palpe- brarum, the muscles of the vocal cords, the muscles concerned in Fig. 166.—The Cortical Centres. deglutition and in respiration. The muscles of the viscera and blood-vessels haA'e no knoAvn representation in the cortex of the human brain. The special sensations have a bilateral representation also; but the more specialized the sense, the less can one hemisphere take the place of the other. Occipital, Parietal, and Temporal Lobes—Centres of Special Sense.—The special senses have two centres—the primary and the secondary. The primary centres are connected with the ganglia at the base of the brain; the secondary centres are situated in the cortex. The primary centre for vision is in the posterior part of the optic thalamus, the external geniculate body, and anterior cor- pora quadrigemina. The secondary centre is situated in the occipital lobe, and particularly upon its mesial surface and in that part known as the cuneus. Each occipital lobe is the centre 320 DISEASES OF THE NERVOUS SYSTEM. for visual impulses from the corresponding half of the retina of each eye; for example, the left occipital lobe is the centre for vision of the left half of the retina of each eye. This relation is shown in the diagram (see Optic Nerve). Total destruction of both occipital lobes, or even of a considerable part of them if the de- struction involves the median surface, Avill cause blindness. De- struction of one lobe causes only half-blindness or hemianopsia. The primary centre for hearing is in the posterior tubercle of the corpora quadrigemina and the internal geniculate body. The secondary centre is in the cortex of the first and second conAro- lutions of the temporal lobe. Destruction of one temporal lobe causes deafness in the opposite ear. This deafness, howeArer, is not complete because the sense of hearing has a bilateral repre- sentation; each ear, in other words, sends fibres to the temporal lobes of each side, although more fibres cross over than go to the lobe of the corresponding side. The consequence is that the loss of one temporal lobe is in a measure supplied by the other (vide Aphasia). The primary centre for smell is in the olfactory lobes. The secondary centre is probably in the uncus and in part of the hippoeampal conATolution. Whether the tracts for the sense of smell are connected Avith the optic thalamus or other ganglia is not definitely known. The primary centre for taste is not knoAvn, but sensations of taste may connect with the optic thalamus before passing into the secondary centre, which is in the hippoeampal convolution. Centres for Memories.—There are certain classes of sensations and perceptions, simple in character and frequently repeated, so that they finally get to be used almost automatically in their Avork. These impressions relate to the use of the muscles in speech, in writing, and in gesture language, also to other fre- quently repeated purposeful movements of the limbs. The mus- cular movements in Avriting and speaking are so often repeated that certain areas in the cortex are set apart for the memories of these processes. The visual sensations and ideas elaborated from them, which are frequently repeated in learning to read, have also a centre Avhich is set apart for them. This forms a centre for the A'isual memories of language. In the same way there are audi- tory sensations and ideas elaborated and so frequently repeated as to be used automatically in acquiring language. These are stored up as auditory memories. We have what may be called motor memories connected Avith speech and gesture. These spe- cial memories have been found to haA-e a certain localization in the brain. The centre for the memories of the articular move- ments of speech is in the posterior part of the third left frontal convolution; the centre for the memories of the movements of ANATOMY AND PHYSIOLOGY OF THE BRAIN. 321 writing is not perfectly well known, but is thought to be at the posterior part of the second left frontal convolution. The centre for the memories of gesture language is unknown. The centre for the memories of ordinary co-ordinate movements is perhaps in the inferior parietal lobule. The centre for the visual mem- ories of Avritten language is in the angular gyrus, extending back- ward from there into the occipital lobe. The centre for the audi- tory memories of spoken language is in the posterior part of the first and the corresponding upper part of the second temporal convolution. In right-handed people all the memory centres are in the left cerebral hemisphere; in left-handed people they are in the right hemisphere. The destruction of these memory centres produces different forms of aphasia, as will be described later. In addition to that, disturbances in these centres are produced by lesions which cut off the associating fibres connecting these centres with each other or with motor or sensory centres proper. The Centrum Ovale, Corpus Callosum, and the Associative Functions of the Brain.—The different parts and centres of the brain are connected together by the associating tracts and with loAver levels by the projection fibres. The simpler and less devel- oped centres of the two hah'es of the brain are closely connected by fibres that run chiefly in the corpus callosum. The more highly specialized and less simple in function a centre, the less close is its commissural connection and the more independent is one-half of the brain from the other. Thus the centres for the movements of the thorax in respiration are closely bound with each other; those for the purposeful movements of the hands less so; those for receiving visual impressions are almost independent; and the centres for the memories, Avhich are still more highly specialized, are practically entirely independent. We infer that the higher mental functions, therefore, work either in one cere- bral hemisphere or in the other, and that the two halves of the brain do not co-operate with each other in much of the higher intellectual Avork. The corpus callosum is the great commissural tract connect- ing the two cerebral hemispheres and their respective centres. The anterior commissure does some of the same work, being more specially connected with the function of olfaction. The posterior commissure has comparatiArely feAV bilateral connecting fibres, its function being more to connect the thalamus with the cranial nerve nuclei and other centres below. The Corpus Striatum.—This ganglion is in close relation with the cerebellum and with nuclei in the pons. It is also in connec- tion Avith fibres that come up from the muscle-sense tract, in the spinal cord. Its functions are therefore probably connected Avith securing co-ordinate and purposeful movements. Destruc- 21 322 DISEASES OF THE NERVOUS SYSTEM. tion, howe\Ter, of this ganglion in the human brain produces no definite symptoms, and local lesions of it cannot be diagnosti- cated. It is therefore called clinically a latent region. The Thalamus Opticus.—The thalamus is in relation by its projection fibres with the frontal, parietal, occipital, and tem- poral cortex. The fibres that go to the occipital cortex are con- nected with the optic tract, and have to do Avith the function of vision. The fibres that go to the temporal lobe are connected with the auditory tract, and have to do with the function of hear- ing. The optic thalami seem to have some relation to the ex- pression of emotions. In cerebral paralyses in Avhich they are involved, the patient cannot involuntarily express joy, grief, etc. Lesions of the posterior part of the thalamus will produce par- tial blindness. Other than this, lesions of the optic thalamus produce no definite symptoms Avhich enable us to make a local diagnosis. Disturbances of hearing haAre not certainly been traced to lesions in the thalamus. It is thought to be a primary centre for sensations of touch, muscular sense, and perhaps for smell and taste, but no definite facts in human pathology haA^e as yet satisfactorily proved this. Lesions of the thalamus some- times produce various forms of mobile spasm, but these are gen- erally attributed to irritation of the fibres of the internal capsule, Avhich go close to it. Hence, aside from disturbances of Aision, the optic thalamus also must be considered clinically a latent region. The Corpora Quadrigemina.—The anterior tubercles of the corpora quadrigemina, together with the external geniculate bodies, form part of the primary centres of vision. The anterior tubercles, howeATer, have more to do with reflex movements of the pupil and ciliary muscles than Avith the actual ATisual func- tion. The posterior tubercles of the corpora quadrigemina and the internal geniculate body are thought to be connected Avith the auditory nerve. They also appear to receive some fibres from the cerebellum; hence their injury or disease produces some dis- turbances in equilibrium and possibly in hearing. Owing to the fact that the nuclei of the third nerA'es and the red nuclei lie be- neath the corpora quadrigemina, lesions of these latter produce irritations and paralyses of the third nerve, disturbances in equi- librium and forced movements. Lesions in this neighborhood sometimes cause somnolent and stuporous states. The red nuclei are connected with the anterior cerebellar peduncles on the one hand and with the lenticular nucleus and optic thalamus on the other, and are concerned in securing equi- librium and the adjustment of the body in space. The Cerebellum.—The cerebellum is connected with the pons, the cerebrum, and spinal cord. It sends impulses through the ANATOMY AND PHYSIOLOGY OF THE BRAIN. middle peduncles to the gray matter in the pons, and thence down into the antero-lateral columns of the cord. It sends im- pulses to the olivary bodies, and thence up to the great ganglia at the base of the brain, and finally it sends impulses through the anterior peduncles, which cross over, enter the red nuclei, and connect with the thalamus, corpora striata, and perhaps with the cortex of the parietal lobe. It receives impulses from the cortex of the frontal, parietal, occipital, and temporal lobes, which go doAvn into the pons, connect with nuclei there, and thence pass up into its hemispheres. It also receives impulses from the spinal cord, through the posterior peduncles. There is therefore a nervous circuit between the cerebrum, brain axis, and cere- bellum . impulses pass down from the cerebral cortex to the pons, thence to the cerebellum; and other impulses pass up from the basal cord to the cerebellum. Having receiATed these impulses, it discharges chiefly along the anterior peduncles into the ba- sal ganglia, which act as its end- organ (Fig. 107). The cerebel- lar influences directly affect the spinal cord but little. The cere- bellum nas undoubtedly poAver of securing purposeful move- ments and of enabling us to keep our equilibrium and maintain our relations in space. The vermis or median lobe is the part which in man is most important in doing this work. Lesions of the lateral lobes or hemispheres produce few direct symptoms, and they are called latent regions. Injuries of the median lobe, however, produce disturbances in equilibrium, forced movements, and a peculiar form of inco-ordination in gait which is known as cerebellar ataxia. Lesions of the middle peduncles produce forced movements also, the forced movements being either toward or aAvay from the side of the lesion, accord- ing as it is an irritating one or a destructive one. The pons varolii contains some of the cranial nerve nuclei and collections of nerve cells Avhich are connected Avith fibres from the cerebral cortex on the one hand and the cerebellum on the other. It also contains the long tracts of nerve fibres that pass from the cerebrum down through into the medulla and spinal cord and transverse tracts of fibres Avhich connect the two hemi- spheres of the cerebellum. Lesions in it cause disturbances in Fig. 167.—Showing the Relations op the Cerebellum to its End-Organs, the Basal Ganglia, and to Other Parts. 324. DISEASES OF THE NERVOUS SYSTEM. function of the cranial nerves and of the motor, sensory, and commissural tracts. The medulla oblongata contains centres of the cranial nerve puclei, and in it also are A'arious reflex and automatic centres con- trolling and regulating the vasomotor system, respiratory and cardiac rhythm, Aisceral movements and secretion. The olivary bodies are connected with the cerebellum and basal ganglia, but not with the spinal cord. Impulses pass to these bodies from the cerebellum, thence up to the brain. When injured, disturbances of equilibrium and co-ordination occur. The Latent Regions of the Brain.—There are certain parts of the cerebral cortex destruction of Avhich and irritation of which produce no special and distinctiA-e phenomena in man. These are the greater part of the temporal lobe of the right side and a portion of the temporal lobe on the left side. A part of the in- ferior parietal lobule also may be regarded as a latent region. The frontal lobe Ave have already spoken of as being concerned with certain mental functions, but lesions here often produce no symptoms, and they may be to a certain extent regarded as latent. The corpora striata, optic thalami, portions of the cen- trum ovale, and the two lateral hemispheres of the cerebellum are latent areas. Brain Weight.—The average weight of the male brain is 1,358 gm.; that of the female, 1,285 gm. The weight A'aries with age, sex, race, and intelligence, and with a number of other factors. The average weight of the brain at birth is 327.8 gm.; the brain grows rapidly until the age of four, then more slowly until the age of seven, then Aery slowly up to the age of sixteen to twenty. At about the age of forty-five in man and fifty in woman it begins to lose weight slowly, and at the age of eighty or OAer it has lost about 120 gm. (4 oz.). The brain of man weighs absolutely about nine per cent more than that of woman. RelatiA'ely to the body Aveight, the brain weight of man is about 2%; that of woman a very little less. The sexual difference is extremely small.* The brain weighs more in the civilized races, and more in cer- tain of the civilized races than others; the brains of English, Ger- man, and Scotch weigh more than those of French, Italian, and Russian. Some of the African and Australian tribes have the smallest brains, the average negro brain weighing 1,250 gm. When a brain Aveighs less than 1,130 gm. in man or 990 gm. in woman, it is called a microcephalic brain; if the weight is above 1,490gm. in man or 1,345 gm. in woman, it is called a megalocephalic brain. Brain weight has a certain relation to intelligence, which is not, hoAveAer, an absolute one. Among a hundred men of more than a Average intelligence, the percentage of large brains would be about 25, whereas the percentage of large brains among persons of ordinary or low intelligence would be not more than 4 or 5. In estimating the importance of brain weight, one must consider the height, the weight or volume of body, muscular mass, and * J. C. Brown finds that after making all allowances, woman's brain weighs about one ounce less than man's. ANATOMY AND PHYSIOLOGY OF THE BRAIN. 325 superficial area; these are called the somatic factors. The fol- lowing formula has been devised by Snell for estimating the mental power of different animals: In this formula P represents the psychical factor or the amount of intelligence, H the brain weight, K the body weight, S the somatic factor. The somatic factor has been estimated to be for mammals about 0.666. Applying this formula, we find that, ex- pressed relatively, the intelligence of man equals 0.87; woman, 0.86; the ape, 0.42; the rabbit, 0.59; the birds, from 0.167 to 0.09. The relative Aveight of different parts of the brain is about as follows: Frontal lobes, 28^; parietal lobes, 36$; occipital, 10$; temporal, 13$; lobus caudicis or island of Beil, 9$; pons, \\%. The cerebellum weighs about one-eighth as much as the cere- brum. The proportion of the gray to the white matter in adults is 60 to 40 (Vierordt). The depth of the primary Assures is not quite an inch (20 to 23 mm.). There are one thousand two hundred to tAvo thousand million cells in the cerebrum, and about ten million large cells in the cerebellum (Meynert). About one million cells to a square centimetre is the estimate of Engel. Preserving and Cutting the Brain. The brain should be placed in a gallon of a 24-per-cent solu- tion of bichromate of potash. This must be changed daily for a week, then twice weekly for a fortnight; then it should remain in the solution for three or four months, a few crystals of thymol being added. After about three months place the brain in 95$ alcohol. In a few days it will be ready for cutting. In cutting the fresh or preserved brain for the purpose of lo- cating gross lesions, remove the pons, medulla, and cerebellum, place the brain on its base, and make sections in accordance with the directions (Fig. 168). The sectional views exposed are shown in the following series of cuts, which are based upon those of Exner. 326 DISEASES OF THE NERVOUS SYSTEM. ABC D E F Fig. 168.—Showing the Points at which the Sections are Made, a, b, Hori- zontal line from base of frontal to base of occipital lobe ; A, vertical section through middle of third frontal convolution ; B, through operculum, o ; C, through superior prrecentral and lower end of Rolandic fissures ; D, through re and posterior end of Sylvian fissure ; E, through angular gyrus and anterior occipital Assure ; F, through parieto-occipital fissure. B should be about half-way between A and C ; E half-way between D and F. (See Figs. 169-174.) Fig. 169.—Section Through Line A, Fig. 168. ANATOMY AND PHYSIOLOGY OF THE BRAIN. 327 Fig. 170.—Section Through Line B, Fig. 168. Fig. 171.—Section Through Line C, Fig. 168. 328 DISEASES OF. THE NERVOUS SYSTEM. Fig. 172.—Section Through Line D, Fig. 168. E Fig. 173.—Section Through Line E, Fig. 168. F Fig. 174.—Section Through Line F, Fig. 168. CHAPTER XVII. DISEASES OF THE BRAIN AND ITS MEMBRANES. General Symptoms. It will add to the intelligibility of descriptions of brain dis- eases and their symptoms if one first makes himself familiar with certain general symptoms that underlie more or less nearly all organic disorders of this organ. Symptoms due to disease of the brain may be placed in four classes: first, general symptoms of brain irritation; second, general symptoms of brain pressure; third, symptoms of focal irritation or destruction; and, last, those due directly to the pathological process itself. The symptoms of brain irritation are headache, vertigo, vom- iting, photophobia, mental irritability, insomnia, peculiar feel- ings of fulness and pressure about the head, noises in the ears or in the head, tenderness about the scalp, and in severe cases con- vulsive symptoms and delirium. The symptoms of brain compression are headache, vomiting, mental hebetude or dulness, perhaps some form of paralysis, con- tracted pupils, and eArentually coma. With this there is often constipation and retracted abdomen. The symptoms of brain irritation are often, perhaps usually, associated Avith a hyperemia. The symptoms of brain compres- sion may be associated with anaemia or oedema, and often in states of malnutrition, where the brain is impoverished, the symptoms resemble much those of compression. Pressure symptoms and irritative symptoms often lap one into the other, and they cannot always be sharply distinguished. Focal symptoms depend almost entirely upon the location of the particular lesion. If it is in a motor area, focal symptoms of irritation would be spasmodic phenomena, such as convulsions. If the lesion were destructive, the symptoms would be those of paralysis or anaesthesia. The symptoms due directly to the pathological process itself may be very slight. Thus in case of a tumor of the brain, the symptoms are mainly caused by pressure, irritation, and local disturbance of certain special parts of the brain. In suppuration, however, the process itself may produce general symptoms su-h 330 DISEASES OF THE nervous system. as are associated usually Avith sepsis—chills, irregular fever, men- tal hebetude, prostration, emaciation, and sweats. Among the symptoms produced by focal lesions there are a few Avhich deserve some preliminary general study because they may be caused by lesions of very different kinds and occur conse- quently in Arery different forms of diseases. Those symptoms Avhich Ave Avish particularly to study here are hemiplegia and aphasia. These represent the two great dominating symptoms pertaining on the one hand to motor disturbance and on the other hand to sensori-motor disturbance. Hemiplegia.—Hemiplegia is a paralysis of one-half of the body, involving the side opposite the lesion. The face, arm, and leg are usually all paralyzed; the arm most, the leg next, the face least. Hemiplegia may be either acute in onset or slow and progres- siA-e. Acute hemiplegia is the result usually of hemorrhages and softenings of the brain, more rarely of inflammations and inju- ries. Progressive hemiplegia begins gradually, as its name im- plies, and slowly increases until the height of the disease is reached. It is usually caused by tumors growing in one side of the brain, but it may be caused by a slowly developing patch of sclerosis, which sclerosis may be in turn only a part of a multiple sclerosis. Further description of the peculiarities of hemiplegia will be given under the head of Special Diseases of the Brain. Aphasia.—Aphasia is a disease of the faculty of language; and it has a number of varieties, in accordance Avith the particular part of the brain involved and the particular portion of the mechanism of this faculty that is destroyed. By the faculty of language we include the processes by Avhich Ave hear, see, and at the same time appreciate the meaning of symbols. It includes also the faculty of expressing to others, by Aoice, writing, or ges- ture, our ideas. It has therefore a receptive side and an emissive side. We may haATe lesions in the brain which destroy that part of the language faculty concerned in our power of seeing and understanding written words or the gesture language. In read- ing understandingly one sees certain words; these words revive certain Adsual memories connected with past perceptions. Thus one sees the word " book;" this suggests to him past memories of form, color, tactile and other sensations associated with the past perceptions of books. There is a certain centre in the brain where these visual memories for letters and words are located. When this centre is destroyed the memories are destroyed, and the word " book" or any other written word conveys no meaning. The patient can spell out the letters, he can see the letters, but he cannot read any more than if he had never been taught. The condition is known as alexia or word-blindness. Again, a person may have learned to associate certain gestures with definite ideas, DISEASES of the brain and ITS membranes. 331 as the motion of carrying a glass to the mouth with that of drink- ing, or the motions of using a knife and fork with that of eating, or the motions of the deaf-and-dumb alphabet with certain words and ideas. These memories of gesture language are located in certain regions; and when they are destroyed the patient is no longer able to understand gestures or the sign language. This condition is knoAvn as apraxia.* Both apraxia and alexia are forms of aphasia which come under the general head of mind- blindness. A person hears certain words, as, for example, the word " knife." This conveys to him a certain idea of the form, color, and other properties associated Avith knife. The memories associated with the auditory perception of different words are stored up in a certain locality which is the centre for auditory memories. When this centre is destroyed the person hears spoken words, but they convey to him no meaning. All that it said to him sounds as if it were in a foreign language: he hears, but he does not understand. This condition is known as word-deafness. So much for the receptive or sensory side of language. In communicating our ideas, we speak, Avrite, and make ges- tures. In speaking we make use of the organs of articulation, and this use involves the fine adjustment of a delicate muscular apparatus. In the act of expressing ideas we have to bring into play the memories of the past muscular movements of this artic- ulator mechanism. These movements were learned by a slow and painful process during infancy. After the poAver of speech is acquired, the mechanism works readily and almost automat- ically because Ave only have to send a stimulus to the centre which presides over the stored-up memories of the impulses to properly innervate the mechanism of speech. There is, there- fore, a centre for the memories of the movements of articulation —a centre which is of course closely connected with the motor areas that directly innervate the larynx, pharynx, and oral and facial muscles. When a lesion destroys this centre for speech memories, a person is unable to reproduce the Avords necessary for expressing an idea; for example, he sees a knife, he knows what it is, but the memory of the motions necessary to express the word " knife " is gone. To him it seems that the name is gone, and that is the common way of expressing it. He cannot say the word " knife.1' The patient may wish to express the idea of pain. He feels the pain, he knoAvs that he has pain, but he cannot re- vive those motor memories Avhich are concerned in expressing the word " pain; " he cannot tell, therefore, in words what is the mat- ter with him. When a person is thus troubled, he is said to have a form of motor aphasia for Avhich the particular name given is aphemia. In the same way there is a centre for the memories of the muscular movements concerned in writing; and when a lesion * Some give this word a broader meaning. 332 DISEASES OF THE NERVOUS SYSTEM. destroys this centre the patient is unable to Avrite, though he maybe able to speak. This condition is called agraphia. Fi- nally there is a centre, less well defined, for the memories of the movements used in gesture language, and when this is destroyed the person is unable to express his ideas by gesture or sign lan- guage. This condition is known as amimia. To resume now, we have the following divisions of aphasia: Sensory Aphasia. Motor Aphasia. Mind-blindness. \ Alexia" Aphemia. (Apraxia. Agraphia. Word-deafness. Amimia. Music-deafness. Paraphasia. Mind-deafness. There is also a form of aphasia in Avhich the patient misplaces words, often to an extent that makes his speech someAvhat inco- herent. This is called paraphasia, and is due to lesions which destroy some of the associative fibre-tracts connecting the special centres for language. Practically we often find mixtures of motor and sensory aphasia, or Ave have a motor aphasia Avith paraphasia. Patients may also lose the power of expressing themselves by ordinary speech, but may be able to use signs; they may not be able to Avrite voluntarily, but can write to dictation; they may not be able to read directly, but can do so when they trace out the letters with a pen. These different forms are due to lesions which destroy various connecting tracts as well as certain of the centres. The commonest form of aphasia is the motor aphasia in which there is aphemia and agraphia; that is, loss of power to speak and Avrite. This may not be complete, and then there will be with the motor aphasia some paraphasia. In examining a patient who has aphasia one should note the following points: Whether he can speak, name objects, repeat words after you, write from dictation, copy; whether he can sing or express himself by gestures; whether he can read, spell, read by tracing letters with the pen, read words that he has written himself; whether he can understand spoken language or gesture language; whether he can appreciate the nature and use of objects. At the same time he should also be tested for hemi- plegia, deafness in each ear, acuity of vision, hemianopsia, and hemianesthesia. The location of lesions in the various forms of aphasia has been made out with considerable definiteness. The lesion in aphemia is in the posterior part of the third left frontal convo- lution or Broca's convolution; for agraphia, sometimes in the base of the second frontal convolution, sometimes in the angular gyrus. For gesture language there is no known centre. The DISEASES OF THE BRAIN AND ITS MEMBRANES. 333 lesion in Avord-blindness and apraxia is in the angular gyrus, ex- tending back into the occipital convolution. The lesion in word- deafness is in the posterior part of the first temporal and upper part of the second temporal convolution. In right-handed peo- ple the lesions are always on the left side; in left-handed people on the right side (see Fig. 165). Malformations of the Brain and its Envelopes. Congenital malformations of the brain are of little practical importance, for in most cases the monsters cannot live and in all Fig. 175.—Acrama. cases they are better dead. I shall simply give a brief enumera- tion of the important forms. TAnencephaly. Abnormalities J Porencephaly. of the brain, j Absences or malformations of parts, e.g., Cy- clopia. | Acrania. J Meningocele. Encephalocele. Hydrencephalocele. Anencephaly is always present with acrania. In anencephaly the cerebellum and part of the basal ganglia may be present. In such case the child can live a short time (Fig. 175). Porencephaly is often an artificial condition. It will be de- scribed later. In cyclopia there is an undivided anterior cerebral vesicle; Abnormalities of brain and its envelopes. 334 DISEASES OF THE NERVOUS SYSTEM. the orbits form a continuous cavity with a single rudimentary eye (Fig. 176). In acrania there is usually anencephaly. Meningocele is a hernia of the brain membranes, arachnoid and dura through a cleft in the skull. In encephalocele the Fig. 176.—Cyclopia. brain also protrudes. Both these forms occur usually in the occipital region and almost invariably in the median line. In hydrencephalocele there is a sac Avith fluid contents. Diseases of the Membranes of the Brain. The diseases to be considered under this head are anaemia and hyperaemia, inflammation of the dura mater or pachymenin- gitis, and inflammation of the pia mater or leptomeningitis. Anosmia and Hyperemia of the Membranes of the Braix.— Anaemia of the membranes of the brain is a condition that cannot be separated from anaemia of the brain substance, and will be considered in connection with it. Hyperaemia of the brain membranes, so far as it relates to hyperaemia of the pia mater, must also be considered in connection with hyperaemia of the brain tissue. Dural hyperaemia, or congestion of the dura mater, is a condition which occurs as the result of injuries, sun- stroke, and of certain infective poisons, especially that of syph- ilis. The symptoms are those of pachymeningitis of the slight DISEASES OF THE BRAIN AND ITS MEMBRANES. 335 grade, and will be described under that head. They consist mainly of pain, occasional attacks of vertigo, and sensations of fulness about the head. The treatment is that for the beginning stages of a meningitis. Inflammation of the Dura Mater or Pachymeningi- tis Externa.—It has been the custom to describe tAvo forms of pachymeningitis, the external and the internal. Internal pachy- meningitis, or hematoma of the dura mater, is properly a hemor- rhagic disorder and is described under the head of Dural Hemor- rhages. A true inflammation confined to the internal surface of the dura alone is of extremely rare occurrence. Pachymeningitis externa is a disease that invoh'es, at first at least, the outer surface of the dura, and is usually of surgical origin and interest. Etiology.—Accidents, injuries, caries of the petrous bone in mastoid disease, of the ethmoid bone in ozaena, necrosis, syphilis, and erysipelas are the usual causes. The symptoms are local headache, fever, delirium, sometimes even compulsions and paralysis. In the seA'ere cases the disease has usually extended and inAolATed the pia. Pus is generally formed, and burroAVs betAveen the bone and dura. The disease is recognized mainly by the discovery of the local cause. The course is acute or subacute. The treatment is a surgical one. Inflammation of the Pia Mater or Leptomeningitis. —Inflammation of the pia mater has the following types: simple meningitis due to some infection, epidemic cerebro-spinal men- ingitis due to a specific general infection, tubercular meningitis, and syphilitic meningitis. All these forms of meningitis may be either acute or chronic; the chronic form being usually simply a sequela of the acute. Acute Simple Leptomeningitis.— Etiology.—Acute lepto- meningitis is ahvays due to an infective process reaching the cer- ebral membranes usually directly from without, but sometimes through the blood. The so-called oedematous inflammation of alcoholism and inanition is the only exception. The most com- mon source of infection is disease of the middle ear and mastoid cells. Disease of the frontal sinuses and upper nasal passages; operations on those parts; disease, injuries, and fractures of the cranial bones—are also common causes. Pneumonia is the most frequent infective disease in Avhich the pyogenic organisms are carried by the blood. After this come pyaemia, septicaemia, vari- ola, scarlet fever, more rarely endocarditis, empyema, rheuma- tism, measles, typhoid fever, and mumps. Occasionally a brain abscess reaches the surface and sets up a meningitis. Insolation can of itself not cause it. The disease is more frequent in males, 336 DISEASES OF THE NERVOUS SYSTEM. and is distributed through all ages of life, though it occurs oftener in the young. Symptoms.—The symptoms in the various types differ some- what, but have a general similarity. They are to be broadly grouped into the prodromal, the irritative, the depressive, and the paralytic stages. Prodromal symptoms are shorter and less marked in simple meningitis than in tubercular. The patient suffers from malaise, languor, headache, A-ertigo, irritability, loss of appetite, and vom- iting. Of these symptoms headache is the most notable. In the second stage the dominant symptoms are headache, delirium, rigidity of the neck, hyperesthesia of the skin, retrac- tion of the abdomen, Amounting, irregular fever, contracted and often unequal pupils, sometimes optic neuritis or retinitis. The headache is usually persistent, Avith exacerbations of great in- tensity. Rather early in this disease the patient's mind begins to Avander; he mutters incoherently; he may haA-e periods of vio- lence alternating with stupor. In some cases there is a continu- ous low-muttering delirium. Vomiting also occurs early and is of a A-iolent, explosive (projectile) character. This symptom is not always present. The head is bent back and the patient can be lifted from the pilloAv by placing the hand under the occiput. There is sometimes a general rigidity which resembles catalepsy. Drawing a dull point along the skin causes a red line to appear (tache ce're'brale). Pinching or rubbing the skin causes much pain. The abdomen falls in and assumes a characteristic " boat- shape." The pupils are usually contracted and uneven. The eyes are intolerant to light. Optic neuritis occurs often when the inflammation is at the base; but it is a late symptom. Con- vulsions and local paralyses of the cranial nerves, causing sight strabismus, ptosis, or facial palsy, may occur. The fever is irreg- ular in course and not high—101° to 103°. The pulse is usually irregular or rather intermittent. It varies greatly in frequency and may be rather slow—50 to 70. Respiration is rather quick- ened and sometimes irregular. The bowels are constipated; the urine small in amount and sometimes albuminous. In the paralytic stage the patient becomes stupid or coma- tose ; there is still some rigidity, except in the very last stages. The abdomen is still greatly retracted, the pupils may now dilate, the skin become moist, and the patient's bowels and blad- der move involuntarily. Death now occurs in one or two days as a rule. When the disease is mainly on the comTexity of the hemi- spheres there is more delirium, convulsive and paralytic trou- bles; when confined to the base there is less delirium, Avhile paralysis of cranial nerves, optic neuritis, vomiting, and retrac- tion of the head are commoner or more prominent. DISEASES OF THE BRAIN AND ITS MEMBRANES. 337 Course and Duration.—The disease may begin suddenly, and the patient pass at once into the comatose state, dying in a feAv days. Usually the process lasts one or two weeks; it may be prolonged for several weeks. The prognosis is A'ery grave, but it is less serious than in tuber- cular meningitis and more serious than in the cerebro-spinal form. The diagnosis is based on the presence of an exciting cause, such as disease of the ear or nose, trauma, infective fevers, and upon the presence of the symptoms given. It is usually easily recognized, the main difficulty being to distinguish it from tuber- cular and cerebro-spinal meningitis. Pathology.—The disease is a fibro-purulent or purulent in- flammation. It inA*olA*es usually the base more than the con- A-exity, but the reverse may happen. The Aentricles are often inAohed and may be independently inflamed. There are de- scriptions, therefore, of simple basilar meningitis, meningitis of the convexity, and ventricular meningitis or ependymitis. The inflammatory deposits are most conspicuous along the course of the Sylvian fissure and the vessels branching from it, about the optic chiasm, and at the posterior and under surface of the cere- bellum and the sides of the pons. It may lie only in the sub- arachnoid ca\rity, but usually the arachnoid and sometimes the dura are implicated. There is increase of fluid in the \Tentricles and arachnoid cavities, and this fluid may be turbid. The sur- face of the Aentricles may show an inflammatory process. The micro-organisms found in meningitis a,-e the pneumo- coecus, streptococcus pyogenes, intracellular diplococcus, the pneumo-bacillus, and a bacillus resembling that of typhoid fever. Still others have been described, and the process is apparently a mixed infection, though the pneumococcus is found oftenest. Treatment.—Prophylaxis is the most important measure, as there is no specific treatment. Chronic disease of the ear and nasal sinuses should be attended to, and injuries of the skull treated with the strictest regard to antisepsis. The patient should be kept quiet, a dose of calomel gi\Ten, and small doses of iodide of potassium administered at frequent intervals. An ice cap may be applied to the head and hot applications to the feet. Hot poultices along the upper spine are useful. Opium must be given for the pain, if needed; and antipyretics or phenacetin sometimes answer, in a measure. The internal use of iodoform has been highly recommended, gr. \\. to gr. xij. daily; shaving the head and rubbing upon it an ointment containing 20,T iodo- form, then covering the scalp Avith an oiled-silk cap, is a treat- ment highly spoken of. Surgical intervention is sometimes justi- fiable. 22 338 DISEASES OF THE NERVOUS SYSTEM Epidemic Cerebro-Spinal Meningitis (Spotted Fever). —This is an acute infective disorder and is produced by a special micro-organism. It has certain peculiar clinical characteristics which lead us to describe it separately. Anatomically the changes involve the spinal membranes as well as the cerebral. Etiology.—The disease most frequently attacks children, but it may occur at any age. Males are affected rather more often than females. It prevails in the form of epidemics which affect cold and temperate climates especially, and which travel from one part of the country to another. It may occur sporadically. It most frequently deArelops during the winter season, and attacks persons who are living in croAvded houses, tenements, or barracks. It is slightly contagious. One attack does not confer an immu- nity against a second. Symptoms.—The general appearance of a person attacked Avith the disease is that of one who has been poisoned by some agent Avhich is extremely prostrating to the whole system and at the same time one which has a specific inflammatory effect upon the meninges of the brain and spinal cord. When the disease is rapid and malignant, the patient seems to die of an acute toxaemia be- fore any inflammatory process has time to de\Telop. In milder cases and those of longer duration the prostration is less, and the evidences of inflammation of the meninges then develop in the typical way. The disease may begin with prodromal symptoms of malaise, discomfort, pain in the neck, vomiting, and headache. As it develops, the headache, accompanied with giddiness, in- creases, pain and stiffness in the neck become more violent, pains run down the back and radiate to the limbs; there is photophobia, and delirium in many cases is marked. The skin is hyperaes- thetic, the pulse rises to 120 or higher, the temperature varies very much and is usually raised to 103°, 104% or even more. The bowels are generally constipated. In most cases there deArelop certain skin eruptions, usually in the form of purpuric spots; herpes, urticaria, and erythema are occasionally seen. These eruptions vary very much in different epidemics; the purpuric spots are the most important from a diagnostic point of view, and have giATen to the disease the name of spotted fever. As the dis- ease progresses the symptoms of irritation and pain give way to those of somnolence, stupor, and paralysis. Optic neuritis, acous- tic neuritis, and inflammation of other cranial nerves take place, and paralyses of the limbs may be added. The disease may run a short and malignant course, killing the person in a few hours or one or tAvo days. In moderate cases it lasts about two weeks. A large number of different A-arieties of the disease are described, such as the abortive form, fulminating form, and typhoid form. The disorder is often complicated with DISEASES OF THE BRAIN AND ITS MEMBRANES. 339 pneumonia and bronchitis, less often with inflammation of the joints and serous membranes. The disease often leaves Aery seri- ous sequelae, the most important being deafness and spinal irrita- tion or chronic spinal meningitis. A large proportion of deaf- mutes owe their affliction to this disease. Pathological Anatomy.—In the very acute cases the post mortem shows nothing but the evidence of very severe blood- poisoning. In the milder and more chronic cases an inflamma- tion iuvolving the pia and arachnoid of the brain and cord is found. This inflammation is fibrinous or fibro-purulent in char- acter, and may be accompanied with the exudation of a good deal of inflammatory material. Bacteriological researches show that this disease is due to the presence of a specific micro-organism Avhich is apparently Arery much like that which causes pneu- monia. The diagnosis is based upon the history of an epidemic of the disease being present, upon the presence of the ordinary symp- toms of acute cerebral and spinal meningitis, such as headache, delirium, retraction of the head, the sunken abdomen, hyperes- thesia and pains; finally, the presence of the peculiar purpuric spots or of herpes of the face Avill enable one to make a positive diagnosis. One must learn to distinguish the disease from typhus, tetanus, uraemia, pneumonia, and from the other forms of men- ingitis, especially the tubercular. The diagnosis is often made difficult by the fact that cerebro-spinal meningitis may occur in a sporadic form, and it is well known that after a community has been once Aisited Avith an epidemic, these sporadic cases are liable to crop up from time to time for many subsequent years. The sudden onset of the disease, the spinal symptoms, the skin eruption, the absence of history of injury or of evidence of tu- berculosis Avill usually enable one to recognize the disorder. The prognosis A-aries much with the epidemic, but the disease is ahvays a serious one. The mortality ranges from twenty to eighty per cent; it is worse when the disease comes on suddenly and seArerely, with early coma. It is better in persons over the age of ten. Cranial-nerve complications are unfavorable, in that they are apt to leave permanent deafness. SeA'ere spinal com- plications are apt to lea\re their mark in the form of a chronic meningeal trouble. Treatment—There is no specific remedy for the disease, and the ordinary antiphlogistic measures such as mercury and iodides are of less value than in other forms of meningitis. The patient should be given sustaining food, and eA^erything possible should be done to counteract the depressing effects of the toxaemia. Opium or morphine internally, chloral, digitalis, quinine, ben- zoate of sodium and salicylate of sodium, and alcohol are the 340 DISEASES OF THE NERVOUS SYSTEM. drugs Avhich haA*e been specially recommended. Warm baths, hot moist applications, and leeches have all been tried with more or less good results. Tubercular Meningitis (Acute Hydrocephalus).—This is a form of meningitis due to infection Avith the bacillus tuber- culosis. It differs pathologically from other forms in the charac- ter of the infect i\*e organism; anatomically, in the fact that the inflammation is usually and chiefly basilar and never purely pur- ulent; etiologically, in that it chiefly affects young children; and symptomatologically, in the presence of prodroraata and a more irregular course. Etiology.—Tubercular meningitis occurs chiefly betAveen the ages of tAvo and ten, sometimes in infancy, rarely in adult life, very rarely after the age of fifty. Males are rather more subject to it. A hereditary history of phthisis, a scrofulous diathesis, bad hygienic surroundings, and the presence of tuberculosis else- where in the body predispose to it. Tuberculous milk, the erup- tive fevers, especially measles, Woavs on the head, and great emo- tional excitement appear to act as exciting causes. Symptoms.—A knowledge of the prodromal symptoms is espe- cially important. These are paroxysmal and intensely seA-ere headaches and darting pains in the head, A'ertigo, loss of appe- tite, explosive vomiting Avithout nausea, the vomited matter being usually colorless and Avatery, constipation, an altered disposition, and irritability. The tache cerebrate or cerebral macule, more rarely ptosis and facial paralysis, may appear early. The pro- dromal stage often lasts, with remissions, three or four Aveeks. When the disease sets in there is more persistent headache; vom- iting, fever, and the other symptoms of meningitis already de- scribed appear. The irritative stage gradually passes into the paralytic and comatose. Death occurs in two or three vveeks. In infants the disease often runs a Aery obscure course, the pa- tient showing chiefly symptoms of brain compression. Pathological Anatomy.—In rapidly fatal cases, with severe symptoms, there may be only an intense congestion of the brain with numerous miliary tubercles in the pia mater at the base and OArer the convexity. Here we must assume that a bacillary toxine causes the symptoms. In most cases there are decided deposits of tubercles at the base, with fibrinous inflammatory deposits about the optic chiasm, along the fissure of Sylvius, at the sides of the pons and elsewhere. Miliary tubercles are seen scattered over the convexity and in the choroid plexus and ventricles. They are generally found in the spinal membranes also, especially over the cauda equina. The tubercles lie beneath the pia sur- rounding the small vessels. They may coalesce into large tuber- cular nodules. There is usually an increase in the arachnoid DISEASES OF THE BRAIN AND ITS MEMBRANES. 341 fluid, and in most cases an increase in the ventricular fluid. Some- what rarely there is very great distention of the A^entricles and compression of the convolutions. This condition used to be called acute hydrocephalus. Small spots of softening may be seen from obliteration of the vessels by the tubercles. The bacillus tuberculosis is found in the tubercular nodules. Diagnosis.—As regards the form of the disease, this is based on the hereditary history, the age, the existence of tuberculosis of the lungs or other organs, and the peculiar prodromata of the disease. Occasionally tubercles can be seen on the choroid. Prognosis.—This is usually absolutely bad, yet post-mortem observation of cases dying Avith practically no inflammatory change makes it seem possible that the disease might be checked, and a good many cases are reported where it apparently has been. Some of these are, however, probably cases of hereditary syphilis. Treatment.—So far as now known, this is not different from that given under the head of meningitis elsewhere. It seems, however, as if in time some anti-toxine may be discovered which Avill check the progress of the poison and the development of the tubercle; meanwhile the best thing to do is to give small doses of iodide of potassium at frequent intervals and use symptomatic treatment. Chronic Hydrocephalus. This is a disease mainly of infancy, characterized by a gradual enlargement of the head, Avith mental deficiency and symptoms of brain irritation caused by an accumulation of fluid in the ventricles of the brain. The old term " acute hydrocephalus " meant an acute inflam- mation Avith effusion, but the name is not needed and is best dropped. Chronic hydrocephalus is not an inflammatory pro- cess, but one due to mechanical causes or to defects in structure or nutrition. The fluid always accumulates in the A-entricles of the brain; hence chronic hydrocephalus is always internal. The so-called external forms of hydrocephalus are inflammatory or else are secondary to meningeal hemorrhage or brain atrophy. Chronic hydrocephalus is almost always a disease of infancy and is generally congenital. It may, however, be acquired. In speak- ing of chronic hydrocephalus, we refer to the chronic internal congenital disease. Etiology.—Four out of five cases begin at birth or within the first six months of life. Syphilis (J. Lewis Smith), alcoholism, lead-poisoning in the parents, and some unknown family taint predispose to the disease. Poverty and poor nutrition and rick- ets are also factors. 342 DISEASES OF THE NERVOUS SYSTEM. Symptoms.—The head may be so large at birth that instru- mental help is needed. More often the parents notice a gradual increase in the size of the child's head, beginning soon after birth. The forehead bulges, the occiput stands out, the fontanelles and sutures widen, and pressure shows evidence of fluctuation. Mean- Avhile the face does not groAV much and the result is to give a triangular shape to the head. It may measure twenty-four, twenty-seven and one-half (Minot), thirty-two (Bright), and even forty-three inches (Klein) in diameter. These extreme measure- ments are reached only after one or two years. With this abnor- mal groAvth of the head, mental and physical symptoms appear. The infant is restless and irritable, its appetite may be good, but the general nutrition is poor and its bodily growth is retarded. Fig. 177.—Chronic Hydrocephalus. The mind does not develop; usually it does not or cannot learn to walk. It may be unable to support the weight of its head. There is strabismus and sometimes optic atrophy. The pressure of the dropsy thins the orbital bones and forces down the axis of the eyeballs (see Fig. 177). Vomiting, coma, and convulsions eventually appear, and the child dies of exhaustion or some in- tercurrent disease in two or three years. In some cases the trouble is less serious, it ceases to progress, the bones solidify, and the child grows up with good intelligence. Chronic hydrocephalus sometimes develops in late childhood and in adult life. It is then due to some tumor or inflammatory process obstructing the venae Galenae and the aqueduct of Syl- vius. The symptoms are chiefly those of brain pressure, and the disease cannot be recognized with certainty. The hydrocephalus which is associated with the brain atrophy DISEASES OF THE BRAIN AND ITS MEMBRANES. 343 of insanity and old age or with general dropsical conditions has no kinship with the process we are now describing. Pathology.—The disease is due to the gradual accumulation of a serous fluid in the ventricles of the brain. The cause of this is an inflammatory or developmental obliteration of the foramen of Magendie and the adjacent lateral foramena of Mierziejewski. This prevents the escape of the ventricular fluid into the general arachnoid cavity. Contributing factors are congenital or ac- quired defect in the absorbents of the ventricles and a rachitic and easily yielding skull. The attempts to make chropic hydro- cephalus an inflammation are failures, though there is at times a thickening of the lining membrane of the ventricles. The lat- eral ventricles are principally and often solely affected, and these are so distended as to press out their cerebral walls, flattening the convolutions, and turning them into a thin shell often less than a quarter of an inch in thickness. Sometimes only one lat- eral ventricle, and in rare cases only the fourth ventricle, is affected with the dropsy. The diagnosis has to be made from rickets and an acute in- flammatory process. In rickets the head is square, the fontanelle does not bulge, the enlargement is less, and there are signs of the disease in the bones elsewhere. Prognosis.—The congenital cases usually die in a feAv months, or at least before the third year. Those developing in infancy may live for four to six years; and in mild cases the disease ceases to progress and a fairly healthy adult life is reached. Treatment—A great many measures have been recommended, but there is no unanimity about any one of them. In such a state of therapeutics it is safe to say that treatment is of little use. The most rational measure is the inunction of mercury and the administration of iodide of potassium combined with tonics. Surgical measures such as tapping the ventricles are irrational and need not be discussed. Quincke's method of tap- ping the spinal canal will not apply in these cases, Though it is a practicable measure as I have found by experiments on the cadaver. Strapping the head with diachylon plaster is recom- mended by Trousseau and by J. Lewis Smith. CHAPTER XVIII. DISEASES OF THE BRAIN. These diseases, like those of other parts of the nervous sys- tem, consist of malformations, Aascular disturbances, inflam- mations, softenings, hemorrhages, degenerations and scleroses, chronic infections, tumors, and functional disorders. Cerebral hyperaemia is a condition in which there is an excessive amount of blood in the cranial caA'ity; it may be acute or chronic, actiAre or passive. Etiology.—In the description Avhich is to follow I shall refer only to those conditions of hyperaemia of the brain Avhich are pathological. It is a well-recognized fact that hyperaemia of the brain occurs physiologically under excitement and over-activity of the heart and from various stimuli; but a pathological condi- tion of acute congestion may be induced by sunstroke, certain drugs such as alcohol, and by injuries; also by mechanical causes Avhich prevent the exit of the blood from the cranium. An acute congestion also occurs in mania and in many forms of fevers, as well as in the initial stage of meningitis. A chronic cerebral hy- peraemia may be induced by the causes already mentioned as bringing on acute congestion. The prolonged use of alcohol, prolonged mental excitement, OArerwork, and worry may also lead to this condition. The foregoing causes lead to what is known as active congestion, in which the blood is driven in excess into the brain through the arteries. A passive congestion may exist in Avhich the blood is prevented from leaving the brain and is kept mainly in the intra-cranial veins. The causes of passive congestion are mainly mechanical, such as cardiac disease and mechanical obstructions about the neck from tight clothes and an obstruction to the flow of blood from the lungs by playing on wind instruments. Symptoms.—A great deal has been written regarding the symp- tomatology of cerebral hyperaemia, but many of the statements made are nothing but guesswork. Probably the main symptoms produced by an actiAre congestion of the brain are a sense of ful- ness and pressure, a feeling of constriction about the head, some headache which may be vertical, mental excitement or irritabil- ity, confusion of ideas, vertigo, insomnia, ringing in the ears, DISEASES OF THE BRAIN. 345 and pulsating sounds in the head. These symptoms are some- times increased'when the patient lies down, and are generally increased Avhen the patient bends the head over so as to prevent the return flow of blood from the brain. It is impossible to diag- nosticate passiAre hyperaemia from active through the symptoms alone, but probably in the former condition the disturbances and symptoms mentioned are less marked; in other words, an active hyperaemia produces more phenomena than passive. In either case examinations of the fundus of the eye and of the tym- panum furnish no sure criteria. Pathology.—Cerebral hyperaemia used to be regarded as nearly synonymous with cerebral neurasthenia. In the writer's opinion. it is secondary to the neurasthenic state; and produced, if it exists in that state, by the impaired vasomotor innervation which is characteristic of neurasthenia. It is not wise, therefore, to make the diagnosis of cerebral hyperaemia often as the primary condi- tion. It is only after traumatisms and sunstroke or after a men- ingitis (hat Ave can speak of the cerebral hyperemia as being in a certain sense the primary condition to be treated. The state- ment made by some Avriters that cerebral hyperaemia underlies certain conditions of acute delirium, of aphasia, of paralysis, and even dementia or insanity can hardly be supported. In many of the cases of cerebral hyperaemia Avhere symptoms are produced, there is undoubtedly a condition of toxaemia which is a con- tributing factor to many of the symptoms. Treatment.—The specific treatment of cerebral hyperaemia, Avhen indicated, consists in giving large doses of fluid extract of ergot and bromide of potassium. One or two drachms of the ergot three times a day and fifteen or twenty grains of bromide of potassium may be prescribed. Wet cups to the back of the neck, the cautery in the same region, ice caps, purgatives, quiet and rest, and a careful regulation of the diet and the bowels are all important measures. Cerebral Anaemia.—This condition, like hyperaemia, may be either acute or chronic. It occurs among the young ; more often in females than in males. It is seen in early adult life, where it is induced by the Aarious causes producing general anaemia, and again after the climacteric, Avhen it is due to organic changes in the cerebral arteries of the nature of an obliterating endarteritis. Bright's disease and syphilis, exhausting diseases and profuse hemor- rhages, and such disorders of digestion and nutrition as lead to general anaemia produce also cerebral anaemia. A potent cause of acute cerebral anaemia is fright. Symptoms.— The symptoms of acute cerebral anaemia are ver- tigo, confusion of ideas, nausea, faintness or complete syncope. 346 DISEASES OF THE NERVOUS SYSTEM. In chronic cerebral anaemia the symptoms are mental apathy and a feeling of disinclination to work, tendency to somnolence in the day-time and insomnia at night, mental depression, head- aches which are usually frontal or vertical, occasionally some vertigo and tinnitus. There may be spots before the eyes and undue sensitiveness to sounds. In children some Aery severe symptoms are attributed to cerebral anaemia, but here, as in hy- peraemia, it is probable that there are other causes at Avork, par- ticularly toxic agents or reflex disturbances. Diagnosis.—A chronic anaemia of the brain can hardly be recognized except through the evidences of a general an;emia. When this is present and there are also symptoms such as have been described, a fairly certain diagnosis can be made. We must look upon cerebral anaemia as being in almost all cases a second- ary phenomenon, except in the aged, and then the trouble is due not alone to poverty of the blood, but to the fact that the circu- latory apparatus is diseased. It is generally believed that in cerebral amemia the symptoms somewhat improve by the hori- zontal position and are made worse by the upright position. It is also asserted that in anaemia the pupils rather tend to be dilated, while in hyperaemia they are contracted. Treatment.—Treatment should be directed toward enriching the supply of blood and toward improving the general nutrition. It consists, therefore, in the administration of preparations of iron and of such tonics as the mineral acids, strychnine, quinine, and nitroglycerin. INFLAMMATION OF THE BRAIN—ENCEPHALITIS. The forms of inflammation of the brain are acute suppurati\Te encephalitis, acute non-suppurative encephalitis, chronic enceph- alitis, chronic polioencephalitis. Inflammations of the brain are analogous to those of the spinal cord; that is to say, there are acute suppurative inflammations or abscesses, and acute exuda- tive inflammations Avith or without necrosis, and there are chronic inflammations. The brain differs from the spinal cord, howeATer, in that acute suppurative inflammation is comparatively fre- quent, while the acute exudatiAre inflammations are extremely rare. Chronic inflammation, also, of the brain is rarer than chronic inflammation of the cord, if we except that type which underlies general paresis. Acute Suppurative Encephalitis (Abscess of the Brain). Brain abscess is a suppurative inflammation which affects the parenchymatous and other structures of the organ. It is always a focal disease, but may be single or multiple. DISEASES OF THE BRAIN. 347 Etiology.—The primary cause of all forms of brain abscess is a microbic infection. The form of microbe, its mode of entrance, and the part of the brain attacked vary greatly. The predis- posing causes relate chiefly to age and sex. Brain abscess rarely occurs before the first year or after the fiftieth year of life. It is rather frequent in young people, and occurs on the whole often- est between the ages of ten and thirty. Males are more often affected than females in the ratio of about three to one. The exciting causes are chiefly disease of the ear and of the cranial bones, injuries, and remote suppurative processes. To this may be added infectious fevers and the presence of tumors. Inflam- mation of the middle and internal ear is the most common cause of brain abscess. The disease affects the tympanum and mastoid cells, more rarely the labyrinth, it is usually a sup- purate process of long standing. Caries of the ethmoid and nasal bones and of the orbital ca\rity leads to brain abscesses in a considerable proportion of cases. After chronic ear and bone diseases, injuries are the most frequent cause. The injury may be a compound fracture with direct infection from the open wound, or the abscess may be the result of contrecoup and may develop in a part of the brain opposite to that which Avas in- jured, or the abscess may develop below the point injured, there being apparently healthy tissue betAveen the surface of the brain and the diseased part. These abscesses develop through lacera- tion of brain tissue and subsequent infection of the Avound with organisms. The most common remote suppurative processes which are folloAved by brain abscess are tubercles, inflammation of the lungs, fetid bronchitis, and empyema. Brain abscess may deA'elop, however, from distant points of suppuration on the ex- tremities or in almost any part of the body. Pyaemia may lead to the production of brain abscess. Among the infectious fevers Avhich are complicated with brain abscess are diphtheria, typhoid and typhus feATers, erysipelas, small-pox, the "grippe." The oidium albicans or thrush may also be a cause. Brain tumors sometimes become surrounded by a suppurative encephalitis or may break down with the formation of mixed suppurative and neoplastic tissue. Tubercular tumors are most frequently accom- panied by suppuratiA'e encephalitis. Symptoms.—Brain abscesses take sometimes an acute and sometimes a chronic course. In acute cases the symptoms de- velop rapidly and the disease runs its course in a few days or Aveeks. The symptoms come under the general head of those of pressure, those of poisoning from the diseased focus, and local symptoms due to irritation or destruction of certain special areas of the brain. The pressure symptoms are those of headache which is often very severe and persistent, vomiting which is quite 348 DISEASES OF THE NERVOUS SYSTEM. frequent though not invariable, a ertigo, and a condition of men- tal dulness Avhich may pass into a delirium, ending finally in coma. Optic neuritis often occurs. The pupils are apt to be irregular, but furnish no definite indications. The pulse is usually slow, ranging from 60 to 70, but it varies a great deal. The tempera- ture is normal or subnormal as a rule, but this also varies, and it may rise seA-eral degrees above normal, always running an irregu- lar course. The toxic symptoms are those Avhich Ave get in septic poisoning; namely, prostration, irregular fever, emaciation, ano- rexia, and such mental and sensory disturbances as have already been referred to. As a result of local irritation or destruction, there occur convulsions, paralysis, aphasia, and disorders of some of the special senses. Convulsions are not very common. When they occur they are generally of an epileptic character. The paralysis is usually in the form of hemiplegia. The cranial nerves are not often involved, if we except the optic. The urine is said to show a diminution in chlorides and an increase in phosphates. The patient dies finally in coma from exhaustion. In the chronic form of brain abscess the symptoms may for weeks, months, or years remain practically latent, after the ex- citing cause has been at work and after the abscess has been es- tablished. The patient during this latent stage may suffer from headache, vertigo, mental irritability, and depression; he may at times have a convulsive attack. Occasionally there will be an exacerbation of the disease, at which time he suffers from intense pain, vomiting, perhaps delirium or a convulsion. From this he recovers and continues in a fairly good state of health again. After a ATariable period, usually of Aveeks or months, the terminal stage sets in. This terminal stage of the chronic form may as- sume very much the characters of the acute form already de- scribed. In other cases it shows itself by a sudden apoplectic or epileptic seizure or a sudden attack of coma, in which the patient sinks and rapidly dies. These terminal phenomena are due to the fact that the abscess, which has been previously encysted and quiescent, suddenly breaks into a lateral ventricle or through the surface of the brain, or to the fact that a hemorrhage occurs into the abscess. Complications.—The common complications of brain abscess are a phlebitis of the superior petrosal and lateral sinuses and a meningitis. The phlebitis accompanies abscesses that are caused by disease of the ear. The meningitis may be caused by ear dis- ease, but more frequently accompanies abscesses due to injury. When phlebitis is present there will be found an oedema about the ear and neck and a hardness of the jugular veins. In men- ingitis there is apt to be more rigidity of the neck, more pain, and there are often cranial-nerve paralyses. DISEASES OF THE BRAIN. 349 Pathology.—Acute suppurative encephalitis resembles acute suppurative myelitis in the intimate nature of the changes that take place. There is an intense congestion of the parts, Avhich gives it a reddened appearance and Avhich. used to giA-e to this process the name of red softening. This condition, howeA-er, is only the initial stage of the suppurative inflammation and does not deserve to be ranked as a special form of inflammatory pro- cess. It is possible that in some cases the inflammation may get no further than the stage of red softening. The congestion then gradually disappears, absorption of exudate occurs, and a more or less complete recovery takes place. When the process contin- ues, howeA-er, the parts become crowded with leucocytes and infiltrated Avith inflammatory exudate. The nerve fibres and cells are destroyed, in part mechanically, in part by the poison- ous influence of the pyogenic organisms. The nerve cells lose their normal contours. sAvell up, and disintegrate; the neuroglia cells absorb the broken-down detritus and SAvell up. forming what are knoAvn as granular corpuscles; the leucocytes increase until a purulent mass is formed. The total result is a mixture of broken-down nerve fibres and cells, leucocytes, and granular bodies. Bacteriological tests show the presence of A'arious pyo- genic microbes. The abscess thus formed varies in size from one to six or eight centimetres in diameter (two-fifths to three inches). It is generally someAvhat round, and if the case is chronic a fibrous wall is formed. It takes from three to four weeks for such a wall to develop (Fig. 178). Brain abscesses are usually single, occasionally there are tAvo or three. In some conditions they are multiple; that is to say, there may be fifteen, tAventy, or more. Multiple brain abscesses are always small and are usually due to pyaemic infection. Location.—Brain abscesses involve the cerebrum oftener than the cerebellum, in the proportion of about four to one (Barr). They occur rather oftener in the right cerebrum. They are very rare in the pons and medulla. The cerebral lobes oftenest affected are the temporal and frontal. In the cerebellum it is the lateral hemispheres that are most frequently attacked. The seat of the abscess has important relations to the cause. Abscesses due to ear disease are almost ahvays either in the temporal lobe or the cerebellum. If the ear disease is in the tympanum, the cerebrum is usually the seat of the abscess. If the disease is in the mastoid cells, the cerebellum is usually the part affected. If the disease is in the labyrinth, the abscess is also more apt to be in the cere- bellum. This distribution of the seat of the disease is due to the anatomical relations of the bony parts to the temporal lobe and cerebellum, respectiA-ely. Brain abscesses due to injuries are more frequent in the frontal and temporal lobes. What are 350 DISEASES OF THE NERVOUS SYSTEM. known as idiopathic brain abscesses—that is, those which arise Avithout any known cause—are most frequent in the frontal lobes. This is because most such cases are due to an unrecognized affec- tion of the nasal cavities and ethmoid bone. Brain abscesses due to suppurative processes in the lungs and pleura are probably embolic; and as the emboli are carried up into the middle cere- bral artery, the brain abscesses having this origin are situated in the field supplied by this artery. In children un'der ten, in whom Fig. 178.—Abscess op Cerebellum. brain abscess is usually due to ear disease, the cerebellum is more apt to be affected. Course.— Acute abscesses last from five to fourteen days, rarely over thirty days. Traumatic cases run the shortest course. Chronic abscesses may have a latent period of Aveeks, months, and in rare cases even one or two years. When terminal symp- toms come on death occurs in a few days. In a few cases brain abscesses have been spontaneously evacuated through the nose. Aside from this, the termination is always a fatal one unless sur- gical interference takes place. There is sometimes a recurrence of the abscess after an operation. Diagnosis.—The diagnosis of brain abscess is based upon the DISEASES OF THE BRAIN 351 history of injury, aural or nasal disease, remote suppuration, upon the general symptoms of sepsis, upon the presence of head- ache, vomiting, slow pulse, normal or subnormal and irregular temperature, a local tenderness of the scalp and rise of tempera- ture over the seat of the lesion, hebetude, delirium, optic neuri- tis, rapid wasting, and diminution of chlorides in the urine. The diagnosis of the location of the abscess is based upon the history of its cause, whether from injury, ear disease, emboli from the lungs, or nasal disease; also upon the presence of hemi- plegia, local convulsions, tenderness and rise of temperature of a certain area of the scalp. As brain abscesses are apt to affect 352 DISEASES OF THE NERVOUS SYSTEM. latent regions like the temporal and frontal lobes, local diagnosis is usually difficult. The diagnosis must be made from tumors of the brain, meningitis, and phlebitis of the sinuses. The differ- ential points are given under the heads of the diseases mentioned. The prognosis of the disease is absolutely unfaATorable unless some surgical interference is resorted to. The feAV rare cases of spontaneous evacuation of the abscess Avould not lead to any practical modification of this statement. Treatment.—The actual treatment of a brain abscess after it has deAreloped is, as already stated, exclusively a surgical one. The successes so far have not been very great, but they have been sufficient to justify operation and to furnish greater hope for the future, when a more exact diagnosis can be made and a Avider surgical experience has been obtained. The accompanying fig- ure shows the points to be located in trephining for abscess from ear disease. Something is due to the patient in the Avay of pre- vention, especially in cases of persons who have chronic aural or nasal disease Avith carious processes. These should be carefully watched and treated. Acute Exudative Encephalitis (Acute Bulbar Myelitis, Polioencephalitis Superior and Inferior, Infan- tile Polioencephalitis, Primary Encephalitis of Friedmann). Acute exudative encephalitis is a disease whose pathological existence is probable, but as yet Ave are not able to establish any definite clinical types associated with the process. An exception to this may be made in the case of acute bulbar myelitis and acute polioencephalitis superior. A third exception is claimed by Striimpell, Avho affirms the existence of an acute polioenceph- alitis of children. A form of acute non-suppurative and primary encephalitis is described by Friedmann, and illustrative cases are given; but as yet it is doubtful if we can place this condition in the category of a distinct disease. Acute bulbar myelitis is a disease Avhich is strictly analogous in course to acute myelitis. The special symptoms simply depend upon the peculiar location of the disease. They consist of an acute glosso-labio-laryngeal palsy, and are referred to under the description of bulbar paralysis. Acute polioencephalitis superior is a disease in which the nuclei of the nerves supplying the eye muscles are involved; it is a disease analogous to poliomyelitis anterior, and has been described under the head of Ophthalmoplegia. • The acute polioencephalitis of children (Striimpell) is a dis- ease that involves the gray matter of the convexity of one of the DISEASES OF THE BRAIN. 353 cerebral hemispheres. The disease is supposed to be strictly analogous to an inflammation of the anterior horns of the spinal cord. It attacks children betAveen the first and fourth years of life, with symptoms of fever, delirium, and often of convulsions followed by a hemiplegia. The acute symptoms pass away in a week or two, leaving the child with the hemiplegia Avhich may improve very greatly, but more commonly continues through life. With it later there are developed contractures of the affected side, some atrophy, mental defects, and epileptic convulsions. The real existence of this disease is very doubtful. Chronic Encephalitis.—Under the older Adews of inflam- mation there were described as chronic cerebritis such lesions as sclerosis and cerebral atrophy. These processes Ave now regard as being simply reparative and as the sequelae of acute destruc- tive or inflammatory processes. They Avill be described, there- fore, under such heads. The only form of chronic cerebritis for Avhich there is a recognized clinical prototype is the chronic cor- tical cerebritis, which is the basis of general paralysis or paralytic dementia. Even this process, hoAvever, is still regarded by many as essentially a degeneratiA-e one and not inflammatory. As the symptoms which result from it are those of insanity, the disease will not be described in this work. THE APOPLEXIES. Apoplexy is a condition characterized by a sudden paralysis and shock, usually with loss of consciousness, and due to the breaking or blocking up of a blood-vessel in the brain. Apoplexy is a general term. Its particular forms are. 1. Intracranial hemorrhage, from rupture of a blood-vessel. 2. Acute cerebral softening, from embolism or thrombosis. Since both embolism and thrombosis cause a rapid softening in the area supplied by the obstructed vessel, the term acute softening covers both disorders. Apoplexy from Intracranial Hemorrhage (Cerebral Hemorrhage, Hemiplegia). Forms.—There are four groups of blood-\ressels in the brain, those of the dura mater, those of the pia mater, and those sup- plying the basal ganglia and white matter. Besides this, Ave may consider the pons, medulla, and cerebellum which are supplied chiefly by branches of the vertebrals as a separate group, sub- ject to somewhat different mechanical conditions. Correspond- ing to this we have: 1. Dural or pachymeningeal hemorrhages. 2. Pial or subarachnoid hemorrhages. 23 354 DISEASES OF THE NERVOUS SYSTEM. 3. Central hemorrhages. 4. Hemorrhages in the medulla, pons, and cerebellum. It is the central hemorrhages (No. 3) due to rupture of the blood-vessels going to the great basal ganglia, internal capsule. and Avhite matter that cause the great majority of cerebral hem- orrhages seen by the physician. It is this class that I have par- ticularly in mind in the following description. Etiology.—At the time of birth and during infancy there is a slight tendency to intracranial hemorrhage owing to the acci- dents and injuries of labor. After this period the liability is very small, but slowly increases up to the age of forty, when predis- position specially begins. Four-fifths of all cases occur after forty, and the tendency to hemorrhages increases in each decade up to eighty, when it diminishes absolutely and relatively.* Males are slightly more predisposed than females (five to four). Rather more cases occur in cold weather, at high altitudes, in the temperate zone, and among civilized races. Heredity has an undoubted, though not great influence in predisposing to cerebral arterial disease. Infective fevers and marasmic states are predisposing causes. Chronic kidney disease is present in one-third of the cases. Chronic alcoholism, syphilis, and gout are powerful predisposing causes. Rheumatism is less impor- tant. Heart disease, fatty and atheromatous arteries, arteritis, and miliary aneurisms may be regarded as more than simply predis- posing—they are determining causes. Leucocythaemia, scurvy, and purpura are conditions which also particularly tend to cause hemorrhage. The so-called apoplectic habit—short thick neck and high shoulders and florid face—has really some importance in the better classes. Congenital anomalies, such as a narrow tho- racic aorta or inherited deficiency in the strength of the walls of the blood-vessels, also play a part. Any sudden physical exer- tion, such as straining at stool, the excitement at coitus or of a passion, eating a large meal and drinking a great deal of fluid, especially alcohol, taking a cold bath, all may lead to rupture of an artery. Often the vessel breaks during sleep, owing perhaps to the contracted condition and consequent higher pressure in the arteries, and to the fact that on account of the horizontal position there is more resistance to the return of the blood from the brain. The symptoms are the prodromal, those of the attack and acute stage, and those of the chronic stage. * Among 53 cases collected by me at Bellevue Hospital, the ages were 10 to 20, 4; 21 to 30, 6; 31 to 40, 10 ; 41 to 50, 11 : 51 to 60, 7 ; 61 to 70, 10; 71 to 60, 5. The right side was affected in 23 cases ; left in 25 cases. The location was: Pachymeningeal, 7 ; pial and cortical, 8 ; ventricular, 23 ; corpus striatum and vicinity, 7 ; optic thalamus, 2; corpora quadrigemina, 1; pons, 1 ; cerebellum, 3. DISEASES OF THE BRAIN. 355 Prodromal symptoms are rare except in syphilitic cases. When present the patient suffers from dizziness, numbness of the hand and foot on one side, and a failure of memory for Avords. He may have " full" feelings or eAren pain in the head and bad dreams at night. Nose-bleed and irregular heart action sometimes occur. The attack always comes on suddenly and may be ac- companied (1) with convulsions and coma, (2) Avith coma alone, or (3) without loss of consciousness. 1. Initial convulsions are rare and generally mean a meningeal hemorrhage. When present they are unilateral or partial, as a rule, but may be general. 2. The common mode of onset is Avith coma. The patient, without Avarning, suddenly becomes dizzy, loses consciousness, and falls. The face is flushed, the pulse hard and rather slow, the breathing is labored and stertorous, the cheek on one side puffs out Avith each expiration, the eyes are partly closed, the eyeballs fixed or deviated to the paralyzed side, the pupils are contracted and rigid, the skin is bathed in SAveat, the limbs are relaxed, but some eAddence of hemiplegia is present; the urine may be retained or it and the faeces inrolun- tarily eA-acuated. The urine is usually of rather high specific graAdty and often contains albumin, even when there is no renal disease. The temperature in severe cases may fall below normal during the first tweh'e hours, even to 96° F., but this is not the rule. It is the rule, hoAvever, for the temperature in a fe\v hours to be 1" or 2° higher on the paralyzed than on the sound side. If the case is rapidly fatal coma continues, respiration often assumes a Cheyne-Stokes character, the pulse becomes faster, the tempera- ture gradually rises, and usually reaches 102° or 103° F., until just before death, Avhen it may sink again. SwalloAving and speech become difficult, hypostatic pneumonia sets in, and the patient dies in from two to four days. In sloAver fatal cases the patient regains consciousness partially and then enters a condition of stu- por or mild delirium. He is restless and suffers from headache. The temperature may continue normal for a time, but is usually higher on the affected side. At the end of tAvo or three Aveeks it rises higher, pneumonia develops, the patient becomes uncon- scious and death ensues. In the favorable cases, which constitute the majority, coma, if present, gradually passes away in from one to six hours, leaAing the patient's mind somewhat weak and confused and his speech disturbed, or more rarely the intelligence may not be at all disturbed. During the first feAv days or weeks after the attack the physician finds that the prominent symptom is the hemiplegia. This affects the arm and leg most and the face least. Only the lower two branches of the facial nerve are hwolved, and the patient can shut the eyes. The tongue, if pro- truded, turns to the paralyzed side; the UArula is turned in various 356 DISEASES OF THE NERVOUS SYSTEM. ways and its position is of no significance. There is often some eA'idence of cutaneous anaesthesia of the paralyzed side, and less often hemianopsia and disturbances of hearing occur. In right- sided hemiplegia the patient, after reeoAering consciousness, is often unable to talk or to understand what is said. Examina- tion shows that he has a motor or sensory aphasia (vide Aphasia). The deviation of the eyes and head to one side usually dis- appears in a day or tAvo. Occasionally there is a temporary ptosis. The pupils at first are contracted, that on the paralyzed side the more so; this condition disappears with returning con- sciousness. The paralysis of the arm and leg is flaccid at first, and the limb falls heavily Avhen lifted; the reflexes are lessened or abol- ished. Sometimes, howeArer, rigidity sets in at once. This symptom occurs when blood has broken into the ventricles, and also in some meningeal hemorrhages. The skin reflexes are abolished or nearly so on the affected side. The usual course of the temperature is for it to rise on the second and third day to 100° F. or 102 F., being |° to 1° F. higher on the paralyzed side. In a fe\v days it gradually falls, so that by the eighth to the tenth day it is normal. If the temperature continues to rise after the fourth or fifth day, it is a sign of an extension or inflammatory reaction of the hemorrhage. Hence the thermometer furnishes a very important criterion of the seriousness of the case. The varying course of the aooplexy is shown in the following diagram: Health line. 3. Chronic stage. 4 to 8 weeks. 1. Death. 2. Death. 2 to 4 days. 2 to 4 weeks. The Chronic Stage, Hemiplegia.—At the end of a month, if fever and symptoms of cerebral irritation have subsided, the chronic stage may be said to begin. The hemiplegia has improved, the patient can move the leg and arm a little, sensory symptoms Attack Improvement. DISEASES OF THE BRAIN. 357 have lessened, the mind is clear, headache has disappeared. Im- provement continues, though more slowly, for several months or even one or two years. During this time the patient is " a hemi- plegic." The hemiplegia affects the arm more than the leg and the face least of all. The distal segments of the limbs, the feet and hands, are affected more than those near the trunk. The mus- cles that act bilaterally, such as those of respiration, phonation, and facial expression, are but slightly involved. The paralysis is not strictly a hemiplegia, for the muscles on the sound side are somewhat weakened, as tests will show. In severe cases, es- pecially in old people, even the visceral muscles, especially those of the bladder, are weakened. At the onset of the attack there is sometimes a temporary " initial" rigidity of the muscles on the paralyzed side, or an " early " rigidity may develop in one or two days. There always develops at about the beginning of the sec- ond week a " late " rigidity. This, which at first is slight, gradually increases, and finally contractures affect the paralyzed limbs. The superficial reflexes, Avhich at first were absent, reappear; the tendon reflexes become much exaggerated, and clonus can be obtained in the leg and arm. The sound side shares to a small extent in these conditions. The contractures affect the extensors of the foot more than the flexors, and bring the toe down and the heel up. The leg is held nearly extended, and the limb in walk- ing is swung around, the toe scraping the ground. The shoulder is adducted, the forearm flexed, and the fingers tightly shut into the palm by the overaction of the flexors. The facial muscles show a slight contraction and drawing to the affected side. The muscles on the paralyzed side do not waste. In infantile hemi- plegia, however, the affected limbs grow less than those on the sound side. The paralyzed limbs may be the seat of peculiar disorders of movement. These consist of Associated movements. Tremor. Ataxia. Choreic movements. Continuous or athetoid movements. Spastic movements and cramps. Such movements, aside from those that are spastic, are rarely seen in the hemiplegia of adults. The electrical irritability may be at first sightly increased and diminished, but the change is slight in amount and never reaches the degenerative stage. Hemiansesthesia, if present at first, disappears to a great ex- tent, leaAdng only residua about the feet and hands. Paraesthe- 35S DISEASES OF THE NERVOUS SYSTEM. siae are common. In rare cases the patient suffers great pain in the arm and leg. This pain is generally of a burning character and Arery obstinate and distressing. Cramping pains in the legs and arms are common in the severer cases. During the first fi\Te Aveeks after the onset joint inflammations and bed-sores may attack the affected side. The temperature of the hemiplegic side is usually a very little higher than that of the sound side. Vasomotor disturbances, sweating, skin eruptions, and in- creased growth of hair are some of the rarer symptoms. The mental condition is more or less affected. The patient becomes irritable, cries easily, and is in general more emotional. The memory is impaired, and the poAver of concentrating the attention and carrying on work is less. Sometimes a progressive mental deterioration sets in and epilepsy or insanity develops. The mental disturbance is greater in old people and depends sonie- Avhat on the size of the hemorrhage. Those forms which produce serious aphasia especially limit and lessen mental activity. Pathology and Morbid Anatomy.—Spontaneous intracranial hemorrhage is ahvays due to the presence of diseased blood-ves- sels in the brain. This diseased condition consists of 1. A degenerative arteritis which results in producing small aneurisms. 2. A fatty degeneration of the Aessel walls. 3. Be- sides this, in most cases the larger blood-A'essels are atheromatous. 1. The arteritis produces small or miliary aneurisms which affect only the smaller arteries, especially those of the central group. They may be fusiform or sacculated in shape; they range in size from one-fifth to one millimetre (7^ to fa in.) in diameter. They are usually not very numerous, but there may be as many as a hundred in the brain. They are the results, not of inflam- mation, but of a degeneration which affects flrst an area in the internal coat; this causes local Aveakness and consequent dilata- tion; secondarily there is a periarteritis. These aneurisms occur almost exclusiA'ely during the degenerative period of life. 2. Fatty degeneration of the walls of the small cerebral arteries occurs in purpura, scuiwy, leucocythaemia, marasmic conditions, and post-infectiAre states, especially in early life, and is the com- mon cause of hemorrhage at that time. 3. Atheroma affects the larger Aressels only. It is indirectly a cause of hemorrhage by lessening the elasticity of the vessel wall. Atheroma is present in one-eighth to one-fifth the cases. Hyper- trophy of the heart is a factor in causing hemorrhage, and such hypertrophy exists in about forty per cent of cases. Emboli lodged in the cerebral arteries may cause hemorrhage by sud- denly stopping the arterial circulation and raising the blood pressure. Hemorrhages are found by far the oftenest (twenty per DISEASES OF THE BRAIN. 359 cent) in the caudate and lenticular nuclei and adjacent parts. The lenticular and lenticulo-striate branches of the middle cere- bral are oftenest affected; next the branches of the anterior cere- bral to the caudate nucleus and the Aentriculo-optic branches of the middle cerebral. The branches of the posterior cerebral break more rarely. The parts affected in hemorrhage, in order of frequency, are about as follows: Caudate and lenticular nuclei. Meninges and cortex. Centrum ovale. Optic thalamus. Pons, cerebellum, medulla. Cortex hemorrhages are generally small and may be sub- arachnoid or may break through into the arachnoid caA'ity. Ven- tricular hemorrhages are almost always secondary to a rupture into the neighborhood of the basal ganglia. Pons hemorrhages occur usually in the median line. Cerebellar hemorrhages are oftenest due to rupture of the superior cerebellar artery. They usually cleaATe their Avay externally and break into the fourth Aentricle. Dural hemorrhages are due to rupture of the menin- geal Aeins and arteries and of the Aressels in newly organized clots. They lie in the arachnoid cavity and flatten the convolutions. The reparatiAechanges after a hemorrhage take the following course: 1st. Coagulation of the blood, which in a few days be- gins to soften and become absorbed. 2d. Formation of a fibri- nous wall about the clot. This occurs from the seventh to the ninth day. 3d. Formation of a cyst with transparent fluid con- tents, and perhaps fibrous trabeculae running through it, twenti- eth to thirtieth day. 4th. Contraction of the cyst Avail, Avhich begins by the fortieth day. 5th. Secondary degenerations begin from the tenth to the fourteenth day. Physiology.—The blood pressure of the cerebral arteries is equal to about 150 mm. of mercury. The resistance or support furnished by the surrounding tissue is equal to about 10 mm. of mercury. Hence there is a special liability to rupture of intra- cranial A'essels. The middle cerebrals are most often affected, because they are in the most direct line from the heart and are nearest to that organ. The pressure lessens as the arteries subdi- vide and get farther away from the heart (Mendel). The diagnosis must be made from alcoholic coma, uraemic coma, opium coma, epilepsy and hysteria, acute softening from embolism and thrombosis. From alcoholic coma the diagnosis is made by the odor of the breath, the incomplete coma, the equal pupils, the absence of low or unequal temperature. From uraemic coma by the absence of albumin and casts in the 360 DISEASES OF THE NERVOUS SYSTEM. urine, though their presence does not surely indicate uraemia; by the unequal pupils, the temperature, the absence of hemi- plegia, and of the physiognomy peculiar to cases of chronic Bright s disease. From opium-poisoning by the history, the stomach contents, the presence of equal and contracted pupils, the slow respirations, the temperature, and the absence of paralysis. From epilepsy by the history of the onset Avith epileptic cry, the dilated and equal pupils, the biting of the tongue, the ab- sence of hemiplegia, the rather rapid return of consciousness. Hysterical attacks present little semblance to that of apo- plexy; hysterical hemiplegia is characterized by its flaccidity, by its not involving the face, and by the presence of the anaes- thesiae and other hysterical stigmata. In embolic softening the earlier age of the patient, the pres- ence of decided Aalvular heart disease, the parturient condition, the slighter degree and shorter duration of coma, the absence of serious disturbance of temperature, the onset first of paralysis and then of conA7ulsiATe movements and coma—all lead to a pre- sumption in favor of embolism. The presence, on the other hand, of a congested face, tense pulse, and throbbing carotids favors the existence of a hemor- rhage. From thrombotic softening diagnosis is more difficult. The occurrence of prodromata, consisting of slight seizures quickly recovered from, the slighter degree of coma, the advanced age, hard atheromatous arteries, evidence of anaemia and asthenia, weak or fatty heart, the absence of stertorous respiration, flushed face, and unequal temperature not much loAvered or raised, the slight pupillary disturbance, and absence of convulsions point to thrombotic softening. Evidence of a lesion in the pons or cerebellum suggests hemorrhage, while evidence of lesion in the medulla points almost surely to softening. The chances in any case between the ages of thirty and fifty, if there is no heart disease, are six to one in favor of hemorrhage. Prognosis.—The majority of cases get over the first attack. They are very liable to have another within one to five years. The minority recover from this. Few survive a third attack. The prognosis of the attack itself depends on the severity of the coma and paralysis, the disturbance of temperature and of respiration, the evidence of rupture into the ventricles, the de- velopment of decubitus, the continuance of loss of control over the bowels and bladder. If profound coma continues four days there is little hope; if fever deATelops and continues steadily, or if there is initial sub- normal temperature, the prognosis is grave. DISEASES OF THE BRAIN. 361 If the patient passes the first Aveek with little or no fever and consciousness has returned, the prognosis is good. The presence of renal disease and of alcoholism is bad. De- velopment of slight delirium Avhich continues is unfaA'orable. Cerebellar and pons hemorrhages are \Tery fatal, meningeal slightly less so. The prognosis of the chronic stage has been given under symptoms. Improvement continues rather rapidly for three months, then Aery slowly. ImproA^enient may continue for one or tAvo years. Complete recoArery is Aery rare. The great danger after middle age is recurrence of the attack. Treatment of the Attack.—The patient should be laid in a hor- izontal position and kept quiet. Ice should be applied to the head and hot bottles at the feet. The feet and legs should be swathed in clothes wrung out in hot water containing mustard, a cupful to a pail of water. A laxatiAe should be given, either one or tAvo drops of croton oil or a quarter of a grain of elaterium. If there is e\ridenceof intense cerebral congestion, the pulse being very full and hard and the heart beating strongly, bleeding eight to ten ounces is justifiable. Ordinarily it is better to give a drop of tincture of aconite every twenty minutes for two or three hours. Pressure on the carotid of the sound side, and even liga- ture of it, has been recommended, but there is no experience yet to justify it. Administration of bromide of sodium and enemata of ergot have been advised, but are of doubtful value. After the first twelve hours treatment must be symptomatic. Should de- lirium and other evidence of mental irritation appear, large blis- ters must be applied at the back of the neck and an elaterium purge given if the patient is not too Aveak. The use of iodide of potassium or mercury is not indicated unless the case is dis- tinctly syphilitic. The passage of a galvanic current through the brain cannot possibly do any good. Great care should now be taken that the patient does not deA-elop pneumonia. The mouth and pharynx should be cleansed antiseptically, and the patient should not be allowed to remain in one position. If there is sufficient evidence of a meningeal or cortical clot, tre- phining should be seriously considered. At the end of three or four weeks the faradic battery may be used carefully on the affected limbs. A stance of fifteen minutes daily for four to six weeks should be given, then treatment should be suspended for a fortnight, to be begun again and kept up sys- tematically for a year if need be. Massage may be alternated with the electricity. When contractures deAelop the stabile gal- vanic current may be tried, though it does little good. Static sparks, however, are helpful: lukewarm baths should be tried; 362 DISEASES OF THE NERVOUS SYSTEM. and measures used to produce hyperextension of the affected parts. Internally during this time the patient is to be given courses of iodide of potassium, tonics, and laxatives if needed. The pa- tient should be made to live a quiet life, preferably in a Avann, equable climate. The kidneys should be kept active and arterial tension low. For these purposes nitroglycerin should be given and at times small doses of chloral, and the diet should be simple and rather non-nitrogenous. Strychnine in very small doses (gr. jfa) sometimes helps the contractures; so also do the bromides and physostigma. Acute Softening of the Brain (Embolism, Thrombosis). Acute softening is a condition caused by the plugging of a blood-vessel with an embolus or thrombus, and is characterized by a sudden apoplectic seizure; the symptoms eventually running a course like that of cerebral hemorrhage. Etiology.—Embolism occurs rather more often in Avomen, thrombosis in men. Embolism is rare in children; it occurs often, est between the ayes of twenty and fifty, thrombosis between the ages of fifty and seventy. The most important predisposing factors in embolism are acute or recurrent endocarditis, infec- tious fevers, profound anaemia, pregnancy, and blood dyscrasiae; in thrombosis, syphilitic, lead, or gouty arteritis, fatty heart, and blood dyscrasiae. The same causes which lead to the arterial dis- ease Avhich produces cerebral hemorrhage also predispose to thrombosis; though in the latter condition atheroma plays the important part. Symptoms.—In embolism there are rarely any premonitory symptoms; the onset is sudden; it may begin with some con- vulsive twitchings, then follow hemiplegia and temporary loss of consciousness. Coma, however, is rarer than in hemorrhage, and if present is usually shorter. There is rarely vomiting, nor do we find the hard, pulsating arteries, flushed face, and severely stertorous breathing. The initial temperature changes are slight, but in a few days fever may develop. In thrombosis premonitory symptoms are frequent. In syphilitic cases there are headaches and cranial nerve palsies. In other cases vertigo, temporary aphasia, transient hemi- plegia, numbness of the hand and foot, and drowsiness may be present. The onset is more gradual; the hemiplegia slowly develops, taking several hours, perhaps, for its completion; meanwhile the patient gradually becomes comatose. The at- tack sometimes is rather sudden, with no loss of consciousness, and it may occur in sleep. The temperature often has a DISEASES OF THE BRAIN. 363 slight initial fall, followed by a rise, just as in hemorrhage. In both embolism and thrombosis the hemiplegia tends to im- prove very much in a few days or weeks unless the vessel ob- literated is a large one. Embolism is rather more apt to affect the left side of the brain, though the difference is not great. The middle cerebrals are most frequently affected (seventeen out of twenty-seven cases). Softenings affect the vertebrals, basilar, and posterior cerebral arteries more often relatively than do hem- orrhages ; then the initial symptoms may not present the char- acter of hemiplegia, but of a bulbar paralysis. Acute softening may kill Avithin twenty-four hours, but, as a rule, the patient survives the onset, and if he dies it is not for several weeks. After the acute stage is over the patient passes into the chronic stage, which resembles in nearly all respects that of hemorrhage. After an acute softening, however, it is belie Ared that there are more spastic symptoms and a, greater tendency to mobile spasm. In embolism, owing to the youth and freedom from arterial disease, the mind is less affected; Avhile in thrombosis the contrary is the case. Pathology.—The embolic plug cuts off the blood supply from a certain area of brain tissue. In twenty-four hours this begins to soften. If the area is in the cortex it becomes red (red soft- ening) ; if in the white and less Avascular part, it is usually white with a few red punctate spots. The red softening gradually be- comes yellow (yellow softening). The dead tissue softens and is absorbed, leaving a cicatrix or cyst. If the embolus contains in- fective microbes there may be a local encephalitis and abscess. In thrombosis there are usually evidences of extensive athe- roma or of syphilitic arteritis. In those instances in which the thrombosis is caused by the blood state and a weak heart, little arterial change occurs. Atheroma affects chiefly the internal carotids and the large arteries at the base, viz., the middle, an- terior, and posterior cerebrals and the basilar and vertebrals. Thrombosis Avith apoplexy occurs oftenest in the corpora striata and optic thalamus, next in the pons and medulla. Embolism almost always affects the great basal ganglia or some cortical branch of the anterior and middle cerebrals. The secondary changes after thrombosis resemble those after embolism; a thrombus, howeAer, may lead to supplementary embolism through breaking off of a clot, and both conditions may cause a complicat- ing cerebral hemorrhage. The Diagnosis.—The important points have been gone over under the head of hemorrhage. They may be tabulated in part here. 364 DISEASES OF THE NERVOUS SYSTEM. Hemorrhage. Age, thirty to fifty. Hereditary history of arterial disease. Sudden onset, with coma and paralysis occurring together, the coma deepening. Initial and early rigidity. Very unequal pupils. Stertorous breathing and hard, rather slow pulse. Peculiar alternating conjugate deviation. Early rigidity. Peculiar disturbances of temperature, as described. Acute Softening. Earlier or later age. History of syphilis. Premonitory symptoms and more gradual onset, more transi- tory coma, or absence of coma. Initial convulsive movements. Presence of Aveak heart or endocarditis. Slight hemiplegia with anaesthesia. The puerperal state. Embolism is distinguished by the age, the presence of endo- carditis, of the puerperium, or infective fevers, and by the sud- den onset, with perhaps some convulsive movements. Thrombo- sis occurs oftener in the aged, and there are prodromata—a slower onset and evidence of arterial disease and a weak heart. The prognosis as regards the attack is somewhat better than in hemorrhage as a rule. In embolism it is good as regards re- currence ; in thrombosis, bad. The mental condition is better in embolism; usually Avorse in thrombosis. The recovery from at- tacks is more complete in acute softening. After the chronic stage is reached, however, the prognosis is about the same in all forms. The treatment of the attacks consists essentially in rest and such attention to the bowels, kidneys, and heart as may be indi- cated. In thrombosis it may be important to give heart stimu- lants and arterial depressants, and for this purpose I advise the use of alcohol, digitalis, or strophanthus with nitroglycerin. Iodide of potassium and mercury ought to be given if there is the slight- est suspicion of syphilis. Later it is well to give courses of the iodides and mercury and of strophanthus, nitroglycerin, strych- nine, and such tonics as may be indicated. The symptomatic treatment of the chronic stage is the same as in hemorrhage. DISEASES OF THE BRAIN. 365 Cerebral Palsies of Children—Hemiplegia, Double Hemiplegia or Diplegia, and Paraplegia. The brain palsies of early life show themselves in the form of. 1, hemiplegias; 2, diplegias or double hemiplegias, in which both sides of the body are involved; and, 3, paraplegias, in which the lower limbs are chiefly or entirely involved. In these palsies, as in the same troubles of adult life, the loss of motor poAver is ahvays accompanied with a rigidity and with some contractures and exag- geration of reflexes, in this respect distinguishing these paralyses from those of spinal origin. The seat of lesion in these cases is in the hemispheres of the brain, and it is the upper motor seg- ment which is invohTed; that is to say, that part of the motor tract which extends from the brain cortex doAvn to the spinal cord as far as the anterior horns. The brain palsies of children are therefore disorders of the cortico-spinal segment, while the spinal palsies of children are disorders of the neuro-spinal seg- ment. Etiology.—The disease occurs rather oftener in males than in females, though the difference is slight. The vast majority occur in the first three years of life; about one-third of them are con- genital. Injuries to the mother during the time of pregnancy, possibly diseases and emotional disturbances at this time, are factors in producing the congenital cases. Those cases that occur at the time of birth are due to tedious labor, the use of forceps, and other injuries at the time of parturition. After birth, the causes are those which lead to the production of intracranial hemorrhages, embolism, and thrombosis; these being injuries and the infectious fe\Ters. Of the latter, pneumonia, whooping- cough, measles, and scarlet fever are the most prominent. Syph- ilis is a rare cause; cerebro-spinal meningitis and epileptic con- vulsions are also occasional causes. Symptomatology.—The disorder in about one-fourth of the cases begins with a convulsion, which may be unilateral, but is usually general in character, and may last for seA'eral hours. At the same time a febrile process develops, and this continues for several days. When these acute symptoms have subsided, or be- fore this, it is noticed that the child is paralyzed upon one side, the paralysis involving the arm, leg, and face as in adult hemi- plegia, or perhaps involving both sides. This paralysis under- goes gradual improvement, the face recovering earliest and most, the leg next, and the arm least. As the child develops it is found that the paralyzed side fails to grow as fast as the other, and there may be half an inch to one or two inches of shortening in the arm or leg. The circumference of the limbs is less, the sur- 366 DISEASES OF THE NERVOUS SYSTEM. face someAvhat colder, and some vasomotor disturbance may be present. With the progress of the case a rigidity of the affected limbs develops: the heel becomes drawn up, so that there is talipes equino-varus or equino-Aralgus. The flexors of the forearm and of the wrist and fingers contract, as do also the adductors of the thighs. In general it Avill be found that there is a contraction of the flexors and adductors of the affected limbs. With this rigidity and'the contractures there is an exaggeration of reflexes and clonus in most cases. In the disordered limbs the peculiar mobile spasms develop. These consist of athetoid, choreic, and ataxic movements, also sometimes tremors and associated Fig. 180.—Post-Hemiplegic Athetosis. Beginning in Childhood. movements. The choreic and athetoid movements are the most common (Fig. 180). Along with the deArelopment of these symptoms it is noticed that there are disturbances in the mental condition of the child. It is usually backward in development, this backAvardness rang- ing from simply a feeblemindedness to complete idiocy. Taking all cases, there is about an equal division between feeble-minded' ness, imbecility, and idiocy (Sachs). Perhaps a little over one- fourth of the cases have a fair intelligence. There is usually slowness in learning to talk, and in a small proportion of cases there is a decided aphasia. Such condition is rather more fre- quent with right hemiplegia than with left hemiplegia, though the rule is not an absolute one. In connection with the mental defect there may develop many of the peculiar moral traits as- DISEASES OF THE BRAIN. 367 sociated with idiocy and low degrees of intelligence. Epilepsy very frequently complicates the disease; nearly one-half of the cases suffer from this trouble. This epilepsy is in most cases general in character; in a few cases it takes the Jacksonian type, in a small number petit mal alone is noted. Examination of this class of sufferers reveals, aside from the paralyses de- scribed, A-arious evidences of defective deA'elopment. These are known as stigmata of degeneration; though they cannot be classed strictly among such, since they are acquired stigmata in most cases, rather than marks Avhich are the result of primary deficiency in deA'elopment. These stigmata consist of a micro- cephalic or a macrocephalic skull, cranial and facial asymmetry, prognathism, imperfectly developed teeth, and a high palatal arch. It has been found that, as a rule, in cases of cerebral hemiplegias of childhood the patient eAentually has a slight flat- tening of the skull on the side of the lesion (Fisher and Peterson). Finally, in a feAV cases there may be found defects in the special senses, such as imperfect hearing, deafness, deaf-mutism, and de- fects in A'ision such as hemianopsia, and perhaps imperfections in smell and taste. Anaesthesia is never observed. The symptoms in the cerebral palsies of children having passed the acute stage and haAdng become somewhat ameliorated, enter into a chronic stage. This chronic stage begins within a feAv months after birth or after the onset of the disease. No great change occurs in the paralyses as the child groAvs older until he reaches the time of puberty, though there is a slight improve- ment in most cases. After the time of puberty, if the mental condition of the child is good, the physical symptoms are apt to improve considerably. Morbid Anatomy.—The primary changes that lead to the cere- bral palsies of children are- 1st, simple agenesis or lack of brain development, producing localized atrophy of the cerebrum and the condition known as porencephalus. True porencephalus is a condition in Avhich, owing to a congenital defect in nutrition, a cavity or depression exists in the cerebral hemispheres, this caA'- ity reaching generally into the lateral ventricle. True poren- cephalus is found in about one-fourth of the cases, though no definite statistics can be given, owing to the different interpreta- tions given to this term; 2d, hemorrhage, Avhich is probably the most frequent of the single causes; 3d, embolism; 4th, throm- bosis; 5th, meningoencephalitis and perhaps polioencephalitis; 6th, a diffuse cortical sclerosis. Many other terms are used to describe the pathological conditions found at the basis of the brain palsies of children; but the principal causes of all are un- doubtedly as has been described—hemorrhages, embolism and thrombosis, and a defective development or agenesis. It is prob- 368 DISEASES OF THE NERVOUS SYSTEM. able that in the hemiplegics the original lesion is generally a central hemorrhage, less often a meningeal hemorrhage. After this, probably the most frequent condition is a porencephalus from some intrauterine accident Avhich may have been defective nutrition causing anaemia and softening, or hemorrhage or throm- bosis. Polioencephalitis or inflammation of the cortex of the brain of the kind similar to poliomyelitis is alleged to be a cause in some cases by Striiinpell, but this has not yet been proven. In double hemiplegias or diplegias of children the cause is in the jfaaWii i-i'i ..jfiMfaa «> ■,„ ■■■•. ^____________________________L_~^___________~_______'•*»■' ■ Fig. 181.—Atrophied Brain with Sclerosis and a Cyst, prom a Case of Infantile Cerebral Hemiplegia. vast majority of cases a meningeal hemorrhage due to some in- jury or disturbance at the time of labor. In other cases of di- plegia the lesion is a double porencephalus, which may be either the result of an intrauterine hemorrhage or simply a defective development. In the paraplegias the lesion is probably Arery much the same as in the diplegias, that is to say, either a menin- geal hemorrhage or a true porencephalus. Occasionally a diffuse sclerosis has been found in these cases. Not infrequently, as the result of hemorrhages, there develop cysts which fill up the atro- phied areas of the brain (Fig. 181). It is difficult to present accu- rately and definitely the relations between the pathological DISEASES OF THE BRAIN. 369 change and the clinical result, but it may be shown with some degree of correctness in the following table • Original Lesion. Later Pathological Condition. Clinical Result. Hemorrhage. Embolism. Thrombosis. Agenesis. Atrophy. Lobar sclerosis. Cysts. Porencephaly. Microcephaly. Hemiplegia. Diplegia. Paraplegia. Sensory defects. Mental defects. Epilepsy, etc. Diplegia or Birth Palsies.—That form of the brain pal- sies of childhood characterized by double hemiplegias or di- plegias has certain special characters .which lead to its being often classed apart. These diplegias in almost all cases are con- genital and are due either to injuries at the time of birth or to some disorders of intrauterine life. There may be convulsions or a prolonged state of asphyxia at the time of birth. After re- coA'ery from this no special trouble is noticed Avith the child by the mother for some Aveeks or months, Avhen it will be found that it does not use its arms or legs. Other convulsions develop, and eventually the features of a double hemiplegia with mental im- pairment and epilepsy are observed (Figs. 182, 183). In these cases the mental defect is much more decided than in the hemiplegias; indeed, few of these cases ever show any good amount of intelli- gence. Epilepsy is extremely common. The anatomical lesion in the cases is, as already stated, either a meningeal hemorrhage which has pressed upon and injured the cortical motor areas in each hemisphere or it is a congenital porencephalic defect. Spastic Cerebral Paraplegia.—In a feAV cases the brain lesion is such that there results Aery little disturbance to the arms or face, and the paralysis is almost entirely confined to the lower extremities. Such cases Avere once described as spastic paraplegias of childhood and thought to be due to lesions in the spinal cord. There is little doubt, hoAvever, now that the pri- mary trouble is in all cases a bilateral lesion of the cerebral hemi- spheres Avith a descending degeneration affecting a portion of the lateral columns of the cord. In these cases there are rigidity and contractures, club foot, exaggerated reflexes and spasms of the flexors and the adductors, so that the child's legs cross each other and interfere in its feeble attempts at walking. Spastic para- plegia is usually, like diplegia, a birth palsy and due to the same causes. It seems also to be associated with defeeth-e intelligence to about the same degree as Avith diplegias. Epilepsy also is common with this type of the disease. Diagnosis.—The clinical diagnosis of cerebral palsies is to be made from the spinal palsies. The latter are distinguished by the 24 370 DISEASES OF THE NERVOUS SYSTEM. fact that in the paralyses of spinal origin there is no rigidity or exaggeration of reflexes, and there are electrical degenerative reactions of the muscles and decided wasting of the limbs with shortening. The mode of onset in cerebral palsies and their dis- tribution in the form of hemiplegias in which the face is involved also indicate the seat of the lesion. The pathological diagnosis Fig. 182. Fig. ia3. Figs. 182 and 183.—Cerebral Diplegia with Contractures and Talipes. Fig. 182 standing ; Fig. 183 suspended by arms. is by no means an easy one. Cerebral palsies occurring at the time of birth and accompanied at that time with general convul- sions or asphyxia may be considered to be due to meningeal hem- orrhage, especially if the delivery of the child has been brought about by the use of forceps or if the labor has been long and tedious. Diplegias and paraplegias which are congenital are probably due to true porencephalus, provided there Avas no diffi- DISEASES OF THE BRAIN. 371 culty at the time of labor and no convulsions or other serious phenomena alter it. Cerebral palsies occurring after birth in the first, second, or third year of life are apt to be due to hemor- rhage, and less often to embolism, or thrombosis. Hemiplegias developing after infectious fevers are likely to be due to henior- hage. In diagnosticating the pathological lesion in such cases it must always be remembered that the hemorrhage is much more frequent than embolism, and that thrombosis as a factor has not yet been A-e:y clearly established. Course and Prognosis.—In all types of the disease the course is chronic and perfect cure is hardly possible, although in the slighter forms of hemiplegia nearly all traces of the paralysis may be absent. In the hemiplegic form the patient often reaches adult life, and if his intelligence is not defective and he has no epilepsy, the motor trouble improves a great deal and he may live a long and useful life. If epilepsy and mental defect are present, there ensues eATentually a further mental deterioration, and such cases rarely live much beyond the period of adoles- cence, or if they do they pass into the asylums for the idiotic and epileptic. The diplegic and paraplegic cases haA7e a much Avorse prognosis both as to duration of life and as to improve- ment in symptoms. The degree of intelligence and the absence of epilepsy are the tAvo factors which measure the seriousness of these cases, as they do those of the hemiplegias. As regards the significance of individual symptoms, the post-hemiplegic move- ments have a bad import; the presence of a microcephalic head or of decided marks of degeneration is unfavorable. Treatment.—The treatment, so far as the paralysis is con- cerned, is largely mechanical. The patient is benefited by occa- sional courses of electrical treatment Avhich stimulate someAvhat the nutrition and functions of the muscles. Massage and stretch- ing of the contractured tendons and limbs also are helpful in my experience. The orthopedic surgeon is able to render valuable assistance by occasional overstretching of the contractured limbs and placing them in splints. Tenotomy may also be resorted to with adA^antage, as I have had occasion to see. The child should be encouraged above all, however, to use the limb as much as pos- sible. He should be taught gymnastic exercises; running, walk- ing, and bicycle-riding are all measures Avhich ghe great help. When the child's intelligence is good and there is little or no epi- lepsy, a great deal can be expected in the way of improvement as the child grows older. So far as the epilepsy is concerned, it should be treated on the same principles as idiopathic epilepsy, except that great care should be had in the use of the bromides; a thorough test must be made in order to determine how much of this drug will sup- 372 DISEASES OF THE NERVOUS SYSTEM. press the fits, and then its use must be graduated in the future in accordance with the knoAvledge thus obtained. The mental de- fects of the child can only be helped by proper training of the body and careful education of the mind. The question of oper ative interference in these cases has of late excited much atten- tion. A priori it would not seem as though surgical interference could do good in relieA'ing conditions in Avhich there is destroyed or atrophic tissue. Still the subject must be dealt Avith em- pirically, and there have been some results which sIioav that apparently a relief is obtained in a few cases by trephining the skull or by Lannelongue's operation of craniectomy. If there is no microcephalus, if the case is one of hemiplegia with imbecility and epilepsy, the surgeon should simply make an exploratory opening. If he then finds any evidences of compression from the presence of a cyst, this may be A'ery cautiously opened. If there is microcephalus, the linear craniectomy is the operation which is indicated. This has been found to be a A'ery serious surgical measure and should only be resorted to Avith great cau- tion. In all cases, in operating on children, it has been found that it is imperathTe that the operation be made as short as pos- sible, and that as little be done at any single operation as is con- sistent with the indications. CHAPTER XIX. DEGENERATIONS AND SCLEROSES. Degeneration of the brain tissue, as in the case of the cord tissue, leads to sclerosis. Destruction, necrosis, injuries from any cause, lead also to sclerosis. Sclerosis is sometimes a primary change due to a gradual proliferation and increase of connecthre tissue and neuroglia tissue. We have, therefore, in the brain primary degenerations and scleroses and secondary scleroses. The primary degenerations are bulbar palsy and ophthalmo- plegia externa, or, as these diseases are sometimes called, polio- encephalitis inferior and polioencephalitis superior; besides these are paralytic dementia, Avhich is a diffuse cortical sclerosis, and disseminated sclerosis; and finally, underlying epilepsy Ave have, it is believed, a diffuse increase of neuroglia tissue which has been called a neuroglia sclerosis or a gliosis. Secondary scleroses are those which are the result of inflammations, hemorrhages, injuries, embolism, and thrombosis. A secondary sclerosis usu- ally affects certain special areas of the brain and is called a lobar sclerosis. Corresponding to these pathological changes we have certain clinical types of disease. Thus the diffuse cortical scle- roses cause what is knoAvn as paralytic dementia; polioencephali- tis superior and inferior cause biilbar paralysis and ophthalmo- plegia; neuroglia sclerosis is perhaps at the basis of epilepsy and other degenerative disorders; lobar sclerosis is the lesion in cases of cerebral palsies of children, such as hemiplegias, diplegias, and paraplegias, and many forms of inco-ordination, motor disturb- ance, and convulsive manifestations. Besides the terms that we have used here, there are in medi- cal literature frequently employed the expressions brain atrophy, hypertrophy, porencephaly, chronic cerebritis, tuberous scle- rosis, all of which terms are more or less synonymous with what we have already given and are superfluous to our nosology. There is possibly a primary chronic softening or degeneration of the brain, but if it exists is extremely rare, and occurring in advanced life is probably due to disturbances in the blood sup- ply- 374 DISEASES OF THE NERVOUS SYSTEM. Multiple Sclerosis (Disseminated Sclerosis, Insi i,ak Sclerosis, Sclerosis en Plaques Disskmixkks). Multiple sclerosis is a chronic degenerath-e disease character- ized by the deA'elopment of small patches of connective tissue throughout the brain and spinal cord, and by symptoms of paral- ysis, tremor, disturbances of speech and of the eye muscles, and by a number of other symptoms, very variable in character. In America the disease is, in the Avriter's experience, rare. The diagnosis, to be sure, is often made, but only two cases ver- ified by post mortems haA'e been reported by American physi- cians. Etiology.—Heredity is a predisposing cause in a small propor- tion of cases. The disease has been directly inherited; but generally the patient simply inherits a neuropathic constitution. The disease develops in the early part of adult life, oftenest be- tween the ages of thirty-five and forty-five, but it may occur in children, and it is probable that a considerable number of cases deA-eloping in adult life are cases in which the seeds of the disease were sown during adolescence. The sexes are about equally affected, the preponderance being rather in favor of the female. The chief exciting cause of most cases is undoubtedly some infective fever, usually typhoid, diphtheria, small-pox, measles, or erysipelas. It has been known to folloAV an acute attack of hemoglobinuria and perhaps of malaria. Myelitis and encephali- tis are said to have led to the subsequent development of multi- ple sclerosis, but this is unlikely. Exposure to cold and wet and traumatisms, especially those Avhich lead to the development of the traumatic neuroses so called, are sometimes the cause of the disease. In fine, acute infections and severe traumatisms involv- ing concussion, co-operating Avith a neuropathic nervous system, form the most important etiological factors. Syphilis is rarely a cause. Symptoms.—The disease probably has existed a long time be- fore A'ery notable symptoms deA-elop. Among the first things which the patient observes is a Aveakness in the limbs, usually in an arm or leg; this is soon accompanied Avith a tremor which is of a jerky, irregular character. The paralysis sIoavIv extends and the patient becomes partially paraplegic or hemiplegic. He may have some ataxia with the paralysis. At the same time disturb- ances in Adsion occur, such as amblyopia, spots before the eyes, nystagmus, and diplopia. Defects in articulation develop; the speech becoming slow and scanning, or " syllabic," as it is called. Attacks of Aertigo or apoplectic or epileptic seizures occur. There may be some sensory symptoms, although these are usu- DEGENERATIONS AND SCLEROSES. 375 ally not marked or permanent. When present they consist of pains in the limbs, resembling those of locomotor ataxia, and anaesthesias Arariously distributed. Mental change is not infre- quent and is somewhat characteristic. The patient's mind is rather dull, but his temper is equable and placid. The memory may become Aveak; very rarely insanity deA^elops. The disease runs a very variable course, depending upon the seat of the multiple lesions. In typical forms these lesions are distributed throughout the brain and spinal cord, but chiefly in the brain axis, and consequently in these cases the progress of the symptoms is fairly uniform. We have referred to them in the brief outline of the disease; they may be enumerated here again. 1st. Paralysis taking the form of hemiplegia, paraplegia, monoplegia, or some cranial nerve paralysis. 2d. A jerky tremor, often called intention tremor. 3d. Spastic phenomena shown by exaggeration of knee jerks, clonus, and rigidity of limbs. 4th. Cerebral disturbances characterized by Aertigo, headache, epi- leptiform and apoplectiform attacks, and the peculiar mental state referred to. 5th. Nystagmus and disorders of vision and of the optic nerve. 6th. Disorders of articulation or scanning speech. 7th and finally, an irregular and intermittent course to the disease. We will take up some of these symptoms now in detail. The paralysis is most frequently of the nature of a hemiplegia or paraplegia which is neArer complete, but rather in the shape of a simple Aveakness. This paresis is almost always accompanied with a spastic condition, so that there is exaggeration of reflexes and clonus. It is often also accompanied with an inco-ordination, but most frequently of all it is associated with the peculiar " in- tention tremor " referred to. This tremor is coarse in its charac- ter; it ceases when the limbs are at rest and is shown only when voluntary moAements are attempted. Thus when the patient tries to raise a glass of water to his lips the jerky tremulous movements increase so that the water is spilled before it reaches his mouth. The tremor affects the muscles of the neck some- times, so as to cause oscillation of the head; and sometimes the muscles of the trunk, but rarely if eAer the facial muscles. The nystagmus, which is another manifestation of the tremor of the disease, is usually lateral and is present in about two-thirds of the cases. Eye palsies involving most often the sixth nerve occur in about one-sixth of the cases. The pupillary and ciliary mus- cles are rarely affected, and the Argyll-Robertson pupil is not found in the disease. The disturbance of articulation is very common, ranking in frequency with the nystagmus and tremor. In speaking the patient separates the words into distinct sylla- bles, or he may simply separate the words very distinctly from 376 DISEASES OF THE NERVOUS SYSTEM. each other. Sometimes Avords are dropped or imperfectly pro- nounced. The trouble seems to be due to inco-ordinate move- ments of the tongue and other muscles and organs concerned in articulation. The cutaneous disturbances of sensation are not A-ery great. They occur in perhaps one-third of the cases, but are often temporary and are perhaps due to a superimposed hys- teria. Severe pain is not a common symptom, but it may exist in the form of neuralgias of the nerves of the limbs or in the shape of girdle pains. The anaesthesias are usually partial and involve only small areas of the limbs. There may be various paraesthesiae affecting the paralyzed parts of the body. Of the nerves of special sense the eye is most frequently involvod, and a study of its condition is most important. The paralyses of its muscles and consequent diplopia have been referred to. Tem- porary disturbance of A'ision is not uncommon. Such disturb- ances consist of constriction of the Arisual field, amblyopia, and scintillating scotomata. The fundus of the eye shows in some cases a slight degree of neuritis, and in the later stages a true atrophy may be present. One eye is usually more involved than the other, and one eye alone may be affected. The ophthalmo- scopic changes in the disc are said to be different from those found in locomotor ataxia and in the neuritis of brain tumors. Disorders of the Aisceral centres producing retention of urine, constipation, and trophic disturbances leading to oedema, skin eruption, arthritis, etc., are relathrely rare and occur, if at all, in later stages of the disease. Aborted Types or " Forms frustes " of Multiple Scle- rosis.—In some cases the nodules of sclerosis are so limited in number and so peculiarly placed that they give rise to very atypical forms of the disease. Perhaps the most common one is that in Avhich the disease takes the type of a progressive spastic paraplegia. The patient suffers from weakness of the lower limbs, accompanied Avith stiffness, cramps, exaggerated reflexes, and disturbances in the bladder and rectal functions. Anaes- thesias, pains, and the girdle symptom may develop. In addition to this, however, a close examination will show some evidence of disease of the optic nerves and perhaps disturbances of the eye muscles. The patient Avill have nystagmus, diplopia, or other visual disorders. There Avill also be some attacks of vertigo or of epileptoid convulsions. The combination of the eye symptoms with the progressive paraplegia will often reveal the true char- acter of the disease. A purely spinal form of multiple sclerosis has been described; it is probable, however, that multiple sclerosis never affects the spinal cord alone. A cerebral form of multiple sclerosis has also been described, but this usually runs a course very similar to DEGENERATIONS AND SCLEROSED. 377 that of the true cerebro-spinal malady, and it is unwise to at- tempt to make any special clinical distinction. Charcot divides the symptoms into cerebral and spinal, and includes under the cerebral the eye symptoms, apoplectic attacks, and speech dis- turbances; under the spinal symptoms, paralysis and tremor. Tremor, however, is often, if not usually, due to a cerebral lesion. Pathology.—Grayish nodules are found distributed through the brain and spinal cord. They vary in size from a millimetre to two or three centimetres in diameter (one-twenty-fifth to one Fig. 184. Fig. 185. Figs. 184 and 185.—Multiple Cerebro-Spinal Sclerosis (Charcot). inch). They are of firmer consistence than the surrounding brain substance, but are not quite so hard as ordinary connective tissue. They consist microscopically of fibrous tissue which does not seem to be connected with the walls of the blood-vessels as a rule. Very often the axis cylinders of nerves can be seen passing through the lesion. The nodules are found most frequently in the white matter of the brain, more especially in the pons, internal capsule, and centrum ovale (Figs. 184, 185). They rarely begin primarily in the gray matter, but may invade it secondarily. The roots of the peripheral, especially of the cranial, nerves occasionally con- 378 DISEASES OF THE NERVOUS SYSTEM. tain or are surrounded by these sclerotic masses. In the spinal cord they may extend up and down the gray and white matter for a considerable distance, or they may involve the whole cord at a certain level, turning it into a fibrous mass. The blood-vessels sur- rounding and in connection Avith these diseased areas show some evidences of thickening and increased vascularity, but no true inflammatory process. The primary pathological change in mul- tiple sclerosis is as yet unknown ; many things point to its start- ing originally from small emboli or thrombi which lead to minute softenings, with a secondary reparative and sclerotic process. The fact that the disease follows infective fevers makes such an origin of it seem probable. On the other hand, pathological anatomy does not yet bear out this view, and it is possible that Fig. 186.—Spinal Sclerosis. J, K, L, M, Sclerotic foci; A, anterior, B, posterior horn (Blocq). the disease begins by a primary degeneration affecting flrst the myelin sheaths of the nerve fibres, this being followed by a neu- roglia and connecth'e-tissue proliferation which ends in the formation of the small islands of sclerosis. An important patho- logical peculiarity of the process is that while it destroys the myelin sheaths of the nerves, the axis cylinders remain intact for a long time, and consequently conduction of nerve impulses takes place imperfectly, directly through the nodular masses. Course and Duration.—The disease runs a very irregular course. Its prodromal stage is long and remissions of consider- able length occur. The disease may last from five to fifteen years, the average duration being five or six years. Death sometimes occurs from involvement of the nerves of the medulla, but more often from weakness and exhaustion or some intercurrent malady. DEGENERATIONS AND SCLEROSES. 379 Diagnosis.—The diagnosis in typical cases is not very difficult; but as, on the other hand, typical cases are not common, the disease has always to be studied with great care before certainty can be reached. The diagnosis is based upon the slow develop- ment of the disease, with attacks of vertigo, weakness, and un- certainty in gait; upon the paralysis of the extremities with intention tremor, ataxia, rigidity, and contractures; upon the disturbances of vision, nystagmus, and the speech troubles. The presence of headache, attacks of vertigo, apoplectiform attacks, and the peculiar mental condition often furnish help. The age of the patient and the cause should also be taken into consider- ation. The disease must be distinguished from Friedreich's ataxia, spastic spinal paralysis, locomotor ataxia, dementia para- lytica, bulbar paralysis, paralysis agitans, chronic meningitis, and hysteria. The points already ghTen and those furnished under the heads of these different diseases must be utilized in making these distinctions. The method of exclusion may be used with advantage in reaching the diagnosis of this protean malady. Prognosis.—The prognosis, while not favorable as regards the ultimate cure, is somewhat favTorable as regards the remission and improvement, and the disease on the whole is not so severe as is locomotor ataxia or the other degenerative disorders. Treatment.—In the treatment the same measures recom- mended for other degenerative diseases of the nerA'ous system must be employed. Hygienic measures, electricity, and hydro- therapy have some therapeutic value. Internally the use of large doses of iodide of potassium, the hypodermic injection of arsenic, the administration of nitrate of silver and of quinine and other tonics are advised. A very regular, systematic, and quiet mode of life, combined Avith the use of iodide of potassium and bichloride of mercury, has produced the best results in my experience, even in cases which gave no history of syphilitic in- fection. Hypertrophy and Atrophy of the Brain. These are both terms which can be dropped from neurological nomenclature as representing distinct disorders. Hypertrophy of the brain has been described as a disease occurring in child- hood, developing either congenitally or in association with rick- ets. It has been said to produce much the same symptoms ob- jectively as hydrocephalus. There is not sufficient pathological evidence to justify us in saying that the hypertrophy is really a hypertrophy of the brain, rather than a chronic inflammation or gliomatosis or some other tumor formation. Atrophy of the brain may be either total or partial. When total, that is, involving the whole of the encephalon, it is con- genital and is described under the term microcephaly. A slight 380 DISEASES OF THE NERVOUS SYSTEM. degree of general atrophy occurs during senility and in the later stages of chronic insanity. Partial brain atrophy is either con genital or acquired. When congenital it is due to some intra- uterine inflammation, vascular obstruction, or aphasia; and Avhen acquired it is due to some of the numerous causes which have been described under the head of infantile and birth palsies. It will be seen that brain atrophy does not have any place as a distinct disease. CHAPTER XX. TUMORS OF THE BRAIN.-SYPHILIS. The kinds of tumor found in the brain are tubercle, syph- iloma, glioma, and sarcoma, which are the common forms; myxoma, carcinoma, fibroma, osteoma, cholesteatoma, lipoma, psammoma, neuroma, vascular tumors including aneurisms, echinococcus, and cysticercus. In fact, all forms of new growths are found in the brain; but the infectious granulomata, tubei cle, and gumma and the sarcomatous type of tumors are the most common. As compared with other organic diseases of the cen- tral nervous system, brain tumors are rare. Etiology.—Brain tumors affect males oftener than females, the ratio being about as two to one (644:320). Sarcomata alone seem to affect females about as often as males. Brain tumors occur with about equal frequency throughout all ages of life up to about fifty; one-third occur under the age of twenty (Gowers). During childhood tumors are about equally distributed through- out all ages (Starr). One-half of all the tumors of childhood are tubercular; after this come gliomata and sarcomata. The gumma, glioma, and sarcoma begin to be more frequent after the age of twenty. Sarcoma and especially cancer occur in the mid- dle and later ages of life; but brain tumors of any kind are ex- tremely rare after the age of sixty. To sum up in tabular form, the relative frequency of the dif- ferent kinds of tumors Avith regard to age is shown in the follow- ing: Childhood, .... tubercle, parasites. Early life, .... gumma, glioma, parasites. Early and middle life, . . sarcoma, glioma, and gumma. Middle and late life, . . sarcoma, gumma, cancer. Heredity has a slight influence in predisposing to brain tumors. Blows on the head and other forms of injury to the cranium are exciting causes in a small proportion of cases. Symptoms.—The symptoms of brain tumors vary extremely in accordance with the location, the kind of tumor, the rapidity of growth, and the age of the patient. The general course of a 382 DISEASES OF THE NERVOUS SYSTEM. case of brain tumor in an adult is somewhat as follows The patient first notices a headache which is very intense and persist- ent and which has exacerbations of frightful severity. With the headache or between the attacks vomiting occurs, Avhich is often not accompanied Avith any nausea. Sensations of vertigo, an- noying paraesthesiae, and compulsive movements affecting one or more extremities develop, and there may even be general con- vulsions. The patient finds that his eyesight is weak and pro- gresshely deteriorates. The mind becomes more or less dis- turbed, the mental processes are dull and slow, a feeling of hebetude and incapacity to attempt any mental exertion is present. As the disease progresses the intense pains and vomit- ing produce weakness and emaciation. Paralyses of A'arious kinds develop. Blindness may ensue. Convulsions of a local or general character become more frequent, and finally the patient becomes bed-ridden and helpless. The course of the disease is not a steady one, there being often slight remissions, or there may be periods Avhen progress seems to be arrested. After a period of time varying from one to four or five years death occurs from exhaustion or some intercurrent malady. The symptoms thus Arery briefly outlined are divided into gen- eral and focal. The general symptoms are at flrst those of cere- bral irritation and of headache, vertigo, and vomiting, optic neu- ritis, convulsions, disturbances of speech, and hebetude. Head- ache occurs in from one-half to two-thirds of the cases; it is very severe and the pains are of a boding or lancinating character; they are so horrible that they often lead the patient to think of suicide. The pains are sometimes periodical, occurring every night or every other day, and suggest by their periodicity a mala- rial character. They are located sometimes in the brow or in the occiput, while sometimes they are diffused all over the head; they are rather more frequent than otherwise in the neighbor- hood of the tumor. They are more frequent with cerebellar tumors than with those located anywhere else. They are also frequent Avith tumors of the mid-brain and of the cerebral hemi- spheres. They are less frequent when situated in the peduncles and at the base of the brain. The pains are due to the increased intracranial pressure and to irritation of the membranes of the brain by the encroachment upon them of the neAv growth. Head- ache occurs in about the same proportion in children and adults, and it does not seem to bear much relation to the kind of tumor, although the pains are generally less Avith the gliomata, and they are more frequent with rapidly growing tumors AA'hatever their character. With the pains there is often a local tenderness of the scalp and cranium which may be elicited by percussion, and TUMORS OF THE BRAIN. 3S3 in most cases there is greater tenderness in that part of the cra- nium lying over the tumor. Vomiting is a symptom which is almost as frequent as head- ache. The vomiting is often of a projectile character and not accompanied Avith much nausea. Vomiting occurs, as does headache, more frequently with cerebellar tumors. It is asso- ciated Avith rapidly groAving tumors such as syphilitic or tuber- cular neoplasms. Vertigo is a general symptom which occurs in from one-third to one-half of the cases. The vertigo may be slight, such as is often felt from ordinary causes. Occasionally it is very severe and accompanied with forced movements. The severer forms and those associated with forced movements occur Avith tumors of the cerebellum and the parts closely con- nected with it. Optic neuritis is one of the most frequent and important of all the general symptoms of brain tumor; it occurs at some period of the disease in at least four-fifths of the cases, more frequently in cerebellar tumors and in those of the mid- brain and great basal ganglia. It is rare in tumors of the me- dulla. It is less frequent and marked in the slow-growing tumors. The neuritis may run a somewhat rapid course and then improve a great deal oreAren for a, time disappear; but ordinarily the course is progressive and it ends eventually in an atrophy of the optic nerve. Hence the examination of the eyes in brain tumors should be made a number of times in order to note the progress of the trouble. Primary atrophy of the optic nerve does not occur in brain tumors. The inflammation almost al- Avays affects both nerves, but it may begin with one and subse- quently affect the other. The cause of optic neuritis in brain tumors has been the subject of a great deal of discussion and theorizing. There are doubtless different factors entering into the mechanism of its production in different cases, but accepting the modern doctrines of inflammation, Ave must believe that the most probable and most essential cause is an irritation of the nerve fibres by the products of the growth of the tumor Avhich infiltrate into the sheaths of the optic nerves. There are pecul- iar mechanical conditions Avhich tend to hold these products within the sheaths and thus enable them to act more energet- ically as irritants. Simple mechanical processes alone—the ten- sion and pressure—would hardly explain the presence of a genu- ine inflammation. Mental defects are almost always present in tumors of the brain. These defects consist in a slowness of the mental pro- cesses, a condition of hebetude, a tendency to attacks of somno- lence, and sometimes a peculiar childishness and silliness or pecul- iar mental irritability. The memory is also usually someAvhat weakened and the power of attention lessened. Such psychical 3S4 DISEASES OF THE NERVOUS SYSTEM. defects are more frequent with tumors of the fore-brain and more frequent also with large tumors. General convulsions occur in about one-fourth of the cases and more frequently when the tumors are situated in the cerebral hemispheres and cortex. There may be also apoplectiform attacks, from which the patient recovers in the course of a few days or weeks. More rarely there is a genuine apoplexy from the bursting of a blood-vessel in the neighborhood of the tumor. The speech disturbances are most marked in tumors Avhich affect the pons and medulla and the origin of the cranial nerves. Such speech disturbances, when characteristic, are shown by a confluent articulation, that is to say, the patient runs the sylla- bles together. The cranial temperature in brain tumors is in most cases someAvhat raised as compared with the normal (Gray, Mills, and Lloyd). The elevation may be several degrees above the normal. The normal average scalp temperatures (Gray) are from 92 to 94.5° F., being somewhat higher over the frontal and parietal than OAer the occipital regions. In brain tumors the temperature has been found raised to 95°, 90°, and 98°. The A-alue of thermometric obserArations, however, in the symptomatology of brain tumors is somewhat doubtful, OAving to the variability in the normal tem- perature and the difficulty of getting accurate records. • Focal Symptoms.—The symptoms of brain tumor are pro- duced in part by the irritation and pressure, in part by destruc- tion of the normal tissues. The symptoms are also modified by variations in the vascularity of the tumors, and perhaps to some extent by direct irritation from products secreted by the tumor cells. Having by a study of general symptoms arrived at a fairly certain diagnosis as to the presence of a tumor, it is necessary to corroborate the diagnosis and to localize the lesion by an exam- ination of the symptoms Avhich are the result of irritation or destruction of certain particular parts of the brain; these are called the focal symptoms. For purposes of special or local diag- nosis we divide the brain into the following parts or areas (Knapp): 1. The praefrontal, Avhich includes all that part lying in front of a line that extends from the upper end of the ascending branch of the fissure of Sylvius directly up at right angles to a horizontal line between the frontal and occipital poles of the brain (see Fig. 187). This region includes probably centres for the move- ment of the head and eyes, but it is chiefly concerned with the higher intellectual processes; its under surface lies on the orbital plate of the frontal bone and upon the right olfactory lobes. 2. The central region, which is bounded in front by the vertical line just described, behind by a line passing down from the an- terior end of the parietal Assure to the fissure of Sylvius, and TUMORS OF THE BRAIN. 385 above by a line that bounds posteriorly the post-central convo- lution. 3. The parietal lobe. 4. The occipital lobe. 5. The tem- poral or temporo-sphenoidal area. 6. The corpus callosum. 7. The great basal ganglia and capsules. 8. The corpora quadri- gemina, deep marrow, and pineal gland. 9. The crura cerebri. 10. The pons and medulla. 11. The cerebellum. 12. The basal surface of the brain. The boundaries of most of these areas are indicated better by the figure than by a description. They correspond to some extent with the cerebral lobes, but not en- tirely so, since the frontal and parietal lobe divide between them the central area. 1. Tumors of the praefrontal area. Tumors in this area often show no particular localizing symptoms, and this part of the brain 25 386 DISEASES OF THE NERVOUS SYSTEM. is consequently put down as a latent one; nevertheless, in a good proportion of cases tumors here produce peculiar mental disi urb- ances that, taken in conjunction with the general symptoms, enable us to make a local diagnosis. The symptoms are pecul- iar mental hebetude, childishness, irritability, often a kind of silliness and emotional AA'eakx.ess, a tendency to laugh and cry and to get angry at trifling causes. The entire character and temperament of the man are sometimes changed. Besides this, owing to implication of the olfactory nerve, there may be loss of the sense of smell on one or both sides; implication of the optic nerves Avill cause hemianopsia and optic neuritis. If the tumor involves the orbit there Avill be paralyses of the ocular muscles and protrusion of the globe of the eye. If the tumor grows back- ward there is gradual invasion of motor centres with irritation, showing itself by spasms, convulsions, and later by paralyses. 2. Tumors of the central region. It is in this area that Ave are often able to make the closest and most accurate diagnosis of the localization of new growths, owing to their involvement of the different motor centres. Through this inA'olvement these centres are at first irritated, with the result of producing local spasms or Jacksonian epilepsy. Such spasms are often preceded by sensory symptoms or aurae. As the tumor groAVs the area of involve- ment becomes larger, spasms become more diffused, and general convulsions may finally appear, Avith hemiplegia. The motor dis- turbances are not infrequently accompanied with sensory dis- orders. These may be simply feelings of numbness or prickling Avhich either are permanent or simply precede spasms, or there may be hemianaesthesia of a moderate degree to pain, touch, and temperature. The muscular sense also may be somewhat involved. In case of slight sensory involvement the capacity for localizing sensations seems to be most implicated. Besides the symptoms mentioned, there may also be motor aphasia and agraphia. The exact localization must be Avorked out with the help of the figures and descriptions ghTen under anatomy. 3. Tumors of the parietal area. The symptoms produced by tumors in this area may be very slight. The most characteristic are disturbances of muscular sense Avhich occur when the supra- marginal gyrus is affected, and word blindness which occurs when the angular gyrus and inferior lobule are affected. When the tumor is higher up near the longitudinal fissure, the muscles of the loAver limbs may be involved, and if the tumor encroaches upon the central area spasms and paralyses of various muscular groups ensue. The cortical representation of the third nerve is thought to be in the neighborhood of the angular gyrus, and some cases haA-e been reported in which paralysis of this nerve resulted from tumors in that area. TUMORS OF THE BRAIN. 387 4. Occipital lobes. Tumors in this region, if situated in the cuneus and first occipital convolution, produce homonymous hemianopsia. If the tumor involves the other parts of the occi- pital lobe and the cuneus is not' seriously involved, there may be a condition known as soul blindness or incapacity to understand the nature of the things Avhich one sees. If the tumor extends up chiefly toward the angular gyrus, there may be Avord blind- ness, along Avith some hemianopsia. If the tumor extends farther forward into the parietal lobe, there may be hemianesthesia, hemiataxia, and perhaps a little hemiplegia owing to involvement of the fibres of the internal capsule. 5. Temporal area. The temporal or temporo-sphenoidal area on the right side is very nearly a latent one. On the left side tumors involving the posterior part of the first and upper poste- rior part of the second temporal convolution produce word deaf- ness. Tumors in either lobe when large and extending well down toward the base may produce attacks of vertigo or forced movements, owing probably to irritation of the internal ear. Tumors that inATolve the hippoeampal convolution and the uncus may produce perhaps some disturbances in the senses of smell and taste. 6. Tumors of the corpus callosum. Tumors situated in this area are very rare. Their symptoms ha.ATe been thought to be somewhat characteristic; but in the writer's experience they cor- respond closely with tumors situated in the third ventricle and lateral ATentricles of the brain; in other words, tumors which, beginning in the central parts of the brain, gradually extend outward toward the periphery. The symptoms credited to tu- mors of the corpus callosum are, first, the general symptoms of brain tumor, to which there are superadded a gradually de- veloping hemiplegia with later a paraplegia. At the same time there is a great deal of mental dulness, stupidity, and drowsiness; the patient often sits for hours mute, refusing to speak, or lies in a half-somnolent condition. There are no paralyses of the oculo- motor nerves or of the other cranial nerves. There is no anaes- thesia. The disease gradually progresses and the patient dies in coma. 7. Tumors of the great basal ganglia and the capsule (the optico-striate region). The general symptoms of tumors of this region resemble in many respects those of tumors of the corpus callosum. The stupidity, hoAvever, may be less marked. There is usually a progressive hemiplegia which may be accompanied with anaesthesia and sometimes with choreic movements, if the tumor involves the optic thalamus and adjacent part of the cap- sule. Tumors of the caudate nucleus alone and of the lenticular nucleus alone seem to give rise to no special symptoms, and these 388 DISEASES OF THE NERVOUS SYSTEM. regions are regarded as latent. Tumors of the anterior three- fourths of the optic thalamus alone may cause no special symp- toms, but in some cases there occur peculiar choreic or athetoid movements. These, however, are probably due to irritation of the fibres of the internal capsule. If the tumor involves the posterior part of the optic thalamus and adjacent areas, there will be a hemianopsia, which may be distinguished from the hemianopsia due to lesions in the occipital lobe by the presence of the hemiopicpupillary reaction, that is to say, a ray of light throAvn in upon the insensitive part of the retina Avill not pro- duce a reflex contraction of the pupil. 8. Tumors of the corpora quadrigemina, deep marrow, and pineal gland. The characteristic symptoms, as shown by Noth- nagel, of tumors of this region are inco-ordination, forced move- ments, and oculo-motor palsies. Together with these there may be hemianopsia or blindness due to destruction of the primary optic centres. It is possible that some degree of deafness or hemi-deafness may be produced by the involvement of the pos- terior tubercles of the corpora quadrigemina. 9. Tumors of the crus. Tumors of the crura cerebri are ex- tremely rare. When present, they cause hemiplegia and per- haps a hemianaesthesia, with paralysis of the third nerve upon the same side as the lesion; in other words, a crossed paralysis. 10. Tumors of the pons and medulla. Tumors in this area necessarily produce very varying symptoms in accordance with their size and location. If the tumor is in the pons it will cause, if situated high up, a palsy of the third nerve upon one side and hemiplegia on the opposite side. If loAver down there may be a palsy of the fifth nerve on one side and hemiplegia on the other side. If the tumor is extensive it may produce not only a hemi- plegia, but a hemianaesthesia. If situated somewhat superficially and on the lateral edge of the pons involving the peduncles, there will be forced movements of the body, either toward or from the seat of the lesion. If the tumor is in the medulla it Avill produce hemiplegia and hemianaesthesia, with paralysis of the hypoglossal nerve or perhaps some other cranial nerves upon the same side. If large and involving both sides of the medulla, there may be the general symptoms of a progressive bulbar paralysis. One peculiarity of tumors situated in the pons is that they some- times produce a conjugate deviation of the eyes which is aAvay from the side of the lesion. In this respect the symptoms differ from conjugate deviation produced by lesion in the cerebral hemispheres where the head and eyes are turned toward the side of the lesion. 11. The general symptoms of tumors of the cerebellum are, as we have already said, more pronounced than those of tumors of TUMORS OF THE BRAIN. 389 other regions; we more frequently have headache, vomiting, ver- tigo, and optic neuritis from neoplasms here. If the tumor is situated in the lateral lobes of the cerebellum, no localizing symptoms develop until the tumor becomes A^ery large so that it presses upon the medulla or other adjacent regions. When the tumor is in the middle lobe a peculiar ataxia deArelops, known as cerebellar ataxia. The gait of the patient is a reeling one like that of a drunken man, or in walking he takes short steps and spreads his legs as if in fear of falling. This has been called the titubating gait. Besides this, seATere forced moArements may occur Avhich usually throAV him sideAvays or perhaps forward, very rarely backward. Secondary symptoms from pressure on the medulla often develop in tumors of the middle lobe; such symp- toms being glycosuria and disturbance of the functions of the cranial neiwes. Late in the disease hemiplegia and paraplegia and bulbar symptoms may develop from extreme pressure. There may be also hydrocephalus due to pressure on the Areins of Galen and obstruction of the return flow of blood from the cen- tral arteries of the brain. 12. Tumors of the base of the brain. Tumors situated in the anterior fossa produce symptoms A'ery much like those described under the head of tumors of the prefrontal area, but there is necessarily destruction of the olfactory lobe and there is more apt to be imrolvement of the optic and oculo-motor nerves and of the tissues of the orbit. Tumors of the middle fossa. Tumors sometimes involve the hypophysis. Such condition has been found in cases of acro- megaly, and it has been suggested that the tumor of the hypo- physis is the cause of the disease referred to; but such cannot be the case, since a number of tumors of this region have been de- scribed in Avhich none of the symptoms of acromegaly were pres- ent. Tumors of this region and of the interpeduncular space produce symptoms such as Avould naturally result from pressure on the optic chiasm, and it is mainly the early presence of optic neuritis and of peculiar forms of hemianopsia Avhich differentiates lesions in this area from those in the anterior fossa. Multiple tumors. About one-seventh of all brain tumors are multiple. Hence in making a diagnosis of the localization of tumors this fact must be borne in mind. The tumors which are most frequently multiple are tubercle, cancer, and melanotic groAvths. Pathology.—Tubercle is a form of tumor found oftenest in children and is altogether the most frequent of brain tumors. It is more often located in the cerebellum, but may appear in the pons or other parts of the brain. It may be a single or, as it is then called, a solitary tubercle, or there may be a multiple 390 DISEASES OF THE NERVOUS SYSTEM. groAvth. The tumor is irregularly round in shape and varies in diameter from one and a half to two inches. It has a grayish- yellow appearance externally; internally, a yellowish or cheesy look. It is not Aascular, but is often surrounded by softened or inflamed tissue. There may be an associated meningitis. The tumors, Avhen solitary, usually start from the central parts of the brain, but they also deA^elop on the meninges of the convexity, particularly in the parietal region, and sometimes they develop also at the base. Tubercle always arises from infection by the tubercle bacilli Avhich are carried by the blood to the brain. The tumors develop usually from some infectious focus, starting in a blood-vessel of the pia mater. Microscopically the tumor shows the ordinary appearances of tuberculous growths. It con- tains in its periphery many round cells, nuclei, and giant cells. In the centre there is usually an amorphous substance, the prod- uct of degeneration and the breaking down of the ordinary sub- stance of the tumor. The characteristics of the growth are the presence of the round cells and giant cells, the caseation and soft- ening of the centre, and the absence of vascularization, Avith the presence of the bacilli. Syphiloma or gumma. Gummatous tumors of the brain are usually associated Avith syphilitic meningitis or some other form of cerebral syphilis such as endarteritis and perhaps inflammation of the cranial neiwe roots. Syphilitic groAvths are usually found upon the brain surface, oftenest on the base, next upon the con- A'exity of the frontal and central convolutions. The process ap. pears either in the form of a somewhat distinct tumor or in the form of an irregular thickened exudate lying upon the surface of the brain and forming Avhat is called gummy meningitis. The gummata may attain great size. They start usually from the pia mater and are due, as in the case of tubercle, to the irritative action of some infective organism. The gumma is irregular in shape; it has a somewhat thick grayish periphery and often a yelloAvish centre, the appearances differing with the age of the tumor. Microscopically it is found to consist of small round cells and spindle cells Avith various broken-doAvn nerve-tissue elements. It presents in the interior the evidence of cheesy degeneration, somewhat like that in tubercle, but less marked. There is a pecul- iar development of fibrous tissue in the syphilitic groAvths Avhich distinguishes them somewhat. Besides this, the blood-vessels are numerous in the periphery and show evidences of endarteritis and periarteritis. The distinctions between gumma and tu- bercle are the less amount of cheesy degeneration in the centre of the former, its more irregular appearance, the presence of arteritis and vascularization, the absence of giant cells and of tubercle bacilli. TUMORS OF THE BRAIN. 391 Actinomycosis is a form of infectious tumor Avhich sometimes extends from the face and neck into the brain, leading to inflam- matory processes, however, rather than true tumors. No other neoplasms of infectious origin attack the brain unless glioma be found to be of that nature. Glioma may occur in any part of the brain, but is most fre- quently found in the cerebrum. It is the only tumor Avhich is peculiar to the nervous centre, being developed from the neu- roglia tissue which forms the supporting structure of these centres. Glioma originates in the Avhite matter of the nerve centre and not from the membranes or fibrous structures. It may grow to a very large size and is the form of brain tumor Avhich becomes the largest. Gliomatous tumors measure from three to eight or more centimetres in diameter. In appearance the glioma can be scarcely distinguished from the brain substance itself, but usually looks like either pale or congested gray matter, or it may haATe a yellowish or gelatinous appearance. The tumor is very vascular and it may show the results of hemorrhages. The cen- tral part sometimes breaks down, forming cavities or cysts. The tumor may grow A'ery rapidly, infiltrating the normal tissue. In those cases there is hardly any definite boundary between the tumor and the normal tissue. In other cases the tumor groAvs slowly, but rarely if ever becomes encapsuled. Microscopically it is found to consist of small cells with delicate fibrous prolonga- tions, these being the glia cells. The tumor is A-ery \~aseular and its whole appearance is suggesth'e of an inflammatory pro- cess rather than a new groAvth; the inflammatory process being one in which the neuroglia tissue reacts to the inflammatory irri- tant. Gliomata may undergo certain changes, e.g., a mucous de- generation of the cells takes place, forming a myxo-glioma. When there is with the neuroglia-cell proliferation a rich proliferation of round cells from the connective tissue it is called a glio-sar- coma. When the tumor is situated near the surface, inA-olves the membranes, and grows slowly, Avith an increase in fibrous tissue, it is called a fibro-glioma. When the gliomatous groAvth is very firm and hard, the fibrous portion of the glia tissue predominates; it constitutes a nodule such as is found in multiple sclerosis, and these hard gliomata are sometimes called neuro-gliomata. Sarcoma. The sarcoma and its A'arious modifications form perhaps the most important and almost the most frequent of the brain tumors. The sarcoma is a tumor of connective-tissue origin; it develops, therefore, from the brain membranes or from the sheaths of the blood-vessels. Sarcomas may be single or multi- ple. They may be of all shapes and they grow to very varying sizes. They often develop a capsule. They may be either pri- mary or secondary. Their growth is often rapid. They are 392 DISEASES OF THE NERVOUS SYSTEM. Avhite or grayish in appearance or may be some\vhat yellowish, dependent on the predominance of the different kinds of cells and blood-vessels. Microscopically they are made up of small round cells, spindle cells, and other cells of various sizes and forms. They contain often considerable fibrous tissue. They contain blood-vessels, but are not richly A-ascular. The essential characteristic of the sarcoma is the rich development of round cells and spindle cells; in other words, its rich cellular contents. Sarcomata are peculiar in undergoing many modifications ■ thus sometimes fibrous tissue develops largely and the tumor is called a fibro-sarcoma; sometimes the tumor undergoes mucous degen- eration and is called a myxo-sarcoma. There may be a breaking down of the centre Avith the formation of cysts. There may be a development of pigment. Not infrequently a sarcomatous pro- cess invades a glioma and we have a mixture of a sarcoma and glioma. Sarcomatous tumors sometimes haAre an alveolar struc- ture. These tumors contain endothelial cells derived from the lymphatics and are called endothelioma. When sarcomata de- Aelop from the dura mater and are slow in growth there may be calcareous deposits in them and they are called psammomata. The fibroma is a very rare brain tumor, unless the pachionian bodies, when enlarged and hardened, may be so considered. Osteoma is not particularly rare, developing in the form of bony plates in the dura, falx, or tentorium. Osteomata in the brain substance are merely pathological curiosities. Enchondromata, lipomata, and angiomata are rare and have no practical importance. Occasionally neuromata or false neuromata are found devel- oping on the roots of the cranial nerves. Cancer is relatively a very rare affection of the brain, especially as a primary development. It usually arises from the membranes of the brain. Cancer is not infrequently multiple and is usually of the soft or colloid character. Parasitic growths. Parasitic tumors are extremely rare in this country. The only forms which are found are the echino- coccus and the cysticercus cellulosae. The echinococcus produces hydatid cysts which may be large or small, few or many, and are usually all upon the surface of the brain. They are much rarer than the cysticerci. These form cysts which are usually multi- ple, slow in growth, lie upon the surface of the brain or in the ventricles, are encapsuled, and show no symptoms (Fig. 188). Aneurisms are anatomically tumors; but clinically they pre- sent some special symptoms and hence are described separately. Diagnosis.—It is necessary first to make the diagnosis of the presence of the tumor, next of its location, and finally of its nature. The existence of a brain tumor is determined by the TUMORS OF THE BRAIN. 393 presence of the characteristic general symptoms—headache, vom- iting, vertigo, optic neuritis, mental disturbances, and progres- sh7e course. The physician must bear in mind the possibilities of meningitis, abscess, lead-poisoning, hysteria, and paretic de- mentia. Very often a localized basilar meningitis of syphilitic or tubercular origin simulates closely the presence of a tumor. Be- sides the general points referred to, in estimating the probabili- ties of the existence of a tumor we must bear in mind the age of the patient and the existence of a tuberculous or syphilitic his- tory, the history of an injury, of local tenderness, and of rise of cranial surface temperature, and the presence of some new growth Fig. 188.—Echinococcus Cyst of the Third Ventricle. in other parts of the body, particularly about the neck or thorax or in the lungs. The diagnosis of the location of the tumor is based upon the rules already given in regard to local diagnosis. The diagnosis of the nature of the tumor can often be made and should be at- tempted. In children, for example, the chances of the tumor being tubercular are very great, particularly if there is a scrofu- lous diathesis or tubercular disease elsewhere. Syphilitic tumors of the brain are almost always accompanied Avith or preceded by manifestations of external syphilis. Gliomatous tumors occur in childhood and early life. They produce, as a rule, fewer irrita- tive phenomena and are accompanied by remissions and by apo- 394 DISEASES OF THE NERVOUS SYSTEM. plectic or pseudo-apoplectic attacks due to the vascular nature of the tumor. Carcinomata occur late in life and are usually sec- ondary. Prognosis.—In extremely rare cases tumor of the brain ap- pears to stop groAving and become encapsulated and atrophied. Such tumors are of a tubercular or syphilitic, perhaps sometimes of a sarcomatous character. As a rule, the brain tumor grows steadily and the symptoms of the disease become more pro- nounced until death occurs. The prognosis is best for tubercle in children and gumma in adults. It is Avorse in those cases of glioma and sarcoma Avhich have a rapid course. In fact, the sooner serious symptoms develop, the more rapid the general development of the disorder, the sooner does a fatal termination come. The disease lasts on an average tAvo or three years, rang- ing from a month to eighteen years. Treatment.—Something can be done in cases of tuberculous tumors, syphilitic tumors, and possibly in the sarcomatous vari- ety. In tuberculous tumors a general constitutional and strength- ening treatment must be resorted to; fresh air, tonics, and a large amount of food being the main reliance. The utility of any form of tuberculin is as yet doubtful. In syphilitic tumors much can be done by the usual vigorous antisyphilitic treatment. In sar- comatous tumors, if they are suspected, some help may be ob- tained from the internal use of arsenic. Symptomatically we must give such drugs as antipyrin, phenacetin, antifebrin, code- ine, and perhaps morphine for the relief of pain. The icecap and leeching often help the headache also. Should convulsions develop the bromides should be used, just as in idiopathic epi- lepsy. In cases in which the location of the tumor can be made out, the question of surgical interference should be considered. The percentage of cases in which surgery can help is extremely small. It Avill only include those cases in Avhich the tumor can be located; of those Avhich can be located, only those Avhich are in an acces- sible region, and finally, of those which are in an accessible region, it includes those which are either superficial, or, if lying in the brain substance, are more or less encapsulated. The removable tumors of the brain amount to less than five per cent. They are, in particular, the sarcomatous, syphilitic, and tubercular tumors lying in the central or occipital areas. In many cases where there is some doubt as to the localization an exploratory trephining is justifiable, and in a few cases in which it is known that the tumor cannot be removed the trephining for the simple purpose of re- lieving pressure is justifiable. It is probable that in adults some tumors from the anterior and middle fossa of the brain can be removed. In children tumors cannot be removed successfully TUMORS OF THE BRAIN. 395 from the cerebellum; in adults it is perhaps possible. Operations for tumors should be undertaken as early as possible; this is a fact on Avhich too much stress cannot be laid. Intracranial Aneurisms. Intracranial aneurisms are of two kinds—"miliary" and those of large size. The miliary aneurisms are minute dilatations of the A-essels and are always multiple; they have been described under the head of cerebral hemorrhage. Large aneurisms affect only the large cerebral arteries at the base of the brain. The arteries are affected in the following order: middle cerebral, basi- lar, internal carotid, and anterior cerebral. The anterior and posterior communicating and A'ertebral arteries are occasionally involved, the posterior cerebral and inferior cerebellar very rarely (Gowers). Etiology.—Males are affected slightly oftener than females. Aneurisms occur at all ages from ten to sixty; before ten and after sixty they are extremely rare. Heredity occasionally plays a part in predisposing to cerebral aneurisms. The exciting causes are embolism, especially when the emboli contain microbes; syphilitic disease, injuries, and in rare cases senile degeneration. The symptoms are Arery indefinite; they resemble to a consid- erable extent those of tumor at the base of the brain; headache and vertigo, mental dulness and irritation, cranial-nerve palsies, and occasionally hemiplegia and convulsions are noted. Optic neuritis is rather rare. In a few cases the patient is conscious of a murmur or recognizes the pulsating sensation in the head. Sometimes Avhen the aneurism is in the vertebral artery a mur- mur can be heard betAveen the mastoid process and the spinal column (Moser). The diagnosis is often difficult; it is based on symptoms of tumor at the base of the brain pressing on cranial nerves and on motor or sensory tracts. The effect of carotid compression should be tried. The prognosis is not good. In perhaps the majority of cases a rupture of the vessel occurs in a few years; however, rupture is not the inevitable event, and sometimes the disease becomes sta- tionary or undergoes spontaneous cure. The treatment of the disease, if it can be recognized, is the same as that for aneurism elsewhere so far as drugs are con- cerned ; surgically the common carotid may be tied and perhaps the vertebral if the aneurism is believed to be connected with that artery or with the basilar. 396 DISEASES OF THE NERVOUS SYSTEM. Syphilis of the Nervous System. Syphilis is an extremely important factor in the causation of the organic diseases of the nervous system. Nervous syphilis makes up o\rer ten per cent of all the hereditary forms, and while in adult life the specific virus attacks nerve centres relatively less often, yet it is a factor Avhose importance is Aery great. In the previous descriptions of nervous diseases we have referred to the syphilitic element in connection with etiology and pathology; but syphilis produces upon the nervous system certain forms of disease Avhich are characteristic, hence it is best to take a brief survey of the effects of this infection independently. Syphilis is beyond much question the result of an infection by a microbe, and the result of the activity of this microbe upon the nervous centres is to produce a condition which is really a form of inflam- mation. The reader can best understand syphilitic disorders, therefore, by remembering that they are all forms of an inflam- mation. The syphilitic infiltration is simply an exudative in- flammation Avith a specific exudate; the syphilitic gumma is a deposit of this exudation analogous somewhat to an abscess. Syphilis attacks chiefly the membranes of the brain and spinal cord and the blood-vessels of these organs; in particular the base of the brain and the blood-vessels that supply this region are affected. Syphilis acts on the nervous centres in four ways: it produces meningeal exudation and inflammation, it forms gum- matous tumors, it causes arteritis, and it leads to degenerations. Etiology.—A neuropathic constitution probably predisposes to the deA'elopment of nervous syphilis. The age at which it occurs most frequently is between twenty and forty, but it may occur at all periods of life from infancy up. It attacks men oftener than women in the proportion of about seAren to one. Hereditary syphilis makes up about three per cent of the cases. Inadequate and improper treatment of the disease at first favors the develop- ment of nervous syphilis later. The neglect in particular of the early use of iodide of potassium tends to render a person more liable to haAre the nervous centres attacked. The use of alcohol, excesses in the way of severe bodily exercise, severe mental strain, and overwork predispose to the development of the disease; in- juries undoubtedly have a similar effect. The time after the infection when the disease is most apt to occur is the third year, but it is not infrequent between the second and the tenth years, and it is possible for nerve syphilis to develop from within a few months up to thirty years after the infection. Symptoms.—Since syphilitic changes may attack any part of the nervous centres, the symptomatology of nerve syphilis is TUMORS OF THE BRAIN. 397 necessarily a varied one. The reader can perhaps best under- stand the Avay in which the disease acts by having presented first a series of tables showing on the one side the clinical symptoms, on the other the chief anatomical changes that underlie them. The first table presents the symptoms of syphilis of the brain, which is unquestionably the most common form. The next table shows the symptoms of syphilis of the cerebro-spinal system, a form which ranks second in frequency. Third we have syphilis of the spinal cord alone, which is somewhat rarer, and last and rarest of all we have syphilis of the nerves. In addition to these four forms of syphilitic manifestation we have two diseases which are acknowledged to be sequelae of syphilis and which are called post-syphilitic degenerative processes. I. Syphilis of the Brain. Clinical Symptoms. Anatomical Change. Severe headache, vomiting, vertigo, men- Gummatous inflammation of the base in- tal dulness, and irritability, attacks of volving nerve roots, or gummatous in- somnolence or coma, convulsions, era- flammation of convexity, arteritis, and nial-nerve palsies, optic neuritis, hem- phlebitis. iplegia, polyuria, and polydipsia. II. Cerebro-spinal Syphilis. Many of the brain symptoms as above, Gummatous basilar meningitis ; diffuse, spastic paraplegia with spinal pains disseminated, or localized meningo- and involvement of sphincters. myelitis. III. Spinal Syphilis. Paraplegia with pains, Brown-S6quard Meuingo-myelitis, gumma, localized paralysis. softenings from obliterative arteritis. IV. Syphilis of Nerves. Cranial-nerve palsies, cauda equina Root neuritis, gummatous neuritis. symptoms, local palsies of peripheral nerves. V.—Post-syphilitic Degenerative Processes. Locomotor ataxia; general paresis. Taking up these different forms of nerve syphilis in order, I. will give some further details with regard to each of them. I. Syphilis of the brain in its most common form shows itself by a gradual development of severe and persistent headache. This is usually associated with vertigo, sometimes with nausea and vomiting. After the headache has developed and has lasted for a time, or even without much delay, there comes on sometimes an attack of hemiplegia. Preceding the hemiplegia, or in some cases without the hemiplegia, there are paralyses of the cranial nerves, more especially of the nerves of the eye. Optic neuritis is somewhat frequent. There may be, before any paralyses de- velop, attacks of epileptic convulsions, either general or partial. 398 DISEASES OF THE NERVOUS SYSTEM. Without any paralyses or with simply cranial-nerve paralyses there may develop attacks of somnolence and coma, Even if such attacks do not appear the patient often shows a mental irri- tability and weakness, a slowness of the reasoning process, and incapacity to fix the attention such as is observed in connection with brain tumors, only Avith nerve syphilis these symptoms are not usually so marked. Polyuria and polydipsia are symptoms which are occasionally met with. It will be seen that the syph- ilitic poison produces very A-arious manifestations when it attacks the brain. The characteristic features are this A-ariability in the symptoms and their remittent character. Elaborate systems of clinical classification might be made out of these various groups, but it Avill be sufficient for the present purpose to call attention to the fact that the intense headaches, optic neuritis, cranial- nerve palsies, attacks of somnolence and coma, and hemiplegia associated Avith some of the foregoing symptoms are characteris- tic of most of the forms. The reason for the peculiar symptoms in brain syphilis is manifest when it is known that the lesion most commonly found underlying them is a gummatous menin- gitis which has a special predilection for the base of the brain. in particular it seems to attack the interpeduncular space and the neighborhood of the optic chiasm and the surface of the pons Varolii. This gummatous meningitis consists of a syj>hilitic in- flammatory exudate Avhich surrounds, presses upon, and injures cranial nerves, attacks the arteries of the base, producing an obliterating arteritis and const-.nient softenings, with the hemi- plegia Avhich is so often a manifestation of the disease. Much less frequently the inflammatory process attacks the convexity, and then it assumes the form of a gummatous patch which produces cortical irritation with headaches, mental disturbances, and conArulsions. II. The next form of nervous syphilis is the cerebro-spinal. In this we have almost exactly the same conditions and symp- toms so far as the brain is concerned; but in addition there are symptoms due to more or less diffuse syphilitic inflammation of the pia mater of the spinal cord. The syphilitic process often extends into the spinal cord, producing an obliteration of the arteries and softening with the symptoms of a transverse or a central myelitis. Thus we have combined the symptoms of cere- bral syphilis and paraplegia with, as a rule, considerable pain in the back, produced by the involvement of the meninges. III. The third type of syphilis is the spinal form. The symp- toms in spinal syphilis are usually those of a transverse myelitis, involving, in the writer's experience, most often the lower part of the dorsal and upper part of the lumbar cord. This myelitis usually comes on rather slowly with the ordinary symptoms of a TUMORS OF THE BRAIN. 399 chronic or subacute transverse myelitis. It is probable that syphilis is a much more frequent factor in the production of so- called transverse myelitis than is usually supposed. The ana- tomical process underlying it is that of a meningitis which passes along the septa into the substance of the cord, im-ohes the arteries of the cord, and produces a more or less complete soften- ing of the part. The only truly inflammatory process, therefore, is that Avhich is produced in the meninges, connective tissues, and arteries. The anatomical changes in the cord substance are mainly Jhose of softening with reacth*e inflammation. Spinal syphilis may show itself also by the development of gummatous nodules which grow from the meninges, press upon the cord, and produce the symptoms of a spinal tumor. Spinal syphilis may also develop itself in three or four different foci, producing the symptomatology of disseminated myelitis. IV. Syphilis of the nerves. Syphilis rarely affects the periph- eral nerves; there are, ho\ve\rer, occasional deposits of syphilitic exudate producing the ordinary symptoms of irritation and com- pression of nerves. There is said to be a form of multiple neuri- tis produced by syphilis, but its actual existence has not yet been absolutely demonstrated. Syphilis has been knoAvn to attack the roots of the cranial nerves, producing a root neuritis; and it is A'ery apt to attack the roots of the spinal nerves Avhen the spinal membranes are involved. V. The post-syphilitic degenerath'e processes are locomotor ataxia and general paresis. Occasionally it happens that the syphilitic deposits in the spinal cord may produce lesions some- what like those of locomotor ataxia, and in this case there Avill be a train of symptoms which also resemble this disease. In true locomotor ataxia, however, the process is neAer in any sense a syphilitic one. The syphilitic poison seems to so affect the ner- vous centres as to predispose them to the peculiar degeneration characteristic of tabes. Syphilis may also produce a chronic meningoencephalitis which will manifest itself by symptoms re- sembling to a considerable extent general paralysis; but it is A'ery generally conceded that true general paresis is not a syphilitic disorder. Syphilis, howeA7er, seems to predispose to it, just as it does to locomotor ataxia. Hereditary Syphilis.—Inherited syphilis Avill lead to anatomi- cal changes and clinical manifestations resembling in all respects those of acquired syphilis. Inherited syphilis, in other words, may produce headaches, cranial-nerve palsies, hemiplegia, epi- lepsy, mental disorders, and paraplegia. The disease probably is the cause of a considerable proportion of the cases of chronic hydrocephalus and of many of the cases of so-called tubercular meningitis. The peculiarities of hereditary syphilis show them- 400 DISEASES OF THE NERVOUS SYSTEM. selves rather more in diffuse symptoms such as would be attrib- uted to a meningitis of the convexity; in other Avords, convul- sions and mental weakness are rather more frequent, while hemiplegia and cranial-nerve palsies are comparatively rare. Hereditary syphilis also very rarely indeed attacks the spinal cord, although it is not unlikely that it is a factor in the production of some of the hereditary scleroses of that organ. Hereditary syph- ilis develops at any time from birth to the eighteenth year, but most commonly under the age of five years. Pathology.—I have already given some indications of the path- ological changes produced by syphilis. The disease affects the nervous system (1) by producing a meningitis with infiltration, (2) by producing gummatous masses, (3) by producing an inflam- mation of the arteries, and (4) by so influencing the nervous sys- tem as to lead to the deA'elopment of degenerative diseases. Of all these forms of anatomical change it is the arteries that are most often affected, and particularly the arteries at the base of the brain. Syphilitic meningitis is characterized by the proliferation of round cells and the preponderance of an exudate Avhich has a tendency to infiltrate into the nervous tissues. The anatomical characteristics of the syphilitic gumma must be studied in special text-books. The inflammation of the arteries attacks first the external coat and adventitia, producing there an enormous mul- tiplication of round cells. The external coat becomes weakened, and as a result there develops beneath it, between the intima and the elastic layer, another exudate which constitutes what is known as endarteritis. In syphilitic arteritis, therefore, there is both a periarteritis and an endarteritis; the former being usu- ally the primary and most essential process. The endarteritis, hoAvever, as it develops gradually produces an occlusion of the arteries. This cuts off the circulation of the blood and leads to softening of the part. There is also a development of a hyaline degeneration in the arteries which some regard as a very essential part of the anatomical change. Diagnosis.—The diagnosis of nervous syphilis is based upon the history of an infection, the irregularity and fugacity of the symptoms, the intense headaches, the presence of an optic neu- ritis, the age of the patient, and the results of treatment. In estimating the importance of the history of infection, it should be remembered that the third year after infection is the serious one for the development in particular of those symptoms produced by obliterating arteritis. In hereditary syphilis the presence of the Hutchinson teeth, the hazy cornea, and deafness or other ear trouble help us in diagnosis. The headache of syphilis is rather characteristic. It may attack any part of the head, but is usu- TUMORS OF THE BRAIN. 401 ally unilateral or irregular, or again it may be bilateral in its dis- tribution. The pain is very intense and sometimes exhibits a certain periodicity. It is usually Avorse at night. It is apt to last continuously for from five days to three or four weeks. Headache of this character, folloAved by the paralysis of one or more cranial nerves or by an attack of hemiplegia, is extremely suggestiA'e of syphilis. Optic neuritis is Aery liable to occur Avhen the disease shoAvs other evidences of being situated at the base of the brain. This optic neuritis is associated Avith contrac- tion of the visual field, and a characteristic feature of this con- traction is that it varies a great deal from week to week. The sex and age of the patient may be taken into consideration in weighing the evidence, and finally the prompt effects of the use of iodide of potassium should haAre very decided weight. Prognosis.—It is very difficult to give definite facts regarding the prognosis of syphilis. Unquestionably the outlook is much more favorable than it is for any other organic disease of the nervous system. When the syphilitic process has not produced so much arterial disease as to lead to obliteration of vessels and softening, a very great degree of improvement and even a recov ery may be expected. So far as injuries to the nerves or nerve roots go, Ave can generally expect a great improAement or cure. Lesions of the convexity are usually amenable to treatment. Syphilitic hemiplegia has a not much better prognosis than hemiplegia from other causes. Syphilitic myelitis has a not A'ery good prognosis, but it is better than that of myelitis due to trauma. NerArous syphilis may last from one to three or four years. The effects of the disease may, if nerve tissue is destroyed, last a lifetime. Treatment.—As regards the prophylaxis, it is important that persons Avho have become infected by syphilis should be treated Avith iodide of potassium in the second as Avell as the third stage of the disease. After the first year at least, the patient should not neglect to take a certain amount of iodide of potassium four times a year, each course of treatment lasting six weeks. The patient should be Avarned against indulging in alcohol, against all excesses, mental as Avell as physical. A laborious life full of worry and anxiety, in which the patient attempts to help him- self along with stimulants, is surely provocative of the develop- ment of nervous syphilis. The treatment of the disease when it has appeared consists mainly in the administration of iodide of potassium or sodium. This should be given in beginning doses of ten grains three times a day and increased gradually until the maximum amount which the patient can bear is taken. This maximum is usually between three and four hundred grains a day. In some cases it is im- 26 402 DISEASES OF THE NERVOUS SYSTEM. portant to give more than this—as much, that is to say, as two hundred grains three times a day, and it is the general experience of American neurologists that results can be obtained by these large doses which cannot be obtained by smaller ones. In my own experience I have known a patient to take five hundred grains three times a day for a considerable time without harm, and indeed with benefit. Usually, however, such extraordinary doses are rarely needed. It is found that, as a rule, patients tol- erate large doses of iodide quite as well as smaller ones, and some- times the iodism produced by small doses disappears when large doses are given. The drug is best administered largely diluted with water or with Vichy or in milk, and taken after meals. Some persons bear it better before meals. It is occasionally ad- visable to combine mercury Avith the iodide. This may be given in the form of the bichloride or by an inunction. Other drugs which are of value are the ordinary tonics such as iron, quinine, and the bitters and mineral acids. Plenty of good food, out-door air, and all those things which will improve the general health of the patient are indicated. CHAPTER XXL FUNCTIONAL NERVOUS DISEASES. Functional nervous diseases are those in which no definite known anatomical change underlies the morbid phenomena. On this account it is customary to classify them on a clinical basis. We can, however, also make etiological and pathogenic subdivisions. Applying such a method now, we have two broadly distinguished classes: the primary, or degenerative, and the secondary, or acquired neuroses. Such a classification is suggest- ive and helpful, though not perfectly correct, because several factors often enter into the cause of the same neurosis. Primary neurasthenia, hypochondriasis. Epilepsy. Hysteria major. Hereditary chorea. General spasmodic tics. Myotonia. Primary degenerative i neuroses. Acquired neuroses. From infectious, autocthonous, and mineral poi- sons. Exhaustion and shock neuroses. Acquired degener- ative neuroses. Miscellaneous. Chorea. I Tetanus. J Tetany. : Rabies. Tremor. (^ Neuralgia. f Neurasthenia. j Hysteria. ] Exophthalmic goitre. [ Occupation neuroses. f Tic douloureux. < Local spasmodic tics. I Paralysis agitans. ( Vasomotor, trophic, ( sleep disorders. and THE DEGENERATIVE NEUROSES. Epilepsy. Idiopathic epilepsy is a chronic functional disorder character- ized by periodical seizures attended with loss of consciousness and usually with convulsions. Mental disturbances may accompany or take the place of the convulsions. 404 DISEASES OF THE NERVOUS SYSTEM. Symptomatic epilepsy is a form in which the periodic convul- siAe attacks are due to gross organic changes in the brain. Jacksonian or partial epilepsy is a form of symptomatic epi- lepsy usually, and is characterized by periodic convulsions affect- ing only certain groups of muscles, and often unattended by loss of consciousness. Hystero-epilepsy is not epilepsy, but a form of hysteria. Eclampsia or acute epilepsy is the name ghen to a single isolated attack of convulsions. It is generally of the symptomatic type. Reflex epileptiform convulsions are considered to form a dis- tinct type by some (Starr). In this class of cases peripheral nerve irritations produce seArere or mild epileptic attacks which are often A'ery frequent in occurrence. Idiopathic epilepsy sIioavs itself in three rather distinct types of attacks, A'iz. : that of seA'ere attacks, called the grand mat; that of minor attacks, the petit mat'; and the rarer larvated forms characterized by acute mental disorder and called jjsgehical epilepsy or the psychical epileptic equhalent. Etiology.—Predisposing causes: Heredity is the most potent of any single influence. A history of epilepsy or insanity is found in the family in about one-third of the cases and rather more on the paternal side. Alcoholism and the intermarriage of neurotic persons contribute povverfully to produce the coriA-ulsiA'e ten- dency in children. PoAverful emotions during pregnancy, ac- couchement injuries, and syphilis have some influence. More cases occur in the country than the city, more in temperate climates, and more among in-bred races. All American statistics (Putzel, Hamilton, Hammond, Starr, and myself—18G cases) show a slight preponderance among males. European observers find it the other way. Age.—The epileptic age is between ten and twenty, and still more definitely between ten to fifteen. In three-quarters of the cases the disease begins before the age of twenty; in one-sixth of my cases before the age of five. After twenty the danger of epi- lepsy is slight, and when it occurs it is usually due to accidental causes, like syphilis, alcoholism, or plumbism. Idiopathic epi- lepsy, however, may develop even after sixty. The accompany- ing table shoAvs graphically the relation of age to the develop- ment of epilepsy, chorea, and neuralgias. Exciting causes. Exciting causes are not present in the ma- jority of cases. The most important are the occurrence of rickets at the time of dentition, fright, injury to the head, sunstroke, in- fectious diseases, especially scarlatina, masturbation, alcoholism, and syphilis. Masturbation is a real but rare cause, so also is syphilis. The so-called reflex causes are ocular and auditory irri- EPILEPSY. 405 tations, Avorms, dyspeptic states, dental irritations, lesions in- volving peripheral nerves. Some American observers put much stress on the importance of ocular irritations; European Avriters have laid more emphasis on disease of the ear. Probably the gastro-intestinal tract and genital organs furnish the most im- portant exciting irritations. True idiopathic epilepsy may be Percentage of total cases 60/* 50 % 40 X 30% 20% 10% up to endoF 5Vr 6 th to 10th 11* to 15* 16* 20* 21s-f to 30* 31* to 40* 4 Is.1 50* 51s.1 to 60* 6ls.r to 70* r *' .--1 r u ' / , \ \ Fiu. 18(J.—Table showing Percentage of Cases of Epilepsy, Chorea, and Neuralgia Occurring at Each Half Decade and (after 20) Each Decade. Double line, epilepsy; dotted line, chorea; single line, neuralgia. brought out by peripheral irritations; more rarely there occurs only a reflex epileptiform neurosis. Symptoms of the Convulsion.—The patient often feels some premonitory symptoms for a fe\v hours or a day, consisting of general malaise, irritability, or giddiness. The attack begins in about half the cases with a peculiar sensation called the aura. Often also a loud cry is uttered and the patient falls unconscious to the ground. The face is pale, the eyes are open and turned up and to one side and the pupils dilated. The head is draAvn back or to one side, and the whole body is in a state of rigidity or tonic spasm. The arms are slightly drawn out from the trunk, the forearms and wrists flexed, the fingers clinched or flexed in other ways, the legs and feet extended. This tonic stage lasts 406 DISEASES OF THE NERVOUS SYSTEM. for fifteen or tAventy seconds; the face becomes congested and then livid from compression of the veins of the neck and stoppage of respiration. Gradually jerky movements of the face and limbs begin and the stage of clonic spasm sets in. The trunk and limbs are now alternately flexed and extended with violent shock-like contractions, the facial and eye muscles twitch, saliva collects in the mouth, and as the tongue is often bitten, it becomes stained with blood. The movements are sometimes so violent that the patient is thrown about the bed or floor, and occasion- ally a limb is dislocated, usually the shoulder. The urine often, and the faeces occasionally, are passed. The temperature is raised i° to 1° F., rarely more. The pulse, feeble at first, becomes frequent and tense, and then, as the attack subsides, becomes feeble again. The clonic spasm lasts one-half to one or two min- utes. It subsides gradually, and the patient sinks into a stupor, from which he can be roused with difficulty. This stupor is suc- ceeded by a heavy sleep of seAeral hours and a feeling of hebetude which lasts all day. Vomiting sometimes occurs as a terminal symptom. Immediately after the attack there is a temporary exhaustive paralysis, with loss of knee jerk. The pupils contract again and often oscillate. There may be a slight amount of transient albuminuria or glycosuria. The earthy phosphates are found increased; urea is not. There is a distinct lessening of haemoglobin in the blood (Fere) and of hsematoblasts. Sometimes the attack is followed by others, and for hours the patient passes from one convulsion into another. This condition is called status epilepticus. It usually la:;ts less than twelve hours, but may last for one or more days and until finally death occurs from exhaus- tion. It only develops in the severer types. Symptoms of the Minor Attacks.—In the minor attacks (petit mal) the patient suddenly stops in anything in Avhich he is en- gaged, the features become fixed, the eyes open, the face is pale, the pupils dilated, often slight twitching of the facial muscles or of the limbs occurs, and consciousness is lost. In a few seconds the attack is over, and the patient, who does not fall, resumes his work or conversation, being unconscious of what has occurred, except that he has had a " spell." Often there is a Avarning sen- sation or aura. This is felt as giddiness, sense of fear, numb sen- sations of the extremities, flashes of light or blindness, or choking sensations. There may be a cry uttered. The minor attacks are in rarer cases accompanied with sudden forced movements; the patient runs a few steps, or turns round or makes some automatic movements. This is called procursive epilepsy. Symptoms of the Psychical Attacks.—Sometimes the minor at- tacks are followed by outbursts of maniacal excitement or by sudden violent automatic movements, and in these states the EPILEPSY. 407 patient may commit crimes of violence. In rare cases the patient passes into a somnambulic state, during which he performs ac- customed acts, such as driving and walking, automatically and naturally (somnambulic epilepsy). This form of epilepsy may come on without a preliminary minor attack, and then it is to be considered a " psychical epileptic equivalent." Minor attacks may end in convulsions of a co-ordinate type in which the patient jumps, kicks, throws the arms about as in hysterical attacks. These are called hysteroid convulsions. The seizure may consist of only a short tonic stage and a few twitchings of the limbs, the whole lasting but a few seconds. This is called an abortive attack. Under the influence of medi- cation, the severe seizures are often reduced to abortive forms. Jacksonian or partial epilepsy is a form of the disease char- acterized by convulsive attacks affecting only a single group of muscles or a limb, and generally not accompanied by loss of con- sciousness. Jacksonian epilepsy is always symptomatic of some focal lesion affecting the cortical motor area of the brain. This may be a tumor, inflammation, or injury. This form of seizure is particularly significant of a slowly growing brain tumor or syphilis. The aura usually consists of a sensation of numbness, prick- ling, or of a breeze beginning in the hand or leg and passing up to the head, Avhen consciousness is lost. Still oftener there is a peculiar sensation starting in the epigastrium and passing up- ward. More rarely there are special sense aura? such as flashes of light, noises, or voices, and peculiar tastes or smells. Besides these there occur feelings of giddiness, dreamy states, peculiar sensations in the head, and indescribable general sensations. The aura? may be divided into Visceral—epigastric, laryngeal, cardiac. Cutaneous sensations. Special senses—flashes of light, etc. Psychical—emotions, dreamy states, etc. Cephalic—giddiness, etc. The aura is thought to indicate the seat of the first discharge of nerAre force, and its study is of most importance in connection with symptomatic epilepsies, as will be shoAvn later. Relative frequency of the different kinds of attacks. The severe attacks are the most frequent, next come combinations of severe and minor attacks, and next minor attacks alone, while the psychical forms are the rarest. Frequency of the Attacks. —The severe attacks may come on only once or twice a year, and this commonly occurs during the development of the disease. The frequency gradually increases until they occur every month or two or three times a month. 408 DISEASES OF THE NERVOUS SYSTEM. Sometimes the fits occur in groups of four or fiAre every month or two. In Aery bad cases convulsions occur every day. The petit mal attacks are more frequent and usually occur daily. Time of Attacks.—The moon and the seasons have no influence. More attacks occur during waking hours than during sleep; but two-thirds of the attacks occur betAveen S a.m. and 8 P.M. Many patients have their attacks early in the morning just after awaking (matutinal epilepsy). Many attacks occur between '3 and .j A.M., Avhen the temperature of the body and the A'ital powers are at the lowest. Practically no epileptic attacks occur between 11 A.M. and 12 M. (only o in 1,985—Fere). State of Patient Between Attacks.—Epileptic patients often feel better for a time after the convulsion is over. They not rarely suffer from severe neuralgic headaches; the appetite is capricious, often in children it is voracious, but in older cases their may be anorexia; the bowels are usually constipated; the pulse is small, soft, and frequent. Mental Condition.—A gradual mental deterioration occurs in the great majority of epileptics; but it is slight in some and not very great in others. It shows itself by feebleness of memory, irritability of temper, selfishness, incapacity to concentrate the mind or to carry out a purpose. In children great mischie\rous- ness and lack of moral sense, Avith vicious impulses, may appear. The mental deterioration is dependent on those underlying fac- tors Avhich cause the disease. It is apparently in some cases due to the excessive number of the fits. This is not necessarily the case, nor is it generally true that it occurs more often with 2Jetit mal. It is more marked in cases beginning very early in life, but this is only true when there are decided marks of physical and mental degeneration present. A certain rather small percentage of epileptics become either demented or insane. True epilepsy is not compatible with extraordinary intellectual endowments. Caesar, Napoleon, Peter the Great, and other geniuses may have had some symptomatic fits, but not idiopathic epilepsy. Physical Condition.—Epileptics are rather undersized and of not very robust constitution (Fere). They always present some of the marks of degeneration, physical, physiological, or mental. Such marks or stigmata are about ten times more frequent than in healthy persons. The physical stigmata are (Fere) short stature, cranial asymmetry (in 71%), short parietal or frontal arc, and triangular skull; in women high prominent forehead; bad teeth badly placed, high palatal arch; facial asymmetry; promi- nence of occiput and lemurian hypophisis; differences in color, size, position, and shape of pupils; astigmatism (in 75* cases); badly shaped and placed ears; misplaced crown of scalp; low vital capacity; small genitals, atrophic uterus; greater develop- EPILEPSY. 409 ment of left side; long fingers. Cranial deformities of pro- nounced type oCcur in epileptics associated with idiocy, hemi- plegia, and brain defects of early origin. Sometimes, apparently from a premature ossification of sutures, there are the peculiar shapes of the skull known as scaphocephaly, or steeple skull, and plagiocephaly, or obliquely deformed skull. The physiological marks of deterioration are a lessened mus- cular strength (as 35 to 50), habit choreas, a rather imperfect eye Avith excessive amount of astigmatism and functional mus- cular Aveakness. There is a lessened vital capacity, weak and sIoav digestion, and sexual atrophy or irritability. The excretion of phosphoric acid is beloAV normal as compared with urea. Fig. 190.—Diffuse Neuroglia Sclerosis Fig. 191.—Same, Enlarged (Chaslin). of the Cortex in Epilepsy. The psychical stigmata are mental feebleness, moral insensi- bility, irritability, wayward and A'icious inpulses, lack of Avill poAver, and sexual aberrations. Pathology.—The body of the epileptic shows sometimes skin eruptions and ulcers, the result of treatment. There are often evidences of local injuries and fractures due to falls. The organs may show vices of conformation. The uterus is frequently in- fantile or sharply flexed. Deformation of the occipital bone or the atlas so as to produce narrowing of the upper spinal canal has been noticed. The brain may be unduly large or small, but there is nothing constant in this, nor is there an abnormal differ- ence in the weight of the tAvo hemispheres. The convolutions show many anomalies, but there is in them nothing specific. On the whole the convolutional type is a simple one. The patholog- ical change found most constantly in epilepsy is an induration or sclerosis (gliosis). This affects the cornu ammonis rather often (4$ to 10$), more rarely the olivary bodies or cerebellum. Besides 410 DISEASES OF THE NERVOUS SYSTEM. this, small patches of induration occur in the gray matter in A'ari- ous parts of the cortex. Chaslin finds a diffuse increase of neu- roglia tissue throughout the brain, more marked Avhen the case is older (Fig. 191). Others have found an increase in the neuroglia cells (Kingsbury). In old cases there is of ten a chronic leptomen- ingitis, and vascular changes due to the frequent congestions of the brain take place. These consist in varicose and fusiform di- latation of vessels, with evidence of small hemorrhages. Slight degenerative changes in the nerve fibres are also observed. Bevan LeAvis finds in epileptics with insanity a fatty de- generation of the nuclei of the "angular cells" of the second layer of the cortex. In the severer and later stages of the dis- ease this nuclear degeneration is increased so that vacuoles are formed. The cells of the deeper layers are also affected, but to a less extent. The change, though not peculiar to epilepsy, is more extensive and pronounced in this disease. To sum up: The anatomical basis of idiopathic epilepsy con- sists in a nuclear degeneration and later a vacuolation of the cor- tical cells, beginning and most pronounced in the cells of the sec- ond layer. Also a proliferation and increase in the neuroglia tissue, this occurring most markedly in A'arious islets or special areas of the cortex. The blood-vessels and connective tissue are invoh'ed only secondarily and later. Physiology.—The epileptic fits are due to sudden discharges of nerve force. The seat of the discharge is the cortex of the brain. The discharging cells are, in the severe seizures, the large motor cells, the function of which is to store up and discharge nerve force. They are under control of the sensory cells (angular cells) of the second layer, which have an inhibitory power. These being diseased their control is Aveakened and the motor cells " explode" periodically. In sensory and psychical epilepsy the same mechanism exists. The more highly organized cells with large nuclei of the second layer are congenitally or otherwise weak and diseased, the cells below them are not maintained in stable equilibrium and hence periodically break down and "dis- charge." The diagnosis is based on the character of the attacks and has to be made from hysterical and various toxic and sympto- matic conArulsions. The aura, the scream, the quick loss of consciousness, the di- lated pupils, the tonic convulsion, the bitten tongue, the emptied bladder, are all characteristic. The hysterical patient sometimes, but rarely, loses consciousness, the epileptic almost ahvays. Hys- terical patients do not hurt themselves in falling or bite their tongue, and their muscular movements, Avhile irregular and vio- lent in character, are yet co-ordinate, i.e., they throw themselves EPILEPSY. 411 about, kick, strike, etc. Their attacks often are produced by emotion and are ended by some powerful mental or physical impression. The slight rise of temperature in epileptics rarely occurs in hysterics. Petit mal and epileptic vertigo are distin- guished by the sudden lapse of consciousness and by the sudden pallor and fixation of the eyes, dilatation of the pupils, and slight twitchings of the face. Nocturnal convulsions are usually epileptic. Eclampsia, or acute symptomatic and reflex convulsions, can- not always be distinguished from epilepsy. The history of the case, the irregular and often prolonged character of the fit, may enable one to make the diagnosis. Course and Prognosis.—Epilepsy shortens life to some extent; most cases do not live beyond the age of forty or fifty. About ten per cent become demented or insane. Five or ten per cent get well. The remainder reach a certain stage of severity in their disease and continue in it for years. This severity depends on the treatment, the nature of the attacks, and the extent of de- generation which the organism shows. While unquestionably treatment cures or suppresses the disease in some cases, it disap- pears spontaneously in others. The prognosis of petit mal is worse than that of grand mal; that of the two combined is worse still, yet not hopeless. The psychical form of epilepsy is the least amenable to treatment. Epileptic insanity and dementia are in- curable. Death occurs rarely in the attacks except in terminal stages. Yet the status epilepticus is ahvays a source of danger. Epileptics are said rather frequently to suffer from phthisis. This is, however, a matter of infection and can be prevented. It should be remembered that epileptics who have only a moderate number of attacks, six to fifteen yearly, can get along comfort- ably for years, doing their work and enjoying a fair share of the duties and pleasures of life. Finally, the following prognostic rules may be laid down: The prognosis is better in males, better if there is a hereditary history, better if the fits are nocturnal or diurnal alone, better in grand mal, better if fits occur infrequently, better if they begin after twenty, and better if due to extrinsic causes. The prognosis is very bad in post-hemiplegic epilepsy and epilepsy due to organic disease. Treatment.—The first and essential rule of treatment is to take cases early and treat them vigorously from the start. Children who have had a few convulsions during the first three to five years of life should be treated as if they might deA^elop epilepsy between the ages of ten and fifteen or -earlier. The recurrence of a fit between the ages of five and ten should excite appre- hension and call for the most diligent treatment. Another rule is that when epilepsy is recognized in children the case should be 412 DISEASES OF THE NERVOUS SYSTEM. treated constantly for at least three years after all attacks have ceased. Constitutional Treatment—Along Avith the evolution of epi- lepsy there is probably a progressive diffuse neuroglia sclerosis of the brain. Whether this is primary or secondary, it is at least proper to use those measures which apparently affect this neu- roglia proliferation. Nitrate of silver and arsenic and perhaps iodide of potassium are drugs which Ave have good reason for be- lieving affect this. Hence I advise that all epileptics as the basal medication should be given courses of these drugs until we find better. Besides this, we should use measures that increase vasomotor tone and strengthen and steady the circulation. Nothing does this better than water. Epileptics should be given shoAvers, douches, cold sponge-baths, or wet-packs according to their needs and opportunities. They should also drink water freely. Again, the nervous system is greatly steadied and quieted by mental occupation that interests one. Nothing is more unfortunate than the idleness often enforced on epileptics. 1 have seen the dis- ease absolutely checked by haA'ing a boy learn a trade that he liked. The next most important indication is diet. In petit mal par- ticularly an absolutely non-irritating diet, such as milk, meat, and bread, will quickly lessen or stop the attacks. Meats can be taken in moderation if eaten slowly. As a rule it is a little safer to keep meat out of children's diet for a time; but in adults it is not necessary. Removal of irritating causes. Malaria if present promotes the compulsive tendency; so also do lead and alcohol; tobacco does not do this, but its use is better stopped, as it is liable to weaken vascular tone and impair digestion. Syphilis causes epilepsy only through producing organic changes. The rheumatic, gouty, and so-called tubercular diatheses do not stand in any close relation to epilepsy. The condition known as lithaemia, however, in which there is insufficient oxidation and excretion of products of tissue waste, needs attention. Hence the use of bicarbonate of potash, the alkaline mineral Avaters, and a restricted diet is not rarely indicated. The importance of reflex irritations has been much overesti- mated. Still they must be considered. The most serious are those arising from the gastro-intestinal tract, the sexual organs. and the eyes. Phimosis if present must be relieved, and mastur- bation or sexual excesses stopped if possible. It is admitted now that removal of the ovaries, even if diseased, never cures true epilepsy, though it may help hysterical convulsions. Astigmatism and hypermetropia should be corrected; also ocular insufficiencies if these are pronounced. EPILEPSY. 413 Proper attention to the frequent constipation and dyspepsia is of course necessary. The use of hot water is often serviceable, a glass being sipped slowly before the morning and evening meals. This helps also to carry off the bromides and wash out the system generally. To still further promote this, a purge should be giA-en every fortnight or month. Out-door life and active physical exercise are indorsed by Hippocrates. They do not have any specific influence unless associated with some employment. Specific treatment. The drugs which haA'e obtained and held a reputation as anti-epileptics are not numerous. They are the bromides, chloral, chloral-amide, belladonna, zinc, nitro-glycerin, antipyrin. Of less value are digitalis, cannabis indica, borax, valerian, and ergot. As adjuvant drugs Ave have quinine, strych- nia, iron, the phosphates, arsenic, silver, the alkalies and iodides. The most Aaluable of the specific drugs are the bromides. All bromides act alike in this disease. If one does not cure another Avill not. Occasionally, changing or mixing reduces the attacks for a time and benefits the stomach. The best bro- mides are those of potassium, sodium, strontium, ammonium, and hydrogen (hydrobromic acid). Bromide of potassium is the most trustworthy. Bromide of sodium is more agreeable to the taste, less irritating to the stom- ach and milder in its effects, but is eventually just as depressing as other forms. Bromide of ammonium has a brief stimulant effect on the circulation. Bromide of strontium has no advan- tages that I can discover. Bromide of gold is of no use. Hydrobromic acid is useful in those cases in which there are indigestion and phosphaturia and an alkali is contra-indicated. It produces acne less readily than the alkaline bromides. Bromides should be given in daily doses of 3 i., increased grad- ually until the attacks are suppressed or the dose reaches 3 iv. to 1 i. daily. Few patients can tolerate more than this latter dose. Thorough bromidization should be always tried if necessary to stop the fits, and it may be occasionally repeated. But bromidi- zation is sometimes injurious, even making the disease worse, and it must always be employed Avith caution. When the fits are suppressed the bromides should be reduced, but never entirely stopped for at least two years after the last fit. In most cases, and especially in nocturnal epilepsy, an extra large dose of bromide or bromide and chloral should be given at night. It is very important that the bromides should be chemically pure (most samples are not), that their use should be continued a very long time, and that their depressing effects should be offset by tonics and all possible roborant measures. Bromides lessen the fits in from eighty to eighty-fi\*e per cent of cases. They do no good or do actual harm, as regards fre- 414 DISEASES OF THE NERVOUS SYSTEM. quency of attacks, in from fhre to ten per cent of cases. Bro- mides do no actual good to the patient in a much larger propor- tion of cases. To prevent bromide acne, arsenic, calcium sulphide, baths, and diuretics are the best measures. To preA'ent bromidization, one should adopt all possible robo- rant measures; use salt-Avater baths and regular physical exercise, gi\~e black coffee, caffeine, cocaine, mineral acids, strychnine, bitter tonics, cod-liver oil. In all cases the patient should dilute the drug, preferably Avith carbonic-acid water or Vicliy, in the proportion of six ounces of water to a scruple of the drug. A few drops of phosphoric acid may be added to this. The continuous administration of an alkaline bromide in an alkaline Avater sometimes affects the bladder, and then the bro- mide can be gh'en dissoh'ed in hydrobromic acid. The best substitutes for the bromides, when these do no good or do harm, are belladonna, zinc, strychnine, glonoin, borax, and antipyrin. The best non-specific adjuvants (drugs) to the bromides are potassium iodide (in syphilitic epilepsy), potassium bicarbonate (in lithamiic and rheumatic states), carbonate of ammonium, the hypophosphites, arsenic, iron, and quinine. The best specific adjuvant to the bromides, as Seguin has shown, is chloral hydrate. By adding five or six grains of this to a mixture the bromide dose can be reduced one-half and the fits still be controlled. Chloral-amide has a similar effect. Both these drugs will sometimes affect the eyes and stomach unfavor- ably. Children bear nearly as large doses of bromide as adults. The remedies that are especially useful in petit mal are, after the bromides, bromide of camphor, belladonna, glonoin, canna- bis indica, cod-liver oil, ergot, counter-irritation at the back of the neck, and cold spinal douches. For epilepsy in children, besides the bromides it is sometimes advisable to employ milk diet, rest, and oxide of zinc. In hemiplegic and in Jacksonian epilepsy the actual cautery applied over the scalp is beneficial. For nocturnal epilepsy one may increase the dose of bromide at night and add chloral or digitalis. Strychnine is sometimes useful. Raising the head of the bed or making the patient sleep in a chair at night are meas- ures that may be tried. For hysterical and erethitic cases, with or in place of bromides give a diet of milk and vegetables, and try turpentine, valerian, or zinc. Belladonna is usually contra-indicated. Counter-irritation by means of blisters, issues, and setons at the back of the neck is of doubtful value. For the status epilepticus give large enemata of chloral and EPILEPSY. 415 use emetics and purges. Venesection is often efficacious, morphine is dangerous, chloroform is only palliative, and nitrite of amyl is of little value. To prevent impending attacks the best remedy is nitrite of amyl, which may be carried in a phial filled with cotton. Inhala- tion of chloroform or ammonia, the internal administration of ammonia, spirits of lavender, or alcohol, a sternutatory, and pressure on the carotids—all are measures which sometimes stop the attack. Alterative and habit-breaking drugs, such as mercury, iodide of potassium, arsenic, and antimony, are useful in epilepsy, especially in acquired forms due to lead, alcohol, and syphilis. Bromides stop the fits oftener if given early in the disease, if given to young children, and if given in cases that develop after twenty-one. Injuries to the head which have caused a fracture or a con- tusion of the brain are the most frequent traumatic irritants. Whenever epilepsy can be distinctly traced to a blow on the head the question of trephining should be brought up. If there is a history of fracture or present evidence of fracture or even evidence of severe head injury, trephining is justifiable. The more marked the evidence of a degenerative constitution and the less marked the evidence of real brain injury, the less hopeful the prognosis. On the whole, surgery can do little for acquired and nothing for idiopathic epilepsy. CHAPTER XXII. HYSTERIA. Hysteria is a chronic functional disorder characterized by nervous crises of an emotional, convulsive, or other nature and by an interparoxysmal state in Avhich certain marks or stigmata are present. Hysteria is essentially a psychosis, and the dominant symptoms are attributable to disorder of the cortical areas of the brain. Its components are the paroxysms, or "crises" as they are called, on the one hand, and the peculiar symptoms of an interparoxysmal state on the other hand. The disease is to be regarded as a definite one, having a certain, as yet unknoAvn, pathological basis underlying it. The use of the word should be much more restricted and definite than has hitherto been the fashion. There are two forms of the disease, hysteria major and hysteria minor. Etiology.—Of the predisposing causes heredity is the most important. In about seventy-five per cent there is a history of hysteria or some neurosis or psychosis in the parents. The disease is transmitted more often by the mother. Heredity is particu- larly apt to be important in the hysteria of children; it is a much smaller factor in hysteria of adult males. A hereditary history of rheumatism, gout, and tuberculosis is of very doubtful im- portance. Hysteria is a disease of early adult life, most cases occurring between the ages of from fifteen to twenty-five in females; it occurs later in males. Hysteria attacks children be- tAveen the ages of eight and fifteen, chiefly betAveen eleven and fourteen. The disease affects women more than men in the pro- portion of four to one, varying much with race, climate, and occupation. Hysteria occurs in all classes of life, but rather less frequently in the middle classes than among the poor and the A'ery rich. Male hysteria is more frequent in the poorer classes who are subjected to the exciting influences of alcoholism, pov- erty, injuries, etc. Hysteria is certainly much less frequent in its severer forms in this country than in some parts of Europe, par- ticularly France. In my experience it is much less frequent than epilepsy in the northern and eastern parts of this country. It occurs, however, quite frequently in the negroes and also in the Latin races of this country. Bad methods of education and bad family training undoubtedly tend to promote the development of the disease. HYSTERIA. 417 The most important single exciting factor is powerful emotion, particularly fear. Other emotions of an allied character—excite- ment, sorrow, anxiety—may bring on attacks. The disease can be developed by imitation. Injuries combined usually Avith mental shock are fruitful causes of producing hysteria. The infectious fevers, syphilis, diffuse hemorrhages, the poisons—lead, alcohol, mercury, and tobacco—the administration of ether, mental and bodily and sexual excesses are all important agents in developing the disease. Symptoms.—The symptoms of hysteria are best described under two general heads—first, those of hysteria minor or the hysterical condition, and, second, those of hysteria major. 1. Hysteria minor is characterized by the interparoxysmal con- dition of emotional weakness, nervousness, hypersesthesia and pains, and by crises of an emotional character. In hysteria minor there are no permanent objective marks like anaesthesia and paralysis, and no decided convulsive seizures. The patient, Avho is almost always a girl or young woman, gradually develops an undue sensitiveness, the mind is depressed, and she gets easily alarmed. She has feelings of nervousness and lacks control over the emotions, she laughs and cries very easily and yields to every impulse. She suffers from headaches which are usually vertical and often severe and chronic, and from spinal pains. She sleeps as a rule rather badly and often has disagreeable dreams. She has, under any little excitement, sensations of tickling, fulness or choking in the throat, forming the condition known as globus. Excitement also brings on attacks of trembling or chilly feelings which come and go. There is more rarely a considerable amount of vasomotor instability, as shown by flushings and by coldness of the extremities. She has with more or less frequency distinct crises of an emo- tional character, during which she laughs or cries Avithout ap- parent cause, or at least to an extent beyond her control. She may have attacks of vomiting or headache, or of intense mental excitement amounting almost to delirium. In some cases the patient has somnambulic attacks at night, or she may have under a little excitement attacks of cerebral automatism during which she involuntarily does things that she is entirely unconscious of when she comes out of the attack. The crises are followed by a copious discharge of very light urine. Hysteria minor is closely allied to a condition of neurasthenia or of simple nervousness. It is associated with neurasthenia oftentimes, and is to be distin- guished from it chiefly by the peculiar psychical state, the hyper- aesthesia, and the crises Avhich have been described. Even in hysteria minor there is a degree of that peculiar mental condi- tion which will be described later and which is knoAvn as sug- 27 418 DISEASES OF THE NERVOUS SYSTEM. gestibility. Hysteria minor is a disease which belongs especially to childhood and early Avomanhood. it is Aery liable to become ameliorated and disappear a little later in life or under the in- fluence of proper treatment, but it may continue or pass into the major form. '2. Hysteria major is characterized by interparoxysmal mani- festations of anesthesia, paralyses, contractures, tremors, pecul- iar mental conditions, and by paroxysms of an emotional, con- vulsive, or other serious nature. Hysteria major is what is usually meant Avhen one speaks of hysteria; it includes also hystero-epilepsy. The onset may be gradual, but not infre- quently it follows some shock, the first symptom being a convul- sion, a paralysis, or some emotional outburst. The symptoms of the crises are the most striking and will be described first. The most common of the paroxysms of hysteria are emotional outbursts of crying or laughing; after this come motor disturbances in the shape of conA'ulsions of various types. Besides this we have attacks of severe pain, forming neuralgic crises; attacks of nausea, gastralgia, and vomiting, forming gas- tric crises; much more rarely there are prolonged attacks of hysterical coughing, hiccoughing, sneezing, or rapid breathing. The hysterical seizure may also take the form of attacks of trance and lethargy, catalepsy, amnesia, and cerebral automatism. The emotional crises are characterized by appearing without any good cause; the patient laughs Avithout reason, and the laughing continues and is quite beyond her power of control. In the same way, and rather more frequently, crying attacks or attacks of furious anger and excitement come on. Associated with these outbursts there is almost always a peculiar sensation of something in the throat. It is described sometimes as being a ball or pressure or a squeezing sensation. It is called hysterical globus, and is due usually to a paresthesia of the nerves of the throat and larynx, but occasionally there is also a muscular spasm of those parts. Following the crises there is a profuse discharge of pale, limpid urine. Hysterical convulsions have two rather well-defined types. One of them is that Avhich comes on also in hysteria minor and is the ordinary form of hysterical convulsions; the other is a much more severe disturbance in every way and is known as a hystero-epileptic or hysteroid attack. In the hysterical convul- sion the patient, under the influence of some excitement, in- jury, or acute gastric disturbance, rather suddenly falls down and begins to go through various irregular movements of the body, such as thrashing with the arms, kicking with the legs, throwing the head from side to side, rolling about on the bed or floor. In the more distinctively convulshe seizure the hands and arms HYSTERIA. 419 and fingers are flexed, the legs and feet are extended, the eyes are generally closed, the eyeballs often conA'erged or moved about irregularly, the pupils dilated. There is some lessening of sensa- tion over the body and of the conjuncti\Tae. The patient often utters noises or screams at intervals. She may bite her lips, but does not bite the tongue, nor does she ever hurt herself in her A'a- rious contortions. The attack may last for half an hour to several hours, unless some measures are taken to break it up. In other forms of hysterical convulsion there is simply a general shaking or trepidation of the body as though the patient had a chill; in other cases again the main type of movement is that of opistho- tonos, the patient rising up upon the head and heels and arching the body as in tetanus. Again the attack may consist simply of a little rigidity of the body, or of a series of rhythmical movements of the head or trunk or limbs, the patient sitting up and oscillat- ing the head or swaying the trunk or moving the arms, uttering at the same time incoherent words. In children the attacks may be associated Avith peculiar noises and movements in imitation of animals, such as the growling of a dog or the meAving of a cat. This condition is called therio-mimicry. In some instances the attack may be accompanied or may end in a condition of mental excitement approaching delirium. The patients while suffering from these seizures generally appreciate what is going on about them, and Avill often respond to some stern order for them to cease or Avill be brought to a state of quietude by pressure upon some part of the body which proA-okes pain. In women in particular, pressure OArer the ovaries or epigastrium Avill abort the attack; the application of cold Avater or an emetic Avill do the same. Tlie Symptoms of the Interparoxysmal State.—Between the crises the patient may be in a fair condition of general health, but usually presents certain definite chronic manifestations of the disease. The most characteristic are sensory symptoms, paralyses, and contractures. Sensory symptoms. These consist of cutaneous and mucous hyperesthesia and anaesthesia and anaesthetic disturbances of the special senses. Cutaneous anesthesia occurs in three forms: the common form is that of hemianesthesia invoh'ing one-half of the body; next in frequency is the segmental anesthesia in- volving an arm or a leg or part of the face or head; rarest of all the forms is a disseminated anesthesia occurring in the form of patches. These A'arious modes of distribution are shoAvn in the accompanying figures. The anesthesia is a pain anesthesia chiefly. The tactile and thermic sensations are less markedly affected. The anesthesia is in some rare cases transferable by means of magnets or electrical irritants or by suggestion. The anesthesia can also be lessened or removed temporarily by the 4-20 DISEASES OF THE NERVOUS SYSTEM. application of magnets or coins or pieces of metal. For example, if a silver coin is fastened upon the ana'sthetic area, in the course of a feAv minutes or a feAV hours there will be a zone of normal sensation under and around the coin. Sometimes the tempera- ture of the skin upon the anesthetic part is lowered '■)' or 4" F., and upon pricking the skin blood does not Aoav. The anusthesia is oftener upon the left side in the proportion of three to one. Hysterical anesthesias are not accompanied Avith subjective sen- sations like organic anesthesias. The skin reflex is usually abol- ished. Anesthesias of some kind occur in a very large proportion of chronic forms of hysteria major. They are rare, hoAvever, in Fig. 192.—The Three Types of Distribution of Anesthesia in Hysteria : Hemianesthesia, Segmental, and Disseminated. Z, Hysterogenic zones. children, and are rarer in women than in men in the author's ex- perience. Anesthesia of the mucous membranes is present chiefly in hemianesthesia; it then involves the mucous membrane of the mouth and throat, and to a less extent that of the nose and glot- tis. Hemianesthesia is usually accompanied with some hemi- plegia and often with some tremor. Segmental ana'sthesia is also often accompanied Avith some degree of paralysis of the part. Visual anesthesias. One of the most common of the perma- nent stigmata of hysteria is an anesthetic condition of the retina. The result of this is the production of a concentric limitation of the visual field and a disturbance in the color sense. Complete loss of this sense may take place or there may be a variation in the way in which the colors are perceived. There may be also HYSTERIA. 421 a distinct diminution in the acuity of vision or even a complete loss of sight of one eye. The visual disturbance is most common with hemianesthesia. It is more marked on the affected side, but exists to some extent on the healthy side. The limitation of the fields is shown in the accompanying cut (Fig. 193). Hearing. There is sometimes a diminution in the acuity of hearing of one ear, and this occurs, if present, in connection with hemianesthesia. There may also be a loss of hearing to high and Ioav notes, while hearing is apparently fairly good to notes of medium range; and finally there may be a diminution in hearing by bone conduction, while hearing by aerial conduction is but O. S. O. D. Fig. 193.—Hysterical Loss of Color Sense and Limitation of Visual Field. Color sense absent in left eye and field contracted; in right eye field less con- tracted; order of appreciation of colors from without in was yellow, violet, blue, red, green (observation by Dr. E. S. Peck). little impaired, this being due probably to an anesthesia of the acoustic nerve. Disturbances of taste in the form of anesthesia or paresthesia are quite frequent and are important signs in hysteria. The loss of the sense of taste may only involve the back portion of the tongue and the palate; in other words, the taste field is here limited as it is with hearing and A'ision. The sense of smell may be abolished, but this usually occurs in connection with hemianesthesia. Hyperesthesias and neuralgias. Pure neuralgias are some- what rare in true hysteria, but hyperesthesia and pains of vari- ous kinds are not at all infrequent. Hyperesthesia occurs in the form of patches at different parts of the body. These sensitive points may, when pressed upon, bring on paroxysms of various 422 DISEASES OF THE NERVOUS SYSTEM. kinds, and they are therefore called the hysterogenic zones (Fig. 192). The most common seat of these zones in women is over the ovaries; in men, in regions correspondng to the ovaries and on the scrotum. Hysterogenic zones, however, may be found just be- neath the mammary gland, on the epigastrium, along the spine, and in other places. These zones are sensitive areas; they can be made to disappear by applications of electricity and by refriger- ation and counter-irritation. Hysterical patients often suffer from local headaches Avhich are apt to be confined to the top of the head or to the sides near the temples. The pain is severe, sharp, and boring, and may exacerbate Avith such intensity as to produce symptoms almost resembling meningitis. The spot-like pains are known as hysterical clavus. Hysterical patients occa- sionally haA'e migraine, facial neuralgia, end intercostal neural- gia. Much more often they have pains along the spine, produc- ing symptoms of spinal irritation. Hysterical patients also have at times attacks of palpitation and pains over the heart, consti- tuting what is known as pseudo-angina. Such troubles are much more frequent in Avomen. Motor symptoms. The motor symptoms of hysteria are paral- yses, amyosthenia, contractures, tremor, and choreic and ataxic movements. The paralyses of hysteria take the form of hemi- plegia, paraplegia, and monoplegias. Hysterical hemiplegia oc- curs usually rather suddenly, often as the result of some severe shock. The left side is more frequently attacked. The arm is most affected, the leg next, while the face is hardly ever in- voh'ed. The paralysis is not an absolute one, and the patient is able to drag himself along. The deep reflexes are usually not exaggerated and they may be for a short time absent. The paral- ysis is thus a flaccid one. The gait of the patient is different from that of hemiplegia due to organic disease; in hysterical hemi- plegia the patient drags the paralyzed leg after him, in organic hemiplegia the patient swings the paralyzed leg around in a half circle. This peculiarity of the gait, the absence of exaggerated reflexes, the absence of paralysis of the face, and the presence very commonly of other hysterical stigmata are sufficient to en- able one to make the diagnosis. Sometimes the face on the affected side is slightly drawn by a spasm so that it appears to be paralyzed, when it really is not (Charcot). Monoplegias affect the arm or leg, very rarely indeed the face, occasionally the eye muscles, and most commonly of all the muscles of the larynx. Hysterical monoplegia is usually accompanied with anesthesia of the affected part and by other symptoms of hysteria. There are no serious atrophic changes or disturbances of the electrical reactions. Hysterical eye palsies show themselves in the form oftenest of an insufficiency of the internal recti, much more rarely HYSTERIA. 423 by a paralysis of the third nerve or some of its branches. In hysterical palsy of the larynx the adductors are imolved so that the patient cannot speak aloud, and the condition is called hysterical aphonia. The trouble often comes on suddenly, the patient finding that he cannot speak above a whisper. The paralysis is not so great but that the adductors can be approxi- mated in coughing. The trouble is distinguished from laryngeal inflammation by inspection of the affected part. The abductors of the larynx and the tongue and other muscles of articulation are in very rare cases also involved, and hysteria may produce symptoms resembling a bulbar paralysis. Paraplegia is a rather common form of hysterical palsy; it is usually brought on by emotions of depressing character, often associated Avith some slight injury. It may be accompanied with a good deal of pain Fig. 194.—Hysterical Contractures. in the back, and the form of disease which is popularly known as " spinal concussion" consists in many cases of hysterical para- plegia combined with hysterical neuralgia of the spine. In hysterical paraplegia there is A'ery little wasting of the limbs and no change in the electrical reactions. The deep reflexes may be somewhat increased or normal; they are never absent. There is never any prolonged or persistent ankle clonus, but there may be a short or spurious clonus due to a general exaggerated irritability of the nervous system. The sphincters are never in- volved except temporarily or through some complication. Amyosthenia is a frequent, peculiar, and interesting symptom occurring in the interparoxysmal stage of hysteria. It consists in a more or less temporary feeling of weakness of an arm or of the legs. Thus a person in lifting a dish from the table suddenly feels the arm give out, and if not careful the dish is dropped; or while walking the patients suddenly feel as though they had lost all power in the lower limbs. This amyosthenic condition is generally temporary, but it may be so permanent as to produce a 424 DISEASES OF THE NERVOUS SYSTEM. certain degree of monoplegia or paraplegia. The amyosthenic condition generally precedes a paralysis. It presents no objec- tiA'e signs in the Avay of electrical reaction; it iiiA'olves a Avhole member, not a single group of muscles; it affects more the ana's- thetic side, and Avhen it exists the deep reflexes are usually exag- gerated (Tourette). Contractures. In some forms of hysteria there is a tendency for the muscles to undergo contracture under slight mechanical stimulation such as pressure or a blow. This tendency to con- tracture in hysteria is called the contractural diathesis, and it is an important sign. The contractures may be temporary, disap- pearing soon after the exciting cause ceases, or they may develop independently and last for a long time. They involve the legs, Repose. Movement. Fig. 195.—Illustrating Intentional Tremor in Hysteria (Tourette). arms, and facial muscles, and may be associated Avith paralysis and anaesthesia. Tremor occurs in hysteria in a considerable proportion of cases, more especially those in which there is hemiplegia and hemi- anesthesia. Hysterical tremor simulates all the A'arious types. The common form is one in Avhich the oscillations occur from five and a half to seven and a half times a second, and it is there- fore a tremor of average rhythm. It ceases for a time when the person is quiet or lies in the horizontal position; also during sleep. It affects the head and tongue as well as the extremities, the latter more upon one side than the other. It may be chiefly in the lower limbs. Sometimes it has the type of an intentional tremor, ceasing on rest of the hand and increasing when the hand is moA'ed, as in raising a glass to the lips (Fig. 195). It then resem- bles exactly the tremor of multiple sclerosis. There may be a slow tremor of four to flA'e and a half oscillations per second; this per- sists during rest and is but little modified by voluntary move- ments. It imitates the tremor of paralysis agitans. Finally there may be a rapid tremor of eight to nine oscillations per second. This also persists during repose and is but little modi- HYSTERIA. 425 fled by movements. It imitates the tremor of Basedow's disease, alcoholism, and neurasthenia. The mental state in hysteria is characterized by emotional in- stability and intense craving for sympathy, weakness of the will, lack of self-control, acuteness of perception, and a constant A-ari- ability of moods. The hysterical mind is not a dull one, it is not a consciously mendacious or eA'il one. But there is an abnormal increase of sensibility and an exaggeration of the personal feel- ing or egotism which leads to selfishness and prompts deceit. The fundamental defect in the hysterical brain is that it is circumscribed in its associative functions; the field of conscious- ness is limited just as is the field of A'ision. The mental actiA'ity is confined to personal feelings, which are not regulated by con- notation of past experiences, hence they flow over too easily into emotional outbursts or motor paroxysms. The hysterical person cannot think. Physiologically the condition is explained by supposing that there is a benumbing of the association fibres which normally connect sensory cortical centres Avith other parts and enable one to compare and adjust ne\v experiences with old. In other words, to reason and form correct judgments. Underlying the hysterical mental state there is a condition of suggestibility, by reason of which ideas and impressions easily be- come fixed and dominate the mind. The person becomes self- hypnotized and believes he or she is suffering from things Avhich haA'e no objective existence. The pains, palsies, and "anesthesias of hysteria major are pseudo-delusions, differing from delusions of the insane in that the false belief or idea is a subconscious one. Trophic disorders. In hysterical paralysis a slight amount of atrophy occurs, but only such as would naturally follow disuse of the part. A very few cases have been reported in which a true neurotic atrophy resembling the atrophy that occurs in neu- ritis or progressive muscular atrophy Avas present, and it is even affirmed that degenerative reactions may be elicited. Cutaneous eruptions and dystrophies practically do not exist, or, if present, are the result of complicating disorders. Visceral symptoms. Hysterical patients often suffer from dyspepsia and constipation, also from anorexia and in some cases from persistent vomiting or regurgitation of food. Occasionally the anorexia and A'omiting become persistent; the patient refuses food or rejects all that is taken; she emaciates, becomes weak and bed-ridden, and develops into that particular phase of hys- teria known as " the fasting girl." In these cases, along with the aArersion to food and vomiting, there may be a great deal of gas- tralgia. The urine in hysteria is apt to be of low specific gravity. Always after hysterical attacks there is a profuse flow of very 42G DISEASES OF THE NERVOUS SYSTEM light-colored urine having a gravity of only 1,003 to 1,00(1. Some- times there is retention of urine; in extremely rare cases there is a condition known as ischuria and anuria, in which for several days extremely small quantities of urine are passed, owing ap- parently to a suspension of the functions of the kidney. Such cases should always be carefully investigated, to see that the patient does not deceive her attendants in regard to the amount of urine passed. Vasomotor symptoms are very common. They consist of flushings and pallor, cold extremities, and at times an oedematous condition of one or more extremities. This oedema may be of the ordinary pale, Avaxy character, pitting upon pressure. In other cases it has a peculiar bluish tinge and it does not pit; the hands, which are the parts generally affected, are several degrees below the normal in temperature, and the limb resembles in some respects the condition in Reynaud's disease. Gangrene, however, never supervenes. This form of oedema is known as the blue oedema of hysteria. There occur in hysteria febrile attacks, and much has been written upon the subject of hysterical fever. These so-called hysterical pyrexias may resemble in their course typhoid or malarial fever; as a rule, the temperature runs a very irregular course, and the fever often lasts for Aveeks or even months. The essentially neurotic origin of these fevers has hardly yet been established, and one can only reach the diagnosis by most care- fully excluding all other possible causes. Anemia is a very common condition in hysterical patients. Hystero-Epilepsy.—The form of hysteria which shows itself by the development of severe crises known as hystero-epileptic at- tacks is extremely rare in this country, at least in its typical phase. It has been particularly studied by the French writers Charcot, Richer, and others. Hystero-epilepsy, as this form of the disease is called, is a true hysteria and not epilepsy at all, nor a mixture of hysteria and epilepsy, though the name would suggest that that was the case. The typical attacks of hystero- epilepsy begin with certain prodromata consisting of a feeling of malaise and irritability which may last for several hours or a day. The attack is ushered in often with an aura, the patient utters a cry, falls to the ground, loses consciousness, and enters into the first phase, known as the epileptoid stage. During this she suffers from tonic and clonic spasms very much like those of true epilepsy. The muscles finally relax, and the patient be- comes comatose for a moment and then enters the second stage, that of the contortions and grand movements. In this there is opisthotonos, the body is arched up, and there are violent move- ments of the trunk and limbs, which undergo flexion and exten- HYSTERIA. 427 sion, the movements being all of large range. The next stage is that of emotional attitudes, during which the patient seems to be experiencing intense feelings of anger, joy, or some other violent passion, which she expresses by the postures of her body, the movements of the eyes and facial muscles. This stage over, she enters into the last phase, which is known as that of delirium, during which there is a great deal of mental excitement of a Fig. 196.—Showing the Different Stages of a Hystero-Epileptic Seizure (after Richer). depressing character, from which she gradually emerges into her normal condition. To recapitulate: we have in a typical attack, first, prodromata; second, the epileptoid phase, lasting from one to three minutes; third, the phase of contortions and grand movements, one to three minutes; fourth, the emotional phase, lasting from five to fifteen minutes; and, finally, the stage of delirium, lasting a variable time; the whole attack lasting from five to twenty minutes (Fig. 196). In this country we occasion- ally see hysterical patients exhibiting one or two of these phases 428 DISEASES OF THE NERVOUS SYSTEM. but \Tery rarely indeed do they eA'er go through the Avhole series. The patients who suffer from hystero-epileptic attacks generally during the interparoxysmal stage present many of the stigmata of hysteria such as paralyses, contractures, and anesthesias. Hysterical crises Avhich take the form of convulsions or emo- tional seizures sometimes end or are associated Avith attacks of catalepsy or trance or attacks of amnesia and cerebral automa- tism. As these conditions all occur in other diseases than hys- teria, they will be described elsewhere in connection Avith the subject of the disorders of sleep and of consciousness. Hysterical persons occasionally are attacked with violent and persistent hiccoughing or sneezing. Sometimes also there come on attacks of extremely rapid breathing or hysterical polypncea, during Avhich the respirations run up to fifty or seventy a minute. A hysterical cough sometimes occurs; it lasts for a long time. CEsophageal spasm Avith consequent dysphagia is another one of the someAvhat rare phenomena of hysteria. Pathology.—-There is no knoAvn anatomical change at the basis of hysteria. We do not find the marks of degeneration as we do in certain forms of insanity and epilepsy. The pathology of hysteria is really its psychology. It is a brain disease affecting primarily the cortex, Avhile secondarily lower centres are involved. The essential trouble is on the one hand a benumbing of the associative and inhibitory tracts of the brain so that the sensa- tions are dammed up till they promiscuously overflow. On the other hand, the receptiA'e areas are over irritable and sensitive. The field of consciousness is narrowed but exalted in intensity. Diagnosis.—Physicians recognize three different phases of hysteria—a hysterical temperament, hysteria minor, and hysteria major. The hysterical temperament is something with which all women and many men are naturally endoAved. It is a condi- tion, not a disease, and does not call for description or elucida- tion here. Hysteria minor is the hysterical temperament plus certain stigmata and the crises. One should not make the diag- nosis of hysteria minor unless he can find these factors. The stigmata we have already enumerated, also the peculiar and varied forms in which the crises show themselves. In hysteria major we have a much greater preponderance of the stigmata and much severer forms of the crises, these being largely of a motor type. Hysteria simulates many organic diseases, and it is often difficult to distinguish surely the real from the spurious thing. The essential characteristics of hysterical forms of dis- ease are the peculiar emotional condition of the patient, the past history of hysterical crises, the presence of the stigmata of hys- teria such as anesthesias, limitation of the visual field, paralyses, and contractures. The variability of the symptoms, their sus- HYSTERIA. 429 ceptibility to influence under suggestion and rigorous moral measures, the absence of serious disturbance of nutrition, the sex and age, and the cause should also have weight in guiding us to our decision. Diagnosis of special forms of hysterical manifestations. Hys- terical paralysis is characterized by the fact that there is no marked degree of wasting of the muscles, no electrical reactions of degeneration, the deep reflexes are preserved or exaggerated, and other marks of hysteria are present. Hysterical anesthesia can generally be lessened over certain areas by the application of the magnet or can be made temporarily to disappear; it is pecul- iarly distributed in the way described under symptoms and is associated with anesthesias of the special senses. Hysterical contractures sometimes cease during sleep and ahvays under deep narcosis, and the use of an anesthetic may clear up the case. They usually follow a fit, an injury, or an operation. They are somewhat increased on attempts to overcome them by force; they are usually associated with paralysis and anesthesia and other hysterical symptoms. Hysterical convulsions. These differ from convulsions of epi- lepsy in the Avay best indicated by the following table: Hysterical Convulsion. Epileptic Convulsion. Brought on by emotion or injury; no The opposite in all these particulars. aura ; no initial cry ; movements co- ordinate ; tongue not bitten, and pa- tient never injures herself. Duration perhaps several hours with intermis- sions ; consciousness generally pre- served. Micturition and defecation do not occur. No rise of temperature; may be stopped artificially. The hystero-epileptic attacks are so characteristic that a mis- take could not be made. Prognosis.—The prognosis of hysteria in children is good. They generally get well, although in some cases there is a recur- rence later in life. In hysteria minor of young adults the prog- nosis varies with the severity of the disease and with the physi- cal strength, mental endowment, and social environment of the patient. Mild forms of hysteria under proper treatment usually get well. The severer forms are often intractable even under the best treatment. When a severe form of hysteria occurs in a person of feeble frame Avho is surrounded with a sympathetic family, the task of rescuing her from her disorder is a \'ery ardu- ous one. Traumatic forms of hysteria which are not infrequently associated with some actual physical injury are often difficult to cure. Hysteria which is associated Avith some organic disease, 430 DISEASES OF THE NERVOUS SYSTEM*. such as a severe pelvic disorder or an organic affection of the central nervous system, has a bad prognosis. Hysteria in the male is generally curable, but it requires vigorous treatment, and spontaneous cure is by no means likely to happen. Treatment—The treatment of hysteria may be divided into the mental, mechanical, dietetic, and medicinal. By all odds the most important factor in the treatment of hysteria is the mental treatment, and the most important meas- ure to be taken is the isolation of the patient. She should be placed Avhere she will not be surrounded by sympathetic friends; where her life will be a regular one; where some occupation may be given Avhich Avill engross her attention, interest her mind, and call into play her physical activities. In the major forms of hysteria associated with anorexia, emaciation, anemia, and pos- sibly pelvic disorders, the 'rest cure" as elaborated and carried out by Weir Mitchell forms by all odds the most successful means of treatment. In many cases of less severe character a partial rest cure in Avhich the patient is separated from her family but is not placed under such severe restrictions may be all that is needed. In the case of children removal from home is often advisable, and the discipline of Avell-conducted schools is a most excellent measure. The mechanical means used in hysteria are hydrotherapy, electricity, massage, and exercise. Of these measures hydro- therapy and electricity take the first rank. In hydrotherapy the douche or jet to the back, the shoAver and cold plunge, and the half bath are the most efficacious. The technique of their use is given elsewhere. In the electrical treatment the static and fara- dic currents give the best results. The static sparks often relieve contractures and lessen or remove the anesthesias, and both forms of electricity seem to have a generally beneficial tonic ef- fect. Massage is of some value in promoting nutrition, and it also has a favorable sedative effect on many cases. Exercise, particu- larly of an active kind such as stimulates the mind and interests one, is a measure of extreme A'alue and one which has perhaps not been sufficiently appreciated. The use of the bicycle, play- ing tennis, and horseback-riding are measures which cannot be too strongly recommended to hysterical women; in fact, it is probable that some cases which are submitted to the rest-cure treatment might do better by an entirely opposite kind of pro- cedure. The drugs which can be recommended in hysteria are not numerous and their poAver is limited. Valerianate of zinc, tur- pentine, asafoetida, tincture of sumbul, iron, and the bromides are the most important of the nervines. In hysterical children a capsule containing two grains of valerianate of zinc and one of THE SPASMODIC TICS. 431 sulphate of quinine is often efficacious. Gowers places more reli- ance upon the oil of turpentine in doses which should be increased to the point of strangury. Pitres recommends the Avearing of colored glasses in order to keep off hysterical attacks. Some ex- perimentation is necessary in order to see which color is most suited to the case. In the treatment of hysterical convulsions the most efficient measure is the administration of an emetic, and this can be best done by giving hypodermically one-twelfth of a grain of apomor- phine. Convulsions can be stopped sometimes by throAving water in the face or on the epigastrium; by firm and somewhat long- continued pressure OA'er the ovaries; by the administration of A'alerian, aromatic spirits of ammonia, or compound spirits of ether. The Spasmodic Tics (Tic Coxvulsif). Spasmodic tic is a disease to which the name of chorea is often, but incorrectly, given. It is a Aery chronic disorder, and sIioavs itself in the form of quick, electric-like spasms of certain groups of muscles or single muscles. The spasmodic move- ments are violent, and several rapid contractions succeed each other, after which there is a period of rest. The spasm has a tendency to become localized in certain nerA-es, especially the facial (mimic tic), or even in a single branch or twig, as that to the orbicularis, the zygomaticus, the diaphragm, or the tensor tympani. Spasmodic tic sometimes im'olves the muscles of ex- piration and the larynx, and then it has been wrongly called chorea of the larynx. Stuttering is a form of tic. The convulsive movements may take a Avide range and affect a number of groups of muscles, producing quick, Aiolent move- ments of the body. They are sometimes accompanied with ex- plosive disturbances of speech. In these cases the patient at the time of the convulsive movement utters some obscene or profane words (coprolalia), or involuntarily repeats the last words of the sentence spoken to him (echolalia), or spasmodically imitates a gesture made to him (echokinesis), or involuntarily exclaims the thought uppermost in his mind, perhaps revealing some secret against his will (tic de pense'e). The peculiar disorder of the Maine "jumpers," characterized by sudden A'iolent movements on being touched or startled, is a form of tic. So also are the similar troubles knoAvn as lalah, occurring in Malay, and myriachit, occurring in Siberia and Kamchatka. Most of the special forms of spasmodic tic (mimic tic, wry- neck, etc.) have been described elseAA'here. Spasmodic tic with coprolalia affects children between the 432 DISEASES OF THE NERVOUS SYSTEM. ages of six and sixteen years, and by preference the masculine sex. There is almost always a neurotic family history, and the children are nervous. The disease begins Avith attacks of violent and irregular move- ments, affecting generally the head, face, and upper extremities first, then involving the whole body. The movements can be con- trolled for a time by the will, only to break out with increased violence later. They cease entirely during sleep, which is gen- erally profound. After having suffered from the disease for a time, the patient Avill, with the attacks, utter inarticulate cries, or he may begin to repeat or echo the Avords that he overhears. All this is done automatically and suddenly, Aviththe accompaniment of grimaces and muscular contortions. The special peculiarity of the disease is the sudden interjection by the patient of obscene words and expressions (coprolalia). The disorder is chronic, lasting for years. It is best treated by isolation, tonics, and ordinary antispasmodics. Paramyoclonus Multiplex (Myoclonus Multiplex, Convulsive Tremor, Myospasia). Myoclonus multiplex is a rare disease allied in nature to the con\'ulsive tics and characterized by attacks of quick clonic spasms affecting the trunk and sometimes the extremities also. The disease occurs most often in adult males. It is caused usually by fright, injury, or some violent emotion. Very different forms of spasm have been described under the name myoclonus multi- plex, but in the typical disease the patient without warning is seized with sudden and lightning-like contractions of the trunk and hip muscles, Avhich cause his body to be alternately flexed and extended so violently that he is often thrown from the chair or couch on which he is lying. The arms and legs may be also in- voked, and the attack takes on the characteristics of a general tremor in which the whole body shakes. The facial muscles may be affected. The spasmodic movements are bilateral, although they sometimes begin on one side. The convulsions differ from those of hysteria in that they affect groups of muscles that haA'e not the same physiological function and produce move- ments which cannot be easily imitated voluntarily. Still this distinction is not a sharp one. The patients are generally neu- rasthenic or hysterical. They have no paralyses, no anesthesias, very few pains, and their bodily nutrition is not seriously im- paired. The pathology and pathological anatomy are unknown. The diagnosis is based on the peculiar character of the spasm, thomsen's disease. 4o>i on the fact that the trunk muscles are involved, and that the spasms are bilateral. The disease usually lasts but a few months, but it may extend over a number of years. The prognosis is fairly good. The treatment consists of tonics and the use of chloral. Gal- vanism seems to be very efficient. Atropine and hyoscine are indicated, and hydrotherapy may also be advantageously em- ployed. Saltatory Spasm. This is a curious and rare form of disease characterized by con\'ulsive nioveinents of the legs brought out by touching the feet to the floor. It occurs in both sexes and at all ages, but usually in those of a neurasthenic and hysterical temperament. The phenomena of the disease are exhibited when the patient attempts to stand. The minute that the feet touch the floor A-io- lent contractions occur in the muscles of the calves and hips, sometimes in the Avhole body; these cause the patient to jump, and the movements may be so severe as to throw him down. The seizures are only brought on by the exciting effects of the weight of the body on the feet. Saltatory spasm is probably a form of hysterical spasm. It has been described chiefly by the older writers, and its symptomatology and pathology have not been carefully Avorked out. Thomsen's Disease (Myotonia Congenita). This is a hereditary family disease characterized by the devel- opment of tonic cramps when the patient attempts voluntary movements. The disorder is very rare. About forty cases have been reported, and in this country only three, one of them being a patient of the Avriter's. Etiology.—Congenital myotony is practically always heredi- tary and runs in families. It affects males by preference and de- velops at the time of adolescence. Symptoms.—The patient notices that on trying to rise or walk his legs are seized with a painless cramp, which in a few seconds relaxes, but comes on again when the muscular movements have been repeated. If he closes his hands tightly a cramp occurs and he cannot relax the grip. If he shuts his eyes he cannot open them for a moment. The muscles of mastication may be affected, but the extremities are the parts most involved. The involuntary muscles are spared. The cramps are increased by cold and nervousness; they are lessened by muscular exercise. The muscles are somewhat hypertrophied, and the patient may present the appearance of a very strong man. The actual strength is fair, but less than would seem. The general health may be good, but the patients sometimes show the signs of low vitality in weak digestion, feeble sexual power, and susceptibility to cold. The electrical excitability of the nerves is normal, that of the 28 434 DISEASES OF THE NERVOUS SYSTEM. muscles is increased, and there is produced a contraction tetanus by both currents. In addition Erb describes a peculiar reaction produced by a strong stabile galA'anic current. It consists in the appearance of AvaA'e-like muscular movements passing from cathode to anode. This was not present in my case or Jacoby's. The mechanical excitability of the muscles is also increased. Pathology.—The disease is probably a primary muscular dys- trophy. There may be, hoAvever, a peculiar defect in innerva- tion, resulting from a congenital anomaly of the motor tracts. The muscular fibres are found to be hypertrophied, the striations indistinct, and the nuclei increased. The diagnosis is easily made by the characteristic tonic cramps. The prognosis is bad as regards cure, but the disorder does not shorten life. Treatment.—Dr. Thomsen, who first described the disease, states that actiA'e muscular exercise benefits patients. Ko spe- cific measures are knoAvn. Congenital Paramyotonia. Paramyotonia is the name given to a form of myotonia in which the symptoms deA'iate somewhat from the typical ones that appear in Thomsen's disease. Paramyotonia occurs symp- tomatically, congenitally, and in a peculiar clinical form known as ataxic. We have, therefore, symptomatic, congenital, and ataxic forms. Symptomatic paramyotonia is noted most characteristically in a certain form of paralysis agitans. Here the patient, Avhen attempting to walk or to rise from the sitting posture, is suddenly seized with an apparent rigidity of the muscles which prevents him from stirring. The myotonic condition appears also in spas- tic paralyses of spinal and cerebral origin. Congenital paramyotonia is a family affection resembling in this respect Thomsen's disease. The muscular rigidity is brought on not by voluntary movements, but by exposure to cold and often very slight degrees of cold. The tonic spasm is a long one and lasts for from a quarter of an hour to several hours. It affects the arms more than the legs. The facial muscles are prone to become rigid. The attacks are folloAved by some muscular weakness. In congenital paramytonia the trouble is undoubt- edly a primary disturbance of the muscles; in other Avords, a myopathy. * Ataxic paramyotonia is the name given to a disorder charac- terized by transient spasms like those of Thomsen's disease, as- sociated with distinct ataxia and also with weakness and some anesthesia (Gowers). This disease is probably located in the spinal cord and should perhaps be considered one of the forms of symptomatic paramyotonia. No special treatment can be given for either of the two latter forms of disease, of which very feAv examples have been observed. Akinesia Algera (Pain Palsy). Akinesia algera is the name given by Moebius to a peculiar form of paralysis which occurs in psychopathic persons and is due to the fact that intense pains are produced by every muscu- AKINESIA ALGERA. 435 lar movement. The result is that the patient lies helplessly in bed, afraid to stir hand or foot. The disease occurs only in per- sons Avho have a very unstable nervous system and generally in those who have a paranoiac tendency. It occurs in adults only. Pain-paralysis comes on gradually and affects eventually all the muscles of the extremities and body. There are no objective dis- turbances such as atrophy, electrical degenerations, and anes- thesias. The muscles and skin, hoAvever, are somewhat tender to the touch. The disease lasts a long time. The patient some- times improves, in other cases insanity ensues. The disease is essentially a form of insanity, a pathophobia, and is allied to the disorder known as mysophobia. The paralysis is the result of pain hallucination, and the patient is afraid to move the arm or leg on account of this hallucination, just as the mysophobic patient is afraid to touch anything on account of the fear of con- tamination. The prognosis is bad, and so far treatment has accomplished little or nothing. CHAPTER XXIII. THE ACQUIRED NEUROSES. Chorea (St. Vitus' Dance). Under this name A'arious spasmodic disorders have been de- scribed. They are to be classed as folloAvs: I. Common chorea, or Sydenham's chorea. II. Hereditary chorea, or Huntington's chorea. III. The convulsive tics. IY. Hysterical chorea, including so-called chorea major. V. Various local endemic choreas, such as the electric chorea of Dubini and the electric chorea of Bergeron. Chorea of Sydenham. This is the common type of chorea, and is the disease ordi- narily meant when the term chorea is used. It is a subacute dis- order characterized by irregular jerking and inco-ordinate move- ments. The disease is a common one, forming about one-fifth of the nervous diseases of children. Etiology.—Most cases occur between the ages of five and fifteen (see chart, p. 405). It is very rare under five. A few cases occur after twenty, and even up to old age, when a senile chorea is sometimes observed. It affects girls more than boys in the ratio of about 2.5 to 1. In adult life the disproportion is less marked. It is relatively rare in the negro race, especially in those of pure blood (Mitchell). In this country it is more common in children of German, Hebrew, and Portuguese race. It occurs in all climates. Most cases develop in the spring months, next in the autumn, next in winter, and last in summer. The seasonal influence varies in different localities. In Phila- delphia more cases occur relatively in the spring. In New York there is an almost equal increase in the autumn. School attend- ance has something to do with these variations. Choreic attacks appear to be related to increase in storms (Lewis). The disease is more frequent in cities, and probably in the poorer classes. Hereditary influence is slight, but it exists. In a small percen- tage of cases one parent has had chorea, epilepsy, insanity, or a decided neuropathic constitution. A phthisical or a gouty his- tory in parents is also not rare. The chief exciting causes are injury and fright, mental worry, CHOREA. 43'/ and rheumatism. Fright or some emotional disturbance is a cause in about one-fifth of the cases. Acute rheumatism is given as a cause in A'ery A'arying proportions, ranging from fiATe to tAventy-five per cent. In this country it ranges from fifteen to twenty per cent (Sinkler, Starr, Sachs, and personal observa- tions). Endocarditis is deA'eloped in the course of chorea in a slightly larger proportion of cases. This may exist without any manifestations of rheumatism. Pregnancy is a cause of chorea generally in primipara'and ahvays in young women under twenty- five. Chorea sometimes folloAvs infectious fevers, especially mea- sles, scarlatina, and Avhooping-cough. It has been caused in rare cases by reflex irritation from an injury, from nasal disease, and sexual disorders. OA-erstudy and the worry of examinations are factors in causing chorea in predisposed and badly nourished chil- dren. Intestinal irritations, such as worms, may excite chorea. Malaria also may aggravate, if it does not produce it. Hamilton describes a form of chorea caused by tobacco-poisoning. Anemia and malnutrition underlie most cases. Symptoms.—The disease may begin suddenly, but usually it develops slowly, and it is not till one or tAvo weeks that the symp- toms are decidedly prominent. It usually begins with irregular tAvitching of the hand or face on one side. The child Avinks, grimaces, and drops things from its hand. The foot and leg be- come affected later and the child stumbles in walking. In two or three Aveeks the opposite side is invoh-ed, but usually less than the one originally affected. In three or four Aveeks the disease reaches its height. The patient's movements are then almost continuous. The hands can hardly be used and the child has to be fed and dressed; even AAalking is awkward and difficult. Speech is indistinct and confused from the irregular movements of the lips and tongue. The muscles of respiration may be in- voh'ed so that the rhythm is uneA'en. It is asserted that the heart's action is affected also; but this is unlikely. The choreic movements usually occur both when the muscles are at rest and during A'olitional acts. In some cases the disease is chiefly characterized by inco-ordinate movements Avhen pur- poseful acts are attempted. In other cases A'oluntary movements can be readily performed, and the muscles twitch only when the limbs are at rest. The movements cease, as a rule, during sleep. But the child sometimes sleeps badly on account of the move- ments. In seA'ere cases attacks of mental excitement and even delirium come on for several successive nights, and this may be so marked a feature as to form what is called chorea insaniens, or maniacal chorea. Apart from such phenomena, the mind in chorea is usually dulled, the temper irritable, and the child much harder to manage. 438 DISEASES OF THE NERVOUS SYSTEM. The appetite is poor and capricious, the tongue coated, and the bowels often constipated. The nutrition fails a little; there is anemia and a tendency to loss of flesh. The eyes present nothing abnormal. Hypermetropia, astig- matism, and muscular insufficiencies exist, but not much more than in other nervous children. The child is often Avorse in the morning and improves toward night. Excitement and physical exertion make the movements worse. There is rarely any pain and never anesthesia or ten- derness. The muscles are weak but not actually paralyzed. The deep reflexes are someAvhat lessened and the knee jerk may be abolished. The electrical irritability of the muscles is, as a rule, increased, but there are no qualitative changes. Nocturnal enu- resis occasionally occurs. The urine contains an excess of urea and phosphates, and at the height of the attack the specific gravity may be increased. Forms.—Maniacal chorea is characterized by great mental ex- citement—especially at night, delirium, with hallucinations and delusions. After one or two weeks the excitement lessens and the patient becomes dull and apathetic. Such cases usually oc- cur in adult women, and they are sometimes fatal. Paralytic chorea. In this form one arm becomes rather sud- denly weak and powerless. A few twitching movements are ob- served. This form occurs only in children and runs the same course as the spasmodic type. Chorea of adult life and senile chorea. The disease when it occurs in the second half of life attacks men rather oftener than women; it is not related to rheumatism. There is usually a neu- rotic family history and even a hereditary history of chorea, The attack is usually caused by emotional disturbances. It runs much the same course as juvenile chorea, but is rather more apt to become chronic. When it occurs in old men it is called senile chorea. This type is not to be confounded with hereditary or Huntington's chorea. Duration—Relapses.—The disease in this country lasts about ten or twelve weeks, ranging, however, from six weeks to six months. There may be great improvement followed by a relapse, and in this remittent manner the disease may last for years. If it lasts more than six months it should be called chronic. Re- lapses occur in about one-third of the cases, and rather oftener in girls. Relapses occur oftenest within a year of the first attack and much oftener in the spring. After three years relapses prac- tically cease. The number of relapses is usually but one, but the disease may recur eight or nine times. Relapses rarely occur in adults except in the chorea of pregnancy. Pathology.—The seat of the lesions in chorea is the gray mat- CHOREA. 439 ter of the cortex and its meninges, the pyramidal tract, len- ticular nuclei, and the spinal cord. The lesions are in acute cases of the nature of intense hyperemia, Avith dilatation of A'essels, small hemorrhages, and spots of softening. There is infiltration of the perivascular spaces with round cells and swelling and pro- liferation of the intima of the small arteries. In chronic cases the evidence of active A7ascular irritation is less, but there are Fig. 197.—Perivascular Dilatations in the White Matter of the Convolutions op a Very Chronic and Severe Case of Chorea. perivascular dilatations and increase of connective tissue (Fig. 197). The process suggests a low grade or an initial stage of in- flammation. The cause of this is probably either an infective micro-organism or a humoral irritation similar to that causing the rheumatic symptoms and the heart lesions. In a consider- able per cent of cases (ninety per cent—Osier), especially in those of long duration, there are fibrinous deposits on the walls of the heart. The hyperemic process may not be confined to the men- inges and motor areas of the brain and cord, but it is only from 440 DISEASES OF THE NERVOUS SYSTEM. the disease in these parts that the symptoms of chorea arise. The presence of points of irritation in the cortex and its men- inges and in the deeper parts excites irregular discharges of nerve force and produces the choreic movements. The interruption of the voluntary nerve impulses by diseased foci makes these move- ments irregular. The apparently special involvement of the len- ticular nuclei may explain some of the inco-ordination. In para- lytic chorea the pyramidal tract is probably more seriously injured by some single large focus of congestion, exudation, or hemorrhage. Indeed, I haA'e seen a true hemiplegia develop in the midst of an attack. In maniacal chorea the meninges and cortex are more invoh'ed. Diagnosis.—The disease is easily recognized by the peculiar twitching movements. It is necessary only to distinguish the different forms. It must be distinguished from convulsive tic, electric chorea of Dubini, hysterical spasms which include myo- clonus, saltatory chorea, and chorea major. The distinctions are not difficult and are given in connection with descriptions of these disorders. Prognosis.—As regards life the prognosis is A'ery favorable. In this country death from chorea hardly ever occurs in children. It is more fatal in adults. In England the mortality from chorea is about two per cent. Nearly all non-fatal cases eventually get Avell. Treatment.—The most important single factor in treatment is rest. The child should not be allowed to take violent exercise or to have any excitement. In most cases he should be taken from school, and in bad cases he should be kept in bed. Cold sponging or the ether spray daily along the back is use- ful. Nourishing food and iron are indicated. As specific remedies, arsenic still heads the list. It should be given in doses of ttj, v. of Fowler's solution t. i. d., increased by one or two drops daily to fifteen or tAventy drops or even more. If this causes nausea and gastric pain or headache, the dose should be stopped for a day and then resumed, if possible, Avhere it was left off. Sometimes the sulphide of arsenic is better tolerated than the arsenite. Next to arsenic come antipyrin (gr. \\), antifebrin (gr. iij.), exalgin (gr. iij.), the doses to be carefully increased if needed. Tincture of cimicifuga sometimes helps Avhen arsenic fails. The bromide or valerianate of zinc is also an excellent remedy, especially when there is a hysterical element. The bro- mides and chloral are useful adjuvants in promoting sleep. Chloral alone is said to be curative if given in doses sufficient to prolong sleep greatly (Bastian). Exalgin given cautiously with iron, in doses increased to fifteen grains a day, is often very use- ful. Hyoscin hydrobromate in doses of gr. T£u is occasionally CHOREA. 441 efficacious. Among other drugs of less value are the salicylates, cypropediuin, lobeline, physostigmine, and tartar emetic. In chronic and obstinate cases hypodermic injections of Fowler's solution should be tried. Gah'anization of the brain and spine is also useful. Change of air sometimes breaks up an attack. Hereditary chorea was first described by a Long Island physician, Dr. Waters, in 1842, later by Drs. Gorman and Lyon, and. in 1872 by Dr. Huntington. The American cases have been observed chiefly in New York, Connecticut, New Jersey, and Pennsylvania. Cases have been reported also from Germany, France, and England. The disease rarely begins before thirty or after fifty; it occurs about equally in males and females. It is always directly hereditary, either through father or mother, usually the latter. It begins Avithout known cause by tAvitchings in the face; the movements then extend to the arms and legs. It is attended Avith progressive mental deterioration, Avith a ten- dency to melancholia, and finally ends in dementia. Its course is chronic and usually A'ery slow, lasting ten or twenty years. Post mortem, chronic pachymeningitis and leptomeningitis with degenerath'e changes in the cortex have been found. Electric chorea is a name sometimes and wrongly given to A'ery \'iolent forms of ordinary chorea of Sydenham. The term was first applied by Dubini to a peculiar and progressively fatal spasmodic affection Avhich has been observed almost solely in Italy, and Avhich is perhaps of a podagrous or malignant malarial origin. M. Bergeron in 1880 also described an "electric chorea" in Avhich the patients are attacked by sudden rhythmical spasms. This latter disease has a uniformly favorable course. Neither of these diseases resembles true chorea, nor do they have the char- acter of the tics. The term electric chorea, therefore, is one that should be only used, if at all, with a qualifying explanation. Habit Chorea (Tic Coordine).—There are many persons who go through life with some trick of speech, of gesture, or some peculiar grimace. It may be only a shrug of the shoulder, a tAvitching of the eyes, or a sniff. These various movements are tics of the co-ordinate kind. The spasmodic motion is of itself normal, but is inappropriate and misapplied. Such movements are often seen in children. They sometimes represent abortive attacks of chorea, and sometimes they are the residuum of old attacks. In many cases they are chronic convulsive tics from the start and have little relationship to Syden- ham's chorea. The condition is to be treated both by moral and medicinal measures. Oscilledory spasms and nodding spasms haA'e been described elsewhere. Procursive Chorea, or Dancing Chorea.—Laycock has de- scribed as a separate kind of chorea a rhythmical or trochaic form, Avhich he says affects children, principally girls, and shows itself in spasmodic rhythmical contractions or in sudden rotating or 442 DISEASES OF THE NERVOUS SYSTEM. procursi\'e movements of the body. This lias been called chorea procursiA'e, or chorea festinans, by other writers. In many cases it is accompanied with vertigo, when the condition of the patient is similar to that of a person who has been Avhirling around a num- ber of times. Such cases ahvays have decidedly hysterical char acters, although these procursive attacks may complicate ordinary chorea. Chorea major is a manifestation of hysteria, and will be de- scribed under that subject. It is not a chorea at all. TETANUS. Tetanus is an acute or subacute infectious disease characterized by violent tonic spasms with remissions and exacerbations. It is called idiopathic Avhen no open Avound is found and traumatic when such condition is present. When it attacks infants it is called tetanus neonatorum; when the jaAvs alone are involved it is called lockjaAv, or trismus. A form which affects the face and throat is called head or cephalic tetanus. Etiology.—It has a special predilection for new-born children in some countries (West Indies) and to a less extent for puerperal Avomen. It affects males more than females. After the first month of life there is practical immunity till after the tenth year. It then increases in frequency up to forty. It is much more fre- quent in dark races and in some tropical climates (West Indies, South and Central America). Symptoms.—The disease sets in from five to fifteen days after infection. It begins Avith feelings of stiffness in the neck and throat and sometimes with chilly feelings. Gradually tonic spasms develop which involve the trunk muscles, causing opis- thotonos and other forms of rigid spasm. Trismus, or lockjaw, also occurs. The spasms are attended with intense pain. Some- times there is a rise of temperature and this may be A'ery high. The disease lasts for two to five weeks. There is evidence of irri- tation and congestion of* the spinal cord and injured nerves, but no special anatomical changes are found. A specific bacillus producing a tetanizing poison has been discoA^ered. The diagnosis is based on the characteristic history and the peculiar spasms. In strychnine-poisoning there is no initial tris- mus or epigastric pain. In rabies there is also no trismus but a respiratory spasm on attempts to swallow. The prognosis is bad. About eighty per cent of the traumatic and sixty per cent of idiopathic cases die. The treatment consists of complete rest and quiet in a dark room and the administration of chloral, bromide, morphia, and physostigma. Successful results from injection of blood serum of an animal which has had the disease are reported. TETANY. 443 Tetany (Tetanilla). Tetany is a subacute or chronic spasmodic disorder character- ized by intermittent or pessistent tonic contractions beginning in the extremities and associated with paresthesie and hyper- excitability of the motor and sensory nerves. Etiology.—The disease is very rare in this country, but rela- tively common in Europe, especially in Austria. It occurs with frequency during the second, third, and fourth years of life and again at the time of puberty. Its rate of frequency then sloAvly declines and it is very rare after fifty. It affects males much oftener than females up to the age of twenty, after that the differ- ence disappears. It occurs mostly in the Avorking classes. In infants rickets is often noted. The exciting causes are exhausting influences like diarrhoea, lactation, sepsis, fatigue, mental shock, and fevers; also exposure to cold and Avet. Alcoholism, dilatation of the stomach, and intestinal entozoa are also causes. It may be produced artificially by extirpation of the thyroid gland. The disease sometimes appears as an epidemic. Symptoms.—Tetany begins sometimes suddenly with symmet- rical tonic contractions of the hands; at other times there are at first sensations of numbness, prickling or pain in the extremities, Avith malaise and perhaps nausea; then spasms begin. The at- tacks affect first and most the upper extremities. The flexors of the forearm and hand are usually iiiA'olved; the fingers are flexed at the metacarpophalangeal joint and extended at the other joints, and the thumb is adducted, producing the " accoucheur's hand." The forearm may be flexed and the upper arm adducted. The knees and feet are extended, the toes flexed, and the foot in- verted. In severe cases the muscles of the abdomen, chest, neck, and face are involved. Opisthotonos and dyspnea may result. The muscles of the face and eyes develop contractions, and tris- mus sometimes occurs late in the disease. The muscles of the larynx, oesophagus, and bladder may be affected. Fibrillary tremors are observed in the contracted muscles. The attacks are accompanied by paresthesie and cramp-like pains. There may be some abolition of sensation in the skin of the parts affected during attacks. The cramps last from a few minutes to hours or days. They occur during day and night and may Avake the pa- tient from sleep. Fever is sometimes present in epidemic cases. The disease has a tendency to recurrence. While it lasts, both during and between the attacks peculiar phenomena are observed as follows: 1st. Increased Mechanical Irritability of Motor Nerves.—The motor nerves show an abnormal irritability, so that on striking the motor point a sharp muscular contraction is brought out. When pressure or a bloAV is made on the face over or near the exit of the facial nerve from its foramen, contractions of the facial muscles occur, especially those of the lips. This is called the " fa- cial phenomenon." By pressing on the artery and nerAe of a limb a tetanic attack can be produced in the muscles supplied. It is probable that it is the pressure on the nerAe alone which causes the phenomenon which is called " Trousseau's symptom." 2d. The electrical irritability of the muscles and nerves is in- creased, especially to the galvanic current. Thus a negative- pole closure contraction (CaCC) is brought out by a very Aveak 444 DISEASES OF THE NERVOUS SYSTEM. current; and if a little stronger, it causes a tonic contraction or cathode closure tetanus (CaCTej The positive-polo opening contraction (AnOC) may be tetanic, i.e., (AnOTe), and there may be even a cathode opening tetanus (CaOTe), a phenomenon not seen in any other disease. According to Gowers there may be a reversal of the polar formula, so that a positive-pole closure con- traction occurs earlier than a iiegatiA'e (AnCOCaCC). This is certainly rare. 3d. An increase of irritability of the sensory nerves is shown by pressing upon them, Avhen sensations of prickling and formi- cation appear along their course. There is an increase also in the electrical sensibility, sIioavh by appreciation of Aery Aveak gahanic currents. The auditory nerve reacts to the galvanic current in about fifteen per cent of normal cases, and then only to strong currents and to only a partial extent; but in tetany it reacts in nearly all cases, and Avith comparathely Aveak currents (2 to 5 or (J ma.) on anode closure, anode fixed, and anode open- ing (AnC Klang, AnDKl, AnOKl) (Chvostek). The phenomena of hyperexcitability aboAe described vary considerably and rapidly during the course of the disease, and are not ahvays present. Types of the Disease.—The disease varies in intensity and dura- tion. This Aariation depends much upon the cause, and there have been made a number of types of the disease based on the etiology. Thus Ave haA'e 1. Epidemic or rheumatic tetany. 2. Asthenic tetany due to Jactation, diarrhoea, exhausting dis- eases, etc. 3. Thyroid tetany, due to remoAal of the thyroid gland. 4. Reflex tetany from gastric dilatation and intestinal worms. 5. Latent forms of tetany in which the phenomena of hyper- excitability and paresthesia occur with A'ery slight if any con- tractions, and no Trousseau symptom. Infantile tetany should perhaps be separated from other forms. Symptomatic tetany from brain disease is also spoken of. When the spasms are continuous the disease lasts but a few Aveeks; Avhen they are intermittent it may continue for months. Epidemic cases last but a few weeks. The disease maybe said in general to last from a few Aveeks to a feAv months. Patients are liable to a recurrence on return of the exciting cause. Pathology.—The phenomena of the disease indicate a congested and irritative condition of the gray matter of the spinal cord. The cause of this state is evidently in some cases (epidemic tet- any) an infectious poison; in other cases mucin in the blood (thyroid tetany), and in other cases it may be a rheumatic or some other toxic influence. Ergot is known to produce symptoms resembling tetany. In infantile tetany the irritation is apparently cortical and due to meningitis or to rickets and the reflex irritation of disor- dered bowels. It is doubtful if any reflex influence can be invoked in adults. Tetany is a functional disease and the symptomatic expression of a central irritation. This irritation may be of differ- ent kinds, hence tetany has a claim to be called a distinct disease simply on clinical grounds. It has no such definite pathology as chorea or epilepsy. In the A'ery few autopsies which have been made no definite organic lesion has been found. TETANY. 445 Diagnosis.—The disease is usually easily recognized by the character of the spasms, their symmetrical nature, their course, and the phenomena of hyperexcitability of the muscles and nerves. Trousseau's symptom is found in no other disease. The " facial phenomenon," the peculiar electrical and mechanical irri- tability of the muscles and nerves are very rare in other condi- tions. The sensory irritability and especially that of the acoustic nerve are also characteristic. From tetanus the disease is distin- guished by the intermittency of the contractions, their feebler character, the fact that they begin in the extremities and extend to the trunk, and by the absence of trismus at least until late in the disease. Treatment—The cause should be removed if possible, lactation stopped, diarrhoea and indigestion corrected, worms expelled, rickets, if present, attended to. Rest, nourishing food, and tonics are indicated. Symptomatically, bromide of potash in doses of 3 iss. to 3 ij. daily with chloral furnishes the surest relief. Hyos- cine in doses of gr. -^ may be tried. Inhalation of chloroform or injections of morphia are needed in seArere cases. In nocturnal tetany Gowers advises digitalis. Lukewarm baths may be of service; so also may ice-bags to the spine. If electricity is used only the weak galvanic current should be employed. CHAPTER XXIY. NEURASTHENIA (NERVOUS EXHAUSTION)-NERYOUS WOMEN. Neurasthenia is a morbid condition of the nervous system of Avhich the underlying characteristics are Aveakness and exces- sive irritability. The disorder is a functional one. In its typi- cal forms the symptoms are distinctive. Etiology.—Neurasthenia occurs most often betAveen the ages of eighteen and thirty, next between the ages of thirty and forty, and then between forty and fifty. It rarely, if ever, begins be- fore eighteen or after fifty.* It affects men and Avomen almost equally in this country. Pure cases are more frequent in men, Avhile atypical forms in which there are complications of hysteria, spinal irritation, and local disorders are more frequent in women. Americans are, as a race, much affected by it. The cold and dry climates of the temperate zone favor the development of the disorder. So also do high altitudes if they are dry. Hence the climate of this country, as Avell as its civilization, undoubtedly help to promote the disease. In the West, ami especially the Northwest lake region and the Colorado plateau, neurasthenia is said to be rather more prevalent than in the South or East. It occurs in rural as Avell as urban populations. The educated classes—professional men, business men, and politicians—furnish a large contingent. Heredity is a very important factor in the primary forms. The exciting causes are excessive mental strain, anxieties, sud- den shocks, injuries, sunstroke, excessive child-bearing, sexual excesses—especially masturbation—irregularities and excesses in eating, drinking, and smoking. Overwork does not cause it, pro- vided there is no great mental worry; and even this can be borne if the patient is regular in eating and sleeping and does not drink or smoke too much. In some cases it follows some single power- * Among 100 consecutive cases there were 53 women, 47 men. Ages : fifteen to twenty-five, 25 ; twenty-six to thirty-five, 38 ; thirty-six to forty-five, 25 ; forty-six to fifty-five, 20; fifty-six to sixty-five, 2. There are relatively more cases in the adolescence of man and in the later period of life of women. Nativity: United States, 59; Ireland, 29 ; Germany, 12 ; others, 9. NEURASTHENIA—NERVOUS WOMEN. 447 ful physical exertion. Malarial-poisoning, syphilis, and the in- fective fevers are important agents in causing neurasthenia. So also are lithemic states, gastric dilatation, and dyspepsia. Reflex irritations. There are many persons, with delicately balanced organizations, who only require some single depressing or irritating agent to put them in a pathological state. This is the case in those neurasthenics who are made so by reflex causes. Given a neuropathic constitution, neurasthenia may be produced by OA'arian and uterine disease. Subinvolution and decided me- chanical displacements are more potent in causing neurasthenia than the chronic inflammatory states. Prostatic and urethral disorders, hemorrhoids and fissures, may excite general neuras- thenic symptoms. Chronic middle and internal ear disease, caus- ing great tinnitus and partial deafness, often aggravates a neu- rasthenia, if it does not excite it. Nasal stenosis and hypertrophic catarrh, acting either directly or by disturbing the visual appa- ratus, may be a cause. Muscular insufficiencies of the eyes, re- fractive errors, especially hypermetropia and astigmatism, are often important factors in the etiology of neurasthenia, but they are not primary or fundamental. Of reflex influences causing and keeping up neurasthenia, disturbances of the stomach, in- testines, and liver are by all odds the most important; next come irritations from the pelvic and generative organs. Symptoms.—In the neurasthenic condition there are certain common symptoms which will be found in all cases, but these symptoms vary in prominence according to the special setting of the case. The modifying elements are these: (1) age, (2) sex, and (3) neuropathic constitution. In ordinary cases the patient after some years of arduous work, anxiety, and irregular habits, during which he has kept himself continually on a strain, begins to have feelings of nervousness, restlessness, and irritability which are new to him. He has trouble in sleeping and wakes unrefreshed; he loses interest in his work, which tires him greatly. His appetite is poor and his digestion disordered; he has vertigoes and peculiar feelings about the head; and he begins to get alarmed about himself. The symp- toms progress until he finds he can no longer work, he is irritable, depressed, and discouraged, and finally begins to take himself in hand. In some cases, after a sudden fright or injury and shock, all these symptoms develop rapidly. In younger persons the history is somewhat different: the pa- tient has perhaps indulged in sexual abuse; then suddenly learn- ing that it is a very dangerous practice he experiences a fright. He becomes nervous, worried, and mentally depressed. He too has cerebral paresthesie and insomnia; he loses interest in his stud- ies, cannot concentrate his mind, broods over his early indiscre- 448 DISEASES OF THE NERVOUS SYSTEM. tions, and is panic-stricken o\'erevery nocturnal emission. Getting some comforting assurances and advice from his physician, he improA'es and perhaps gets avoU, but not infrequently has for several years a train of disturbing neurasthenic symptoms. As in older cases, the neurasthenia may come on suddenly from shock, violent physical exertion, and o\er-use of tobacco. Symptoms in Detail.—The neurasthenic patient suffers from a peculiar feeling of nervousness, discomfort, uneasiness, and sense of unrest; or from feelings of tension, as though under a stimulant. He loses interest in his work, dreads to assume any responsibility, has morbid fears regarding his business, his sexual function, his general health, his future, or some trivial subject. Some idea fixes itself upon him and he cannot rid him- self of it. He has difficulty in concentrating his mind on work. Periods of depression attack him. These mental states vary much, and may be so paroxysmal as to form "crises." His sleep is poor, disturbed by dreams, and he awakes unref reshed; some- times there is a morbid somnolence. Slight attacks of vertigo annoy him. The sensory symptoms consist of feelings of pressure on the top of the head, as of a hand or cap pressing on the scalp (the helmet symptom); pain or weariness in the back of the neck; numbness of the hands or feet, creeping sensations up the back or limbs, burning feelings in the ears, pricking of the tongue, a sense of oppression of the chest and of " sinking " in the epigas- trium. These form Avhat are termed neurasthenic paresthesia. Neurasthenics in about half the cases suffer from headaches. These are diffuse and frontal or occipital. The pain is persistent, worse after exertion, and not very intense. A boring occipital pain, neckache, and neck weariness are very common, and women often have seA'ere pains along the spine. Intercostal neuralgia, especially on the left side, is common. General neuralgia, aching of all the limbs, feeling of soreness of the scalp or of the mus- cles, as though one had been beaten, are often complained of.* The Special Senses.—Neurasthenia does not, as a rule, cause very serious visual troubles. There is always some weakness and increased irritability of eyesight. If the patient uses the eyes much these symptoms may become very marked. There is a feeling of pressure and discomfort or pain in the eyeballs. Head- ache comes on. Vision gets blurred; there are spots before the eyes; excessive light is annoying and moderate light dazzles. Reading soon tires and causes pain; the lids twitch; the eyes easily redden and water. Examination shows in early life mo- * Neurasthenics with a hypochondriacal tendency sometimes suffer from a persis- tent delusional pain located in a certain region, such as the arm or back. This con- dition has been called topoalgia. NEURASTHENIA—NERVOUS WOMEN. 449 bile and often dilated pupils; they are rarely uneven; there is a slight lessening of visual acuity. The visual field is normal, but sensation in its periphery tires very easily, so that after long test ing there is apparently a concentric limitation of the field. The color sense is unaffected. Muscular insufficiencies, especially of the internal recti, often occur. The patient's visual memories are lessened, so that the neurasthenic cannot remember faces and places as he has been accustomed to do. If the patient has any refractive error, especially hypermetropia or astigmatism, his eye symptoms are more marked and cause him so much annoyance that the general symptoms get worse. The eye trouble may thus keep up the neurasthenia, but it Avill not alone cause it, and treatment of the general and local symptoms by attention to the eyes alone is irrational and disappointing. Neurasthenics are often over-sensitive to noise. This is usually simply due to the general mental irritability; but sometimes there is a distinct hyperacousia, and slight noises or even agree- able music drh'e the patient nearly Avild. Subjective disturbances of taste occur in cases complicated with digestive troubles. There are no peculiarities regarding the sense of smell other than a general over-sensitiveness to odors. The general muscular strength is lessened, and the patient very soon tires, or even completely collapses, after slight exertion. Muscular effort or mental excitement causes a tremor of the hands; often this is a persistent symptom. This tremor is " fine " and vibratory in character (about tAvelve to the second). The skin reflexes and tendon reflexes are exaggerated. There is a slight amount of "static ataxia," i.e., the patient sways more when standing erect Avith closed eyes than when his eyes are open, the reverse being the case in healthy people. The eyelids quiver when tightly shut. The general nutrition is not usually much affected; if anything, the patient loses Aveight. There is decided evidence of loss of vasomotor tone. This is shown in the cold hands and feet, tendency to hyperidrosis of the palms and soles, flushings and pallor of the face, sense of fulness in the head, variations in the specific graA'ity and amount of the urine. Palpations of the heart easily occur, and examination of the pulse shows it to have frequent and rapid variations in ten- sion, there being generally abnormal lowering. The vasomotor reaction produced by drawing a blunt instrument over the skin is more pronounced than in healthy people. A deep red line appears after pressure, Avhich lasts twenty or thirty minutes. In rare cases an artificial urticaria can be produced. The phe- nomenon is called " dermography." The sexual functions are weakened and irritable, and inter- 29 450 DISEASES OF THE NERVOUS SYSTEM. course is imperfect and exhausting. In the younger and more neuropathic cases emissions occur, and morbid fears regarding this function annoy and depress the patient. These fears and introspections occupy the mind and furnish to the patient the belief that all his troubles hinge upon his early indiscretions or his present rather frequent emissions. Sometimes there is, in fact, r.uch an extreme degree of seminal loss as to keep up the neurasthenic state. The genitals become relaxed, there is a slight discharge of urethral and prostatic secretion, especially after stools. In women dysmenorrhcea, menorrhagia, and slight irreg- ularities in menstruation occur. The digestive organs, including the metabolic tissues of the liver, are almost always at fault. There are a great many ner- vous affections of the stomach, such as gastralgia, gastroxynis, muscular atony, etc. These disorders may be associated Avith neurasthenia and be the cause of part of the trouble. The gastric trouble in rare cases may even be primary, or hold equal rank Avith the nerves in the symptom complex. Such, however, is by no means the rule. The nervous asthenia leads to the gastric dyspepsia, and this again makes the neurasthenia worse. The special symptoms caused by the stomach complication are a sense of congestion and fulness in the head, dizziness, headache, palpitation, and abdominal pulsation; belching, feeling of pres- sure and fulness in the epigastrium, nausea, pyrosis, anorexia, and alterations of taste. The hepatic functions are weakened and sloAved down; and a neurasthenic liver is one of the common and fundamental condi- tions of the neurasthenic state. This produces intestinal dyspep- sia, fermentation, and constipation. The blood absorbs an excess of ptomaines and imperfectly oxidized products, causing many of the general nervous symptoms already described, such as the paresthesie, dizziness, somnolence, and head pressure. This condition is called " lithaimia" or nervous gout. It is not so much a distinct diathesis, like the gouty or rheumatic, as it is a morbid condition from accumulation of metabolic products. The intestinal movements are sluggish, and the patient suffers f.o:n flatulence and feelings of distention. Sometimes there is a nervous diarrhoea alternating with constipation.* Sometimes the striking symptom in a neurasthenic patient is the disturbance in the heart's action. This shows itself in feeble- :: Enterontosis and Neurasthenia.—A form of neurasthenia has been described by Olenard under the head of enteroptosis, or prolapse of the abdominal viscera. This occurs in women who have lax abdominal walls, with some descent of the stOMiach and intestines, and stretching of the suspending ligaments and mesentery. In these cases there is usually some dilatation of the stomach, atony of the intestinal wr.lls. ai.d consequent symptoms of inuigestion. NEURASTHENIA—NEKVOUS WOMEN. 451 iiess of the heart beat and heart sounds and smallness of the pulse. Palpitation occurs on slight exertion, and there may be pseudo-anginal attacks, or sensations of oppression and discom- fort over the heart. The patient also complains of feeling the beating of the heart, perhaps all over the body. The pulse may be very slow, especially in the morning. General neurasthenic symptoms are present. Patients Avith heart disease are liable to be especially annoyed by various evidences of heart weakness and irregular action. The respirations are normal in number, but shallow, and de- ficient respiratory expansion may be noted. A feeling of pres- sure on the chest is often described. The younger patients and Avomen are generally anemic, but in middle-aged adults this is not so; the face is full and ruddy and the mucous membranes of good color. The urine in the young and neuropathic cases is variable in specific graA'ity, but generally low, 1.012 to 1.018; under excite- ment it may drop to 1.002. Phosphates, earthy and alkaline, are excreted in excess, Avhile the nitrogenous solids are often dimin- ished in amount. In older cases Avith more digestive and hepatic disturbance and litheinia the urine is heavy, 1.024 to 1.03G, quite acid, and contains at times excess of phosphates and urates. Ox- alates are also found, but indicate no more than does excess of urates, i.e., a lithemic state. The amount of urine passed is variable. At times there is polyuria, but on the whole the total amount is below normal. The Modified Types.— Neurasthenia in Adolescence—De- generative Neurasthenia.—When neurasthenia begins under the age of twenty-five, there is a more distinct evidence of neuro- pathic constitution. The mental symptoms are more marked and approach those of hypochondriasis. There is greater de- pression and greater introspection. Morbid sexual ideas, fear of impotence, remorse over past indiscretions in A-enery; spermato- phobia; morbid fears of contamination, of being foreA'er inca- pacitated for procreation or sound mental and physical work, annoy the patient. The general nutrition is affected. He is anemic, has cold extremities, clammy hands, dilated pupils. His urine is of low specific gravity and contains an excess of phos- phates, both earthy and alkaline. Pains, paresthesie, Aertigo, head pressure, and gastric disturbances are not so marked. This type of neurasthenia is often described as " sexual" or as " primary." It is really a manifestation of neurotic degeneracy, and may be looked upon as an abortive form of paranoia. When more fully developed the degeneracy shoAvs itself by such symp- toms as fixed ideas, and morbid fears such as agoraphobia (fear of open places); claustrophobia (fear of closed places); mysophobia 452 DISEASES OF THE NERVOUS SYSTEM. (fear of contamination); pathophobia (fear of disease); anthro- pophobia (fear of society). Abortive forms of folic da doute, or the doubtness-madness, are also present in this type. Neurasthenia of ]Yomen in Adolescence.—Young nervous women are usually anemic, dyspeptic, and constipated; their nutrition is not good; they are thin; they excrete large quanti- ties of limpid urine; they often have spinal pains and headaches of the migrainous and other types, and almost all of them suffer more or less at the time of menstruation. They have mobile pupils. Their special senses are keen, to the point of hyperes- thesia. The heart is irritable; the vasomotor centres are un- stable. They ha\'e cold, clammy extremities. They are vivacious, quick, observant, impatient, living on their "nerves," fond of excitement, and indulging in amusements, for which they pay the penalty by prolonged exhaustion. Neurasthenia of Women in Early and Middle Life.—It is the nervous women between the ages of twenty-five years and forty who make up the majority of female neurasthenics. They are, so to speak, the Avreckage of the young nervous women and of healthy young women for Avhom the burden of life and domes- ticity was too heaA'y. For they are usually married and are some- times prolific mothers, though the worst cases are the childless or the "monopedic." The principal symptoms from which they suffer are nervousness, weakness, insomnia, dyspepsia, morbid and depressing ideas, headaches and neuralgias, vertigo, tremor, and vasomotor symptoms. They often have migraine and backaches, but they do not have fully developed spinal irritation; they suffer from peculiar feelings of numbness in different parts of the body; they often exhibit a marked tremulousness of the hands, while the cold ex- tremities and wet hands are not so commonly observed. They become easily exhausted. They are excessively nervous and irri- table ; slight noises will startle them; they cannot read long with- out getting a pain in the head; they suffer from time to time from attacks of profound mental depression, and often have fixed ideas of a melancholy type; they have, at times, "crises," or "neiwous storms," which may take the form of a headache, a fit of blues, or a lively domestic disturbance. The dyspepsia they have is not of a very severe type; it is usually accompanied with fermenta- tion and acid eructations. The urine ahvays varies in quantity and specific gravity. Sometimes they will pass large amounts of limpid urine. Such women are often called hysterical, but the somatic and asthenic symptoms are more prominent than the psychical, and they do not have hysterical stigmata. Climacteric Neurasthenia.— At the climacteric in women, and sometimes at a corresponding age in men, neurasthenic symptoms NEURASTHENIA—NERVOUS WOMEN. 453 develop. In women these symptoms are mostly of a vasomotor character. Hot flashes, flushing, nervous irritability, poor sleep or morbid somnolence, pains in the back and head, sensations of fainting and sinking, tendency to mental depression, are among the chief symptoms in women, among Avhom this trouble may be regarded as a climacteric neurasthenia. Evidences of Aascular tension and of beginning arterial degeneration Avill be found. In men the symptoms do not greatly differ from those of the ordinary type. Both in men and vvomen this form of neurasthe- nia runs a comparatively short and favorable course. Course and Duration.—Neurasthenia is a chronic disorder and lasts from one to five or ten years, depending largely upon treatment and habits of life. The forms occurring at the climac- teric are the shortest and most favorable, those occurring in early middle life come next, while those forms Avhich develop in youth, if dependent upon neurotic constitution, are the most chronic. The disease lasts longer in Avomen than in men. Pathology.—Neurasthenia is a condition in which the nutri- tion of the nerA'e cells is primarily at fault. These cells have lost their poAver of building themselves up into stable compounds. They easily break down under slight irritation, and send out consequently but feeble impulses. These facts are indicated by the terms "irritability" and " Aveakness." It is thought by some that this dystrophic condition especially involves those parts which make up the vasomotor neuro-mechanism; and if this be so, it is the nerA'ous tissue of the medulla and central parts of the spinal gray matter that are the most involved. There is lit- tle doubt, however, that the cortical gray matter and higher cen- tres of the brain are also implicated, for the mental symptoms are ahvays prominent. It is certain that the peripheral nerA'es are not primarily at fault. Since it has been shown that the sympa- thetic system is only an outfloAV from the cerebro-spinal, and that many of its ganglia are rudimentary and functionless, the idea that neurasthenia is located in the "ganglia" of this system be- comes quite untenable. The vie\v that neurasthenia is usually lithemia and of gastro-hepatic origin I have tested thoroughly. Patients rarely get any better by treatment based on this hy- pothesis. Vascular changes in the nerA-ous system take place. These are of the nature of cerebral hyperemia, and probably hyper- emia of the spinal gray matter. More rarely there is anemia. The importance and dominance of the vasomotor changes in the skin and internal viscera haA'e been already alluded to under the head of symptoms. This A'asomotor disturbance is one char- acterized by a weakness of the inhibitory A'asoconstrictor centres. As a consequence the vessels dilate and contract irregularly in 454 DISEASES OF THE NERVOUS SYSTEM. the different systems of the body. Furthermore, they do not re- spond normally to the stimulus of functioning. When brain or stomach acts it calls for a definite and Avell-regulated supply of blood; in neurasthenia it does not get it, and hence the morbid symptoms. The ner\'ous system controls the metabolic processes of the body, Avhich are especially active in the Ih-er, spleen, and mus- cles. In neurasthenia this process is disturbed, and the lh'er particularly is atonic or sluggish. This disturbance has already been described under the head of digestion. In other cases metabolism is affected differently; it seems to be simply too sIoav. The tissues do not build up and break down at a normally rapid rate. The urine is of low specific gravity and the total solids excreted are less than normal. One exception to this slowness of metabolism occurs. In all forms of neurasthenia there is a tendency to excessive breaking up and discharge of the phosphates, both alkaline and earthy. Diagnosis.—?\ e\\va,sthenii\ must be differentiated from simple nervousness, degenerathe forms of insanity, such in particular as paranoia, from hypochondriasis, from melancholia, hysteria, and spinal irritation. Nervousness may be a natural characteristic, a part of the temperament. As long as the patient does not suffer and is not incapacitated from Avork and enjoyment, Ave can somewhat arbi- trarily say it is not neurasthenia. Peculiar sexual perA'ersions, doubting mania, pronounced forms of morbid fears, may be associated with some neurasthenic symptoms, but the diseases mentioned are essentially psychical disorders and dependent on a congenitally deficient brain. The hereditary history is usually bad. The clearness and dominance of the mental symptoms are sufficient for a diagnosis. The same remarks apply to hypochondriasis. The mental depression and fixed ideas are altogether disproportionate to the other symptoms. In melancholia there are pallor, anemia, loss of flesh, ano- rexia, insomnia, coated tongue, and constipation, often a loAvering of temperature, a profound and constant mental depression. This must often be looked out for in women at the time of the climacteric. The mild types of melancholia are found oftener in women. Hysteria may complicate neurasthenia. It is found much oftener in women, but in the neuroses following shocks and inju- ries it is seen in men. Hysteria is essentially a mental disease involving the emotional faculties and the will, Avhile the bodily condition may be good. It is characterized by A'arious crises of a convulsive or emotional character. There are certain stigmata NEURASTHENIA—NERVOUS WOMEN. 455 almost always present which enable one to recognize it. These are the anesthesie of the special and general senses. Spinal irritation is usually a complication of neurasthenia or hysteria, and presents easily distinguishable characters. It may occur quite independently of the distinctive symptoms of the neurasthenic state. The prognosis is in general favorable. Most patients get Avell, or practically well, so that Avith care they can enjoy life and at- tend to its duties. But the patient almost always has some re- minders that he cannot overtax himself or do quite as much as can a person of strong nerA'es. This is especially true up to the age of forty-five or fifty. The lessened sensibility of the nei ves in the declining years then comes to his help; he gets the benefit of his past years of regularity and temperance; his late years are his best, and he lives to enjoy many of them. Neurasthenics, if they get Avell, get old. Neurasthenia does not lead to insanity or epilepsy or organic disease; but it may be supplanted for a time by an asthma or severe neuralgia or other neurosis. Treatment.—It is of the first importance for the physician to get a firm control of the patient. This can only be done by mak- ing the most careful and scrutinizing examination, and by so acting as to make the patient feel that he understands his case and is master of its character. The patient should then have his course of treatment laid out for him. If he does not folloAV it strictly all treatment should be stopped. Women are harder to manage at their homes than men, and it is better to isolate them somewhere if possible. Rest or lessening of business and domestic duties is fundamen- tal. Travelling is bad, but the patient can be sent to stay at such places as the Azores, West Indies, Bermuda, or to some special point in Southern Europe. A trip along our great lakes, camping out, or long sea voyages in rather warm climates are to be advised. The diet should be rather nitrogenous than otherAvise, but fats and green vegetables and certain fruits may be added. Sugars and starches are to be avoided, though malt preparations usually agree. The nutrition of the patient cannot be too carefully watched. He should be weighed and sometimes fattened, using water, malt, oil, and cream for this purpose. The amount and specific gravity of urine must be noted, and his diet regulated accordingly. Neurasthenic patients usually drink too little water or else too much at meal-time. Water should be drunk betAveen meals or half an hour to an hour before meals. Neurasthenics need to be properly fed, but not to be stuffed. In many cases a low diet, but one perfectly digestible, is most indicated. Meals should be taken at fixed hours. A cold sponge bath, or a shower or a strong jet of cold water 456 DISEASES OF THE NERVOUS SYSTEM. on the back, or a cold plunge, are measures that are almost in- variably indicated. In irritable cases the A\et pack for three- quarters of an hour, followed by the cool Avash-off, has a very quieting effect. A lukewarm bath at 95 to 98~ at night for half an hour relieves the paresthesie and insomnia. The skin should haA'e a thorough rubbing every day. Respiratory exercises for expanding the lungs, light exercise, such as swinging clubs or dumb-bells, throwing balls, swinging from horizontal bars or rings, bicycling, horseback-riding, tennis, rowing, fishing, tic, should be encouraged. The exercise should not be severe; it should be interesting, it should be done in fresh air, and it should bring into play the lungs and arms more than the legs. Walking does little good, though it is better than nothing. The drugs of most use in neurasthenia are the bromides, nux vomica, mineral acids, quinine, iron, valerian, the hyp- notics, and saline and alkaline laxatives. Many drugs of re- pute, such as arsenic, phosphorus, zinc, cannabis indica, bella- donna, are of no especial A'alue. The bromide of sodium or potassium should be given in doses of fifteen or tAventy grains three times daily; it should be kept up for only a week and then gradually reduced to one-half dose once daily. At the same time the patient may be given a tonic mixture containing quinia, strychnia, and, if indicated, iron. Quinine must be given carefully, as it causes increase of nervous- ness in many. Phosphoric and muriatic acids are the tAvo mineral acids most often of use. These acids are usually better given after meals. In mild cases a tonic and sedative may be combined by giving a mixture containing hydrobromic acid with nux vomica and pepsin. As a matter of convenience the bromide of lithium in fh-e-grain doses may be put up in capsules with hydrobromic acid and glycerin. Tincture of nux vomica sometimes acts bet- ter than strychnia, but it must be given in large doses—ni x. in- creased to m xxv. or n xxx. The saccharated carbonate or albu- minate of iron, or Blaud's pills, if given, should be given generously, i.e., in doses of thirty grains daily. The insomnia, if present, yields usually to the bromides, but will return unless further treatment is given. After using bro- mides for a time, therefore, it is better to substitute half a drachm of sulphonal or of chloralamide, or gr. xv. of chloral, or a drachm of paraldehyde. Lukewarm baths (95° to 100') may be used as adjuvants. The dose of the hypnotic should be gradually less- ened and not suddenly and irregularly stopped. If the patient is lithemic or arthritic, he should be made to drink an alkaline Avater, like the lithia waters or Carlsbad, and his bowels are better kept open by means of salines than pills. NEURASTHENIA—NERVOUS WOMEN. 457 Antipyrin, potassium bicarbonate, and the salicylates often help painful symptoms in such cases. In those forms of nervousness in Avhich there is a great deal of melancholy quinine is of use, and Avhen quinine cannot be borne in ordinary doses the patients will often tolerate Warburg's tincture. in cases in which there is a good deal of cerebral hyperemia and occipital pain, aconitia and cupping or burning at the back of the neck are indicated. In young patients with seminal troubles, atropia, camphor, and turpentine may be added to quieting mixtures at night. In those with an hysterical element, fh'e to teu grains of valerianate of zinc should be given daily for three or four weeks. Young nervous women require tonics, such as Warburg's tinc- ture and large doses of Blaud's pills, together Avith systematic cold applications to the spine; and, for certain periods, the bro- mides, valerian, and nervines of that character. Marriage may help them; but, unfortunately, these Avomen are sometimes Arery prolific. The culth'ation of athletics Avould be the greatest boon that young women could receh'e. All girls should be examined, shown AA'hat deficiencies exist, and taught to make them up by gymnastic exercise. In neurasthenic Avomen with painful backs or with a hysteri- cal complication, much can be said for electricity. General and spinal galvanization and the static sparks are the specially effi- cient forms. General electrization is a decided mechanical tonic and useful in almost all forms of neurasthenia; but it is more useful in cases in early life, in women, in the asthenic, and in those Avith spinal pains. Electrical treatment should be gh'en three or four times Aveekly for about six weeks, then suspended. Massage has no special or curath'e A'alue in neurasthenia, ex- cept as part of the rest-cure. Mildly used it soothes and quiets many patients and has a symptomatic use. Vigorous massage is injurious. The rest-cure, as described by Dr. Weir Mitchell, is indicated for a certain class of neurasthenic Avomen with decided impair- ment of nutrition and a complicating hysteria. The discovery and treatment of the reflex irritations are im- portant. After the stomach and liver, the pelvic organs and the eyes are the most fruitful sources of trouble. The Sexual Neuroses axd Psychoses. Of the aboA'e disorders the neurologist has to deal chiefly with the vicious habit of masturbation (which may, however, be also a manifestation of disease) and the sexual neuroses, spermator- rhoea and impotence. 458 DISEASES OF THE NERVOUS SYSTEM. Masturbation axd Spermatorrhea.—Masturbation is the name given to the vicious habit of artificially exciting the sexual orgasm. It is very common among boys and less common but present among girls and adult men and women. It is usually only a \'ice due originally to low associations and teachings among children. In some cases it is a disease or the symptom of a neurotic or insane constitution. Etiology.—It is most common between the ages of fourteen and eighteen, but may begin earlier. EA'en infants and very young children sometimes masturbate, usually as the result of some local irritation which leads them to rub the genitals. A tight prepuce, eczema, or Avorms may lead to the habit, but it is usually taught by a companion. The practice sometimes at- tacks schools almost like an epidemic, for in every institution a certain per cent of the boys are sexually precocious or vicious, A\'hile the others are ignorant and innocent of the evils of the practice. Masturbation is relatively rare after twenty, but is practised by some throughout life even up to old age. Results.—Masturbation as ordinarily practised leads after a time to a feeling of malaise, mental depression, disinclination to Avork, study, or to enjoy one's self as before. The appetite is a little impaired, the extremities easily get cold and perspire read- ily. Peculiar numb feelings are felt in the hands and feet. There is an unnatural nervousness and irritability, and the power of concentrating the mind is a little Aveakened. The patients often have dilated pupils and hyperesthetic skin. After a time noc- turnal emissions occur. The organs become irritable and slight excitement causes erections. These symptoms may be slightly marked and pass away in a day or two, or until another indul- gence occurs. Masturbation is sometimes done to an extraordinary extent,, even daily or twice daily for a considerable time. After a while the young man begins to find that he is not well and realizes that this habit is hurting him. Then if he be sensible and of healthy constitution he stops. Others are frightened out of it by friends or by reading the terrorizing stories printed in quack ad- A-ertisements and circulars. Sometimes the fright thus caused leads the unhappy youth into a condition of hypochondriasis, which is helped on by the occurrence of nocturnal pollutions and the nervous debility resulting from his past indiscretions. In other cases in which there is a decided neurotic history, a genuine neurasthenia of a sexual type develops and annoys the patient for years. Masturbation rarely leads to insanity and is oftener a symp- tom than a cause of such disorder. It is occasionally the cause of epilepsy. When this is the case the convulsive attacks are NEURASTHENIA—NERVOUS WOMEN. 459 likely to put on a hysteroid phase and are accompanied with peculiar co-ordinated convulsions and emotional disturbance. Masturbation is the common cause of hystero-epilepsy in women. Diagnosis.—-Many victims of the masturbation habit who have come to recognize its evils and tried to stop it develop a hypochondriacal condition, and feel sure that there is something in their faces which reveals to the Avorld their trouble. This is not the case. But there is a certain physiognomy which in a measure characterizes the masturbator to such an extent that an experienced observer can detect it, The pale, pasty complex- ion, moist, furtive eye, dilated pupil, listless, restless, and de- pressed manner, the wet, flabby palms and hyperesthetic skin, all help to tell the story. Locally the penis is often reddened and more or less turgid, the scrotum relaxed, and a varicocele may be present. Examination of the urine may reveal spermatozoa. The urine also is almost ahvays of rather low specific gravity, and contains a great excess of phosphates, both earthy and alka- line. Treatment.—The patient must be told plainly the necessity of stopping the practice. He must be impressed, but not terrorized. He should be kept out of doors at vigorous physical exercise, for sedentary and solitary work is always bad for such cases. He should be made to take cold-water baths and should sleep on a hard bed Avith light covering. He had better sleep with some one whose presence may exercise a controlling influence. He should not eat heartily at night, never just before going to bed, and what is still more important, he should not drink before going to bed. Sometimes it is well to have him wakened at an early hour in the morning, Avhen he should empty his bladder; for emissions occur often early in the morning and are promoted by the irritation of a full bladder. Locally cold-steel sounds may be introduced and allowed to remain for ten minutes three or more times a week, or the psychophor or Ultzman's short catheter may be used. In bad cases with a great deal of prostatic irritation, local applications of nitrate of silver are needed. Internally a mixture of tinct, opii, tinct. camph., and tinct. lupulin may be given at night, the ingredients being somewhat varied in amount to suit the case. Bromides, chloral, atropia, and salix nigra are also drugs which are often useful. The mechanical measures which have been devised for preventing erections, such as rings with sharp teeth, are rarely needed and rarely useful. They may even do harm by directing the mind to the affected function. I do not believe it right for the physician to prescribe fornica- tion. It is not safe nor curative, apart from the moral aspect of the matter. It has always struck me also as pretty small busi- 400 DISEASES OF THE NERVOUS SYSTEM. ness for a man to purposely select a wife to relieve him of the results of a Aveak Avill and vicious sensual indulgence. If mar- riage comes in the natural course of events, as it often does, so much the better. But to select a Avife as a remedial agent for masturbation is unjust to the woman and a confession of moral and mental feebleness. Man is distinguished from the brute by his self-control. Let him bear this fact in mind and raise him- self above the animals by a determined effort of the Avill. Pure thoughts and chaste associations, vigorous physical exer- cise and a resolute effort to act a manly part Avill always be successful. Traumatic Nervous Affections (Traumatic Neurosks and Psychoses), Spinal, Concussion. The present tendency of neurology is to deny the existence of any special nervous affection produced by trauma or shock. There may folloAV from these causes ■ 1. Surgical injuries. 2. Neurasthenic states. 3. Hysterical states. 4. Hemorrhagic, inflammatory, and degenerath'e diseases. 5. Combinations of the foregoing. These troubles may follow not only railway but other injuries, but are especially liable to follow those associated Avith intense fright. 2. Traumatic neurasthenia, or "traumatic neurosis," does not differ from forms of neurasthenia produced by other causes, ex- cept that with it there may be certain sprains and surgical trou- bles. Traumatic neurasthenia not infrequently is associated Avith much spinal pain, and in Avomen especially the clinical symptom group known as "spinal irritation" may develop. In other cases there may be more of the features of spinal asthenia. When to these spinal symptoms a partial paraplegia is added, Ave have the disease that has been called " raihvay spine," or spinal concussion. The anatomical names given to this used to be spinal anemia, spinal hyperemia, and spinal meningitis. But no evidence has as yet proved the exact nature of the lesion. 3. Traumatic hysteria is a rare affection in this country. It does not differ from hysteria produced by other causes, except for its sudden onset and occasional surgical complications. It is usually a hysteria major and has the characteristic stigmata of that type. In this city electrical injuries and frights have pro- duced some classical cases of hysteria major. 4. There is considerable evidence that in some rare cases trau- matism may produce minute multiple hemorrhages throughout NEURASTHENIA—NERVOUS WOMEN. 461 the nervous centres. In such cases there are usually neuras- thenic or hysterical symptoms and in addition symptoms of organic disease. In the majority of cases the symptom complex is something like this (Knapp): " The patient has headache and A'ertigo; he is depressed, irritable, and hypochondriacal, with a diminished poAver of application; he may haA'e some Aisual disturbance, he often has a contracted field of vision and occasionally optic atro- phy; there is some tremor and perhaps inco-ordination; he has anesthesia, usually not limited to one-half of the body, and with it numbness and prickling; his moA'ements are sIoav and weak; his tendon reflexes are exaggerated; there is often some lack of control over his bladder; and he may haA'e pain and stiffness in the back from muscular strain." The symptoms eventually re- semble a disseminated sclerosis. Massive hemorrhages and serious mechanical injury of the nervous centres may be also produced by injury. Finally, it is a Avell-knoAvn fact that traumatisms may excite in the predisposed locomotor ataxia, inebriety, insanity, or may lead to the deA'elopment of a cerebral tumor. It is the mental impression, the shock, much more than the physical injury, which produces the neurosis or psychosis. The symptoms may appear soon after the accident, or after a period of relative health lasting a few weeks the neurosis grad- ually deA'elops. The most important practical point in connection Avith the subject is the diagnosis and the elimination of malingering. This is additionally difficult for the reason that the hopes and anxieties depending upon litigation tend to cause introspection, exaggeration of symptoms, and unconscious bias even in the most honest. The opinion among American neurologists tends to favor the seriousness of traumatic neuroses. While malingering is not rare, yet if the patient has really a traumatic neurasthenia or hysteria the disease may not be a trifling one. Careful research, hoAveA'er, often tends to elicit the fact that preA'ious to the in- jury the patient Avas an alcoholic, syphilitic, or neurotic, and perhaps had already the beginnings of his alleged traumatic disorder. In no part of clinical medicine is a careful and searching examination and weighing of symptoms more ur- gently called for. The methods of carrying out such examina- tions are given elseAvhere. Special methods for testing anesthe- sia are sometimes needed. The two sides of the body should be tested simultaneously Avith concealed needles, beginning on the trunk, or the faradic current Avith a double-pointed electrode may be used. There are feAv patients Avho can successfully de- ceive in an examination covering all the special senses. 462 DISEASES OF THE NERVOUS SYSTEM The treatment of the traumatic neuroses calls for no special notice. EXOPHTHALMIC GOITRE (BASEDOW'S DISEASE, GRAYES' DISEASE). Exophthalmic goitre is a chronic neurasthenic neurosis char- acterized by rapid heart beat, enlargement of the thyroid gland, protrusion of the eyeballs, and various neurasthenic and vaso- motor symptoms. Etiology.—The disease occurs much oftener in women than men (four to one). It is a disease of early adult life, occurring chiefly between fifteen and thirty-five, very rarely in childhood, and never after fifty.* It is apparently more common in the Anglo-Saxon race, but is not very frequent in America. There is very rarely any direct inheritance of the disease, but the family is often a neuropathic one. As a rule, the patient is of a neurotic temperament. Anemia and debilitating diseases pro- mote its deA'elopment. Goitre and heart disease do not seem to predispose to it. The most frequent exciting causes are poAver- ful depressing emotions and severe physical exertion. Rarer causes are injuries and infectious diseases, such as measles, scarlet fever, and pneumonia. Symptoms.—The disease usually begins gradually and the first symptom is in most cases rapid heart beat and palpitations, accompanied Avith some nervousness and tremor. The next symptom is enlargement of the thyroid gland, and at about the same time the eyeballs begin to protrude. This order of devel- opment does not always take place, and occasionally one of the three principal symptoms is not present. The disease is usually one or two years in developing, the heart symptoms being those which continue by themselves longest. With the symptoms mentioned there occur many minor troubles which are more or less characteristic. The patient is usually very nervous and irri- table; a distressing insomnia may be present. There is almost uniformly a fine tremor (eight to nine per second) of the hands, less marked in the lower limbs and not present in the face or tongue. The reflexes are exaggerated. There is a tendency at times in walking for the knees suddenly to give Avay. The patient rarely has neuralgias, but does have burning or fever- ish sensations and headaches. The skin is rather reddened and the patient SAveats profusely. Pigmentation and vitiligo are sometimes seen, and urticaria may develop. The electrical re- * Among 33 cases at N. Y. Post Graduate Clinic (Fiske-Bryson) there were 8 males, 25 females. Ages: thirteen to twenty, 8; twenty-one to thirty, 8; thirty-one to forty, 6; forty-one to fifty, 5; fifty-one to sixty, 1. EXOPHTHALMIC GOITRE. 463 sistance of the body is much diiuinished, being 800 to 1,500 ohms instead of 2,000 to 3,000. There is sometimes a dermographic skin, as in other neurasthenic states. The respiratory function is weakened and chest expansion often falls beloAv one inch (Fiske-Bryson). Attacks of a persistent Avatery diarrhoea occur. Anemia is usually present. There is occasionally polyuria, more rarely glycosuria. The menses are irregular and amenorrhoea often exists. A slight rise in temperature may occur. The major symptoms of the disease are: Tachycardia and pulsating arteries. Goitre. Exophthalmus. Tremor. The minor symptoms are: Nervousness. Sweating/ Insomnia. Lessened electrical resistance. Diminished respiratory expansion. Subjecth'e sensations of heat. Diarrhoea. Polyuria. Symptoms in Detail.—Tachycardia is the most constant single symptom. The pulse beats from 100 to 120 per minute usually, but may rise to 1G0 or even 200. Its rhythm is usually steady; but palpitations occur easily, even without exciting cause. The patient may Avake up at night Avith distressing attacks, some- thing like those of angina pectoris, but the intense pain and sense of impending death are usually absent. The heart is di- lated and a systolic murmur is often heard at the base propagated along the arteries. Real organic disease, however, is rare. The arteries are dilated and soft. They pulsate strongly, particularly the carotids. A thrill is sometimes felt over the heart and al- ways over the goitre. The arterial tension is normal or Ioav. The thyroid gland is usually enlarged symmetrically; later in the disease the isthmus is affected and the three lobes of the gland stand out prominently (Fig. 198). If only part of the gland is invoh'ed it is oftenest the right lobe. A thrill is felt OA'er it and a systolic murmur can be heard. The bulging of the eyes or exophthalmus is usually bilateral and even. If one eye is alone or more affected it is the right. The exophthalmus A'aries much in degree. It is not usually very great, but may be so excessive as to prevent closing of the lids and to expose the insertions of the recti. The eyeball may be slightly enlarged (one-tenth). The pupils are normal and A'ision is not impaired, though myopia occasionally occurs. The fundus 464 DISEASES OF THE NERVOUS SYSTEM. and A'isual field are normal. Paralysis of some of the eye muscles is a rare complication. Weakness of the internal recti and ex- ophoria are frequent. The lids shoAv certain peculiarities. One of these, knoAvn as Von (fraefVs symptom, consists in tlit* in- ability of the lid to follow the doAvmvard movement of the eye- ball. When the patient is told to follovv the movement of the finger vertically downward the eyeball moA'es steadily, but the lid catches, as it Avere, and refuses to folloAV or does so in a jerky manner. Another symptom, known as Ste.lltragus symptom, is a considerable retraction of the lids, especially the upper one. Both this and Yon Graefe's symptom are due to a common tendency Fig. 198.— Exophthalmic Goitre, with and without Exophthalmus. of the lids to retract—due perhaps to overaction of the muscle of Muller. A tremor of the lids sometimes occurs. Course.—The disease progresses sloAvly. After a year or two it often becomes stationary for a long time. < Vises of gradual spontaneous recoA'ery occur. The natural duration of most n - coA'erable cases is two to four years. In those which do not re- cover the disease lasts fh'e, ten, or more years. Eventually the patient emaciates, the heart becomes Aveaker, albuminuria and dropsy appear, diarrhoea sets in, and the patient dies of exhaus- tion or is carried off by phthisis or some intercurrent disease. Other cases having improved up to a certain point remain in this state for years. Complications.—Mental derangement occasionally occurs in the later stages of the disease. Hysterical crises, epileptic at- EXOPHTHALMIC GOITRE. 465 tacks, choreic movements, paralysis of the ocular muscles, mus- cular atrophy, paralysis agitans, Addison's disease, diabetes, loco- motor ataxia, and local oedema have all been observed. With the exception of hysterical attacks these complications are rare. Abortive Forms.—This name is applied to cases in which only a part of the distinctive symptoms develop. Tachycardia al- ways exists; with it are tremor and moist skin, lessened electrical resistance and nervousness. Or tachycardia and goitre may alone be present. Pathology.—The disease may be regarded as a neurasthenic or atonic condition of the A'asomotor centres and of the great vis- ceral nerves, the vagus and spinal accessory. As a result of the first condition the blood-vessel A\ralls are relaxed and the cutane- ous hyperemia results. The enlargement of the thyroid is ex- plained by a vasomotor paresis of its A'essels. It is a kind of erection of the organ. The exophthalmus is also due chiefly to paralysis of the orbital vessels. A tonic spasm of the muscle of Muller is thought to help in producing this symptom. This muscle consists of unstriated fibres originating in the membranous lining of the orbit and inserted into the lids. It is rudimentary in man, and its influence in causing protrusion of the globe must be very small. The deposit of retrobulbar fat is a secondary phenomena. The rapid heart beat is probably due to impair- ment of the inhibitory fibres of the spinal accessory. Thus all the symptoms may be explained on the theory of a vasomotor and cardio-inhibitory paresis. Another theory suggested of late is that the disease is primar- ily an affection of the thyroid gland; that this organ is overactive and throws into the blood substances that irritate the nerves. More properly the mechanism should be that it withdraws from the blood too much of those substances which are needed for nerA'e nutrition. The principal substance so far as knoAvn which develops in excess Avhen the thyroid fails to act is mucin. In myxoedema the thyroid gland atrophies, and a long list of symp- toms almost directly the opposite of those of exophthalmic goitre occurs. The thyroid theory is weakened by the fact that tachy- cardia and many other characteristic symptoms may develop without a goitre, and that in simple enlargement of the thyroid the symptoms of Graves' disease do not appear. Small hemorrhages and congestion of the medulla have been found in a few cases. Aside from this, no important changes in the central nervous system have been discovered. The heart is dilated and enlarged, endocarditis is sometimes present, oftener not. The arteries are dilated. The thyroid gland is vascular and its arteries dilated; its proper structure is increased in amount. There is increase of fat and vascular dilatation in 3° 466 DISEASES OF THE NERVOUS SYSTEM. orbit. The thymus gland is usually present to a greater extent than normal. Prognosis.—About one-fifth of the cases get well or practically well. Probably over half the cases, if they can be properly treated, reach a fairly comfortable condition of improvement. The cases in which symptoms come on quickly have the most favorable prognosis. In those with marked exophthalmus and goitre the prognosis is not so good. Diagnosis.—The disease can be distinguished by the persist- ent tachycardia, with goitre or exophthalmus, and in its early stage by the tachycardia with tremor, moist skin, sensations of heat, nervousness, insomnia, lessened respiratory expansion, and electrical resistance. A symptomatic Graves' disease may some- times be caused by a goitre pressing on the vagus or sympathetic and causing irregular heart beat and perhaps exophthalmus. In these cases the history of a long-standing goitre exists, the heart's action is irregular, the exophthalmus is usually partial and one- sided. In abortive forms it is necessary to have tachycardia and at least one other of the four major symptoms to make a diag- nosis. Treatment.—Rest is the most important single thing. The patient should be put to bed or kept on the back for one or more months. Freedom from excitement and worry must be en- joined. No especial diet is needed, nor do climatic influences or baths or mineral waters have much effect. Some cases are said to be improved, howeA'er, by removal to heights of one to three thousand feet. In most cases a, sea-voyage is the better change if one is made. The drugs used are numerous. The most efficient are tincture of strophanthus in doses of fifteen to forty drops daily, iodide of potassium or the syrup of hydriodic acid, arsenic and bromide of potassium used together; quinine, mineral acids, and iron, used together. Other remedies are tincture of aconite in ni v. or aco- nitia gr. ^y doses, tincture of belladonna increased to the limit of tolerance, tincture of cactus grandiflorus in iU x. to xx. and tincture of veratrum viride, ttj, x. to xxx. dose, and the picrate of ammonia, gr. i. to ij. t. i. d. Of these drugs, strophanthus, the iodides, bromides, and iron have served me best. Digitalis is of doubtful value. Electricity possesses some utility. It should be given, if possi- ble, two or three times daily in the form of galvanism and in doses of two to six milliamperes for ten minutes. The technique is as follows: Positive pole on back of neck, negative drawn along course of vagi in the neck; each side two minutes. Same with positive pole placed subaurally one minute; negative pole over thyroid two minutes, negative over cardiac region one min- EXOPHTHALMIC GOITRE. 467 ute, positive pole over eyes, negative over thyroid one minute, tAvo milliamperes. The faradic current may be used for general tonic effects or combined locally with the galvanic. The patient should lie down during treatment and remain quiet for an hour later. For the palpitations, sulphate of sparteine or strophanthus with Hoffmann's anodyne may be used. The ice-bag placed over the heart and neck is helpful and may be used systematically. Tonic hydrotherapy is often useful, but should be carefully em- ployed. Surgical treatment until late years has been unsuccess- ful. Recently several cases have been reported in which cure has been produced by partial removal of the thyroid gland. This measure is yet in an experimental stage. Treatment of the nose has been said to cause disappearance of symptoms, but its utility is A'ery doubtful. Respiratory exercises by which the patient is taught to increase his chest expansion do much good, as shown by Dr. Bryson. Mild compression of the lids at night seems to help the ex- ophthalmus, and slight and steady compression of the thyroid gland sometimes reduces its size a little. CHAPTER XXV. PROFESSIONAL NEUROSES, OCCUPATION NEUROSES (WRITERS' CRAMP AND ALLIED AFFECTIONS.) Writers' cramp is a chronic functional neurosis character- ized by spasmodic, tremulous, inco-ordinate or paralytic disturb- ance when the act of writing is attempted, and associated with feelings of fatigue and pain. Etiology.—It is a disease of the present century, and has been particularly noted since the introduction of steel pens about the year 1820. A neuropathic constitution is often present, and some- times there is a hereditary history. Men are much more subject to the disease than women. The most susceptible age is between twenty-five and forty. It rarely occurs after fifty or before tAventy. Clerks and professional writers are naturally much more subject to the disease. Excessive worry, intemperance, and all debilitating influences predispose to it. The chief excit- ing cause is excessive writing. But this is not all. The writing that is done under strain or a desire to finish a set task is the harmful thing. The style of writing is also an important factor. Writing done in a cramped posture with movements of the finger alone or with the little finger or wrist resting on the table is most injurious. Free-hand writing done from the shoulder ac- cording to the American system is least harmful. Shaded or heavy writing with sharp steel pens is also productive of harm. Copying is much more harmful than composing. Authors seldom have writers' cramp. Albuminuria, lead-poisoning, exposure to Avet and cold, and local injuries are sometimes exciting causes. Symptoms.—Writers' cramp very rarely attacks a person sud- denly. The patient first notices a certain amount of stiffness oc- curring at times in the fingers, or the pen is carried with some uncertainty and jerky movements are made. He feels a sensa- tion of fatigue in the hand and arm, and this may amount to an actual tired pain. The first symptoms may last for months or even years. The hand is rested as much as possible, new pens or penholders and new modes of holding it are tried. Often the patient, fearing the onset of the cramp, and as its result loss of employment, becomes anxious, worried, and mentally depressed. PROFESSIONAL NEUROSES, OCCUPATION NEUROSES. 469 Sometimes the trouble is Avorse when beginning a daily task, and it gradually wears off in a few hours. At other times exactly the reverse is the case. When the disease has reached its highest stage, writing becomes almost or entirely impossible. The mo- ment the pen is taken in the hand and an attempt at using it made, spasmodic contractions of some of the fingers, or even of the arm, occur, the pen flies in any direction, and it is impossible to control or co-ordinate the movements. The rule is that al- though Avriting cannot be done, all other complex movements are performed as well as eA'er. Thus the sufferer from writers' cramp may be able to play the piano, or paint, or thread a needle, or use the hand in any complex movements. This limitation, however, is not ahvays present. Telegraphers, who use to some extent the same muscles as in writing, and who also often have to do a great deal of Avriting, are liable to suffer from both writers' and telegraphers' cramp at the same time. No evidences of actual paralysis are present in the affected muscles, and there is rarely anesthesia, but the arm aches and is sometimes tender. Sensations of numbness and prickling are present: in rare cases vasomotor disturbances are observed; associated muscular move- ments of the other arm or of the neck or face sometimes occur. The hand may tremble on attempting to write or fall almost paralyzed when the pen is taken. The various symptoms occur with different degrees of promi- nence, so that the disease has been classed under the heads of (1) the spastic, (2) the neuralgic or sensory, (3) the tremulous, and (4) the paralytic forms. These forms are, however, often more or less mixed. 1. The spastic form is undoubtedly the most common, and it has given to the disease its name. Cramp of some muscle or muscles is present in over half of the cases. The muscles of the thumb and first three fingers are oftenest affected, and in some cases the flexors, in some the extensors, are chiefly involved. In telegraphers' cramp it is the extensors, but in writers' cramp the flexors, that are mainly attacked. The thumb or forefinger or the little finger alone may suffer from the spasms. The prona- tors and supinators are quite often involved. The spasm is usu- ally a tonic one. With the spasm there is also inco-ordination so far as writing movements are concerned, and this fact is quite as important in producing the bad writing as the spasm. The inco-ordination is apparently of the motor type, and is not due to anesthesia of the muscle sense, as in locomotor ataxia. 2. The neuralgic form resembles the spastic plus sensations of fatigue and pain, which are quite severe and are brought on by writing. There may be tenderness along the arm also. 3. The tremulous type, though rare, is very characteristic 470 DISEASES OF THE NERVOUS SYSTEM. when present. The patient when attempting to write observes a tremulous movement of his hand and arm. This ceases when his attempts to write cease. The tremor usually affects most the fingers used in pen-prehension, but it also spreads to the forearm and may even involve the entire extremity. An oscilla- tory or lateral tremor, due to involvement of the pronators and supinators, has been observed. The tremor is of the character known as " intention-tremor," such as is observed in disseminated sclerosis. It is shorter in range and more rapid than the tremor of that disease. 4. The paralytic form, or that type in which muscular feeble- ness is the dominant symptom, is said to be rare by Gowers, and this accords with my experience. German writers speak of it as common. In the typical paralytic form the patient, as soon as he begins to write, feels an overpowering sense of weakness and fatigue in the fingers and arm. The fingers themselves loosen their grip and the pen may drop from the hand. Powerful im- pulses of the will and change in the mode of holding the pen enable the sufferer to continue, but the arm aches and finally is absolutely painful, and weakness and fatigue compel the writer to desist. Sometimes the paretic condition is succeeded by the spastic. Many of the cases of paralytic writers' cramp are not true examples of the neurosis, but are rather cases of neuritis of a rheumatic or other type. General Symptoms.—Writers' cramp is essentially a motor neurosis, and its leading symptom is the impairment of a motor function. Other symptoms, however, both general and local, are ahvays associated with it. These are mainly (1) psychical and (2) sensory, more rarely (3) vasomotor and (4) trophic. 1. Psychical symptoms. The patient is often nervous, emo- tional, and mentally depressed at times. He suffers from in- somnia and A'ertigo. Patients are generally unwilling to admit that there is any other trouble than the local one, and only care- ful examination may bring evidence of constitutional trouble. There are cases of purely mental writers' cramp. 2. Sensory troubles. These consist of pain, sense of fatigue, feelings of numbness, prickling, pressure, weight, tension, con- striction, etc. Hyperesthesia, and more rarely anesthesia, are also observed. The most common sensory symptom is that of aching and fatigue, and this is usually confined to the arm, and oftenest runs along the course of the radial and median nerves. The cervical vertebre may be tender, and sometimes pa- tients have a headache in the parietal region of the side opposite the affected arm. 3. Vasomotor, trophic, and secretory disturbances. The con- dition known as digiti mortui has been observed, coming on par- PROFESSIONAL NEUROSES, OCCUPATION NEUROSES. 471 oxysmally. It is a symptom which the general neurasthenic state helps to produce. When the nerves are involved decided vascu- lar changes may occur, such as passive congestion of the hand and arm, with swelling and turgescence of the fingers, and a sensation of throbbing. In bad cases the fingers will look as if they had chilblains. Local sweating, dryness of the skin, and cracking of the nails, all are conditions which may folloAV impair- ment of writing power from neuritic causes. Electrical Reactions.—The results of obserA'ations upon the electrical reactions of the affected parts are somewhat contradic- tory. Ordinary tests will, as a rule, reveal very little change. Sometimes there is a quantitative increase, sometimes a decrease, of irritability to both forms of current. The increase occurs in the earlier stages, the decrease in the later. An increase or modification of electro-muscular sensibility has been noted. The electrical examinations, therefore, are only of value in ex- cluding a neuritis or possibly in determining the stage of the disease. Pathology.—Neuritis is undoubtedly present in some forms of writers' cramp, so called. It is not present, however, so far as external tests go, in the typical neurosis. Nor are there any post-mortem observations throAving light on the anatomy of the disease. We must believe, therefore, that it is a neurosis having no appreciable anatomical basis. The act of writing is a very complicated one, calling into play numerous sets of delicately innervated muscles. These muscles are employed: 1, in pen-prehension; 2, in pen movement; 3, in holding the arm and wrist tense. 1. The muscles employed in pen-prehension are the two outer lumbricales, two outer interossei, the adductor muscles of the thumb, the flexor longus pollicis; to some extent the deep and superficial, short and long flexors, and the extensors of the thumb. These are supplied mostly by the ulnar (interossei, adductor pol- licis, inner heads of deep flexor of fingers, and inner head of short flexor of thumb). The rest of the muscles are supplied by the median. 2. In moving the pen, if the writing is done mainly by finger and not by arm movements, the muscles brought into play are the flexor longus pollicis, extensor secundi internodii pollicis, flexor profundus digitorum, extensor communis digitorum, and to some extent the interossei. The musculo-spiral and ulnar nerves innervate these groups about equally. In moving the pen by the "American" or free-hand method there is a very slight play of the above muscles, while most of the pen move- ment is done by the muscles of the upper arm and shoulder, viz., the teres major, pectorales, latissimus dorsi, biceps, and triceps. 472 DISEASES OF THE NERVOUS SYSTEM. The spinal centres for these muscles are distributed along the fifth, sixth, and seventh cervical segments of the cord. The cells are larger and situated more superficially in the anterior gray horns. 3. Besides these movements involved in pen-prehension and in the letter-making, a certain amount of muscular tension is ex- ercised in "poising" the forearm and hand and steadying the wrist. The biceps and triceps, the supinators and the flexors, and extensors of the hand are here brought into play. From the foregoing it will be seen that the muscles of pen- prehension are most used in all but the free-hand style of writ- ing, since the same groups have a double duty, that of clasping and of moving the instrument. While Avriters' cramp is often complicated with some neurotic disturbance leading to associated symptoms of pain, paralysis, tenderness oA'er nerves, Aasomotor disturbances, etc., there can be no doubt that the lesion in typical cases is central. Writing is an acquired automatic movement, and it must haA-e as its ana- tomical basis a certain established arrangement of nerve-cell groups in the cervical part of the spinal cord. The nerve im- pulses generated in the cerebral cortex pass along the pyramidal tracts and set at Avork those ganglion groups which, in turn, in- nerA'ate the muscles used in writing with motor impulses. These groups are themselves innervated also sensorially by the nerves of muscle sense in movement. In writers' cramp the spinal groups of cells are more or less used up or exhausted, and the motor impulse which naturally would innervate them strikes cells which respond unequally, or it overflows to other cell groups, and hence the spasmodic, irregular moAements of the arm. The cerebral centres in the cortex or basal ganglia are closely connected with those in the cord, and may be said to form part of the writing mechanism. It happens in some cases that this centre too is exhausted and discharges its impulses irregularly. In some cases, therefore, the cerebral, and in some the spinal, cell groups are the more affected, and a diagnosis of the exact condition in each is approximately possible and may be not Avithout practical importance. Writers' cramp is a disorder of efferent paths and stations. The muscular sense does not seem to be involved. The pathology of writers' cramp is that of all the other forms of occupation neuroses, and nothing need be said upon this point regarding them Avhen they come to be considered. The diagnosis of well-marked cases of writers' cramp presents no difficulty. In the earlier stages, however, it may be confounded with a large number of disorders, viz., post-hemiplegic chorea, hemiataxia, progressive muscular atrophy, progressive locomotor PROFESSIONAL NEUROSES, OCCUPATION NEUROSES. 473 ataxia, Aarious forms of tremor, lead paralysis, rheumatoid arthritis, neuritis, cerebral and nerve tumors, and tenosynovitis. In many of these cases it is only necessary to bear in mind the history of the disease in order at once to reach a safe conclusion as to its nature. If there is a great deal of pain in the arm, with tenderness along the course of the nerves; if there is decided change in the electrical reactions; if there are sensations of tingling, numbness, etc.; and if the patient shows an absolute loss of poAver in the various groups of muscles, Avith some incapacity for doing other acts besides the one with which he is specially concerned, then the trouble is undoubtedly peripheral and due largely to an un- derlying neuritis. The prognosis in these cases is much more fa Adorable. If, on the other hand, the disorder comes on in per- sons who haA'e done an excesshre amount of A\riting; if it is associated Avith nerve strain; if the electrical reactions are but slightly changed, the sensory symptoms slight, and the motor inco-ordination marked, limited to the special class of work, and not accompanied with absolute paresis, the disorder is central and needs both a different treatment and prognosis. It is these cases that form Avriters' cramp proper, although no doubt neuritic and central forms are associated, or the former may run into the latter. Course and Duration.—Writers' cramp is a chronic disease. It begins insidiously and attacks one group of muscles after an- other as each is brought into play by new methods of writing. If the left hand is used, that, too, is liable to become affected. The course A'aries, however; for a time progress may be arrested or improvement set in. When the disease becomes well estab- lished it will most often last a lifetime. Prognosis.—The prognosis is unfaA'orable, yet not so much so as has once been thought. Undoubted cases of complete recov- ery haA'e been reported, even under unfaA'orable conditions. The prognosis is much more favorable if the patient begins treatment early and before marked spastic symptoms are present. It is more favorable in the neuralgic forms. Some patients who suffer from a mild form of the trouble manage, by the help of in- struments or special pens, to do their Avork for years. The more acute the disease and the more eA'idently peripheral and neuritic its origin, the better the prognosis. In over one-fourth of the cases, patients who use their sound arm will not be affected in it. The facts stated regarding the cause, physiology, and general symptomatology of writers' cramp apply to the other forms of occupation neuroses. A few special details, however, will be gh'en regarding these. The most common and important are musicians' cramp and telegraphers' cramp. 474 DISEASES OF THE NERVOUS SYSTEM. Musicians' Cramp.—Under this head Ave include pianists' cramp, \'iolinists' cramp, flutists' cramp, and the cramp of clar- ionet players. Pianists' cramp occurs usually in young women who are studying to become professionals or who are especially hard- working and ambitious. The absurd " Stuttgart method" of teaching the piano, in which the motions are confined as much as possible to the fingers, predisposes especially to this disease. The symptoms are those of fatigue, pain, and Aveakness. The pains are of an aching character. They are felt in the forearm especially, but extend up the arm and betAveen the shoulders. Spasmodic symptoms are rare. The right hand is oftener affected, but both hands eventually become involved. Violinists' cramp may attack the right hand A\'hich holds the bow or the left hand Avhich fingers the strings, but more often the left hand is affected. Clarionet players sometimes suffer from cramp of the ton; ue and of the laryngeal muscles. Flute players suffer not very infrequently from slight laryn- geal spasms. A similar trouble affects elocutionists. The tei in mogophonia is applied to this type. Telegraphers' cramp affects especially those operators using the Morse system, an instrument which is still the one most widely in vogue. Contrary to the opinions of previous writers, Dr. Lewis believes that this neurosis is not a rare one and is destined to become more frequent. In this city the cramp is not rare, the proportion being about one in every two hundred. The technical name among operators for the cramp is "loss of the grip." In telegraphing, the extensors of the wrist and fingers are called most into play, and hence are most and earli- est affected. The symptoms come on \'ery slowly, the thumb and index-finger being first affected. The A'ictim finds that he cannot depress the key on account of spasm in these muscles, and he finds most difficulty in making the dot characters, such as h (....), or p (.....), or z (. . . .). When the flexors are most affected the key is depressed with undue force and a dash is made instead of a dot. Sufferers from the " loss of grip " gen- erally suffer from writers' cramp also. While spasm is usually present, the disease may show itself simply in pain, paresis, and incapacity to co-ordinate the muscles. In sewing spasm, Avhich affects tailors, seamstresses, and shoe- makers, clonic and tonic spasms attack the muscles of the hands on attempting to use them in the regular Avork. Tailors who sit cross-legged sometimes suffer from a peculiar spasm on assuming this position. It is possible, however, that these are cases of tetany, and not the functional neurosis under consideration. Smiths'1 spasm, hephastic hemiplegia, appears to have been observed only by Duchenne and Dr. Frank Smith. It occurs in persons engaged in pen-blade manufacturing, saw-straightening, razor-blade striking, scissors-making, file-forging, etc. In doing this work they have to use a light or heavy hammer, with which strokes are delivered very rapidly and carefully. After a time spasmodic movements occur in the arm used, and the arm falls powerless. As in the cases reported there are generally hemi- plegic symptoms, and also neuralgias, vertigo, and other cerebral troubles, the disease cannot be a pure " occupation " neurosis. Drivers' spasm has been observed in veterinary surgeons by Dr. Samuel Wilkes. PROFESSIONAL NEUROSES, OCCUPATION NEUROSES. 475 Milkers'1 spasm is an extremely rare affection, which was first described by Basedow and seems to occur in milkmaids, never in milkmen. Cigurmakers' cramp is very rare. Watchmakers'1 cramp and photographers'1 cramp are also to be regarded merely as pathological curiosities. Ballet-Dancers'1 Cramp.— Under this name certain painful and paralytic troubles occurring in ballet-dancers, especially premieres danseuses, have been described by Schultz, Onimus, and Kraus- sold. It does not appear that the trouble is really a co-ordinati\'e functional one, but is rather neuralgic, or the result of local strain upon the parts. The list of professional neuroses is made to include, besides those above given, cramps and co-ordinative troubles affecting artificial-flower makers, billiard-players, dentists, hide-dressers, electrical-instrument makers, stampers, turners, sewing-machine girls, money-counters, weavers, painters, and pedestrians. Prophylaxis and Treatment. — The introduction of type- writers, gold pens, and improved penholders has prevented some- what the increase of writers' cramp. Stenographers rarely have it unless they write in long hand. Persons who have to write a great deal should use large cork or rubber penholders and gold or quill pens with smooth paper. The best style of writing is that done from the shoulder, but this is a method that book-keepers and those who have to keep accounts cannot easily adopt. Many nervous persons have a bad habit of gripping the pen very tightly and pressing down on the paper with excessive force. Fatigue soon results and painful sensations develop in the arm. Proper attention should be paid to the position of the paper written upon, the height of the desk, the light, and the sleeves of the coat or dress. The paper should be laid at an oblique angle to the edge of the desk, and not at a right angle as many writing-teachers are accustomed to direct. As some cases of "cramp" are undoubtedly cerebral, it is very unwise to attempt any extraordinary exploits in writing or to work with the ambi- tion to put the writing capacity to the utmost test. Cramp is often dated from days when such extra work is done. When the cramp is fully developed, the most essential thing is rest. This may be secured by getting a new form of pen- holder, holding the pen in a different way, using the unaf- fected arm, using some form of mechanical appliance. The me- chanical appliances are splints, rubber bands around the wrist, and various instruments contrived to preA'ent spasm and throw the work of writing on new and larger groups of muscles. Instruments for writers' cramp are \Tery numerous. Those that are of some value are Mathieu's, Nussbaum's, and some mod- ification of Cazenave's (see Figs. 199, 200). All the various instru- ments have been of service, or have even been curative in some 47G DISEASES OF THE NERVOUS SYSTEM. Fig. 190.—Mathieu's Instrumeni for AVriters' Cramp. special cases, but not too much must be expected of them. As a rule they are only palliative. A cheap instrument that may proA'e satisfactory is that of Mathieu. In the medical treatment of writers' cramp, the two most im- portant agents are massage and electricity. By massage only very mediocre results were obtained until greater attention Avas draAvn to it by Mr. J. Wolff, a Avriting-master of Frank- fort-on-the-Main. This gentleman has cured many cases, though not all that he has treated (Berger), and be has secured many testimonials for his method. The treatment, as described by Schott (G. W. Jacoby), consists of a system of gymnastics and masage. The gymnastics con- sist of movements performed by the patient alone and movements executed with the co-operation of the operator. The first are performed by the patient during from twenty to thirty minutes, rarely for forty-five minutes. These movements consist of gym- nastics of the fingers, extension, flexion, abduction, and adduc- tion being performed, and the thumb being exercised separately. After this the same four motions are executed at the Avrist joint, then extension and flexion of the forearm, and ulti- mately the arms themselves are exercised in the same manner and are to be lifted over the head. Each single exercise is to be performed from six to twelve times. After each motion a pause is to be ob- served. The op- posed 'movements are to be carried out in the same manner, except that the operator must carefully resist their execution as though he were endeavoring to force the patient to perform a motion just the reverse of his intentions. Reg- ularity of pressure is to be observed in this, so that the same amount of force is always used and so that the pressure does not vary in intensity from moment to moment. The time to be de- Aroted to these opposed movements should be the same as that for the unopposed ones. According to the intensity of the affec- Fig. 200.—Nussbaum's Instrument. PROFESSIONAL NEUROSES, OCCUPATION NEUROSES. 477 tion, the exercises must be repeated tAvo to three times daily. The massage itself consists of tAvo parts—nerve and muscle massage. The nerve massage is effleurage along the course of the nerve trunks, the median, ulnar, and radial, going upward to the axillary and cervical plexuses. This effleurage lasts about ten minutes. Following this is the muscle massage. This con- sists of petrissage, beginning with the hand and ending at the shoulder. The duration is the same as that of the last move- ment. One sitting a day has always proved sufficient. Wolff, in addition, uses " a peculiar method of writing instruction " and employs rubber bands and rings in his manipulations. Electricity ranks second to massage in the treatment of oc- cupation neuroses. The faradic current may be used when the affection is paralytic, but the galvanic current is usually more efficacious. It has been almost uniformly helpful in my experi- ence. It must be given daily, howeA'er, or even twice a day. The anode is placed oA'er the cervical spine and the cathode over the various muscular groups affected. A stable current of five to ten milliamperes for from ten to fifteen minutes is given. Gal- vanization of the sympathetic is recommended by some. Gal- vanic belts applied about the arm seem irrational enough, but have been known apparently to effect cures. Lotions containing muriate of ammonia, liniments, hot and cold douches, the cautery, all have been recommended in profes- sional neuroses. Tenotomy was once employed, but has been abandoned. Very little can be expected of drugs. The most trustworthy are atropine, strychnine, cannabis indica, the io- dides and bromides, and cod-liver oil. It should be remem- bered that sometimes the disease is almost purely cerebral, and then an anti-neurasthenic treatment is called for. But in other cases, when the disorder is largely peripheral, the usual treat- ment for a low grade of myoneuritis must be employed. CHAPTER XXVI. PARALYSIS AGITANS (SHAKING PALSY, PARKIN- SON'S DISEASE). Paralysis agitans is a chronic progressive disease, character- ized by tremor, muscular rigidity and weakness, and by a pecul- iar attitude and gait together Avith sensations of heat, pain, and restlessness. Etiology.—It occurs oftenest between the ages of fifty and sixty, then between sixty and seventy and forty and fifty. In very rare instances it occurs in early life, but the genuine disease does not occur before puberty. Males are affected much oftener than females (five to three in seventy-eight American cases). It occurs in all clases of life, but oftener among those who incur exposures and endure hard labor. It is not a disease of vice and is not the result of alcoholism, syphilis, or sexual excess. Heredity is a rare factor, but 1 have known hereditary family tremor to end in paralysis agitans. It appears to have some relation to rheumatism and especially to rheumatoid arthritis. It occurs oftenest in this city among the Irish, German, and Polish races (twenty Irish, thirteen Germans and Russians, the last mostly Hebrews). The exciting causes in the majority of cases are exposure to wet and cold, fright, injury, and prolonged mental anxiety. An attack of sciatica or rheumatism, a sudden severe muscular strain, and fevers are rare causes. I have never been able to trace a case to malaria. Symptoms—-The disease usually begins slowly with some ach- ing pains in the arm and a slight tremor in the fingers of one hand, oftener the left. This gradually extends and involves the foot of the same side, then the other side becomes affected. The neck, face, and tongue are rarely attacked, and then to a small extent. After or with the tremor there comes on a stiffness in the arms and legs, and indeed of the whole body. With this there is a general contracturing and shortening of all the flexor groups; so that the head and body are bent forward, the fingers are straight but are flexed as a whole on the metacarpus, the fore- arms flexed on the arm, the trunk flexed forward on the thighs, and the knees slightly bent. The attitude gives the idea of ex- treme senility (Fig. 201). The gait is slow, the steps short and PARALY'SIS AGITANS. 479 shuffling; the patient has trouble in starting, stopping, and turn- ing corners, OAving to the slowness in initiating new movements in the voluntary muscles. When once started he may be unable to stop and has to run along. The speech early becomes affected. The Aroice is high-pitched, weak, and piping or senile in quality. There is a sloAvness in getting out words or in starting a sentence, though after it is begun the words come rapidly. The condition is analogous to the hesitation in the gait. Along with the other symptoms there are often, though not always, sensations of heat, burning, fever, and rarely of coldness. These sensations are felt most in the feet, legs, or arms diffusely. Often there is a general feeling of restlessness and nervousness. Fig. 201.—Attitude and Gait in Paralysis Agitans. Aching pains and a sense of fatigue occur; neuralgic pains are more rare. There is always a peculiar redness and flush in the faces of the patients. Sometimes they sweat profusely. Their temperature in the axilla is normal, on the skin it is sometimes increased (Peterson). The appetite is excellent, often abnormally great, and digestion is good. Visceral compli- cations are rare. Muscular Aveakness comes on early; it slowly increases, but complete muscular paralysis does not occur. The disease ends in rigidity, Avhich makes the patient as helpless as if paralyzed, but the muscles preser\re considerable functional power to the last. The deep reflexes are present and not, as a rule, exaggerated; but exaggeration and even clonus occur in a small percentage of cases. As the disease progresses the tre- mor increases in extent, and continues without remission dur- ing all the waking hours; the limbs get more rigid; the patient becomes bedridden and is finally carried off by exhaustion or some intercurrent illness (Fig. 202). 480 DISEASES OF THE NERVOUS SYSTEM. It Avill be seen that the dominant symptoms in paralysis agitans are: 1. Tremor. 2. Rigidity, progressively increasing. 3. Sensory and A'asomotor disturbances. Further details must be gh'en regarding these symptoms: The tremor is at first rather fine, but later is coarse. It ranges from about G vibrations per second to 3.7. The average rapidity is 4 or 5 per second, AA'hich is about one-half the normal muscular rhythm. But the chief characteristic of the tremor is that it continues when the hand or limb is at rest, while voluntary motion causes it to cease. As the hand rests on the knee it shakes; as it is moved the tremor stops. When held straight out there is no shaking for a moment, but it soon begins. A glass of Avater is carried safely to the lips. The patient can control the tremor for a moment, especially in the early stages of the disease. These facts about the tremor apply in ninety per cent of cases. But there are patients whose tremor is slight Avhen the limb is at rest and is increased on voluntary effort. The hands are affected in a characteristic way. The fingers and thumb are slightly flexed and held about in the writing position; the tremor moves the fingers and thumb as a whole, and they vi- brate so that the one pats the other gently. Sometimes the tremor is one of alternate supination and pronation of the fore- arm. The neck and face muscles are not usually or extensively iiiA'oh'ed, the shaking of the head being generally the result of the general bodily tremor. Sometimes one sees a tremor of the lips or neck muscles. The tongue and eye muscles are prac- tically never involved. Rigidity.—The tremor may be almost or even entirely absent in this disease. If so, there is a corresponding dominance of the symptom of rigidity. The rigidity, as stated, comes on early, and may be the first and even the only prominent symptom. It affects chiefly the flexors of the arms, head and trunk, and legs, producing a characteristic senile position. In rare cases the ex- tensors of the neck are affected and the head is drawn back. Cramps occur, and there is always a sense of stiffness. The mus- cular movements are slow, especially the initiation of a move- ment. Once started, a motion may be quickly done. The gait is peculiar: the steps are short and shuffling; the patient may have difficulty in starting, but once started he goes along well; or while walking there may be a sudden running forAvard. This is called " festination." Rarely there is a tendency to run backward or sideways. The facial muscles are stiffened and little used, so that the face has a peculiar expressionless look. The patient is often emotional, but the mind is not seriously affected. The PARALYSIS AGITANS. 481 urine is usually about normal, but contains an excess of phos- phates. There may be polyuria and less often glycosuria. Course and Duration.—The disease slowly but steadily pro- gresses until a full development of symptoms occurs, when it may remain stationarj'. It takes about two years for the whole body Pig. 202.—Terminal Stage of Paralysis Agitans, showing rigidity and contractures. to be affected, though this varies much. It lasts from three to twelve years. In three cases of mine death occurred in three, six, and eleven years. It may last for thirty years or even more. Death is due to exhaustion and may be accompanied with mild delirium and fever. The diagnosis must be made from senile tremor, multiple sclerosis, post-hemiplegic tremor, and wry-neck affecting the ex- 3i 482 DISEASES OF THE NERVOUS SYSTEM. tensors bilaterally (retrocollic spasm). Senile tremor occurs in the very old and affects the head first and most. In multiple sclerosis the tremor is more jerky and is a tremor of motion; t here is nystagmus, syllabic speech, and often apoplectiform attacks, eye trouble, and paralyses. Post-hemiplegic tremor is accompanied with a history of hemi- plegia ; there are paralysis and exaggerated reflexes and the disease is unilateral. In retrocollic spasm only the neck muscles and frontalis are inA'olved. The absence of exaggerated reflexes, the peculiar voice, gait and attitude, and the sensations of heat and nervousness often help greatly in the diagnosis. The jjrognosis is favorable as regards life; unfavorable as t i; *yy i V T„ Fig. 203.—Anterior Horn of Spinal Cord, showing dilated veins. regards cure; moderately good as to bringing about a cessation of progress in the symptoms. Pathology.—The following are among the changes that have been found in the central nerAous system: Hypertrophy of the nerve cells of the pons, induration of the pons, medulla, and cord, thickening of blood-vessel walls and of the pia mater, increase of connective tissue in the motor tracts, nerves, and muscles. In some cases autopsies have revealed nothing. The most constant change described is an increase of connective tissue in the motor tracts and pons, Avith congestion and hyperplasia of the vessel walls. I have found a peculiar dilatation of the vessels of the anterior cornua and roots, with some atrophy of motor cells (Figs. 203, 204). PARALYSIS AGITANS. 483 Everything points, however, to the seat of the disease being primarily in the upper motor or cerebro-spinal segment. Forms.—The unusual types of paralysis agitans are the hemi- plegic or the monoplegic, the rigid type, and the retrocollic type. The only one of importance is the rigid type, in Avhich there is practically no tremor. t Treatment.—The most important measure is rest, mental and physical, with plenty of fresh air. No special diet is indicated. LukeAvarm baths and mild massage are agreeable and helpful. 1 knoAv of no climatic cure. The galvanic current produces tem- porary relief; it should be given daily. Hyoscine hydrobromate, first used by Charcot and introduced into this country by Seguin, is of much temporary value in relieving the tremor (gr, yfo in- Fig. 204.—Showing Atrophied Cells. creased). Codeia and morphine give the best permanent results. Quinine and mineral acids are of much service in relieving the vasomotor and sensory symptoms. I have used bromide of uranium (gr. fa) with some apparently good results. Arsenic, Indian hemp, tinct. veratrum viride, salicin, and salicylate of soda rank next in value. Nitrate of silver, conium, curare, bro- mides, atropia, phosphorus, cod-liver oil, iron, and picrotoxin have all been recommended. They are of doubtful value. Sus- pension is of some use in a minority of cases not too much ad- vanced. The mind in paralysis agitans is sometimes in an emo- tional, almost hysterical, condition, and patients are easily made better for a time by some psychical influence. Hypnotism by means of fascination is said to be of use, but it has failed in my experience. CHAPTER XXVII. TROPHIC AND VASOMOTOR DISORDERS. Progressive facial hemiatrophy is a disease character- ized by a progressive wasting of one side of the face. Etiology.—It begins oftenest in the young between the ages of ten and twenty. Females are more affected.* There is in rare cases a hereditary history. Injury and infectious fe\ers sometimes start up the trouble. The left side is oftener attacked. Fig. 205. Facial Hemiatrophy, Early Stage, showing alopecia and osseous depressions. Symptoms.—-The disease begins very gradually and shows itself first in patches. The skin gets thinner, there is loss of pig- ment, hairs fall out, and the areas may have a yellowish appear- ance. Sometimes the periosteum and bone are affected, and shal- low depressions are formed which may be anaesthetic (Fig. 205;. The subcutaneous tissue is most involved, the muscles least, and there are no changes in electrical reaction. The muscles of mastica- * About 100 cases have been reported. Among 5 seen by myself, 3 were in females, 2 in males. The disease in all cases, so far as could be found, began between the tenth and twentieth years. TROPHIC AND VASOMOTOR DISORDERS. 4S5 tion are usually spared. The bone undergoes general atrophy and the lower jaAv may be reduced to two-thirds the normal size. The secretion of sebum ceases, but that of sweat may be increased. The temperature falls. There is a sinking in of the eye, nar- rowing of the lid, and dilatation of the pupil. There is some- times pain and rarely anaesthesia. The tongue and other parts of the body may be involved. Spasmodic moA'ements of the muscles of mastication haA'e been noted (B. Sachs). Scleroderma sometimes appears on the face or hands. The disease progresses rather rapidly at first, but finally comes to a standstill. It does not shorten life. Pathology.—There has been found a degenerath'e neuritis in- voh'ing the fibres of the trigeminus; its descending root and the substantia nigra were atrophied (Mendel). The diagnosis is easy. Hemiplegia with atrophy in children, congenital asymmetry, and atrophy from gross lesions of the nerve are distinguished by their stationary character or the pres- ence of seA'ere pain. Treatment.—There is no treatment knoAvn to be of service. Tonics, iodide, and electricity may be tried. Dercum has sug- gested resecting the trigeminal nerA-e. Acromegaly (Marie's Disease). Acromegaly is a chronic dystrophy characterized by gradual enlargement of the hands, feet, head, and thorax, and by a dorso- cerA'ical kyphosis. Though the disease Avas first described only six years ago by P. Marie, the number of cases reported is rapidly increasing, and if one includes A'arious abortive types it is not extremely rare. EleA'en American cases haA'e been recorded. Etiology.—it affects the tAvo sexes nearly alike. It begins between the ages of eighteen and twenty-six; recently a congen- ital case has been reported. No hereditary influence or definite exciting cause is known. The patients are sometimes naturally endowed Avith large extremities. Symptoms.—The disease begins with a gradual enlargement of the hands, feet, and head. In women there is amenorrhoea, in men sexual weakness; slight rheumatic pains, headaches, malaise, mental hebetude, anaemia, and general weakness are present. The skin is dry and there is polyuria. The hypertrophy affects the soft parts as Avell as bones. In these latter there is periosteal thickening and hyperplasia, with the result of producing increase in Avidth more than length. The arms are not much involved, nor is the shoulder girdle, except the clavicle. The lower jaw is much more involved than the cra- nium. The tongue, lips, and nose are enormously hypertro- phied. The thorax is enlarged antero-posteriorly and flattened. There is sometimes dulness OA-er the sternum due to persistence of the thymus. The pelvis may be enlarged, but the hip and leg bones are generally spared. The feet undergo enormous hyper- trophy. The following are some of the measurements in the case 486 DISEASES OF THE NERVOUS SYSTEM. that has come under ::;y observation, reported by Adler, and in cases reported by Osborne and Packard : Length of hand, Length of foot, Cranial circumference, . Circumference of thorax, The vision is sometimes impaired and there may be hemi- anopsia. The muscles may be at first hypertrophied, later atro- phied. There are no paralyses and rarely any an«sthesi;c. The disease runs a very chronic course, lasting ten or t.Aventy years. 7.6 to 8J inches. 11.7tol2± " L'4 to 2(51 41 Fig. 206.—Acromegaly. Pathology.—There has been found an enlargement of the pitu- itary body, and it has been suggested that the disease is due to disorder of its function. But this enlargement is not constant, and tumor of this organ does not cause acromegaly. The at- tempts to place the disease in relation with a persistent thymus, sclerotic changes of the sympathetic, and disease of the thyroid, all of which conditions have been found, are equally unsuccess- ful. The disease must be regarded as a perversion of nutrition of unknown origin. The enlargement of the bones is a true hypertrophy, not an inflammation. The diagnosis must be made from congenital enlargements, from so-called giant growth which affects single members, and from osteitis deformans. In the latter disease it is the shafts of the long bones and the cranium, not the face, which are involved. Pneumogenic osteo-arthropathy is the name given by Marie to a disease associated with pulmonary and pleuritic disease, and TROPHIC AND VASOMOTOR DISORDERS. 487 characterized by enlargement of the extremities and peculiar deformities of the terminal phalanges. The enlargements are not uniform. The tongue is not affected. The wrist and ankle bones are hypertrophied, the finger-tips are bulbous and spade-shaped. Prognosis.—Acromegaly is incurable, but it has been arrested, or at least has ceased to progress, and it may not greath' shorten life. Treatment.—Cases have been reported in Avhich iodide of potassium and arsenic haA'e arrested the disease. In general, the treatment is only symptomatic. ANGIONEUROTIC CEDEMA (CIRCUMSCRIBED CEDEMA). Angioneurotic oedema is a functional disorder characterized by the rather rapid appearance of circumscribed swellings upon different parts of the body, these swellings being due to disturb- ances of vasomotor innervation and not of an inflammatory character. The disease occurs oftenest in early adult life, the average age being from twenty to thirty, but it has been observed in young children and even in the aged. It occurs oftener in males than in females, except in this country, where the reverse ratio exists. Hereditary influence plays a part in some cases; the disease has been known to run in families. It occurs oftener in winter and oftener in the early morning hours. Exhausting oc- cupations predispose to it. The exciting causes are sudden expo- sure to cold, slight traumatisms, fright, anxiety, grief, and the ingestion of certain kinds of food such as apples or fish. A pecu- liar form of this oedema seems to develop in connection with menstruation. Symptoms.—The disease appears without much if any warn- ing. In a feAv minutes or hours there develops a circumscribed swelling upon the face or arms or hands. This swelling varies in diameter from one-half inch to tAvo or three inches. It may be dark reddish or rosy or it may be pale and waxy. It does not easily pit on pressure. There is sometimes a local rise, sometimes a fall in temperature. It is accompanied with sensations of ten- sion and stiffness, scalding, burning, and sometimes itching, but there is no actual pain. The swelling is usually single, but it may be multiple. It is located most often upon the face, next upon the extremities, particularly the hands; next on the body, then in the larynx and throat, and then on the genitals. The swellings last from a few hours to tAvo or three days. Between the attacks the patient feels well. They are apt to return at intervals of three or four Aveeks to several months. Sometimes they are only brought out by certain peculiar exciting causes, such as indigestion or mental anxieties or emotional disturbances. When the disease attacks the larynx or throat, serious symptoms of dyspnoea and suffocation may appear; surgical interference 488 DISEASES OF THE NERVOUS SYSTEM. may even be called for, and death has been known to result. It has been thought that neurotic oedema may sometimes attack the stomach, producing symptoms of nausea, vomiting, and great gastro-intestinal distress, and an acute neurotic oedema possibly sometimes attacks the lungs. This, however, is unlikely, since the vasomotor innervation of the pulmonary blood-vessels is a very stable one. The pathology of the disease is not known, except that it is unquestionably a disorder due primarily to disturbance in nerve innervation. The nerves affected are, furthermore, undoubtedly vasomotor nerves. The oedema is precisely similar to that which is associated with attacks of tic douloureux and migraine. Diagnosis.—The symptoms of the disease are so peculiar that they are easily recognized. The spontaneous appearance of the oedema, its recurrence at certain intervals, and the absence of pain and eA'idences of inflammation are sufficient usually to en- able us to recognize it. The giant urticaria is a disease resem- bling neurotic oedema and probably closely allied to it. The blue and the Avhite oedema of hysterics differs in being persistent and associated with paralyses, anaesthesias, and contractures. The prognosis, so far as cure is concerned, is not A'ery good. The attacks, hoAvever, can be ameliorated, and the disease itself is not serious as regards life and the enjoyment of a fair degree of general health. The treatment consists in the adoption of such measures as will give tone and stability to the nervous system; the use of cold baths, exercise, and massage is indicated. Internally mineral acids and strychnine may be of some value. Cascara, nux vomica, the salicylates, arsenic, quinine, and atropine are all drugs which have been recommended. CHAPTER XXVIII. THE DISORDERS OF SLEEP. Insomnia, Hypnotism, Morbid Somnolence, Catalepsy, Trance, Lethargy, the Sleeping Sickness. Sleep is a condition in which consciousness is normally lost and in Avhich the Avhole body, but particularly the brain, enjoys functional rest, while constructive and nutritive actiA'ity goes on. Physiology.—The most conspicuous phenomenon of sleep is the subsidence of the higher cerebral functions; yet other organs, notably the muscular system, also take part in the resting pro- cess. The brain during sleep is slightly anaemic, the deficiency in blood being a part of, but not the cause of, the phenomenon. The remote cause of sleep is inherent in the nervous tissue itself, Avhich follows the great rhythmical law common to all living tissue of rise and fall in its irritability. It is probable that the immediate cause of droAvsiness is the exhaustion of the ir- ritability of the cortical cells and the benumbing of them by the circulation of Avaste products in the blood. Many facts in the history of the pathology of the brain point to the ex- istence of a sleep centre, Avhich, being especially acted upon, tends to inhibit the consciousness and draAv the mind into a somnolent state. As sleep is only a function, we cannot speak of its diseases, but only of its disorders, and these really form but a part of the diseases of the brain or of general diseases. It is a matter of convenience, however, to discuss some of these separately. Classification.—Custom has established the use of certain terms for the A'arious disorders of sleep, and such terms must be for the most part adhered to. It will be proper, however, for the sake of completeness, to arrange the A'arious disturbances we are to discuss in accordance with the modern methods of study- ing the pathological changes of bodily functions. We propose, therefore, the following classification, Avhich indicates the va- rious depressions, exaltations, and perversions of the function of sleep: 490 DISEASES OF THE NERVOUS SYSTEM. I. State of normal sleep. Hypnosis. Somnus. II. States of absence of sleep. Ahyp- Insomnia. nosis. III. States of perverted or artificial Dreams, nightmare, night-terrors, sleep. Parahypnosis. sleep - drunkenness, somnambulism, hypnotism. TA'. States of excessive or frequent Morbid somnolence, paroxysmal sleep, drowsiness and sleep. Hyperhypnosis. epileptic sleeping attacks, trance-sleep, lethargy, sleeping-sickness of Africa. I. Normal sleep A'aries much in accordance Avith age, sex, the individual, and, to a slight extent, Avith occupation, race, and climate. The infant sleeps fourteen or sixteen hours out of the twenty-four, the adult needs about eight hours, while the aged live healthfully with but six. Women need half an hour or an hour more than men. A feAV persons, generally men, need nine, ten, or even twelve hours of sleep daily; others require only six. Brain-Avorkers, as a class, take less sleep than laborers. Sleep is sounder and longer in cold climates and among northern races. II. Insomnia is a term given to conditions in Avhich persons simply suffer from insufficient and restless sleep or from entire absence of sleep for a long time. Such conditions result from a great A-ariety of causes. It is my purpose to discuss only those forms in Avhich the trouble is functional or nutritional, leaving out of consideration the symptomatic insomnia of organic brain disease and that occurring as the result of painful diseases. An entire absence of the capacity to sleep occurs most often and typically at the onset or in the course of insanity. It is here a prominent and most distressing symptom. The length of time during which a person can lh'e without any sleep is about the same as that during which he can go Avithout food, A'iz., three weeks. Many hysterical, neurasthenic, or incipiently insane in- dh'iduals Avill assert that they haA'e not slept for weeks, but care- ful examination shows that they ha\'e at least been in a drowsy, somnolent condition, which is, in a measure, physiologically equh'alent to sleep. Etiology.—The cases in which persons can only get a troubled rest of a few hours are much more numerous. It is a dis- order of the third, fourth, and fifth decades of life. Women are less liable to suffer from it than men, and the laboring classes less than those engaged in business or professional pur- suits. A frequent symptom of neurasthenia is an imperfect, and especially an unresting, sleep. In these neurasthenic cases there is a loss of vasomotor tone. In gout and in the so-called latent gout, or lithaemia, insomnia is a frequent symptom. One of the few nervous symptoms of secondary syphilis is in- somnia. Insomnia may develop as a bad nervous habit in per- sons who are neglectful of themselves. It occurs sometimes as an THE DISORDERS OF SLEEP. 491 hereditary neurosis. I am acquainted with a family in which, for four generations, one or more of the members have suffered from chronic insomnia throughout life. In anaemia and chlorosis there is often insomnia at night, combined with somnolence dur- ing the day-time. Disease of the heart and arteries may lead to insomnia, and under this head come the cases which occur in Bright's disease with tense arteries and anaemic brains. Disorders of the stomach lead to disturbed sleep oftener than complete in- somnia, and the liver, when inactive, causes somnolence rather than the contrary. The poison of malaria and the toxic agents of feAer must be added to the list of causes of imperfect sleep. It will be seen that the causes of chronic functional insomnia may be classed under the folloAving heads: 1. Neurasthenic and vasomotor, including hereditary and habit insomnia. 2. Vascular and cardiac, including heart disease, arterial fibro- sis, and general anaemia. 3. Auto-toxic or diathetic, including lithaemia, gout, and urae- mia. 4. Toxic, including syphilis, lead, malaria, tobacco, and vari- ous drugs, such as coffee, tea, and coca. In many cases there exists a combination of these causes. Symptoms.—The forms and degrees of insomnia A'ary greatly. In children it is accompanied usually with much mental and physical disturbance. The patient is restless, excited, talkathe, or querulous and irritable. The insomnic child is more ill than the insomnic adult. In neurasthenic insomnia there is a tumult of thoughts which prevent sleep, or sleep is superficial, unresting, and interrupted by dreams. In many cases of insanity insomnia is characterized by great motor restlessness. In old people in- somnia is generally of the quiet kind. Treatment.—As insomnia in all its phases is often a symptom of some general disorder, treatment of a curative kind must be directed to this. Anaemia, lithaemia, uraemia, malaria, and the other toxic influences must be removed by remedies adapted to these conditions. But besides constitutional treatment there is a symptomatic treatment which will be discussed here. The older physicians, in treating insomnia, used to depend largely on hyoscyamus, camphor, opium, and the fetid drugs, such as asafoetida, musk, and valerian. Hyoscyamus is still used. It is to be given in large doses, such as five or ten grains of the extract, or even more, and from ten to twenty drops of the fluid extract. The hydrobromate of hyoscin, in doses of gr. -^ to gr. ■r^jf or more, is one of the best forms. Hyoscin is indicated in the insomnia of the insane, especially in forms accompanied with motor acth'ity. Chloral hydrate still holds its own as one of the 492 DISEASES OF THE NERVOUS SVSTEM. surest of hypnotics. The dangers involved in its use haA'e been somewhat exaggerated, though they are sufficiently real. Doses of gr. x. and gr. xv. are often quite large enough, but in alcoholic insomnia it may be gh'en in tAvice the above amounts, guarded with ammonia and digitalis. Not a fe\v persons find that chloral has bad effects. The patient awakes Avith a dull, heavy sensation in the head, slight headache, or gastric disturbance. The ATarious bromides are efficient and safe hypnotics if prop- erly used. The immediate effect of them is simply sedative, and sleep is not produced unless A'ery large doses are given. Some persons are even kept aAvake by average doses (gr. xat. to xx.). In insomnia, therefore, bromides are best prescribed in doses of gr. xv. three times a day. By the second evening sleep is gen- erally secured. The bromide habit is rarely formed, and is in itself not so seriously injurious as the chloral or opium habit. The bromides alone are hardly strong enough hypnotics for alcoholic insomnia or the insomnia of insanity. 1 haA'e found them to fail in the insomnia of the aged. Paraldehyde ranks close to chloral in its A'alue as a hypnotic. In some persons it disturbs the stomach, but not in all, and it may be used as a hypnotic for months Avithout its power being impaired. It is a disagreeable drug, and there is nothing, so far as I knoAv, that palliates its offensiveness. I prefer, however, to prescribe it in 3 i. doses poured upon a teaspoonful of powdered sugar. Doses of 3 ss. are sufficient to cause sleep in many cases, and collapse may be caused by 3 ij. given to weak patients. Urethran, in doses of a scruple or more, is a mild and agreeable hypnotic, but not so certain as paraldehyde. Amylene hydrate is a hypnotic of similar properties to paraldehyde, but less disagreeable. It is given in doses of about one drachm. Lupulin in large doses, gr. x. to gr. xx., is a good hypnotic. Sulphonal in doses of gr. x. to gr. xxx. given two to four hours before retiring is one of the best hypnotics. Chloralamide is more agreeable and safer than chloral, though it acts practically in the same way. The dose is 3 i. to 3 ij. Somnal, trional, tetronal are ne\v drugs Avhich act well in many cases. Among the antispasmodics are several drugs which occasion- ally answer well in the insomnia due to nervous irritability. A drachm of the fluid extract of valerian or of spirits of lavender, for example, may be prescribed. In some forms of insomnia— perhaps best in those due to fever, or pain, or some rheumatic or gouty trouble—antipyrin in t\venty-grain doses acts Avell. It is known that in many cases of mild types of insomnia a dose of whiskey, brandy, or beer will put the patient to sleep. Besides drugs, there are many hygienic or mechanical measures to which the physician may successfully resort—listening to monotonous THE DISORDERS OF SLEEP. 493 noises, reading dull or heavy books, counting, or keeping before the fancy some blank or wearying picture— " A flock of sheep that leisurely pass by One after one ; the sound of rain and bees Murmuring ; the fall of rivers, winds and seas, Smooth fields, white sheets of water, and pure skies.11 Mechanical remedies have nearly all for their purpose the withdrawal of the blood from the brain to the skin and abdomi- nal viscera. Hot foot-baths or warm general baths, cold douches down the spine, beating the limbs Avith rubber hammers, brisk exercise, a light meal, massage, all are at times efficient hypnotics. Persons who suffer from insomnia should sleep in cold rooms, the head should not be too high nor very low, and in most cases they are better without late suppers, eA'en though these be light. Mental work should be laid aside seA'eral hours before retiring, and the evening devoted to quiet conversation and reading or amusements that do not actively excite the nerves. Many per- sons live in good health though they sleep in the day and stay awake at night. Journalists and editors, whose work obliges them to go to bed in the early morning, often continue for years without impairment of physical vigor. Yet despite this, it is true that the best time for sleep is at night, and that the old maxim, "early to bed," is a sound one. The human system requires a certain amount of sleep and should have it. The industrious and ambitious often try to train themseh es to shorter hours, but though they may succeed for a time, nature Avill not be cheated out of her due and health suffers in the end. It is a wide-spread custom in some countries to take a short nap in the day-time, and the custom is a good one. America has not adopted it, but might do so with benefit to the health of her brain-working class. Many from childhood up do not get a sufficient amount of sleep. III. Perversions and Disturbances of Sleep.—Sleep is said to reach its deepest stage in from one to two hours after it begins. There is then after this a gradual lessening of the depth of sleep. Probably there are great A'ariations in this rule, for many persons seem in soundest slumber several hours after fall- ing asleep. But, at any rate, there are slighter stages of sleep at its inception and toAvard its end. These are the favorite times for dreams, and at this period also there develop the peculiar phenomena of sleep-drunkenness. Dreams, Nightmare.—-When sleep is perfect and profound, dreams afterward remembered do not occur. Dreaming is, there- fore, a morbid symptom, although often of trivial significance, especially if it occurs at about the time of natural waking, Avhen slumber is, in its physiological course, passing into the lighter stages. In sleep, no matter how light, the action of the regulat- 494 DISEASES OF THE NERVOUS SYSTEM. ing centre which directs thought, controls emotion, and exhibits itself in A'olition is suspended; the psychical mechanism, if ex- cited to action at all, Avorks Avithout purpose, like a rudderless ship at sea. Ideas and emotions succeed each other by the laws of association, but are not properly correlated, and judgment and logical reasoning are gone. As a rule, dreams are made up of somewhat ordinary ideas and fancies incoherently associated, and shifting too rapidly to call up much feeling. When from some point in the body painful sensory excitations do excite disagreeable images, emotions of a most violent kind may be felt. In the earlier stages of civilization, among primitive people, dreams were comparathely rare. When they did come Avith vividness they were regarded with importance, and often were considered visitations of spirits. Civilized man dreams more, but he has learned to treat his fancies Avith corresponding indiffer- ence. The attempts of scientific men to formulate laws regard- ing them have been producth-e of small results. Some diseases, hoAveA'er, produce, as a rule, dreams of a more or less peculiar kind. Thus heart disease is accompanied with dreams of im- pending death. Previous to attacks of cerebral hemorrhage, patients haA-e dreamed of experiencing some frightful calamity or of being cut in two. Intermittent feA-er is often announced by persistent dreams of a terrifying character. Hammond has collected a large number of what he terms prodromic dreams, all going to shoAv that before recognizable signs of disease are pres- ent morbid dreams of various kinds may occur. Albers says: " Frightful dreams are signs of cerebral congestion. Dreams about fire are, in women, a sign of impending hemorrhage. Dreams about blood and red objects are signs of inflammatory conditions. Dreams of distorted forms are frequently a sign of abdominal obstructions and diseases of the liver." Nightmare is a disorder incident to the hypohypnotic state, or that of incomplete sleep. It is one of those minor ills that are nearly ahvays symptomatic of an irritation in some part of the body. The usual causes of it are some digestive disturbance (repletion) and cardiac disease. Persons of a nervous tempera- ment are more subject to it; and there are individuals whom it makes suffer all their lives. The popular belief that sleeping on the back favors it is, in general, a correct one. When nightmare occurs in cardiac disease a certain position, semi-recumbent or on the right side, must be maintained, or the painful fancies awaken the patient. Healthy people can get sound sleep Avhether lying upon the back, the side, or the stomach. But light sleepers, and those with sensitive abdominal A'iscera,generally find that the posi- tion on the right side is the most comfortable and less provoca- THE DISORDERS OF SLEEP. 495 tive of unpleasant dreams. Prolonged mental or physical strain, excitement, and worry predispose to nightmare. Farinaceous foods, excessive use of strong liquors, coffee, and tobacco, all hiaA-e a similar tendency. Nightmare occurs also in anaemia and malaria, and it may, in fine, be excited by morbid conditions in any part of the body. It sometimes occurs about the menstrual period in Avomen. Its most common feature is a sense of suffoca- tion or impending death. Pator nocturnus, or night-terrors, is a sleep disorder peculiar to children. It is allied to nightmare on the one hand and sleep- drunkenness on the other. It differs from the former condition in that the child continues to suffer from the distressing fancies for some time after he is awake. Night-terrors occur usually one or tAvo hours after sleep has begun. The child wakes up scream- ing with fright, and perhaps runs about the room or seeks its parents for protection against some imagined harm. The dis- order occurs in weakly, anaemic, nervous, or rheumatic chil- dren. It is due sometimes to lithaemia, or, as the older writers put it, rheumatism or gout of the brain. Digestive disturbances, worms, dentition, hereditary syphilis, mental strain, fright, and excitement are placed among the causes. It sometimes appears to be a paroxysmal neurosis allied to epilepsy. The disorder is usually harmless and the prognosis favorable. Somnolentia, or sleep-drunkenness (Schlafentrunk), is a condi- tion of incomplete sleep in Avhich a part of the faculties are abnor- mally excited while the others are buried in repose. It is a kind of acted nightmare. The person affected is incoherent, excited, and often A'iolent. He experiences the delusion of some impend- ing danger, and while under it acts of A'iolence have been com- mitted. The condition is one of medico-legal importance, there- fore, and has been discussed by writers on that science (Wharton and Stille). Minor degrees of it are often noticed in children and in adults who are roused from a very profound sleep. It at times becomes a habit, and a most annoying or dangerous one. The disorder in its seA'ere form is fortunately very rare. The treatment of morbid dreams, nightmare, and pavor noc- turnus must be directed to a removal of the causes. Tonics, car- diac stimulants, laxath-es, anti-rheumatics, attention to diet, are called for according to the condition of the patient. Change in surroundings is often necessary. Among symptomatic remedies the bromides are the best, except in lithaemia, when alkalies and salicylates may prove more serviceable. In somnolentia the pa- tient should be prevented from getting into too profound sleep. He may be awakened once or twice during the night, or take a nap in the day-time. The head in sleeping should be raised high and the body not too heavily covered. 496 DISEASES OF THE NERVOUS SYSTEM. Somnambulism.—Somnambulism is a condition similar to hypnotism or the mesmeric state. In it volition is abolished, and the mind acts automatically under the dominance of some single idea. Sight, hearing, and nearly all the avenues of sense are closed. The sleep-walker avoids obstacles and performs ordinary acts automatically, like an absent-minded man, Avhich in reality he is. All those mechanisms Avhich have been trained by con- stant repetition to act automatically, like that Avhich preserves equilibrium, are active, and their powers may even be height- ened, so that the somnambulist may Avalk along roofs or on dan- gerous roads and thread intricate passages Avithout harm. The automatism of the somnambulist may continue for hours, until a journey has been performed or a task completed. He may carry out Avith success intricate mathematical calculations, write a letter, or work upon a picture, but he only folloAvs along the lines established by constant iteration in his Avaking moments. He can originate nothing neAV. He is roused from his state with difficulty, and when out of it he remembers nothing of Avhat has occurred. Somnambulism usually arises from overeating. Sleeping with the head too Ioav is another cause. Yiolent emotions act in- directly by disturbing digestion. The habit being once estab- lished, hoAvever, attacks occur Avithout apparent cause. The dis- order occurs oftenest in young people about the age of puberty, and it then attacks the sexes alike. Later in life women are more often affected. The disease is fostered sometimes at school by the attentions of the schoolmates, in most cases a condition of morbid sensitiveness underlies it. The patients are neurotic. Hereditary somnambulism has been observed. Its attacks have alternated Avith those of catalepsy. They are likely, after a time, to become periodical, occurring every Aveek, fortnight, or month. The somnambulic state may come upon a person in the day- time. It is then regarded as spontaneous trance, or hypnotism. It is not the case, however, that persons who are easily hypno- tized are usually somnambulists, though the reverse may be true. Somnambulism is a term that should include not only sleep- walking, but sleep-talking. The treatment of somnambulism is very much like that for sleep-drunkenness. The patient's surroundings must be inves- tigated, and unfaA'orable influences, such as may occur at school or from injudicious nurses, be removed. He should be prevented from sleeping too soundly, the head should be raised, the cloth- ing light, the diet regulated. Remedies like iron, quinine, phos- phorus, and cod-liver oil may be given. When the patient is discoA'ered in the somnambulistic state he should not be awak- ened, or at least not until he is safely back in bed. THE DISORDERS OF SLEEP. 497 Hypnotism, Trance, Mesmerism.— Hypnotism is a morbid mental state artificially produced and characterized by (1) per- version or suspension of consciousness; (2) abeyance of volition; (3) a condition of suggestibility leading the patient to yield readily to commands or external sense impressions; and (4) in- tense concentration of the mental faculties upon some idea or feeling. The proportion of persons of all ages found to be hypnotizable by Beannis was about eighteen or twenty per hundred. Children up to the age of fourteen are very susceptible. After the age of fifty-five susceptibility lessens. Men are almost as easily affected as women; but persons of a docile mind and those trained to some degree of mental discipline and capacity for submission, such as soldiers and artisans, are more sensitive. In this coun- try the percentage of hypnotizable subjects is less than it is in Europe. Hysterical and insane persons are not very susceptible. Those Avho have been mesmerized once are more easily affected afterward, and may even pass into the state involuntarily. Methods.—There are two ways of inducing hypnotism, the fixation method and the suggestiA'e method. The former and older plan, devised by Braid, is to make the patient fix his eyes for five to ten minutes on some bright object at a distance of six to eight inches from the eyes and a little above the horizontal plane of vision. A modification of this is the fascination method of Luys, by Avhich the patient is made to fix his eyes at revolving mirrors. In the " suggestive method" devised by Liebault and Bern- heim the subject is placed in a chair in front of the operator. The operator then talks to the subject in a firm and confident voice, assuring him that he will go to sleep in a short time, tell- ing him to make no resistance, that his sleeping will be natural, that nothing will be done to Avorry or fatigue him, that he will dream pleasant dreams, that he Avill wake up feeling better; then that he is feeling drowsy, his eyes are heavy, objects look con- fused, the lids are falling, they are closed—in a moment more the patient goes off to sleep. This requires some little time—five to fifteen minutes. It may fail the first time and succeed the second. Hypnotic states may be self-induced by rigorously fixing the attention upon some object. The ecstatic states of the saints and the nirvana of the Buddhists are forms of hypnotism; so also are the trance states into which some clairvoyants and spirit- ualistic preachers place themselves; this same curious phenom- enon is at the bottom of the so-called " mind-healing" science, and it enters into rational therapeutics and orthodox religion. The capacity of the human mind for hypnotism or semi-hypnotic states is, therefore, a most curious and important fact. 32 498 DISEASES OF THE NERVOUS SYSTEM. Symptoms.—The person Avho has been hypnotized at first sits or lies quietly in the position he had assumed during the manip- ulations of the operator. No notable physiological changes occur, as, for example, in the pulse, respiration, temperature, pupils, skin, etc. Some increase in the cerebral blood supply, howeA'er, is said to be present. The patient will now respond automatically to any outside command or Avill be dominated by any idea Avhich is suggested to him. He will talk, or Avalk, or run, or gesticulate, assume expressions of fright, anger, or joy, entirely in accordance with the command given. Apart from these commands he is entirely dead to the outside Avorld. He hears, sees, smells, tastes, and feels nothing. He can be burned, cut, or injured Avithout shoAving any signs of feeling. At a sug- gestion he may be made cataleptic, somnambulic, or paralytic. This state is termed somnambulistic trance. If left to himself, he gradually sinks into a deep sleep, from Avhich he can Avith difficulty be roused. After a time, rarely more than one or two hours, he awakes as from ordinary slumber. This latter state is called trance-coma, or lethargic hypnotism. The attempts of the Charcot school to dh'ide hypnotic phenomena into three forms, the somnambulic, cataleptic, and lethargic, are hardly success- ful. Sensitive subjects can be throAvn at once into lethargy, cat- alepsy, or somnambulic states at the command of the operator. The phenomena of hypnotism depend upon the Avonderful sensith'eness and quickness of the subject in responding inA'olun- tarily, with all his nervous energy, to outside suggestion. Dis- honest persons may learn the latter trick and thus simulate the hypnotic state. TraA-elling mesmerizers utilize such persons largely, hence no confidence can be placed in the phenomena ex- hibited by them. Besides the aboA'e hypnotic state, which I call the major hyp- notism, Aarious minor stages occur. These are produced by the "suggestiA'e method" of hypnotizing. By this latter plan patients are throAvn into various degrees of the hypnotic state from slight droAvsiness to complete lethargy. Patients naturally come out of the mesmeric state through the channel of deep sleep or lethargy. Ordinarily they are de- hypnotized by word of command, or by a pass of the hand, or any impression which the patient expects to be used for the purpose. Hypnotized persons have been observed to haA'e a diminution in the spinal reflexes and a muscular hyperexcitability. They sometimes show a most extraordinary exaltation of visual, audi- tory, or other special sense. Pathology.—The underlying changes of the hypnotic con- dition are unknown and will probably long remain so. Hyp- notism is no doubt associated Avith changes in the \-ascularity of THE DISORDERS OF SLEEP. 499 different parts of the brain and with rapid breaking-down of nerve tissue. Animals constantly subjected to hypnotic influ- ence become demented (Harting, Milne-EdAvards). The state of major hypnotism is probably pathological. It is a neurosis. Minor hypnotic states are but slightly removed from the normal, and their production is not injurious. Diagnosis.— As hypnotic states may be imitated and as inju- ries or crimes may be done during this state, it is very important to be able accurately to distinguish it. Since the phenomena are all subjective, this is very difficult. The methods of value are these: 1. Careful examination of the general phenomena by experts while the subject is in the alleged hypnotic state. 2. Testing the muscular hyperexcitability by percussing motor points. 3. Tests of alleged anaesthesia by sudden burning, or pinching, or injur- ing the subject. 4. Tests of the tetanic muscular rigidity by the revolving tambour. In the hypnotic state the hand may be ex- tended and held with perfect steadiness, while in conscious states a tremor soon appears. 5. Tests with glasses and other appa- ratus may be made to determine alleged anaesthesias of the special senses. Therapeutics.—The practice of using major hypnotization is injurious, tending to exhaust the nervous force and weaken the will. It should be done only with the greatest care. Its utility in therapeutics I greatly doubt. It may relieve symptoms in the hysterical for a time, but it cannot be of permanent benefit and is likely to lead to actual harm. The induction of minor hypnotic states by suggestion is not harmful if carefully and moderately employed. Its practical re- sults, however, are not great, and the method is tedious, uncer- tain, and sometimes ridiculous. It has its value in pedagogy, among children, in neurasthenia and morbid habits. The gen- eral popularization of hypnotism by means of mind-cures, Chris- tian science, etc., accomplishes its results at the expense of mental demoralization; and faith-healing institutes are more pernicious elements in society than gin-mills. Morbid Drowsiness.—This is a very common symptom, which may be due to any one of the following causes: 1. Old age, Avhen there is a weakened heart or diseased arteries, with cerebral mal-nutrition. 2. The diseased vascular conditions which precede cerebral hemorrhage. 3. The cerebral mal-nutrition or inflam- mations occurring before or during certain forms of insanity. 4. Various toxaeiniae, e.g., malarial, uraemic, cholaemic, and syphi- litic. 5. Dyspepsia and gastric repletion. 6. Diabetes. 7. Obe- sity. 8. Insolation. 9. Cerebral anaemia and hyperaemia. 10. Exhausting diseases. 11. Concussion of the brain. 12. Climatic conditions, cold, etc. 500 DISEASES OF THE NERVOUS SYSTEM. A A'ery common cause of droAvsiness is dyspepsia attended with some torpidity of the lher, the condition popularly known as " biliousness."' Another frequent cause is malarial infection, which perhaps acts indirectly by impairing the functional activity of the lh'er. Drowsiness from these causes oftenest conies on in the afternoon. Anaemia is attended with drowsiness during the day, while there is often insomnia at night. Syphilis is more likely to cause insomnia, but in its third stage somnolent conditions may be produced which are of serious significance. Drowsiness occurs from the effects of severe cold. It sometimes develops Avhen persons change their surroundings, especially on going to the seashore, for low levels and a high degree of atmospheric pressure seem to promote sleep. The drowsy state that some- times follows concussion of the brain is a familiar phenomenon. Some persons, no doubt, acquire the habit of droAvsiness. At first the trouble may have been induced by indigestion, " bilious- ness," or malarial infection, but it persists after the cause is re- moved. Such persons can hardly sit through a lecture, a church service, or any exercise requiring quiet and attention. As the morbid drowsiness here described is only symptomatic, its treat- ment need not be discussed. Such remedies as coca, coffee, tea, atropia, glonoin, do not produce results equal to expectations. Morbidly Deep Sleep.—Certain persons, when they sleep, pass into an almost lethargic slumber. Persons who sleep in this way often sleep a longer time than normal. They are aAvakened with difficulty, and then suffer with headache or disagreeable sensa- tions throughout the day. The symptom may be a prodroma of insanity. Instances in which persons retire at the usual hour, but can Avith great difficulty be roused in time for the ordinary duties of the day, are not rare. Some of these are illustrations of the vice of indolence, but in other cases there is an absolute need of nine, ten, or eA'en fourteen hours of sleep. This disorder of sleep is most liable to occur in the young and in those of nervous temperament. It often seems to be a congen- ital condition, for which nothing can be done. In other cases it results from over-feeding and indolent habits. Treatment is .much the same as that indicated for sleep-drunkenness and som- nambulism. 3. Paroxysmal Sleep, Narcolepsy, Sleep-Epilepsy.—-It some- times happens that persons suffer from sudden attacks of uncon- querable drowsiness; they fall off into slumber despite every effort of the will. These are more than drowsy sensations, for sleep, or a state resembling it, cannot be kept off. Some of these cases are of a purely nervous character, i.e., the trouble is not due to a humoral poison or to organic disease, but to a paroxys- mal change in the nervous centres of a vascular or chemical THE DISORDERS OF SLEEP. 501 character, causing sleep. It may be that the patient is epileptic and the sleep-seizure takes the place of the ordinary epileptic spasms. Cases of epileptic sleep, or narcolepsy, and allied forms are not of frequent occurrence. Females are rather more often affected than males, and the susceptible age is from fifteen to forty. The disorder is brought on sometimes by fright, OA'er-strain, and humoral poisons acting on a predisposed nervous system. The course is chronic and relief is not always obtained. It should be remembered that syphilis, malaria, or anaemia, and in- digestion may be elements in the trouble which are important, if not fundamental. Bromides in small doses are often useful Fig. 207.—A Case of Catalepsy. factors in treatment. Change of occupation, of mode of life, or of climate may be essential to a cure. Catalepsy, Trance, Lethargy.—Most of the so-called cases of prolonged sleep, lasting for days or weeks, are cases of sponta- neously developed mesmeric sleep in hysterical women or cases of incipient insanity (katatonia or stuporous melancholia). The phenomena in these cases may take the form of catalepsy, Avith Avaxy rigidity of the limbs, or lethargy. In cataleptic states the limbs may be placed in A'arious positions and Avill remain there for several minutes (Fig. 207). In lethargy or trance states the patient may be plunged into a deep arid prolonged unconsciousness, lasting from one day to several years. These are the " sleep- ing girls" of the neAvspapers. Others are persons of a too ready susceptibility to mesmeric suggestion, Avho get into a morbid habit of going into mesmeric sleep spontaneously. In these states there may be a lowering of bodily temperature, 502 DISEASES OF THE NERVOUS SYSTEM. slowing of respiratory and heart action, and excessh'e sluggish- ness of the action of the boAvels. The patients can hear and may respond to suggestions, but they are apparently insensible to painful impressions and do not appear to smell, taste, hear, or see. The eyes are closed and turned upAvard, and the pupils con- tracted as in normal sleep. Many variations, however, occur in the physiological phenomena of these states. The duration of the attacks of trance lethargy is from a feAv hours to ten years. Ordinarily, however, profound trance sleep lasts not more than a fe\v days, Avhile those cases in Avhich the sleep is from mesmeric suggestion last but a feAv hours. The katatonic cases after a few weeks or months gradually awake, become excited, and then pass into a condition of demen- tia or into catalepsy again. 5. Morbid Sleep from Organic Disease.—Prolonged and excessive sleep occurs as the result of syphilis of the brain, brain tumors, and the degenerath'e changes in old age and insanity. Morbid somnolence and stupor are not very frequent in cerebral syphilis, but are quite characteristic. The patient in some cases lies or sits all day in a semi-soporous state; in other cases he walks about, but continually falls asleep at his task. This state of partial sleep may pass off or end in complete stupor (Wood). It does not necessarily signify a serious issue, even though it last for weeks. Somnolence or sleep is a rare symptom in cases of cerebral tumors other than syphilitic. Conditions of drowsiness or stupor have been noted especially in tumors of the corpora quadrigemina and the parietal lobes (Putnam- Jacobi). Organic diseases of the brain tend to produce conditions of mental weakness, hebetude, or comatose states, rather than any- thing allied to sleep. The Sleeping Sickness, Sleeping Dropsy, Maladie du Sommeil.—This is a peculiar disorder, apparently infectious in character, which occurs among the negroes of the western coast of Africa. The disease has been transported to other regions, but is endemic only in Africa. It begins gradually with some headache and malaise. Soon there is felt a drowsiness after meals. This increases until the patient lies for nearly the whole time in a stupor. When awake he is dull and apathetic. There seems to be no fever, and the temperature may even be subnormal; the pulse, too, is not rapid; the skin is dry, the tongue moist but coated, the bowels regular. The eyes become congested and prominent. The cervical glands are enlarged. The disease ends in coma and finally death. Recovery rarely occurs. Sometimes the course of the disease is more violent, and toward the end there are epileptic convulsions and muscular tremors. Autopsies have revealed no definite pathological changes. THE DISORDERS OF SLEEP. 503 Accidents of Sleep.—Owing to the fact that sleep is a rest- ing state of the organism, and that many of its functions are lowered, or their cerebral control lessened, peculiar crises, or phy- siological and pathological disturbances of nervous equilibrium, occur. Attacks of gout, of asthma, and of pulmonary hemor- rhage are most liable to occur during the early morning hours. Deaths and suicides occur oftener in the forenoon, but births oftener at night. Epileptic and eclamptic attacks occur with much frequency at night. Involuntary emissions of spermatic fluid, orgasmic crises, and incontinence of urine are among the pathological incidents of sleep. Disorders of the Pr^edormitium.—Sudden attacks of starting of the whole body, shock-like in character, accompanied with peculiar feelings in the head or occiput, not infrequently attack persons as they are dropping off to sleep. They are of slight significance. CHAPTER XXIX. CRANIOCEREBRAL TOPOGRAPHY. The object of cranio-cerebral topography is to map out upon the scalp the underlying fissures, convolutions, and other parts of the brain. As this is for purposes of surgical operations, the mapping is done upon the shaved aseptic scalp, with a soft anilin pencil dipped in strong carbolic solution (1 to 4), or with a brush and carbolized tincture of iodine. The only instruments needed are a steel tape measure and an instrument, of nickel-plated soft iron. This consists of a flat strip 25 cm. long and 1 cm. Avide. From its middle there branches a second strip 10 cm. long mak- ing an angle of G7° with the longer strip.* Practically, the prin- cipal points to be determined are the position of the longitudinal, Rolandic, Sylvian, and parieto-occipital fissures and the lower outline of the brain. The measurements are based chiefly upon the known relations of certain landmarks on the skull to the parts beneath. These landmarks are the glabella, bregma, lambda, stephanion, aste- rion, and pterion, which are points at the junction of the A'arious sutures Avith each other and with certain ridges or protuberances. Their position is shown in the cut (Fig. 208) except that of the glabella or prominence just above the naso-frontal suture. The inion is identical with the occipital protuberance. The following rules are based upon the observations of Heftier, Thane, Reid, Horsley, Fraser, and myself: I. The longitudinal fissure. This corresponds with the naso- occipital arc. II. The fissure of Rolando. Measure the distance from the glabella to the inion; find 55.7 per cent of this distance, and the figures obtained will indicate the distance of the upper end of the fissure of Rolando from the glabella. It should be about 48 mm. behind the bregma in male adults, 45 mm. in women, 30 to 42 mm. in infants and young children respectively. The fissure runs downward and forward for a distance of about 10 cm. measured on the scalp, the real length being about 8.5 cm. The fissure makes an angle of about 67° with the ante- * Special instruments called cyrtometers have been devised by Wilson and Hors- ley, but are not necessary. CRANIO-CEREBRAL TOPOGRAPHY. 505 rior part of the longitudinal fissure. This direction is determined by the instrument above described or by the cyrtometer. The lower third of it is more vertical, and the lower end is 25 to 30 mm. behind the coronal suture. A line from the stephanion to the upper part of the asterion should about pass through it. The fissure is shorter in children. III. The fissure of Sylvius runs nearly horizontally, and lies either under or a little above the uppermost part of the parieto- squamous suture. This suture, the external orbital process, and the parietal eminence are the guiding landmarks by help of Fig. 208.—Showing the Position op the Bony Points on the Cranium, the Sutures, and the Principal Underlying Fissures, also the Basal Outline of the Brain (after Fouillehouse). which the surgeon can often operate without marking down lines on the scalp. In children the fissure is sometimes higher and more oblique. To outline it, draw a vertical line from the stephanion to the middle of the zygoma. Draw a horizontal line from the ex- ternal angular process to the highest part of the squamous suture; continue this back, gradually curving it up till it reaches the parietal eminence. The junction of the two lines will be at the beginning of the fissure of Sylvius. The vertical line indi- cates nearly the position of the ascending or vertical branch of the fissure, which is, however, directed a little more forward, and is about 2.5 cm. (1 inch) in length. The posterior part of the line indicates the position of the posterior branch of the fissure. 506 DISEASES OF THE NERVOUS SYSTEM. Reid"s method of finding the fissure of Sylvius is to " draAv a line from a point 1* inches behind the external angular process to a point f inch below the parietal eminence. The ascending branch starts from a point f inch back from the anterior end of this line, and 2 inches (5 cm.) back of the external angular pro- cess." IV. To outline the parieto-occipital fissure, find the lambda, mark a point 3 mm. anterior to it, draAv a line through this at right angles to the longitudinal fissure, extending about 2.25 cm. (1 inch) on each side of the median line. This marks the position of the fissure. If the lambda cannot be felt, its position may be found by measuring the naso-occipital arc and taking 22.8 per cent of it. This indicates the distance of the lambda from the inion or external occipital protuberance. The average distance in male adults is 7.42 cm. (2 J inches). It is greater in women than in men by a little OA'er a millimetre. Y. To outline the frontal lobes: The anterior end of the frontal lobes reaches to a point determined by the thickness of the frontal bone. This ranges from 2 to 8 or more mm. (fa to | inch). The floor of the anterior fossa reaches in front to a level a little above the supraorbital margin (10 mm., f inch—Heftier). It slopes doAvn and backward, its posterior limit being indicated by the lower end of the coronal suture. VI. To outline the temporal lobe and the lower border of the cerebrum: The temporal lobe is limited above by the fissure of Sylvius, below by the contour line of the lower border of the cerebrum. This latter corresponds to a line drawn from a point slightly (about 12 mm.) above the zygoma and the external audi- tory meatus to the asterion, and continued on along the superior occipital curve to the inion. The anterior border of the lobe corresponds to the posterior border of the orbital process of the malar bone. The temporal lobe is about 4 cm. (If inches) wide at the ex- ternal auditory meatus. A trephine, as Bergmann states, placed half an inch above the meatus Avould enter the lower part of the lobe. The middle of the lobe is in a vertical line from the posterior border of the mastoid process. A line from the upper end of the fissure of Rolando to the point of the process Avould pass through this important sensory area (Fig. 208; see also p. 351). VII. To find the position of the central ganglia, viz., corpus striatum and optic thalamus, draAv a line from the upper end of the fissure of Rolando to the asterion, practically a vertical line. This limits the optic thalamus posteriorly. A vertical line par- allel to the first, a little in front of the beginning of the fissure of Sylvius, limits the corpus striatum anteriorly. A horizontal plane 45 mm. (If inches) below the surface of the scalp at the bregma CRANIO-CEREBRAL TOPOGRAPHY. 507 Lmits the ganglia superiorly. The ganglia lie about 35 mm. (If inches) below the superior convex surface of the brain (F£r6). VIII. To reach the lateral ventricles: A number of routes may be taken. The lateral is recommended by Keen. Mark a point IJ inches behind the external auditory meatus and 1| inches above a base line made by drawing a line through the lower border of the orbit and the external auditory meatus. Trephine at this point and plunge the director into the brain in Fig. 209.—Showing the Relative Position of the Fissures and Cortical Centres of the Brain. the direction of a point 2i to 3 inches vertically above the oppo- site external meatus. The ventricle lies at a depth of 2 to 2J inches (5 to 5.7 cm.). Mr. Alec Fraser has devised a way of mapping out the fissures by means of a series of composite photographs, so taken as to show the relation of the underlying parts to certain tapes tacked upon the skull. One of his figures is reproduced here (Fig. 210). In applying this method the surgeon tacks the tapes on the shaved scalp. Then looking at the diagram he finds Avhere the point in the brain is that he wishes to reach and notes its rela- 508 DISEASES OF THE NERVOUS SYSTEM. tion to the median lateral or circumferential tapes. Then as the circumference of the illustrated head is to the circumference of the living one, so is the position of the area on the tapes in the illustrated head to the desired position of the same area in the living one. The illustration is a composite of several adult heads varying in circumference from 20£ to 231 inches. The tapes are divided into inches and half inches. The pri- mary tape is the circumferential passing horizontally round the vault of the head (on the shaven scalp) from the root of the nose (glabella) to the maximum occipital point, which is about one inch above the inion. The tape Avhich thus entirely surrounds the head is divided into four equal parts. The points where the division is made are at the anterior and posterior poles and mid- way on each lateral half of the tape. From these lateral mid- points a tape is run vertically over the top of the head, and other tapes are run anteriorly and posteriorly half-way between the point Avhere the transverse tape crosses the sagittal suture and the anterior and posterior poles. Another longitudinal tape is run from the anterior to the posterior pole half-Avay between the sagittal suture and the circumferential tape. SUPPLEMENTARY CHAPTER. ON GENERAL AND SPECIAL NEUROLOGICAL THERAPEUTICS. General. Hydrotherapy, Electrotherapy, Vibratory Therapeutics, Suspension Methods, The Rest Cure, Organic Extracts. Special. Alcoholism, Epilepsy, Insomnia, Impotence, New Drugs for Insomnia, Locomotor Ataxia, Masturbation, Meningitis,- New Drugs for Neuralgia and other Painful Affections, Neuritis, Neuralgia, Sciatica, Tic Douloureux, Writers' Cramp. Hydrotherapy in Nervous Diseases. General.—The apparatus needed for applying water in therapeutics consists of a room at least sixteen by tAventy feet, well ventilated, with waterproof floor and walls. The floor must be made so that it will drain away the water flowing upon it. The room should contain a stationary bath-tub, a shower or rain bath, an apparatus for giving hot and cold douches at various pressure, a hot-box in which a patient can take a hot bath with the head exposed, a few foot-baths, ice-bags and ice-caps. The most important point in detail is the douche apparatus, which should be supplied with all the improvements for regulating the heat, pressure, and impact of the stream. The stationary bath- 510 DISEASES OF THE NERVOUS SYSTEM. tub should be of the largest possible size, rather shallow, and placed Ioav down so that patients can move their limbs easily and get exercise while in it. Among the accessories may be a "va- porium,1' devised by Dr. Percy Wilde for local application of heat or cold. It consists of a double copper coA'er (Fig. 212), made in two sizes, one suitable for a single limb, the other for both ex- tremities, the abdomen, or thorax. Boiling Avater is poured into the upper part (at B), and permitted to es- cape by two outlet pipes (C) at the bottom. A certain quantity is allowed to run through until the metal is thoroughly heated, and then both inlet and outlet are closed. The end (E) may lie closed when the limb is not required to project beyond it. A flannel saturated with hot water is applied to the part, the cover is placed over it, and heat radiation prevented by. wrapping the whole in a blanket. While all the foregoing things are needed in an in- stitution and should be placed in every hospital and asylum, most of the hydrotherapeutic procedures can be carried out fairly well with a stationary tub and a shower above it. A cheap hot-box Avith a hole in the top and a lamp for heating below can be easily added if needed. Special Applications of Hydrotherapy.— Epilepsy — Most patients should be made to take cold showers or sponge- baths with a vigorous rub-off daily in the morning. Once a week they should take a hot bath. A cold plunge into a tub full of water is a good substitute for the shoAver. Persons who have neither shower nor tub should get a foot-tub and a large sponge. Standing in the tub with a basin of cold water be- fore them, they should fill the sponge and let the water trickle over the head, back, and body generally This is done for two or Fig. 210.—The Hot-Box. NEUROLOGICAL THERAPEUTICS. 511 three minutes, then the patient rubs himself down. The foot- tub may have a little warm Avater in it at first. In delicate persons hydrotherapeutic treatment must be begun carefully. The first applications should be dry, warm Fig. 211.—Scottish Douche. flannel packs, then wet packs gradually made cold. Finally, cold drip-sheets, shoAA'ers, plunges, and rubbing may be used. A good method for a fairly robust person is that originally described by Fleury. This consists in giving simultaneously the rain-shower and the jet. The patient standing in the shower receives a jet of water on the posterior surface of the body for fifteen seconds, then the jet alone for fifteen seconds; finally the jet alone on the anterior surface of the body for thirty seconds. Fig. 212.—The Vaporium. In neurasthenia of adult life in men the patient should take the cold shower or plunge daily. In addition to this or in place of it, if needed, I strongly advise the Scottish douche (Fig. 211), thrice weekly or oftener. This may be preceded by a short hot bath. In neurasthenia of adolescence the same treatment is often indicated, but it must be applied more carefully, as many 512 DISEASES OF THE NERVOUS SYSTEM. patients do not react well at first. They may require wet packs and lukewarm baths as sedatives for a time. Nervous women al- most always do better with a preliminary course of dry and Avet packs, followed later by showers and douches. Thus I prescribe first a hot flannel pack for one-half to one hour (see p. 51); next day a Avet pack, using a hot sheet; next day a cooler sheet, until in one or two Aveeks the patient takes a cold wet pack thrice weekly. If this, however, does not lessen irritability and quiet the patient, I prescribe a hot-air bath followed by a shower or douche. Insomnia. —The lukewarm bath at a temperature of 90° to 96° F. is often efficacious. It should be taken at night before retiring, and should last from fifteen minutes to three-quarters of an hour. A cold cloth may be laid on the patient's head. A simpler method of inducing sleep is to make the patient thrust the feet into a basin of cold Avater, 40° F. to 50° F. The legs are sponged up to the knees. This is done for fifteen or thirty seconds, then the feet are taken out and briskly rubbed. The most efficacious measure often is the hot Avet pack. The pack is taken like a cold pack, only the sheet is wrung out in hot water. The patient lies upon this, and the sheet and then the blanket are folded about him. The duration is an hour or all night. In the rest-cure treatment a drip-sheet is used (see Partial Rest-Cure, p. 520). Headache of a congestive character is helped by cold foot- baths or cold douches to the feet. The bath at 60° F. should last ten or twenty minutes and be accompanied with friction to the feet and legs. In anaemic headaches the head should be Avrapped in thin linen bandages wrung out in very cold water and covered with a feAv layers of flannel. After removal the head is to be rubbed dry and covered with a dry cloth. In hysteria much the same kind of treatment is indicated as in neurasthenia. Where there is much excitement the wet packs are indicated. In most of the major forms a half bath at 60° with cold affusions, or the shower, with Charcot or Scottish douche, should be given. The ordinary treatment at the Montefiore Home consists of: Cold affusions while standing in warm water, or a hot-air bath, followed by rain-bath for thirty seconds at 85°, daily re- ducing until 60° is reached, this to be followed by a spray douche for five seconds at 65° or jet douche for three seconds at 65° to 55°. Reduce the douche gradually to 50" or less, increasing the pressure from two pounds to thirty (Baruch). When there is spinal irritation the filiform douche may be used as a counter-irritant, or the shower at 65° to 85°. NEUROLOGICAL THERAPEUTICS. 513 In locomotor ataxia different patients get relief from different forms of treatment. The very painful and hyperaesthetic cases are not in my experience much helped by hydrotherapy. One may try, however, lukewarm baths, 85° F. to 95° F., for ten to tAventy minutes, with or without pine-needle extract. For leg pains, hot-air baths to the legs alone, followed by affusions at 60° to 70°, are recommended. The extremities may also be wrapped in flannels wrung out in hot Avater and covered with dry cloths. Some patients are greatly refreshed and helped by cool affusions, 70° to 80°, poured over the back and legs. Spermatorrhoea.—Cold sitz-baths may be given for from five to twenty minutes, 50° to 70°, daily at bed-time; they are contra- indicated in sexual irritability and active pollutions, where pro- longed warm or hot sitz-baths at 90° to 98° should be used. Impotence.—Brief cold sitz-baths, daily, at 56° to 64°, for from one to five minutes. The psyehrophore, i.e., application to the prostate of cold by a rubber condom or bladder secured over a rectal irrigator au double courant, is sometimes helpful. Incontinence of Urine.—In paresis of sphincter or detrusor brief cold sitz-baths, daily, 56° to 64°, one to five minutes, are indicated. Also cold rain-baths (50° to 60°) and douches as general tonics. In spasmus detrusorum vesicae, on the contrary, prolonged lukewarm sitz-baths, daily for thirty to sixty minutes, at 70° to 90°, should be given. Electro-Therapeutics. High and Low Potential Currents.—Currents of "Tension''1 and "Quantity.''''—The current of the faradic battery varies in quality in accordance, 1, with the length and number of turns in the coil, 2, the form of the electrical waA'e, 3, the number of vi- brations, and, 4, the strength of the battery. The currents from short coils of coarse wire have a lower potential and slightly more voltage. They are more efficient in producing muscular contractions and are more irritating to the sensory nerves. These qualities are increased with slow interrup- tions of three or four per second. When muscular contractions and mechanical exercise with stimulation are desired the short coils (primary or secondary) with slow interruptions are indicated. The current from long coils has a higher potential and less voltage; it has less power in contracting muscles and a different effect on the sensory nerves. When the interruptions are very rapid and the coil very long the effect on the sensory nerves seems more sed- ative, perhaps in part because of a change in the form of the elec- trical waves. 33 514 DISEASES OF THE NERVOUS SYSTEM. Instrument makers haA'e devised instruments Avith long coils (1,500 yards) which are tapped at three places, so that with one coil it is possible to get a current of low potential (or "quantity" as it has been called) or of high potential (or "current of tension"). The vibrator is made also so that currents of extremely rapid inter- ruption can be obtained. These (Fig. 213) instruments are ex- pensive, but are of special use to the neurologist in those cases in which he desires to apply faradism for spasm or neuralgia. They are said to be very useful in gynecological work (Goelet). Dr. Rockwell has advocated their use and shown their value. My own experience in the very high tension long coils is slight, Fig. 213. but the theory on which they are based is sound; and the fact of their peculiar physical properties is attested by Mr. Kenelly. Sinusoidal Currents.—The physiological effect of a current depends, as I have stated, in part upon the character of the wave of electrical force. If this is high and sharp the stimulation is different from that produced by a wave which gradually rises to its height. D'Arsonval has devised an instrument for produc- ing these blunt-topped waves, and at the same time reversing the current. The current is produced by revolving magnets and the machine is expensive and complicated and not yet complete. The same result, I am told by Mr. Kenelly, is approximately pro- duced by the faradic machine Avith long coils and very fine in- terruptions by means of a vibrating band, as described above. NEUROLOGICAL THERAPEUTICS. 515 Spinal Electrization.—In the ordinary practice of applying electricity for spinal cord disease, with galvanic currents, a very minute amount of electricity reaches the cord. With large elec- trodes, howeA'er, and currents of 50 to 140 milliamperes the cord is reached with a current of \ to \\ m.a. strength. In locomotor ataxia and progressive muscular atrophies such currents should be tried. One (positive) electrode, six by tAvelve inches, is placed on the upper part of the back, and a second electrode of the same or larger size placed on the abdomen, the lower part of the back, the legs, and the perineum. The current should be increased very gradually and should be kept on for only a minute in each Fig. 214.—D'Arsonval Battery for Producing Sinusoidal Currents. place. The method must be varied somewhat according to the size and sensitiveness of the patient. Continuous Unipolar Electrical Applications.—All electrical belts, magnetic belts, etc., are supposed to generate constantly a certain amount of electricity. This they do not do, and no dependence can be placed upon them. In order to obtain a long- continued application of electricity of small dosage I have had constructed for me a small box, measuring three inches by three inches, weighing only a few ounces, and containing four dry silver chloride cells. Between the negative pole and its electrode. is interposed a water rheostat of 1,500 ohms resistance. The poles are connected with one large and one small electrode, the! large one being the negative. This is Avorn on some indifferent spot such as the back of the neck. The positive pole is fastened 516 DISEASES OF THE NERVOUS SYSTEM. over the area to be treated, say the facial nerve or a painful point on the head or neck. It is kept on for six hours or more daily. A continuous current of | to 1 milliampere is obtained. Since the object is usually to secure sedation as in spasm or pain, the positive pole is used. The resistance is interposed so as to bring the treated area more surely under the influence of the sedative pole. Whether it does this I cannot say, but I know that with this instrument I can apply a Aveak current for hours. The battery lasts about 100 to 150 hours. The cells can then be renewed at a cost of three dollars. The battery is inexpensive, costing eight dollars. It is made by H. E. Stammers, of this city. Voltaic Alternatives have been found to have some utility in optic atrophy according to Dr. Webster Fox and Dr. Eugene Riggs. VIBRATORY THERAPEUTICS. Dr. Mortimer Granville has devised a percuteur which is run by electricity, the movements being produced by the automatic interruption of the faradic coil. I have used this in neuralgias with some benefit; but the instrument is of relatively slight value. Gilles de la Tourette has invented a casque vibrant, or vibrat- ing helmet. This is placed on the head, and vibrations are pro- duced by a small motor at the rate of 6,000 per second. It is said to relieve migraine, headache, neuralgia, parasthesia, and insomnia. The seances are from fifteen to twenty minutes. I have used this for too short a time to express a positive opinion; but doubt if the results are permanent. A vibrating chair, fauteuil trepidant, is being used by Charcot in the treatment of paralysis agitans. Eight cases have been so treated, with amelioration in the sensory symptoms but not in the tremor. Some years ago I noticed that patients with paralysis agitans felt better while riding in the horse-cars; and I have often advised this mode of locomotion. The patient is made to ride three-quarters of an hour once or twice daily. Treatment by Suspension.—Bogrojfs Method—Dr. Bogroff, of Odessa, has made some experiments which lead to the conclu- sion that in suspension there is a hyperaemia of the spinal meninges produced and a slight mechanical stretching. He rec- ommends a suspension upon an inclined plane at an angle of from 60° to 10°, for eight to fifteen minutes, three to seven times weekly. The patient is suspended by straps attached to the arms only. I have an apparatus of this kind which I have used very little, owing partly to its imperfections and partly to my NEUROLOGICAL THERAPEUTICS. 517 lack of confidence in its superiority over other methods. In chronic myelitis and in early and painful types of tabes and in spinal irritation it is, I believe, safer and more useful than the other method. Sprimon's apparatus for suspension consists of a seat with a vertical post-like back, about sixteen feet high. At its upper end is a pulley over which runs a cord. At the anterior end of the cord is the suspension bar with its notches for the attachment of straps to go around the neck and to the arms. At the pos- terior end of the cord is a place for the attachment of weights. The pulley or wheel at the top has a diameter of two feet. The seat is removable. The lateral straps are attached to the elbows and forearms as described by Mitchell and Brogroff. Weights of only 5 to 15 pounds are used and the stance lasts five to fifteen minutes. If heavier weights are used the patient is strapped to the seat. This mode of suspension can be applied with the or- dinary apparatus. The patient is seated in a chair and the straps applied as directed. A dial scale is placed between the suspen- sion bar and the pulley. Weights are then attached sufficient to pull upon the patient 15 to 25 pounds. Suspension is of value chiefly in three classes of cases: loco- motor ataxia, paralysis agitans, and chronic sciatica. It helps about twenty-five per cent of ataxia much and improves thirty per cent. More than one-half are not benefited. Sprimon's method seems to have benefited some cases of optic atrophy. It is best to use the head-piece as modified by Molchowkowsky (made by Ch. Dubois, of Paris). Suspension by the feet and ankles is of service in chronic my- elitis, ataxia, and sciatica. The patient lies on a lounge and the feet are drawn up till 25 to 60 pounds lift is exerted. The Rest-Treatment. This form of treatment was devised and perfected by Dr. S. Weir Mitchell and has been popularized by him and his pupils. Its value in many types of neurasthenia and hysteria, especially among women, is unquestioned. It seems more difficult to apply it to men, though it is often useful with them. Among Avomen it answers best in my experience in young women or those this side of middle life, of not very forceful character and not very strong will. The active, keen-witted, in- tellectual woman who suffers from backache, headache, brain- tire, and exhaustion from slight exertion does not do so well under a method which for a time renders the patient entirely abulic. 518 DISEASES OF THE NERVOUS SYSTEM. The essential features of the rest-cure are: Isolation, diet, rest in bed, massage, electricity, and the forceful personality of a wise physician. Isolation.—The patient can rarely be treated successfully at home even if the relatives are not allowed to see her. The best place is a comfortable room in a boarding-house or private hospi- tal. A private room in a general hospital may answer. A special nurse is necessary, and she should be young, neat, careful, sufficiently intelligent and tactful, but not over-educated or one 1 who feels too keenly her social position. Decayed gentleAvomen are sometimes very interesting characters, but they make poor nurses. I am afraid of nurses with an English or Irish accent. She should be a stranger to the patient, rather than one who has nursed the patient in previous illnesses. She should preferably know hoAv to give massage, electricity, and the simpler forms of water treatment. The patient is allowed to see the doctor once a day, and the masseuse if the nurse does not knoAV hoAv to give this treatment. The diet should consist as far as possible of milk. During the first two weeks this is especially important. Skim-milk is used and it should be perfectly fresh. Four ounces are given at first every two hours. This amount is increased to two or four quarts a day. The milk may be treated in various ways in order to make it more palatable or digestible. The addition of a little salt or lime-Avater, or of tea, coffee, or cocoa, or Vichy water, accomplishes this end. It may be varied with malted milk, lacto-preparata, Nestles food, or the milk may be mixed Avith barley or rice water. Two to four ounces of liquid malt may be given before the milk three times a day. At the end of a week a pint of beef tea is added. It is made (Mitchell) by chopping up one pound of ra\v beef and placing it in a bottle with one pint of water and fi\-e drops of strong hydrochloric acid. This mixture stands all night, and in the morning the bottle is set in a pan of water at 110° F. and kept two hours at about this temperature. Strain through a stout cloth and squeeze the mass till nearly dry. The resulting fluid is given in three portions daily. If the taste be objected to, the meat may be roasted a trifle on one side, or the ordinary com- mercial extracts may be used. It is better at first for the patient to be fed by the nurse. The milk and other food should be taken slowly. Rest.—It is extremely important that the patient be made to go to bed and lie flat on her back, not even sitting up to be fed. The object is not only to secure absolute rest, but to make the pa- tient feel that she is in the hands of her physician, who is to man- age her till she is well. The enforced quiet also adds to the desire NEUROLOGICAL THERAPEUTICS. 519 later to get well and regain her freedom. She is to be kept in bed for a month; then allowed to sit up for ten minutes twice a day, this time being lengthened by five or ten minutes daily. After five or six weeks she may be allowed a drive or a short walk. About this time one must also begin systematically to en- force walking and other exercise, and the patient must be taught to ignore the slight pain and fatigue that at first ensues. Massage.—The system of massage recommended by Mitchell is simpler than that ordinarily used by the Swedish professionals, and consists mainly of kneading and centripedal friction. It is given at least an hour after a meal and lasts at first fifteen or twenty minutes once a day. In a few days this is increased to three-quarters of an hour and an hour. The legs are massed first, then the abdomen, chest, and arms. The head and neck are not touched. No ointment or lubricating substance is used. Par- ticular attention is paid to the abdomen in order to prevent con- stipation. After massage there should be a rest of an hour. After four or eight weeks Swedish movements are added to the massage. Electricity.—The faradic current is used with a primary coil and a slow interrupter. In very sensitive persons a long second- ary coil with fine interruptions is better. Electrodes of the "nor- mal " size are employed and each segment of the limbs is gone over, beginning with the periphery. The two electrodes are placed over the muscles a few inches apart and each muscle contracted four to six times. The question of poles may be ignored. The feet, legs, abdomen, back, and arms are gone over successively, then the fine secondary current is turned on. A large electrode, of the " indifferent " size, is placed on the back of the neck, and the other electrode placed on the sole of one foot; a current is passed for seven and a half minutes; then the electrode is shifted to the other foot and the current given for the same time. It is best for the physician himself to give the electricity jf possible. The duration of each seance is three-quarters to one hour, and it is continued for six weeks. Very mild currents are used at first. The duration of the rest-cure should never be less than a month. It is usually about six or eight weeks. A typical schedule for a rest-cure patient as given by Dr. John K. Mitchell is the following: 7 A.M.—Cocoa. Cool sponge-bath with rough rub and toilet for the day. 8 A.M.—Milk, breakfast. Rest an hour after. 10 A.M.—8 oz. peptonized milk. 520 DISEASES OF THE NERVOUS SYSTEM. 11 A.M.—Massage. 12 M.—Milk or soup. Reading aloud by nurse. 1.30 P.M.—Dinner. Rest an hour. 3.30 p.m.—8 oz. peptonized milk. 4 p.m.—Electricity. 6 p.m.—Supper with milk. 8 p.m.—Reading aloud by nurse one-half hour. 9 p.m.—Light rubbing by nurse with drip-sheet. 8 oz. malt extract with meals, tonic after meals. 8 oz. peptonized milk with biscuit at bed-time and a glass of milk during the night if desired. Laxative, cascara 10 to 30 drops p. v. n. Later Swedish move- ments are added to the massage. Additional Measures.—A sponge-bath is given every morning. Insomnia is to be feared at the start, and for this bromide of so- dium may be given in doses of gr. xxx. at 6 and 9 p.m. and gradu- ally decreased grain by grain; or sulphonal (gr. xx. to xxx.) in hot water, or trional (gr. xv.). Some form of hydrotherapy may ansAver better than drugs, and a favorite measure is the "drip-sheet." The following are the directions for its use (Mitchell): Basin of water at 65° F. Lower the temperature day by day by degrees to 55° F., or to still less. Put in the basin a sheet, letting the corners hang out to be taken hold of. The patient stands in one garment in comfortably hot water. Have ready a large, soft towel and iced water. Dip the towel in this, wring it, and put it turban-wise about the head and back of the neck. Take off night-dress. Standing in front of patient—the basin and sheet behind—the maid seizes the wet sheet by two corners and throws it around the patient, who holds it at the neck. A rough, smart, rapid rub from the outside applies the sheet every- where. This takes but two minutes, or less. Drop the sheet, let the patient lie down on a lounge upon a blanket, wrap her in it, dry thoroughly and roughly with coarse towels placed at hand. Wrap in a dry blanket. Remove ice wrap; dry hair; put on night-dress. Bed, the feet covered with a flannel wrap. As tonics, lactate, pyrophosphate, or subcarbonate of iron are given in doses of gr. xxx. daily. Small doses of strychnia, salicin or quinine, or dilute phosphoric acid may be useful. The partial rest-cure is indicated in the milder cases of neu- rasthenia and hysteria. The following is the schedule given by Dr. Weir Mitchell: A.m.—On awaking, cup of cocoa. Take bath. (Temperature given.) Lie down on lounge Avhile using drying towels; or, better, NEUROLOGICAL THERAPEUTICS 521 be sponged and dried by an attendant. In this process the sur- face to be rubbed red, or, if drying one's self, to use flesh-brush. Bed or lounge again. Breakfast. Before each meal take three ounces of malt extract; aperient at need in malt. Tonic after each meal. Detail as to breakfast diet. If eyes are good, may then read seated in bed. At 10 to 11 a.m., one hour's massage. Rest one hour; may be read to, or read if eyes are good, or knit. At this time, 11 a.m., four ounces of beef soup or eight ounces of milk. At noon may rise, dress slowly, resting one or twice a feAv minutes while dressing, and remain up until 3 p.m. See children, attend to household business; see one visitor, if desira- ble. 1 to 1:30 p.m., malt, etc., and lunch. Detail as to diet. At first, as a rule, let this meal represent dinner. Tonic, and after it to rest on a lounge, occupied as above, reading or being read to. If possible, to drive out or to use tramway, so as to get air. Walk as little as possible. On return from drive repeat milk or soup. About 5 p.m., electricity, if used at all. Rest until 7 p.m. Supper at 7 p.m. Detail as to meal. Malt as before, with or without aperient, as occasion demands. Tonic. To spend even- ing Avith family as usual. Best not to use eyes at night for near view. Bed at 10 p.m. No letters to be written for two months, Avhen most of these details have to be revised. After tAvo months of massage it should, in these cases, as in com- plete rest, be used on alternate days, and by degrees given up. If the nurse or masseuse is able to teach the patient the use of SAvedish movements, it is desirable that these or some definite, slowly increased system of chamber gymnastics be continued for months. Finally, walking must be resumed with slow and sys- tematic increase. After the second month write out a schedule of less restriction, to be followed for six months. Organic Extracts. The Thyroid Gland.—This is used successfully in the treat- ment of myxcedema. It does no good in other diseases so far as known. It is most conveniently administered by feeding the raw gland to the patient. Or an extract may be made by mincing the gland in glycerin and a one-half-per-cent solution of salt, one part by weight of gland to one of glycerin and one-half of the saline solution. This mixture is alloAved to stand on ice over night; then it is filtered through paper; then through a clay filter. In order to drive it through the clay a pressure of 600 to 800 pounds per square inch is made by connecting the filter Avith a cylinder of carbonic-acid gas. It is then again put under pres- sure of 600 pounds. The resulting liquid is transparent, clear, and sterile, and will remain so for over a week. It may be injected 522 DISEASES OF THE NERVOUS SYSTEM. under the skin or given by mouth. In healthy people, a whole gland can be eaten daily or a drachm of the extract injected without producing any physiological effect. In myxcedema, hoAv- ever, the dose at first should be gr. x. to half a gland or ten drops of the fluid daily. This is gradually increased until a whole gland or 3 c.cin. (tij, xlv.) of the extract are taken. After the patient has been nearly or quite restored a gland once a week or so is still to be given. The extract of testicle is made in this city chiefly from the organs of the ram. It is obtained in precisely the same way as has been above described for the thyroid. Dr. Gibier takes the additional precaution of subjecting the filtered fluid to a A'ery high pressure. The extract is given daily in doses of 2 to 8 grammes (3ss. to 3 ij.). Its use requires considerable care and attention to details. The physician should have a large hypo- dermic syringe holding 3 c.cm., a small flask, an alcohol lamp, a stand, absorbent cotton, a bottle of ether, and a dish holding a five-per-cent solution of carbolic acid. The syringe should be thoroughly disinfected and washed in the carbolic solution. Water is freshly boiled and thus sterilized in the flask. The syringe is then filled half with the extract and half with the sterilized water. The mixture is shaken. The skin of the ab- domen or thigh is then washed off with ether and the injection made. A second or third injection may be made at each sitting. The syringe is then washed in the carbolic solution. If daily injections cannot be made they should be at least as often as twice a week and then 6 to 8 grammes should be admin- istered. In locomotor ataxia 3 to 5 grammes should be given daily. Favorable effects are not observed until two or three weeks. If no change is noted after three weeks the treatment should be discontinued. Extracts of the brain and spinal cord are made and adminis- tered in just the same way as those of the testicle. The extract of testicle seems to be most effective in locomotor ataxia and neurasthenia. The brain extract is best in epilepsy. Neither extract seems to be of any use in progressive spinal amyatrophy, at least in late stages. In bulbar paralysis in the first stage I strongly advise the use of the brain extract. The use of tuberculin in some of its modifications may prove useful in the early stage of tubercular meningitis and in tuber- cular tumors of the brain. The injections, however, should be given in minute doses at first (■£ to 1 milligramme). Extract of the thymus gland has been used with some benefit (McAlister) in the progressive muscular dystrophies. I am at present using it on several cases. NEUROLOGICAL THERAPEUTICS. 523 SPECIAL THERAPEUTICS. Alcoholism.— R Strychniee nitrat.,......gr. i. Aquae distilat.,.......3 v. Acid carbolic,.......gr. i. M. Sig. ni x. hypodermically q. 4 h. R Atropiae sulph.,.......gr. i. Strychnia^ nitrat.,......gr. ij. Glonoin,........ gr. \. Tinct. strophanth.,......3 iij. Extr. cinchon. fl., . . . . q.s. ad § vi. M. Sig. 3 i. t. i. d. Acute Alcoholism.— 5 Sodii bromid.,.......§ i. Tinct. capsici,.......3 ss. Chloral hydrat.,.......3 ss. Aquae menth. pip.,......§ iij. M. Sig. § ss. q. 4 h. Epilepsy.—A method of treating epilepsy has been recom mended by Dr. P. Flechsig as being successful in some obstinate cases. It consists in giving opium in doses of gr. \ t. i. d., increased to gr. iij. or v. t. i. d. This is kept up for five or six weeks. The patient is then placed at once on large doses of bromide of potassium. I have found in applying this treatment that a short course of opium enhances the subsequent effect of the bromide. It is not always wise or possible to give large doses of opium for so long a time as six weeks. I have insisted upon the necessity of giving large doses of bromides for a time in all cases of epilepsy. Dr. Ch. Fere" recom- mends yearly a gradual increase of bromides from 3 i. daily to I iv. or 3 v. Such doses diminish attacks from one or two weekly to one monthly. The criteria to be depended upon in advising such treatment are the weight of the patient and the number of attacks. If the weight falls and gastric trouble ensues, or if the attacks are not lessened, the drug should not be increased. The injection of brain extract has some effect in reducing the number of attacks in cases in which the general health is not good and the vitality lovvered. Such at least has been my experi- ence up to the present time. The orchitic fluid does no good. In many cases it is not wise to continue the alkaline bromides indefinitely, on account of the condition of the bladder and urine. The latter becomes cloudy, feebly acid or alkaline, and the blad- 524 DISEASES OF THE NERVOUS SYSTEM. der is irritable. The following prescription I find most useful as an adjunct to the ordinary formulae of bromides: R Acid hydrobromic dil., . iU x. to xx. Ferri bromid., .... • gr. i. Potas. bromid., .... . gr. a', to x. Sodae salicylat., .... • gr. ij. Spts. rectificat., .... . nix. Glycerol, pepsin, .... . nil Olei gaulth.,..... . mi Liq. ammon. citrat. (Br. P.), . TU XXX. M. Sig. i. dose. This may be doubled or tripled. Antifebrin and sulphonal are drugs which sometimes control the convulsions. Antifebrin may be given in the form of a five- grain tablet ter in die with a bromide solution. Sulphonal is given best in the form of a powder at night. Fifteen to twenty grains can be administered then. I do not think the drug a very useful one. Trional in fifteen-grain doses is better. The following are some special prescriptions which may be used in epilepsy: R Antipyrin........3 iss. Ammon. bromid.,......3xvi. Aquae,.........§ iv. M. Sig. 3 ij. t.i.d. To be used without other medication except tonics. R Beta-naphthol,.......3 i. Bismuth salicylat.,......3 ss. M. Sig. i. daily in two doses with 3 i. to 3 v. potas. bro- mide daily or with gr. xlv. borax. R Ext. belladonn., . Stannii oxid., M. Div. in pil. No. lx. To be used with bromides. gr- 3i. Sig. i. A.M. and p.m. R Chloral amid.,.......3 ij. Strontii bromid.,......§i. Elixir simplic,.......§ iv. M. Sig. 3 i. increased to 3 ij. t.i.d. To be used when small amounts of bromide must be given. R Camphor monobromid.,.....3 ij. Ext. valerian,.......3 i. M. Div. in capsul, No. lx. Sig. i. t.i.d. In epilepsy with hysteria. NEUROLOGICAL THERAPEUTICS. 525 R Trional,........gr. xv. Sodii bromid.,.......gr. xx. M. Sig. i. dose. At night in nocturnal epilepsy. i Ethyl bromate is recommended in epilepsy by J. Donatti, but I do not advise the use of so unstable a compound. Tinct. cenantha crocata in doses of 2 to 5 drops seems to have some influence in checking epileptic attacks. I have used it in only two bad cases, hoAvever, and cannot estimate its exact value. The Surgical Treatment of Epilepsy .—This is only indicated in traumatic forms of comparatively recent character, before more than twenty-five fits haA'e occurred. It is much more indicated in local or Jacksonian epilepsy. The mortality from the operation is seven per cent. Among 159 cases collected by Laurent and Agnew there were 58 cured, 52 improved, 28 unimproved, 11 died. Among 42 cases collected by Starr ("Brain Surgery") there were 13 cured, 11 improved, 15 not improved, 3 died. The term "improved" has little mean- ing. The percentage of cures given by Starr is nearest correct (about twenty-five per cent) and not too high. Hysteria. Bf Zinci valerianate.......3 iij. Ext. sumbul.,........3 ss. Quiniae sulph.,.......3 i. M. Div. in capsul, No. lx. Sig. i. t.i.d. R Spts. ammon. aromat., Spts. lavendul. co., Spts. ether co.,......aa, 3 i. M. Sig. 3 i. p.r.n. Apomorphia i gr. hypodermatically and pilocarpin fa gr. in the same way often break up a hysterical crisis. Impotence.—In the treatment of impotence by electricity the galvanic or faradic current may be used. My own method is to combine the tAvo, using the De Watteville switch. The posi- tive pole Avith a large electrode is placed over the dorso-lumbar region, the negative pole with normal or large electrodes is placed on the perineum. A current of 5 to 10 milliamperes is turned on. Then the faradic current is added. The secondary long coil with fine vibration may be employed if there is much irritability; the short coil with coarse vibrations if there is anaesthesia or great insensibility. The current is passed with occasional interruptions for five minutes. The lower electrode is then moved for a time 526 DISEASES OF THE NERVOUS SYSTEM. to the root of the penis and the current passed for a minute. A steel sound as large as the urethra will hold is then introduced and the lower (negative) electrode connected with it. The galvanic current is reduced to 2 or 3 milliamperes, the faradic made as strong as the patient can stand it. The application lasts two or three minutes. Sometimes I employ a basin-shaped electrode which just holds the scrotum. In other cases the penis is placed in a hollow zinc cylinder filled Avith salt water, and the current passes through this. The object is to conA'ey the electrical stimulation to all parts of the genital organs. By means of the special interrupting handle the static induced current can be applied with benefit. In addition I employ hypodermic injections of strychnia, orchitic fluid, or cantharidate of potash (gr. ^J^). Cupping and ligature of the dorsal veins haA'e been successh'ely used. ' New Drugs for Insomnia.—Amyl Hydrate.—This is a* fairly good and safe hypnotic, but disagreeable to the taste. The dose is about a drachm, given in syrup and water. It has a pungent taste like paraldehyde and sometimes disturbs the stom- ach. Chlordlamide is a good hypnotic, acting like chloral hydrate, but more slowly. It is less irritating and is safer than chloral, though the dangers of the latter drug are very slight. The dose is 15 to 45 grains in powder or dissolved in alcohol or tincture of cardamom. Chloralose is a hypnotic in doses of 3 to 10 grains. Chloralose has been given in hysteria and epilepsy in doses of 20 or more grains. It is made by heating chloral hydrate with glucose. The advantages are the small dose, its harmlessness, and the fact that it does not disturb the stomach. Duboisine sulphate has been warmly recommended as a hypnotic in doses of gr. fa to gr. fa. I have not found it of especial value either in insomnia or tremor. It is usually given hypodermatically but may be taken at bed-time dissolved in water. Hypnal is made from chloral and antipyrin. I find no evi- dence that the drug is of special value, except from the fact that it has no taste or odor. It is slightly soluble in water. The dose is 15 grains. It is to be distinguished from hypnone, a drug of no value whatever. Somnal is a clear liquid made of chloral, alcohol, and methan. It is given in doses of 3 ss. to 3 i. It is a fairly good and safe hypnotic, to be classed with paraldehyde and amyl hydrate. Trional is a disulphone, or diethylsulphon-methylethyl- methan. It is closely related chemically and therapeutically to NEUROLOGICAL THERAPEUTICS. 527 sulphonal. It is a white powder slightly soluble in water and best given in milk or wine. It acts within ten to thirty minutes and produces a quiet sleep. It is an excellent hypnotic, ranking with sulphonal and having the advantage of acting more promptly. The dose is 10 to 40 grains. At least 30 grains are needed in bad cases. . Tetronal, a substance closely allied to trional, is a less certain hypnotic but is said to be more of a motor sedative. The dose is the same as that of trional. Ural or uralium is a compound of chloral and urethan. The dose is about 15 grains. Both it and urethran are hypnotics of not sufficient value to entitle them to be kept on the list of useful remedies. Locomotor Ataxia.—Erb has recently reported many cases showing that the inunction of mercury is followed by decided benefit in this disease. He accompanies or follows the "cure" Avith electricity, nitrate of silver, baths, and tonics. Some improvement in co-ordination can be obtained by mak- ing the patient systematically go through simple and co-ordinate muscular exercises. Thus he is directed to walk a line ten times twice daily, to describe a circle with his toe six times four times daily; also to alternately flex and extend the foot, then the leg and hip, to lie on the bed and go through walking movements, etc. I have had a patient practise daily on a stationary bicycle. All this helps to give certainty and confidence, but it should not be done too much. Leyden has strongly advocated what may be called the tonic, expectant, and training treatment of tabes. He does not expect much of drugs, but depends on diet, baths, exercise, and quiet. This is very well so far as it goes, but is a most unfortunate view as a Avhole, for it takes no account of the fact that in tabes there is a specific something continually at work eating away the spinal cord. The physician must find an agent to counteract this. Rest and proper nourishment and exercise do it to some extent only. Brown-S6quard thinks he has found the specific in the testic- ular juice, Avith which he has secured amelioration in seventy- five per cent of cases. It does seem to have some value. Suspension by the Sprimon method, as described under the head of the suspension treatment, secures good results in the hands of those Avho haA'e tried it. My experience is yet too limited to enable me to speak positively regarding it. The Bonuzzi method of stretching the spinal cord is advocated by Benedict. It is only a modification of subcutaneous stretching and was practised in my clinic six years ago. The patient lies upon the back, the head maintained in an elevated position by a 528 DISEASES OF THE NERVOUS SYSTEM. bolster; the loAver extremities are then flexed upon the body, forming a semicircle, the knees being placed upon the chest of the patient and the legs held straight; the operator seizing the diverging ankles carries them strongly toAvard the floor (see Fig. 215.—Method op Performing Extension in Locomotor Ataxia. Fig. 215). This apparently difficult manoeuvre is in reality easily executed. Masturbation.—An efficient remedy against this practice is to insert a piece of silver or copper wire through a portion of the foreskin at the edge of the glans. This is a rather heroic measure and called for more especially in those suffering from mental de- terioration or insanity. A somevvhat less severe measure is to paint the glans with cantharidal collodion. Treatment of Meningitis. In tubercular meningitis I have seen undoubted cure from the use of small doses of iodide of potassium, gr. ij. or iij. eA-ery two hours. Some diagnostic help may be gained by using injec- tions of tuberculin. The beginning dose (Denison) is one milli- gram. This should be very carefully increased. Possibly some curative effects may be obtained if the process is not active and there is no fever. Paracentesis of the spinal dura mater has been recommended by Quincke and Ziemssen for the treatment of meningitis with serous effusion. The relief obtained is usually but temporary, but the measure may be of help in diagnosis. I have tried it in NEUROLOGICAL THERAPEUTICS. 529 a few cases with negative results, but have found that the opera- tion is not difficult or dangerous if carefully done. Quincke's directions concerning the operation should be fol- lowed—that is, the patient should lie on his left side with his lum- bar spine flexed well forward; the needle is cautiously inserted to a depth of 5 cm. between the arches of the third and fourth or fourth and fifth lumbar vertebrae near the spinous processes. Multiple Neuritis.—The pains and sensitiveness of the early stage may be met with powders of the following: R Salophen, gr. xv., 4in die; or R Sodii iodid., Sodii salicylat., Antipyrin,.......aa gr. v. M. Sig. i. three or four times daily. Salicylate of potash or soda in large doses sometimes helps the pain, but as a rule it does no good. Croton chloral in doses of gr. v. may be used for a time. Later one should give ferri iodide and potass, iodid. in small doses every four hours, alternating with phosphorus (gr. fa). Still later, that is to say, five or six weeks after full development of the disease, give hypodermic injections of strychnia. If the patient is very alcoholic I give strychnia in the first week. Static sparks, galvanism, or faradism should also be administered in brief daily stances for a period of six weeks. Galvanism is best used first, later fine high potential faradic cur- rents or sparks. New Drugs for Neuralgia, Headachb, Painful Af- fections.—Under this head I propose to give a brief description of the numerous new drugs whien have appeared mainly from German laboratories, and which have been recommended as hav- ing special value in headaches, neuralgias, painful rheumatic troubles, and insomnia. Many of these have been tested by my- self. So far as I have been able to discover, none of the new drugs surpass in A'alue antipyrin, antifebrin, and phenacetin, or chloral, chloralamid, paraldehyde, and sulphonal. Some of them are, however, useful in combination or alternation with the older preparations; some are more palatable, convenient, or may cause fewer unpleasant symptoms. It is to be supposed that most of the new drugs have some commercial house behind them which is interested in popularizing their use. This has to be con- sidered in estimating the value of some published reports. Agathin is a salicyl-alpha-methyl-phenyl hydrazon. It has some anodyne properties in doses of gr. viij. to gr. x. It is a taste- less, insoluble powder. 34 530 DISEASES OF THE NERVOUS SYSTEM. Aniline Methyl-blue.—-This has a feeble anodyne poAver, in doses of three grains thrice daily. It is of no practical value except to color the urine. This it does in doses of three grains a day. It is given in pill form. Methyl-blue, not methyl-violet (pyoktanin), should be used. Antinervine is a trade preparation composed of salicylanilid and bromo-acetanilid (Fileppi). Bromamide has some anodyne properties but is more used as an antipyretic and antirheumatic. The dose is 10 to 15 grains. Euphorin, or phenylurethan, is a white powder, of slightly aromatic taste, soluble in alcohol. It is antipyretic, antiseptic, and has a feeble anodyne power. The dose is about 5 grains. Exalgin, or methylacetanilid, is not a very powerful or safe anodyne. It is said to have a value in depressed mental states. I use it only in chorea (vide Chorea). The dose is 2 to 5 grains. Phenocoll hydrochlorate is a white powder, a derivative from phenacetin. It is soluble in sixteen parts of water. It acts fairly well as an analgesic but is not superior to others of the class. I haA-e seen cyanosis produced by it in large doses. The average dose is 10 or 15 grains. Pyrodin is a feeble and unsafe analgesic. Its dose is gr. i. to gr- ij. Iodopyrin is a combination of chlor-iodine and antipyrin. It acts like antipyrin in doses of about 15 grains (Mtlnzer). Phenidin is para-acetphenelidin and is a derivative of phen- acetin. The dose is 15 grains hourly for four doses (Depasse). It is probably about the same thing as phenacetin. Salicylamid is said to be safer and to have more analgesic power than salicylic acid (Nesbitt). I have had no experience with it. Salpyrin is said to be a salicylate of antipyrin. It has the antirheumatic, antipyretic, and antineuralgic properties of its two components, but that is all. The ordinary dose is 15 grains. Thymacetin, a drug recommended by Jolly, has not been much used. It is valuable in nervous headaches and neuralgia, in doses of gr. v. to gr. xv. It has a slight hypnotic power. External Applications for Pain. R Spts. chloroform, Alcohol, Menthol, . M. Sig. Ext. use. Paint on part and cover Avith bandage. 3iJ- 3 iij. X ah. NEUROLOGICAL THERAPEUTICS. 531 1$ Olei sinipis,........3 i. Menthol,.........3 ij. Alcohol,.........3 i. Ether sulph...... . . . 3 i. M. Sig. Ext. use. Rub on carefully. R Olei sinipis,........3 i. Olei dulcis,.........3 iij. M. Sig. Rub over affected part night and morning till it is sore, as counter-irritant. Sciatica.—In chronic and in early cases the rest treatment as indicated in the body of my book will usually be of most ser- vice. The leg should be carefully and firmly enveloped in a flannel bandage from toe to hip. Then a Thomas splint is applied. Fig. 216.—Apparatus for Writers' Cramp. Every day the splint is removed and the leg cautiously exercised. At the end of two or three weeks the patient can be allowed to use the limb himself for a time. With the flannel bandage, an ice-bag or hot-water bag is not always needed. The experience of the clinic at La Salpetriere is that suspen- sion does good service in sciatica. Tic Douloureux.—Local injections of five to ten drops of four-per-cent or two-per-cent solution of cocaine often give relief for a considerable time. The chloride of methyl spray or a bit of cotton wet with the methyl and drawn OA'er the affected area until it is frozen will prove helpful. I haA'e also found the Gran- ville percuteur gently applied for five or ten minutes of great ser- 532 DISEASES OF THE NERVOUS SYSTEM. vice. Along with such measures one should give pills of aconitia gr. ^fff ev'ery four hours and a tonic as follows: R Acid phosphor, dil.,......§ i. Ferri pyrophosphate.....3 i. Quiniae sulph.,.......3 i. to 3 ij. Aquae,........3 iij. M. Sig. 3 i. t.i.d. Croton chloral in doses of five to fifteen grains three times a day may be substituted for the aconitia, and codeine or cannabis indica combined with it. Writers' Cramp.—A new form of apparatus for this disease has been devised by Dr. R. Harcourt Anderson; an illustration of it is given here. The object aimed at is to produce a coun- ter-extension when the flexors or extensors are in spasm. Such apparatus gives some help in mild cases. It is only a help, however. INDEX. Abdominal reflex, 30 Abducens nerve, paralysis of, 117 Abscess of the brain, 346 of cerebellum, 350 spinal cord, 210 Accommodation, loss of, 116 Acrania, 333 Acrocephalic skull, 27 Acrodynia, 70, 74 Acromegaly, 485 Acro-neuroses, 85 Actinomycosis of the brain, 391 Acute ascending paralysis, 227 iEsthesiometer, 35 Age, etiological influences of, 40 Ageusia, 146 Agoraphobia in neurasthenia, 451 Agraphia, 332 Akinesia algera, 434 Alcoholic paralysis, 70 Alcoholism, treatment of, 523 Alexia, 330 Allochiria, deflnition of, 22 Amaurosis, 108, 111 Amblyopia, 108, 111 Amimia, 332 Ampere, definition of, 55 Amputation neuroma, 90 Amyelia, 199 Amygdalum, 298 Amyosthenia, 423 Amyotrophy, progressive spinal, 264 Analgesia, definition of, 20 Anaemia, cerebral, 345 of the membranes of the brain, 334 of the peripheral nerves, 64 spinal, 204 Anaesthesia, definition of, 20 hysterical, 419, 429 trigeminal, 131 visual, in hysteria, 420 Angio-ataxia, definition of, 22 Angioma of the brain, 392 Angio-neurosis, definition of, 22 Angio-neurotic oedema, 487 Angio-paralysis, definition of, 22 Angio-spasm, definition of, 22 Anencephaly, 333 Aneurisms, intracranial, 395 Anidrosis, definition of, 22 Ankle clonus, 31, 34 Anode, 58 Anosmia, 107 Ansa lenticularis, 299 Anthropophobia in neuras- thenia, 452 Aphasia, 330 table of forms of, 332 Aphemia, 331 Aphthongia, 148 Apoplexy, cerebral, 353 spinal, 200 Apraxia, 331 Arachnoid, spinal, 180 Arbor vitae of the cerebellum, 303 Arcades, interfascicular, 9 534 INDEX. Argyll-Robertson pupil, 34, 117, 230 Arm, paralyses of the, 160 Arteries of the brain and its membranes, 312 of the spinal cord, 192 Arthropathies oflocomotor ataxia, 237 Association fibres, 297, 306 Associative functions of the brain, 321 Asthenopia, definition of, 108 muscular, 118 Ataxia, definition of, 21 family, 251 Friedreich's, 251 generic, 251 locomotor, 231. See Loco- motor ataxia progressive spastic, 249 testing for, 38 Ataxiagraph, 38 Ataxic paraplegia, hereditary, 255 Athetosis, 19 Atrophia musculorum lipoma- tosis, 270 Atrophy, arthritic muscular, 275 of the brain, 379 progressive muscular, 261, 264 progressive muscular, of the leg type, 268 Auditory nerve, anatomy and physiology of the, 100 diseases of the, 138 Aura, epileptic, 407 Axis cylinder, 5 Axis cylinder processes of nerve cells, 2 Baillarger, stripe of, 297 Ballet-dancers' cramp, 475 Bar aesthesiometer, 36 Basedow's disease, 462 Baths, forms of, 49 Batteries, varieties of, 55. 514, 515 Bell's palsy, 134 Beri-beri, 70, 74 Bilateral representation, 318 Birth palsies, 369 Blepharospasm, 134 Blood supply of nerves, 8 of the brain and its mem- branes, 312 of the spinal cord, 192 Brachial paralyses, 160 Brachial plexus, arrangement of the, 158 diseases of the, 159 Brachycephalic skull, 20 Brain, abscess of the, 346 actinomycosis of the, 391 acute softening of the, 302 anaemia of the, 345 anatomy of the, 290 aneurisms in the, 395 angioma of the, 392 architecture of the, 307 associative functions of the, 321 atrophy of the, 379 blood supply of the, 312 cancer of the, 392 cutting the, 328 degeneration of the, 373 diagnosis between hemor- rhage and acute soften- ing of the, 363 diseases of the, general symptoms of, 329 embolism of the, 362 enehondroma of the, 392 extract of, 522 fibroma of the, 392 functions of the, 317 glioma of the, 391 gumma of the, 390 hemorrhage in the, 353 hyperaemia of the, 344 INDEX. 535 Brain, hypertrophy of the, 379 inflammation of the, 346 latent regions of the, 324 lipoma of the, 392 localization, 317 localization of tumors of the, 384 malformations of the, 333 membranes of the, blood supply of, 313 membranes of the, diseases of, 334 membranes of the, func- tions of, 312 motor area of the, 317 osteoma of the, 392 parasitic growths of the, 392 preserving the, 325 red softening of the, 349 relation of the different parts of the spinal cord to the, 186 sarcoma of the, 391 sinuses of the, 316 sixteen ganglionic deposits of the, 292 softening of the, 349, 362 syphilis of the, 397 syphiloma of the, 390 thrombosis of the, 362 tracts of the, 305 tumors of the, 381 weight of the, 325 Brauch-Rom berg symptom, 38 Brown-Sequard paralysis, 278 Bulbar myelitis, acute, 352 paralysis, progressive, 262 Burdach, column of, 185, 186, 188 Caisson disease, 202 Cancer of the brain, 392 Capsule, internal, 306 Caput obstipum, 148 Catalepsy, 501 Cathode, 58 Cavities in the spinal cord, 280 Cells, angular, of Lewis, 296 Deiter's, 8 ganglion, 1 granule, of Lewis, 296 nerve, 1 of the cortex cerebelli, 304 of the cortex cerebri, 296 of the spinal cord, 183 Purkinje, 304 spider, 8 spider, of the cortex cere- bri, 296 Centres, cerebral, 317 spinal cord, 188, 190 Centrum ovale, physiology of the, 321 Cephalalgia, 121 Cerebellum, anatomy of the, 303 physiology of the, 322 Cerebro-spinal meningitis, epi- demic, 338 Cerebrum, anatomy of the, 290 CerA'ical nerves, diseases of the, 153 Charcot-Marie type of progres- sive hereditary muscular atrophy, 268 Children, cerebral palsies of, 365 Choked disc, 109 Chorea, 436 dancing, 441 electric, 441 habit, 441 hereditary, 441 Huntington's, 441 insaniens, 437 maniacal, 437 of adult life, 438 of the larynx, so-called, 431 paralytic, 438 procursive, 441 senile, 438 Sydenham's, 436 536 INDEX. Choreic movements, 18 Cigarmakers' cramp, 475 Civilization, etiological influ- ences of, 41 Clarionet-players' cramp, 474 Clark's column, 183, 189 Claustrophobia in neurasthe- nia, 451 Claustrum, 298 Climate, etiological influences of, 41 therapeutic uses of, 52 Clonus, ankle, 31, 34 Coccygodynia, 177 Collaterals of a nerve fibre, 2 Columns of the spinal cord, 184, 188 Compression myelitis, 205, 217 Conductors, relative value of, 54 Conjugate deviation of the eyes, 114 Contractures, 19 hysterical, 424, 429 Convolutions of the brain, 292 microscopic anatomy of the, 296 Convulsions, 18 epileptic, 405, 429 hysterical, 418, 426, 429 reflex epileptiform, 404 Convulsive tremor, 432 Coprolalia, 431 Cord, spinal. See Spinal cord Corpora quadrigemina, 300 physiology of the, 322 Corpora striata, 298 physiology of the, 321 Corpus callosum, physiology of the, 321 Cortex cerebelli, 303 cerebri, 292 Cramp, 18 ballet-dancers', 475 cigarmakers', 475 clarionet-players', 474 Cramp, musicians', 474 photographers', 475 telegraphers', 474 watchmakers', 475 writers', 468 Cranial measurements, table of, 25 nerA'es, anatomy and phy- siology of the, 92 nerA'es, diseases of the, 107 reflexes, 30 Cranio-cerebral topography, 505 Cranium, dimensions and shape of, 26 Cremasteric reflex, 29 Crises in locomotor ataxia, 239 neurasthenic, 448 Current strength, definition of, 54 Cyclopia, 333 Cycloplegia, 116 Cycling, value of, 49 Deafness, nervous, 138 Degenerations, 44 diseases in which the reac- tions of, may be expected, 62 marks of, 24 neuritic, 79 of brain tissue, 373 of nerA'es, 65 of the spinal cord, second- ary, 259 testing for reactions of, 60 Degenerative diseases of the spinal cord, 229 Deiter's cells, 8 Delayed sensation, 37 Deviation, conjugate, defini- tion of, 114 Diagnosis, electro-, 60 of nervous diseases, 23 Diaphragm, paralysis of the, 155 INDEX. 537 Diatheses, etiological influence of, 41 Diathesis, contractural, 424 Diet for brain-workers, 47 Digiti mortui, 85 Diplegia, definition of, 19 in childhood, 365, 369 Diplopia, 113 Divers' paralysis, 202 Dizziness, 141 Dolichocephalic skull, 26 Dorsal nerves, diseases of the, 168 Double sensations, 37 Douche, Scottish, 511 Drip-sheet, method of applica- tion, 520 Drh'ers' spasm, 474 Duchenne-Aran's disease, 264 Duchenne, subacute spinal paralysis of, 226 Dura mater, inflammation of the, 335 spinal, 180 Dynamometer, 27 Dysesthesia, definition of, 21 Dystrophies, progressive mus- cular, 261, 269 ECHOKINESIS, 431 Echolalia, 431 Eclampsia, 18. See Convul- sions nutans, 151 Elbow jerk, 33 Electric irritability, alterations in, 60 Electrical applications, contin- uous unipolar, 515 currents in nerves, 13 currents of tension and quantity, 511 Electricity, definitions of tech- nical terms, 53, 513 methods of application, 58, 515 Electricity, sinusoidal currents, 514 therapeutic uses of, 53, 519 Electrization, 58 motor points for, 59 spinal, 515 Electrodes, 57 Electro-diagnosis, 60 Electromotive force, definition of, 54 Electro-therapeutics, 513 Electrotonus, 14 Embolism of the brain, 362 Encephalitis, 346 acute exudath'e, 352 acute suppurative, 340 chronic, 353 primary, of Friedmann, 352 Enchondroma of the brain, 392 End-brush of a nerve fibre, 2 End organs of nerves, 12 Endoneurium, 4 Enteroptosis, 450 Epigastric reflex, 30 Epilepsy, 403 diagnosis, 410 etiology, 404 hydrotherapy in, 510 Flechsig's method of treat- ment, 523 hystero-, 426 Jacksonian, 404, 407 laryngeal, 144 mental condition in, 408 pathology, 409 physical condition in, 408 physiology, 410 prognosis, 411 surgical treatment of, 525 symptoms, 405 treatment, 411, 524 Epineurium, 4 Erb, chronic atrophic paralysis of, 326 juvenile form of pseudo- 53 S INDEX. muscular hypertrophy of, 270 Erb's palsy, 161 Erector-spinae reflex, 30 Erythromelalgia, 87, 177 Etiological table of peripheral nervous diseases, 178 Etiology of nervous diseases, 40 Examination of patients, methods of, 23 Exercise, prophylactic value of, 48 Exhaustion, spinal, 288 Exophthalmic goitre, 462 Eye, anatomy and physiology of the motor nerves, 95 diseases of the luotor nerves, 113 muscular asthenopia or in- sufficiencies of the, 118 spasmodic diseases of the muscles of the, 120 Facial hemiatrophy, 484 nerve, anatomy and physi- ology of the, 100 diseases of the, 132 Faradic current, testing by the, 61 electrical batteries, 56 Feet, pains in the, 87 Festination, 480 FeA'er, hysterical, 420 Fibres, association, of the brain, 297, 306 connecting different gan- glia of the brain, 306 nerve, medullated and non- medullated, 7 nerve, a prolongation of nerve-cell processes, 2 nerve, structure of the, 4 of the cortex, 297 projection, of the brain, 306 Fibrillary tremor, 18 Fibroma of the brain, 392 Fissures, cerebral, 292 Fleury's method of hydrothera- peutic treatment, 511 Flute-players' spasm, 474 Formula for applying electric- ity, 58 Fothergill's neuralgia, 130 Friedmann, primary encepha- litis of, 352 Friedreich's ataxia, 251 Functional nervous diseases, 403 Galvanic current, testing by the, 61 electrical batteries, 57 Ganglion cells, 1 habenulae, 300 Gangrene, symmetrical angio- neurotic, 85 Gedvelst, network of, 6 Geniculate bodies, 300 Gerlier's disease, 144 Giddiness, 141 Glenard's disease, 450 Glioma of the brain, 391 Gliosis, 46 Globus pallidus, 298 Glosso-labio-laryngeal paraly- sis, 262 Glosso-pharyngeal nerve, anat- omy and physiology of the, 101 diseases of the, 146 Glossoplegia, 148 Grand mal, 404 Graves' disease, 462 Gray matter, five principal de- posits of, 10 Goitre, exophthalmic, 462 Goll, column of, 185, 188 Gout, nervous, 450 Gowers, column of, 185 Gumma of the brain, 390 INDEX. 539 H.EMATOMYELIA, 201 Haemidrosis, definition of, 22 Habit chorea, 441 Habits, etiological influence of, 41 Hands, numb, 84 Headache, 121 new drugs for, 529 treatment of, 512 Hearing, primary centre for, 320 Hemianaesthesia, hysterical, 419 Hemianopsia, 112 deflnition of, 108 Hemiatrophy, progressive lin- gual, 148 Hemicrania, 125 Hemiopia, definition of, 108 Hemiplegia, 330, 353, 356 definition of, 19 in childhood, 365 Hemorrhage, cerebral, 353 spinal, 200 Heredity, etiological influences of, 41 Herpes zoster, 170 Heterophoria, 118 spinal, 199 Hiccough, 155 Huntington's chorea, 441 Hydatids of the brain, 392 Hydrencephalocele, 334 Hydrocephalus, acute, 340 chronic, 341 Hydromyelia, 280 Hydrorachis externa, 198 interna, 198 Hydrotherapy, 49 special applications of, 510 use of, in nervous diseases, 509 Hygiene, 47 Hyperacusis, 145 Hyperaemia, cerebral, 344 of the membranes of the brain, 334 Hyperaemia of the peripheral nerves, 64 spinal, 203 Hyperaesthesia, auditory, 145 definition of, 21 hysterical, 421 retinal or ocular, 111 Hyperalgesia, definition of, 21 Hypercyalgesia, definition of, 37. Hyperidrosis, definition of, 22 Hyperosmia, 107 Hyperplasia of nerve trunks, 89 Hyperthermalgesia, definition of, 37 Hypertrophy of the brain, 379 pseudo-muscular, 270 Hypnotism, 497 Hypoglossal nerve, anatomy and physiology of the, 104 nerA'e, diseases of the, 147 Hysteria, 416 amyosthenia in, 423 critical symptoms of, 418 diagnosis, 428 etiology, 416 use of hydrotherapy in, 512 interparoxysmal symptoms of, 419 major, 418 minor, 417 motor symptoms of, 422 pathology, 428 permanent stigmata of, 419 prognosis, 429 sensory symptoms of, 419 symptoms, 417 treatment, 430, 512, 525 visceral symptoms of, 425 Hystero-epilepsy, 426 Ignipedites, 70, 74 Impotence, 513 use of electricity in, 525 Impulses, rate of travel of, 13 Inco-ordination, testing for, 38 540 INDEX. Infantile polioencephalitis, 352 spinal paralysis, 220 Infections, etiological influ- ences of, 42 Inflammations, 43 of nerA'es, 68 Insomnia, 490 new drugs for, 526 treatment of, 512 Insufficiencies, muscular, of the eye, 118 Insulators, relatiA'e A'alue of, 54 Intention tremor, 18 Iridoplegia, 116 Irritability, electrical, altera- tions in, 60 Irritation, spinal, 280 Isolation in rest treatment, 518 Jacksonian epilepsy, 404, 407 JaAV reflex, 33 "Jumpers," 431 Knee jerk, 31 Labile electrode, 58 Landry's paralysis, 227 Laryngeal syncope, or vertigo, or epilepsy, 144 Larynx, chorea of the, so- called, 431 Latah, 431 Lead palsy, 164 Leg, peripheral palsies of the, 173 Lenticular loop, 299 Leptomeningitis, 335 acute simple, 335 spinal, 206 Lethargy, 501 Lid reflex, 30 Light reflex, 33 Lingual hemiatrophy, progres- sh'e, 148 paralysis, 148 spasms, 147 Lipoma of the brain, 392 Lissauer, column of, 185 Lithaemia, 450 Lobes, cerebral, 294 Localization, cerebral, 317 of brain tumors, 384 spinal, 190 Lock-jaAV, 132, 442 Locomotor ataxia, 231 arthropathies of, 237 cerebral symptoms in, 240 complications of, 241 course of, 241 crises in, 239 diagnosis of, 246 disorders of hearing in, 236 etiology, 231 eye-symptoms in, 235 forms of, 231 gait in, 233 in children, 248 muscular atrophies in, 240 optic atrophy in, 235 pathological anatomy and pathology of, 241 prognosis of, 246 reflexes in, 233 stages of, 232 symptoms, 232 treatment of, 246, 513, 527 Lumbar nerves, diseases of the, 170 Luys' body, 302 Malformations of the brain, 333 Massage, 52 Mastodynia, 169 Masturbation, 458 efficient remedy in, 528 Medulla oblongata, physiology of the, 324 Medullary sheath, 5 Membranes of the brain, anae- mia of the, 334 INDEX. 541 Membranes of the brain, blood supply of the, 313 of the brain, diseases of the, 334 of the brain, functions of the, 312 of the brain, hyperaemia of the, 334 of the brain, malformations of the, 333 of the brain, symptoms of diseases of the, 329 of the spinal cord, 180 Memories, centres for, 320 Meniere's disease, 141 Meninges, cerebral. See Mem- branes of the brain spinal, 180 Meningitis, epidemic cerebro- spinal. 338 spinal, 205 tubercular, 340 treatment of, 528 Meningocele, cerebral, 334 spinal, 198 Meningo-myelitis, 208 Meningo-myelocele, spinal, 198 Mesmerism, 497 Mesocephalic skull, 20 Meynert's bundle, 306 Micromyely, 199 Migraine, 125 Milkers' spasm, 475 Milliamperemeter, 55 Mimic tic, 132 Mind-blindness, 331 Mogophonia (flute-players' spasm), 474 Monoplegia, hysterical, 422 Morton's neuralgia, 88 Morvan's disease, 79 Motility, symptoms of disor- dered, 27 Motor area of the brain, 317 points for electrization, dia- gram shoAving the, 59 Movements, choreic, 18 forced and associated, 19 Multiple neuritis, 70. See Poly- neuritis treatment of, 529 Muscles, centres for movements of the, 317 Muscular anaesthesia, 38 atrophies and dystrophies, 261, 269, 276 atrophy, arthritic, 275 atrophy, progressive, 264 atrophy, progressive hered- itary, of the leg type, 268 sensibility, testing the, 37 Musicians' cramp, 474 Mydriasis, 116 Myelin sheath, 5 Myelitis, acute, 210 acute bulbar, 352 central, 218 chronic, 216 compression, 205, 217 disseminated, 211, 216 forms of, 210 periependymal, 218 transverse, 210, 216 Myoclonus multiplex, 432 Myoidema, 29 Myosis, 117 Myospasia, 432 Myotonia congenita, 433 Myriachit, 431 Mysophobia in neurasthenia, 451 Narcolepsy, 500 Neck pains, 157 paralysis of the muscles of the, 152, 155 Necrosis, perforating, of the cord, 214 Nerve roots, spinal, 180, 186 Nerves, afferent and efferent, 11 anaemia of, 64 542 INDEX. Nerves, auditory, anatomy and physiology of the, 100 auditory, diseases of the, 138 cervical, diseases of the, 153 cranial, anatomy and phy- siology of the, 92 cranial, diseases of the, 107 degeneration of, 65 dorsal, diseases of the, 168 end organs of, 12 facial, anatomy and physi- ology of the, 100 facial, diseases of the, 132 glosso-pharyngeal, anat- omy and physiology of the, 101 glosso-pharyngeal, diseases of the, 146 hyperaemia of, 64 hyperplasia or hyper- trophy of, 89 hypoglossal, anatomy and physiology of the, 104 hypoglossal, diseases of the, 147 inflammation of, 68 inter-central or commissu- ral, 12 lumbar, diseases of the, 170 motor, of the eye, anatomy and physiology of, 95 motor, of the eye, diseases of, 113 olfactory, anatomy and physiology of the, 92 olfactory, diseases of the, 107 optic, anatomy and physi- ology of the, 94 optic, diseases of the, 108 peripheral, functional dis- orders of the, 80 peripheral, relation of the different parts of the spi- nal cord to the, 186 res, peripheral, table of dis- eases of, 178 phrenic, paralysis of the, 155 pneumogastric or vagus, anatomy and physiology of the, 102 pneumogastric or vagus, diseases of the, 147 regeneration of, 68 sacral, diseases of the, 173 spinal accessory, anatomy and physiology of the, 103 spinal accessory, diseases of the, 147, 148 spinal, diseases of the, 513 structure of, 1, 4 syphilis of, 398 trigeminal, anatomy and physiology of the, 98 trigeminal, diseases of the, 120 tumors of, 89 Nervous diseases, functional, 403 diseases, methods of study- ing, 15 exhaustion, 446 system, anatomy of the, 1 system, general arrange- ment and functions of the, 10 system, mechanisms of the, 13 tissue, chemistry of, 14 Neuralgia, 81 cervico-brachial, 166 cervico-occipital, 157 congestive, of the feet, 87 digital, 166 epileptiform, 130 Fothergill's, 130 hysterical, 421 intercostal, 168 mammary, 169 Morton's, 88 new drugs for, 529 INDEX. 543 Neuralgia of the lumbar nerves, 172 plantar, 177 red, of the feet, 87 sciatic, 174 trigeminal, 128 Neurasthenia, 446 course and duration, 453 climacteric, 452 degenerath'e, 451 diagnosis, 454 etiology, 446 in adolescence, 451 in adult life, 452 modified types of, 451 pathology, 453 primary, 451 prognosis, 455 sexual, 451 spinal, 2S8 symptoms, 447 treatment, 455, 511 Neurilemma, 6 Neuritic degeneration, 79 type of syringo-myelia, 79 Neuritis, 68 complicated forms of, 79 dermatitic intercostal, 170 migrating, 168 multiple, 70. See Polyneu- ritis plantar, 177 retrobulbar optic, 109 sciatic, 174 symmetrical spontaneous ulnar, 166 Neuro-fibromata, plexiform, 89 Neuroglia, 8 Neurological therapeutics, 509 Neurology, definition of, 16 Neuromata, 89 on the roots of the cranial nerves, 392 Neurons, 1 Neuro-retinitis, 108 Neuroses, aero-, 85 Neuroses, degenerative, 403 different forms of, 16 of mixed origin affecting the extremities, 85 paraesthesic, 84 professional and occupa- tion, 468 sensory, 81 sexual, 457 traumatic, 460 NeAv drugs, 529, 530 Nictitating spasm, 134 Nightmare, 494 Nodding spasm, 151 Nodes of RanA'ier, 5 Nucleus, caudate, 298 fastigium, 303 globosus, 303 lenticular, 298 red, of the brain, 302 red, physiology of the, 322 Numb hands, 84 Numbness, Avaking, 80 Nystagmus, 120 Occupation, muscular atro- phies from, 276 OZdema, angio-neurotic, 487 blue, of hysteria, 426 circumscribed, 487 Ohm, definition of, 54 Olfactory nerve, anatomy and physiology of, 92 nerve, diseases of the, 107 Olivary bodies, physiology of the, 324 Ophthalmoplegia, 114 progressive, 117 Optic atrophy, 110 atrophy in locomotor ataxia, 235 nerve, anatomy and physi- ology of the, 94 nerve, diseases of the, 108 Organic extracts, 521 Orthophoria, 118 544 INDEX. Oscillating spasm, 151 Osteoma of the brain, 392 Oxycephalic skull, 27 Pachymeningitis externa, 335 spinal, 205 Pain, external applications for, 530 Pain palsy, 434 sense, testing the, 37 Pains in the feet, 87 transferred, diagram show- ing the location of, 82 Palmar reflex, 30 Palsy. See Paralysis Papillitis and neuro-retinitis, 108 Paraesthesia, 84 definition of, 21 trigeminal, 131 Paracentral lobule, 317 Paradoxical contraction, 33 Parageusia, 147 Paralysis, acoustic, 138 acute atrophic, 220 acute curable atrophic, 225 agitans, 478 alcoholic, 70 analgesic, with whitlow, 79 BroAvn-Sequard, 278 cerebral, in children, 365 chronic atrophic, of Erb, 220 compression, 164 crutch, 165 definition of, 19 divers', 202 Erb's, 161 facial, 134 from intracranial hemor- rhage, 355 glosso-labio-laryngeal, 262 hereditary ataxic, 255 hypertonic, 257 hysterical, 422, 429 infantile spinal, 220 Paralysis, lingual, 148 night, 80 of the brachial nerves, 100 of the cervical muscles, 152, 155 of the circumflex nerA*e, 163 of the diaphragm, 155 of the iris, 116 of the lumbar nerves, 170 of the median nerve, 105 of the motor nerves of the eye, 114 of the musculo-spiral nerve, 164 of the oculo-motorius, 114 of the phrenic nerve, 155 of the posterior thoracic nerve, 163 of the suprascapular nerve, 164 of the ulnar nerve, 166 painful, 434 peripheral facial, 134 peripheral, of the leg, 173 progressive bulbar, 262 recumbent, 80 spinal spastic, 257 subacute spinal, of Du- chenne, 226 Paralyzing vertigo, 144 Paramyoclonus multiplex, 432 Paramyotonia, congenital, 434 Paraphasia, 332 Paraplegia, ataxic, 249 definition of, 19 hereditary ataxic, 255 in childhood, 365 senile, 220 spastic, 257 spastic cerebral, of child- hood, 369 Paresis, definition of, 19 Paridrosis, definition of, 22 Parkinson's disease, 478 Partial rest cure, 520 Patellar reflex, 31 INDEX. 545 Pathology, general, of nervous diseases, 43 Pathophobia in neurasthenia, 452 PaA-or nocturnus, 495 Pedodynamometer, 28 Perforating ulcer of the foot, 239 Perineurium, 4 Peripheral nervous system, general diseases of the, 64 Petit mal, 404, 406 Photographers' cramp, 475 Phrenic nerve, paralysis of the, 155 Physiognomy, 24 Pia mater, inflammation of the, 335 mater, spinal, 180 Pianists' cramp, 474 Plagiocephalic skull, 27 Plantar neuralgia, 177 reflex, 29 Pneumogastric nerve, anatomy and physiology of the, 102 nerve, diseases of the, 147 Podalgia, 87 Poisons, etiological influences of, 42 Policeman's disease, 88 Polioencephalitis, 352 Poliomyelitis, acute anterior, 220 chronic anterior, 224 Polyaesthesia, 37 Polyneuritis, 70 acute pernicious, 75 diagnosis, 77 endemic and epidemic types, 74 etiology, 70 malarial, 75 onset, 72 pathology, 75 prodromas, 72 prognosis, 78 35 Polyneuritis, symptoms, 73 treatment, 78 Pons varolii, nuclei of the, 302 varolii, physiology of the, 323 Porencephaly, 333, 367 Potential, difference in, 53 Pnedorniitium, 503 Pressure sense, testing the, 36 Progressive muscular atrophy, 229, 261 Projection, erroneous, defini- tion of, 113 Projection fibres, 306 Prosopalgia, 130 Pseudo-muscular hypertrophy, 270 Psychiatry, definition of, 16 Psychical epilepsy, 404, 406 Psychophore, 513 Psychoses, definition of, 16 sexual, 457 traumatic, 460 Ptosis, 114 morning or waking, 117 Pulvinar, 300 Pupillary skin reflex, 30 Purkinje cells, 304 Putamen, 298 Rachischisis posterior, 197 Ranvier, nodes of, 5 Raynaud's disease, 85 Reaction time, 14 Reactions, degenerative, dis- eases in which they may be expected, 62 degenerative, testing for, 60 Re-enforcement of the knee jerk, 31, 32 Reflex action, 14, 20 epileptiform convulsions, 404 irritations, neurasthenic form, 447 546 INDEX. Reflex pains of the lumbar nerves, 172 Reflexes, 20 deep, 31 examination of the, 29 superficial, 29 table of spinal-cord levels for the superficial, 30 tendon, instrument for testing, 23 varieties of, 29 Regeneration of nerves, 68 Representation, bilateral, 318 Rest treatment, 517 diet in, 518 electricity in, 519 massage in, 519 rest in, 518 Retinal hyperaesthesia, 111 Rheostat, 55 Roots, spinal nerve, 180, 186 Sacral nerves, diseases of the, 173 Salaam spasm, 151 Saltatory spasm, 433 Sarcoma of the brain, 391 Scaphocephalic skull, 27 Scapular reflex, 30 Schmidt, incisures of, 6 SchAvann, sheath of, 5 Sciatica, 174 rest treatment for, 531 Scleroses, 44 Sclerosis, amyotrophic lateral, 265, 268 disseminated, 374 insular, 374 multiple, 374 multiple, aborted types of, 376 multiple cerebral, 376 posterior spinal, 231 primary lateral, 257 spinal, combined with soft- ening, 256 Sclerosis, spinal, forms of, 229, 248 Scotoma, definition of, 108 Secretion, neurosis of, 22 Senile chorea, 438 paraplegia, 226 vertigo, 143 Sensation, delayed, 21, 37 double, 37 examination of the disor- ders of, 134 transferred, 21 Sense, pain, testing the, 37 pressure, testing the, 36 tactile, testing the, 35 temperature, testing the, 36 weight, testing the, 38 Sensibility, muscular, testing the, 37 Sewing spasm, 474 Sex, etiological influences of, 40 Sexual neurasthenia, 451 neuroses and psychoses, 457 Shingles, 170 Shock, etiological influence of, 41 Sick-headache, 125 Side pains, 163 Singultus, 155 Sinuses, cerebral, 316 Skin reflex, 29 Skull, dimensions and shape of, 26 Sleep, accidents of, 503 disorders of, 489 normal, 490 paroxysmal, 500 perversions of, 493 Sleep-drunkenness, 495 Sleeping sickness, 502 Sleeping girls, 501 Smell, disorders of, 107 instruments for testing, 145 primary centre for, 320 Smiths' spasm, 474 INDEX. 547 Softeningof the brain, red, 349, 362 of the cord, 210 Somnolence, morbid, 500 Spasm, facial, 123 flute-players', 474 idiopathic muscular, 29 lingual, 147 milkers', 475 nodding, 151 of the ocular muscles, 120 oscillating, 151 salaam, 151 saltatory, 433 sewing, 474 smiths', 474 winking, 134 Spasmodic tic, 431 Spasmus nutans, 151 Spastic paraplegia, 249 spinal paralysis, 257 Spermatorrhoea, 458, 513 Spina bifida, 197 Spinal accessory nerve, anat- omy and physiology of the, 103 accessory nerve, diseases of the, 147, 148 amyotrophy, progressive, 264 anaemia, 204, 286 apoplexy, 200 concussion, 460 cord, amyotrophic lateral sclerosis of the, 265, 268 cord, anatomy of the, 180 cord, cavities in the, 280 cord, combined sclerosis with softening of the, 256 cord, hemorrhagic cavities in the, 280 cord, malformations of the, 197 cord, myelitic cavities in the, 280 cord, physiology of the, 188 Spinal cord, primary lateral sclerosis of the, 257 cord, relation of different parts of the, to the per- ipheral nerves, brain, and each other, 186 cord, secondary degenera- tions of the, 259 cord, syphilis of the, 398 cord, tumors of the, 377 exhaustion, 288 hyperaemia, 203, 286 irritation, 286 meningitis, 205 nerves, diseases of the, 153 neurasthenia, 288 paralysis, spastic, 257 Spotted fever, 338 Stabile electrode, 58 Stammering, 148 Static electrical batteries, 55 Status epilepticus, 406 Stellwag's symptom in exoph- thalmic goitre, 464 Stigmata, 24 permanent, of hysteria, 419 Stuttering, 148 St. Vitus' dance, 436 Substantia nigra, 302 Subthalamus, 302 Suggestibility in hysteria, 425 Suspension, treatment by, 516 by Sprimon's apparatus, 517, 527 value of, 517 Sydenham's chorea, 436 Syllabic speech, 374 Syncope, laryngeal, 144 Symptomatology of nervous diseases, 16 of peripheral nervous dis- eases, 178 Syphilis, hereditary, nervous symptoms of, 399 of the nervous system, 396 Syphiloma of the brain, 390 548 INDEX. Syringo-myelia, 281 neuritic type of, 79 Syringo-myelocele, 198 Tabes dorsalis, 231. See Loco- motor ataxia dorsalis, pseudo-, 70 Tachycardia in exophthalmic goitre, 463 Tactile sense, testing the, 35 Tarsalgia, 88 Taste, disorders of, 146 instruments for testing, 145 primary centre for, un- known, 320 Telegraphers' cramp, 474 Temperature sense, testing the, 36 Tendon reflexes, 31 reflexes, instrument for testing, 233 Tension, definition of, 53 Testicle, extract of, 522 Tetanilla, 443 Tetanus, 442 Tetany, 443 Thalami optici, 299 optici, physiology of the, 322 Thermo-anaesthesia, definition of, 20 Thomsen's disease, 433 Thrombosis of the brain, 362 Thymus gland, extract of, 522 Thyroid gland, mode of prepar- ing and use of, 521 Tic, convulsive, 18, 431 coordine, 441 de pensee, 431 douloureux, 130, 531 mimic, 132 spasmodic, 431 Tinnitus aurium, 139 cerebri, 139 Tongue, hemiatrophy of the, 148 Tongue, paralysis of the, 148 spasms of the, 147 Topoalgia, 523 Topography, cranio - cerebral, 505 Torticollis, 148 Tracts, cerebral, 306 of the spinal cord, 185 Trance, 497 Transferred pains, diagram showing the location of, 82 Trauma, etiological influence of, 41 Traumatic neuroses, 460 Tremor, 18 convulsive, 432 fibrillary, 29 hysterical, 424 testing for, 28 vibratory, 28 Trigeminus nerve, anatomy and physiology of the, 98 nerve, diseases of the, 120 Trigonocephalic skull, 27 Trismus, 132, 442 Trophic disorders in hysteria, 425 Tropho-neuroses, 22, 484 Tubercula dolorosa, 90 Tuberculin, use of, 522 Tubercular meningitis, 340 Tumors of nerves, 89 of the base of the brain, 389 of the brain, 381 of the central region of the brain, 386 of the cerebellum, 388 of the corpora quadrigem- ina, deep marrow, and pineal gland, 388 of the corpus callosum, 387 of the crus, 338 of the great basal ganglia and the capsule, 387 of the occipital lobes, 387 of the parietal area, 386 INDEX. 549 Tumors of the pons and med- ulla, 388 of the praefrontal area, 385 of the spinal cord, 277 of the temporal area, 387 Urine, incontinence of, 513 Vertigo, senile, 143 Vibrating chair, 516 Vibrating helmet, 516 Vibratory therapeutics, 516 Vicq d'Azyr's bundle, 306 Violinists' cramp, 474 Vision, primary centre for, 319 Volt, definition of, 55 Voltaic alternatives, 516 Von Graefe's symptom in ex- ophthalmic goitre, 464 Watchmakers' cramp, 475 Watt, definition of, 55 Weight sense, testing the, 38 Word-blindness, 330 Word-deafness, 331 Wrist drop, 164 Wrist reflex, 33 Writers' cramp, 468 new apparatus for, 532 Wry-neck, 148 Zones, hysterogenic, 422 Vagus nerve, anatomy and physiology of the, 102 nerve, diseases of the, 147 Vaporium, 510 Vasomotor symptoms, 22 disorders, 484 Veins of the spinal cord, 194 Vertigo, 141 arterio-sclerotic, 143 auditory, 141 bilious, 142 laryngeal, 144 lithaemic, 142 mechanical, 143 Meniere's, 141 neurotic, 142 ocular, 142 paralyzing, 144 MEMORANDA. 0 CuC